primary 2

Dr Robert Palmer

CHANGES DURING 50 YEARS IN MEDICINE

Medicine has changed greatly in the last 56 years and I will attempt to record the important changes that I have experienced, in addition to personal recollections.

I went to medical school (St Mary’s Hospital, London) in 1962. I started my clinical years as a medical student in early 1964 and worked until my 70th birthday in 2014.

As a Student

When I was medical student a lot of medicine was like ornithology, you could spot things but there wasn’t a great deal you could do about it. That is most certainly no longer the case. At St Mary’s management of renal failure was in its infancy, dialysis and renal transplantation were just starting. I vividly remember an Oxford don in renal failure who died because he was over 30 (he was 31), and they only performed transplants on those under 30, inconceivable nowadays.

After qualification

When I did my house physician post at St Mary’s Hospital, Harrow Road in early 1968  the ward was full of men in their 60’s, mostly with advanced chronic bronchitis and emphysema (now called chronic obstructive pulmonary disease). Back then most men were heavy smokers and London had its smogs. We were not allowed to resuscitate any patient who had reached 70, again unthinkable today.

After my house jobs I worked in hospital medicine, so this account will be primarily about the changes in hospital medicine that I have witnessed.

Early Experiences as a young Doctor

After my house jobs I worked for six months in 1969 as a casualty officer in Kingston upon Thames. There was absolutely zero teaching or help from more senior doctors, and I well remember that after seeing the patient, and looking at the X ray if there was one, I would excuse myself and read up in a textbook in an adjoining room what to do next, not in front of the patient of course. I would hope and expect things to have changed for the better in this respect.

My next job in 1970 was anaesthetics in Westminster Hospital. On about my fifth day in anaesthetics as a complete novice I was with a consultant anaesthetist who happened to be president of the English anaesthetic faculty. He excused himself before the list started (probably he had a private case) and I had to do it by myself. It was a trans sphenoidal excision of a pituitary tumour (i.e. inside the brain) with a consultant ENT surgeon. How I didn’t kill the patient I will never know, and the terror lives with me still, and I nearly gave up anaesthetics then and there. I vowed that in no circumstances would I ever do the same thing with a trainee anaesthetist in the future.

Certainly, supervision of trainee surgeons and anaesthetists in the UK has improved markedly. I remember many instances when junior trainee surgeons were left to do cases by themselves inappropriately, with on occasion serious adverse consequences for the patient.

General Practice

During my career I have done general practice, as an addition to my junior hospital jobs. General practice is a very important field of medicine and it is not easy to be a first rate GP. Sadly it seems that the pressures on GP’s nowadays are so much greater, with 10 minute appointments, targets to meet, the growing and ageing population, and the higher expectations of the general public and growing treatment options. Consequently, many doctors do not choose general practice as a career option any more, and if they do they tend to take early retirement. Also, the majority of medical students today are of the fair sex, which was certainly not the case when I was at medical school when it was much harder for ladies to be accepted and was certainly not a level playing field. Ladies tend to be more diligent students, they are articulate and interview well, they mature earlier and of course are better looking. However, in general practice and throughout medicine they are more likely to be part time, and of course their families are their first priority. This has a knock-on effect inevitably on availability of doctors for general practice and elsewhere.

I remember when I was a Senior House Officer in maternity and paediatrics at St Richards in 1971 being invited by a Chichester GP to come and meet him and his partners. That was pure gold dust back then when GP jobs, especially in a place like Chichester, had very many applicants. Now sometimes they don’t have any applicants, even in places like Liss and Gosport.

 

 

I met my wife Valerie (above)in early 1972 when she was a student nurse at St Richard’s Hospital, Chichester, and poster girl for the hospital.

 

 

 

 

 

 

 

 

 

 

My time in America at Memorial Hospital, Worcester Massachusetts in the early 1980’s.

Having worked in North America for 14 years from 1976 to 1990 I have to say that supervision of juniors was always superior there to that in the UK. On that same theme another of my bugbears is that still in maternity units in the UK there is an absence of senior doctors out of hours, and this is in the most critical area of medicine. I remember over 40 years ago in the States there were always at least two attending (consultant) obstetricians and an attending anaesthesiologist in our maternity unit 24 hours every day of the year. That still cannot be said for UK units. Certainly it was much more the norm in the USA for senior doctors to be in the hospital out of hours, particularly in the acute specialties, with clear benefits for the patients.  I enjoyed my years in the USA (Worcester, Massachusetts) and found Americans welcoming, hospitable and generous.

 

 

QA Hospital.

After returning from America and two years working in Wales I came to QA Hospital Portsmouth for 22 years until my retirement in 2014. Below are experiences in the improvement in medical services I have witnessed.

Surgery

There has been significant progress for the better in the field of surgery. In orthopaedics in the 60’s total hip replacements were developed and in the   70’s arthroscopic surgery for knees  and total knee replacements.

