By Sir JAMES [LEARMONTH, K.C.V.O., C.B.E., Ch.M., F.R.C.S.E.. Regius Professor of ..... Stewart was a Nova Scotian who qualified at Edinburgh and who.
SOME OBSERVATIONS ON VISITS TO THE UNITED
STATES, By
CANADA AND
[LEARMONTH,
Sir JAMES Regius Professor of Clinical
SCANDINAVIA
K.C.V.O., C.B.E., Ch.M., F.R.C.S.E.
Surgery and Professor University of Edinburgh
When
of Surgery,
upon a journey that is other than a holiday, the should be other than terrestrial. That is, one should leave from a point of view, which should have been carefully P^t together. The journey may alter it?indeed very likely it will. Oil one's return, any changes in point of view must be as carefully one
Point of
sets out
departure
scrutinised
before
leaving. These processes are all the more journey is at least partly a sentimental journey : for then one may be tempted, like Yorick, and on as insufficient founds, to begin by saying, They order these things better in Canada?or in the United States?or in Scandinavia." Any or all ?f these statements may be true enough, but if they are to be made tlley must be made after return, and not before departure. Thus I shall begin by telling you what was in my mind when I set ?ut to visit these other clinics. I had always been of the opinion that
necessary
as
when the
"
^ Veprofessor and
at
I
should take stock of himself
longest began with
ten
years. what I
When I
sat
intervals of at shortest down to do this, naturally
at
thought might be on the credit side. had been war years years but my department had managed to crowd into them?thanks to a series of hard-working junior colleagues ^s?me well-documented experience in the management of lesions of
plough he
first five
Peripheral Ve
nerves
and vessels which
years had their
difficulties,
but
was
at
still
bearing
any rate most
fruit.
The
of my
next
strategic
airn had been accomplished with the help of the University Court pnd the various hospital authorities ; the establishment of lectureships certain major specialties?experimental surgery with a link with
^
e
clinical side, anaesthesia, thoracic surgery, plastic surgery, paediatric and urology. None of these undertakings had I any cause rcgret, and I was grateful that the University had made them
^Urgery
Possible,
in
generous a way as it could. About some of them there differences of opinion with colleagues?even profound rlw? 6rences ?f opinion?which I had respected. But I could, I reflected as
^een
th
back upon the co-operation and often wise advise of of my colleagues. But, I reflected further, these majority e doubtful grounds for complaisance. They may fill, and fill crably well at that, the immediate needs of this great medical
thangreat
'
e
l95cfea^ CHIR.
a
meeting
?f the
Medico-Chirurgical Society
of
Edinburgh
on
3rd May
SIR JAMES
48 school.
Are
LEARMONTH
to the future ? And are there any more surgery and of the education for surgery which they do not meet, or even envisage ? For a professor ought to try to cast his mind forward, and try to imagine what surgical practice will be like when his students come to their full professional
fundamental
they adapted problems of
activity. In meeting
these more fundamental problems, the credit side of the balance was not so conspicuous ; and it was clear that they What enables me," I asked myself required further examination. to undertake the surgical management of a patient at the present "
"
not the contributions anaesthesia, asepsis, radiology, blood transfusion, instruments of precision chemotherapy, immunology, designed by physicists, chemical methods devised by biochemists ? And all of these, with the exception of anaesthesia, have been primarily advances thought of and in certain cases partly perfected in the and certainly laboratory. Ahead of us," I continued to myself, within the lifetime of most of us, there are possible primary advances in biophysics and biochemistry which will be revolutionary, and of enormous benefit to mankind, advances which we and our pupils must eagerly accept, though inevitably they will reduce the extent It is the primary advance, of the field in which surgery is useful. and its first offsprings, that we must reach out for." This was a sufficiently humbling thought : and in its turn it posed an academic problem. If, to keep our place in the surgical world, we must make at best primary and at least first secondary advances, when is the student to be guided into the right path : in his undergraduate days?or in his post-graduate days ? Fortunately the answer is easy. It has been calculated that if the expansion of knowledge of the basic sciences continues at its present rate, by 1970 the undergraduate curriculum would have to be extended to seventeen years to keep pace with it, which would be absurd. It is as absurd f01" is what to blind critics who are going on around them to object to some extra time being given in the new curriculum to the basic sciences,
time ?
