Open sesame. by Steve Salfield. October 2006

In 1970 a medical degree was a passport. A key to many doors. Medicine was, scarily, scarcely regulated. A doctor’s freedom to practice as he or she saw fit was sacrosanct and it was assumed that would be in patients’ best interests. Medical negligence and medical litigation were terms rarely if ever heard. Bureaucracy although already invented was, in retrospect, in it’s infancy. The National Health Service had not been reorganised – not even once.
After passing finals I was required to spend a year in hospital practice as a junior houseman, nominally under supervision, and then was free to practice in whatever field or place would employ me. Doctors were in short supply so there was ample choice.
One evening at the end of my houseman year in Newcastle upon Tyne, standing next to me at the bar of the Medical Institute a genial elderly doctor sipped his malt whisky. He was a general practitioner as it transpired, with a practice just around the corner from my home. I overheard him saying to his drinking partner that he needed a holiday but couldn’t find a locum.
“I’ll do your locum for you” I said flippantly, and introduced myself.
“Fine, start on Monday morning” said Dr Black.
I was concerned for the doctor and his patients at his casual way of appointing staff so I asked him whether he would need some evidence that I was qualified and suitable for the job.
“Oh I suppose I should” he said, “what are the green and black tablets?”
“Librium” I said, naming the ubiquitous tranquilliser of the time.
“That’s all you need to know. The job’s yours” he laughed.
On Monday morning in a side street I found Dr Black’s neglected brass plate on a scruffy brown door next to a small sweet shop. I climbed the steep stairs to the surgery. You had to be fit to be a patient in this practice. In the large dingy waiting room twenty or thirty people sat and behind her desk was small, plump, white haired Mrs McTaggart the receptionist. She was a friendly, motherly woman and showed me into the small shabby consulting room which contained a large oak desk and chair and two hard backed upright chairs. There was no toilet, wash basin, or examination couch.
Pale green peeling paint swung towards me as my first patient entered through the squeaky door. I had a sensation of adventure into the unknown. This was to be my first clinical encounter outside the protected environment of the large Victorian hospital building with mile long corridors and Florence Nightingale wards, which had been my training ground. This felt very different from working in the hospital. I felt exposed. Would I be able to deal with the problem with no advice from a registrar or consultant? No nurses. No equipment. Just me and the patient and this room. I ventured outside to ask Mrs McTaggart for the patient’s records.
“Oh Dr Black doesn’t really bother with those” she said. “He knows all of his patients. But there is some correspondence in that cardboard box over there under the table”.
The people I met were friendly, respectful, sometimes deferential and unquestioning of my ability. I was the doctor after all so I had the answers. Most patients wanted repeat prescriptions – black and green tablets or more of the purple tonic that had no active ingredient but made them feel so much better. The little white lie, now obsolete, since full information, honesty and informed consent robbed the placebo of its effectiveness.
I thought I was learning general practice quite quickly. I took a brief history from each patient and made notes as I had been taught in medical school. I even tried to prod or peer at the problem part of the body without the benefit of an examination couch or getting the patient to undress. I suppose I was spending five to ten minutes with each patient. After a couple of hours I realised that the waiting room was still full and that some people had already been waiting for two hours. At morning coffee time Mrs McTaggart was looking a little anxious so I asked her how Dr Black could cope with such a large number of patients in a session.
“Well” she said “He comes into the waiting room in the morning and counts how many people are waiting. Say there are thirty, he says to them, “there’s thirty of you and I’m here for an hour so that makes two minutes each.”
I was beginning to suspect that this type of general practice was not the pinnacle of quality that I, still young and idealistic, aspired to. But I soon discovered that his patients adored Dr Black.
“He’s a wonderful, kind Doctor” they would say, “If he thinks there’s anything at all wrong with you he sends you straight to the hospital”.
This was the kind of GP we young hospital doctors, perhaps arrogantly, used to despair of. The type who wouldn’t take any responsibility and clogged up the hospital system with unnecessary “rubbish”. Yet here I was seeing it from the other side of the hospital doors and the patients loved and valued him.

“Locum GP for three months wanted for the small town of Towawa, Saskatchewan, Canada” said the ad in the BMJ.
“Good pay and all expenses paid”.
I sent off a letter of application and a few days later the phone went at six in the morning.
“It’s Bill Jiaomeng and I want you to come as soon as possible. I need a holiday.” said the voice in English with a strong French accent. It appeared that appointment procedures in Canada were no more rigorous than in Newcastle but that is where the similarities to my previous post ended.