Similarly, laparoscopic surgery was a major step forward, particularly for gall bladder surgery and hernia repair, but more recently for major abdominal surgery and major urological surgery. I remember it coming into use widely in the late 80’s, and it is now pretty much the norm, with shorter recovery times.

An enormous development was phaco emulsification for cataract surgery in the 90’s. Cataract surgery used to involve a general anaesthetic, and a one-week hospital stay. Now it is an outpatient procedure with just eyedrops and taking 10 to 15 minutes.

Some operations are not being done any more, for example vagotomy and pyloroplasty for duodenal ulcer now treated with antibiotics, and tonsillectomy in children is much less common.

Another big change is that when I qualified; any lady below 28 weeks of pregnancy who lost the foetus was an abortion (miscarriage). This has been successively lowered to the current 24 weeks. Along with that has been the development of neonatal intensive care units and neonatal ventilation. The results of this intervention are not always easy to predict and may lead to long term  care which can be difficult for the family and expensive for the NHS. Also in vitro fertilisation which has resulted often in older mothers, more often multiple pregnancies, and more abnormalities. On the other hand, there are couples who are desperate for children. It is a difficult one and I have mixed feelings about it.

A big step forward is the development of intensive therapy units (ITU’s). When I started at QA there were 1, sometimes 2, intensivists. There are now 16 and counting. At the recent CQC visit to QA our unit was assessed as excellent. There is no doubt that patients are getting much better care when they are seriously ill compared with 50 plus years ago. The unit at QA was largely developed by Gary Smith (earlier Alex Larson) with great help from Bruce Taylor.

Two other major advances at QA are the cardiac unit, which will provide a consultant cardiologist to insert one or more stents if appropriate into the coronary arteries of a patient who has had a heart attack, immediately, and at any time of the day and night. This saves the heart muscle and enormously improves the outlook for the patient. There is similarly at QA a stroke unit to treat patients who have had a cerebral thrombosis or embolus, again with good effect.

The stroke unit at Southampton General is very advanced and if a patient with a thrombotic stroke can get there quickly after their stroke a catheter can be threaded from the femoral artery, through the heart and up into the brain and a small metallic net extruded beyond the tip of the catheter and envelop the clot and remove it, all done by a senior neurologist and radiologist (under xray control) and they can go home very quickly without paralysis.

Another advance are chronic pain units, though there is a tendency for these to be farmed out into the community.

Anaesthetics

My specialty, anaesthesia, became much safer with the advent of capnography monitors (which measure the carbon dioxide in exhaled air, confirm the correct placement of an endotracheal tube, and identify a disconnection in the circuit);  and pulse oximeters which measure the degree of oxygenation of the patient. These were both introduced in the early 1980’s and dramatically reduced the number of anaesthetic disasters.

More recent Developments

Open heart surgery developed during my career. So now aortic and mitral valve replacements and coronary artery bypass procedures are common practice, and for the less fit balloon valvuloplasty for mitral stenosis and transcatheter aortic valve implantation for aortic stenosis are available. Complex cardiac operations for congenital heart disease and operations for other congenital disorders in the very young are also performed.

More recently robotic surgery has been introduced, with the surgeon operating the robot some distance away from the patient in the operating room.

In the investigative field we have CT scans and MRI scans, and so it goes on.

Advances in chemotherapy and radiotherapy have prolonged life in cancer cases and in some cases cured previously fatal cancers such as Hodgkin’s lymphoma and some leukaemias.

Screening has become widespread. Screening for bowel cancer (occult blood) is very successful, though screening for prostate and breast cancer has had more mixed results.

Of course, scrutiny of doctors with appraisals and revalidation together with continuing medical assessment to ensure they remain up to date is a major component of a doctor’s life. In a way it has almost gone too far, significantly impacting on time that could be spent on patient care.

In summary I have had a very fulfilling and interesting career in medicine. I always wanted to be a doctor, even my primary school reports give that as my career choice. I have not in any way been disappointed. I was particular pleased to have chosen anaesthetics which suited me very well. I worked until I was 70 because I enjoyed it. I had already decided not to go beyond 70 because with age there is inevitably a deterioration on all fronts, and in an acute specialty this is particularly critical. I did have a near miss at 69 (the patient was fine thank goodness) which reinforced my intention.

 

Above is me aged 69 in 2013.

Probably I have said enough. I hope I haven’t been controversial, as that was not my intention.

Family and other interests.

Robert Palmer is a retired anesthetic consultant, working most recently in Queen Alexandra’s Hospital, Portsmouth. He moved with his wife and family to live in Rowlands Castle in 1993, with  family and grandchildren now also living nearby. He has enjoyed playing tennis and can be frequently seen cycling in the village. He has also been a British Universities water polo player as a student, and  a competitive masters swimmer in later life, and was three times national champion in his age group in the 200 metre backstroke, and co holder of an age group European record for the 4 by 200 metre freestyle relay.  He currently contributes to the U3A History Group, cycle group, quiz group and poetry group in the village. He is also an ambassador for the charity CHASE Africa, and a member of population matters. And of course duties for his 9 grandchildren.

5/6/2018.