A few days later as I flew across the Atlantic at someone else’s expense, well dressed and with a smart new briefcase, I felt, self importantly, that I must have something special to offer. I spent a night in Montreal which seemed a very suave modern city. Next day I caught the internal flight to Regina in Saskatchewan where Dr Bill Jiaomeng was waiting for me. He was an enormously fat Chinese man who had spent his early life in Mauritius and later moved to the UK. He and his young family now lived in the sticks in Canada. I later learned that he spent most afternoons on the phone to his stockbroker. He wined and dined me before we drove the two hundred miles of Saskatchewan prairie and parkland in his large Buick. Towawa was a small Canadian “town” with a population of five hundred and another fifteen hundred farming people living in the surrounding area. A village in reality, it had one street with a few stores and a few scattered wooden or fibro houses. The next day Bill handed over to me his house, his cars, his premises, the small hospital and then he was gone. Perhaps I had overstepped the mark this time. I had been qualified eighteen months and now I was in the back of beyond in charge of a hospital and the only doctor for two thousand people was me! The nearest other doctor was fifty miles away and if I wanted to send someone to hospital it was a two hundred mile drive or in an emergency a flight.
This was indeed a new experience for me. Next morning as I walked down the wooden sidewalk past the stores, the bar, sherrif’s office and the funeral parlour, to the doctor’s office I felt I was in a movie set for a western film.
“Hi Doc” said the cowboy as he got out of his truck at the hardware store.
After doing the ward round with matron in hotpants in the modern twelve bedded hospital, I spent a few hours seeing patients in the well equipped doctor’s office with an efficient appointment system, an examination room and a smart nurse receptionist.
That night, my first night on call in Canada was the night of the graduation ball at the local high school. At three in the morning I received a call to go to an automobile accident on the highway. Two kids were killed and two were injured, one with a fractured pelvis and multiple other injuries. I certified the dead and resuscitated the living before an ambulance took them the 200 miles to Regina hospital. I was in the deep end but fortunately that was the worst disaster I had to deal with in Canada. Finding that I was coping, I was gaining confidence and thoroughly enjoying being a proper family doctor in the old fashioned sense. I delivered a baby, set many fractures, sutured lacerations, did minor surgery and saw many people with general medical illnesses. I reduced a dislocated knee joint, a very rare injury and fitted intrauterine devices (which I had even been trained to do). I began to feel that I was a competent doctor. When I had my first patient with appendicitis I had to call Dr O’Leary from Greenfield, fifty miles away as two doctors were needed for major surgery.
“Do you want to do the operation or the anaesthetic?” he asked.
Never having done either before, this brought home to me how theoretical and lacking in practical experience my training had been. I opted for the anaesthetic. The operation was successful and what’s more the patient survived.
I heard about the GP in a nearby town who enjoyed appendicectomies and the accompanying fee. Anyone he saw with bellyache had their appendix taken out. When there were no more appendices in the area he moved into the next state and started the task of removing the population’s vestigial organs and filling his own coffers.
This was proving an epic teach yourself practical medicine experience for me with the local population as my learning material. As far as I know I did no harm and the patients and nurses seemed to like me. Even though I was inadequately prepared for what I was doing, I felt justified because I was the only doc in town. If I didn’t do it no one else could.
After the appendicectomy, I suggested a drink back at Jiameng’s.
“Yes. let’s drink Jiameng’s whisky” said Dr O’Leary, a garrulous Irishman who seemed good humoured enough. I hadn’t yet discovered that he was on the wagon and that I was about to start him on a binge of drunkenness which was to last for months. Over the next few weeks I received many calls from Dr O’Leary’s secretary asking me to cover his practice as “Dr O’Leary was “unwell” that afternoon”. I met him several times and discovered that his good nature was intermittent and that he also had black moods and a biting wit at times.
Once a week I drove in Jiaomeng’s Buick to the next little town to do a clinic. This really was the wild west. Farmers and cowboys and their families would drop in to see me with their complaints. These people were old fashioned and stoical and showed huge respect for the doc. I also had the privelege of visiting some people in their homes.
I and my twenty six year old wife were invited to homes for barbecues. We spent weekend afternoons at the lake, boating and swimming in hot summer weather. We spent one unforgettable evening at the home of an eccentric German veterinarian, Baron von Hagen, who clicked his heels and saluted when we met. He kept an index card system with details of everyone he met. His wife was away and after dinner he put on soft music and insisted on dancing cheek to cheek with my wife while I sipped schnapps and plotted how to escape from what I feared was an ex nazi war criminal.
I thought this was a grand life. My wife had the use of Jiaomeng’s second car, a convertible, Dodge. She was invited to play tennis and socialise with the local ladies – a mixed blessing for her. She learned of the high suicide rate of doctors’ wives in these small prairie towns, presumably related to boredom and social isolation. She soon talked me out of any ideas of this way of life in the longer term. She had her own career to develop and was not the type to be a professional “doctor’s wife”. She was writing a book and was happy to spend a summer working here but the Canadian winters were hard with snow and ice for six months. After three months in Towawa and a short stint working for Dr O’Leary we left Canada to tour the USA.
My appetite for novelty was stimulated and shortly afterwards I travelled to the other side of the world to Papua New Guinea.
The door to an even more exotic experience was opening.