Are
"
take the extreme view that any extension of the medical curriculum should be devoted largely to clinical work ; for it is quite obvious that it is easier to continue clinical studies after graduation* and
to
than to achieve a satisfactory working knowledge of the basic sciences before it. These ruminations provided me with one purpose, that I must look around to see if elsewhere teachers were thinking of the surgery of the future, without in any way jeopardising the present
patient as a person. And the immediate problem to consider* help of visits to other clinics, was whether the surgeon with some considerable acquaintance with the basic sciences was more likely to think of some primary advance, or the basic scientist possibly with ^ some acquaintance with surgical and technique surgical problems. would be easy, and as loose a piece of thinking as it is easy, to argue that such problems could be solved by team work. No doubt some of care
of the
with the
VISITS TO
them
UNITED
STATES, CANADA AND SCANDINAVIA
49
this some soluble only by team work ; translatable into concentration of material.
can, and there may be
implies opportunity, usually But I remembered
a
great continental surgeon,
now
dead, saying
to
defect in British medicine was the tendency to publish textbooks, and to avoid the more intellectually satisfying at a monograph : a remark that still, I regret to say, finds me is a it that has been It written, quite recently, disadvantage. that no one who bothers about British
me
that
to
his mind
characteristically
the
of his modern way of
theory
one
assumption subject is competent to practise expressing the equally fatuous
it
:
view
which is
a more
implied
in the
Those who can, do : those who can't, teach." I recalled saying : the number and high standard of the monographs written by Scandinavian authors ; roughly, I have been told, twelve monographs for every hundred students. And so I was glad to have the opportunity even a short visit to Scandinavia soon after my visit to Canada "
and the States. In the United States I visited the Universities of Minnesota in North Western University and the University of Illinois and the University of Harvard in Boston. In Canada I
?Minneapolis, Chicago,
of Toronto, and Dalhousie University in Halifax, In most of on Edinburgh in more ways than one. them I had the opportunity of talking with administrators as well as ^vith clinicians. And everywhere, and not in the Medical Faculty alone, I found the and women uneasy feeling that on the whole young men ^vere spending too great a proportion of their lives in preparing, or rather in for a career, and had too little time left for
visited
the
University
the latter modelled
being prepared,
Jts prosecution.
of tendency is to be corrected, there are only two ways the was doing it?by shortening the undergraduate course, which recommendation of the Goodenough Committee and which I still think is the right plan ; or by shortening the period of post-graduate training. If the former, what subjects are to suffer ? In America, as indeed in Scandinavia also, I was much impressed by the grasp the majority of undergraduate students seemed to have of the modern Methods of application of the fundamental sciences to medical problems, ^t is true that in America the are longer, preparatory years in college and in what amounts do students medical all for Toronto, example, If this
t? an
honours course in science as part of Precedes their medical training proper. It is
?nlY
the
^vhich is also t
most
require
brilliant students a
much
higher
are
a
cultural
true
accepted by
entrance
course
which
that in Scandinavia the medical schools,
standard than do of scientific
our
own.
matters may
true that an improved knowledge eave less time for what is loosely called general education, although have always been very doubtful of the validity of this argument seeing the school curricula in the sciences proposed by the English Science Masters' Association : it is as salutary to write english ab?ut a science as about a minor Nevertheless I think that
^nce
poet.
SIR
50
JAMES
LEARMONTH
students with this type of training will be better equipped twenty years hence than the average product of a medical school in this country. If the time is to come off post-graduate training, immediately there is
conflict with the
requisites for recognition laid down by the various and associations, requirements which, quite rightly, emphasise colleges that experience is more important than diplomas. I think that in this matter we also have something to learn from our American and a
Scandinavian friends, who arrange that at least the best of their young and women spend some of their post-graduate years in the laboratory, confident that this training puts upon them a professional and men
intellectual hallmark to which the operator can never aspire, however useful his place in the community ; a confidence that is common to the universities, If only serve. to come
Let
to
the
we
can
by. give you
me
two
and to the hospitals which they choose the right man, experience is easy
colleges
examples
methods of which I have been
of the familiarity with highly technical speaking. In one American clinic I
working on the plotting of the distribution of radioisotopes in the brain, a type of work which involved the use of a special Geiger counter. To my enquiry as to progress, he replied that he had not had much time, but was getting ahead. How long ? Six weeks. What preparatory training ? None but his student courses. And both he and his professor were surprised that I should be surprised that he could tackle his problem so readily. The other happened in a Scandinavian clinic. In the department of radiology two young men very kindly showed me some arteriograms : but their real research work was on the physical properties of blood flow through arteries, with the ultimate object of producing an injection medium with the same physical properties as blood. I thought a great deal about these young men and others, who had found problems so fundamental and who were able to tackle the mathematics and physics of them ; and I thought very highly of themsaw a
young
man
active
It is this attitude of
"
back
"
that is so arresting : first visit to America my twenty-five years agOr could hold my own in fundamental matters but was much behind in the finer technical points of specialties.
especially since, I thought that I
developing
?
It
fundamentals
on
what
Against
to
background was this proved fairly easy to sort
North out
American
the factors
attitude
concerned-
There seemed on the whole to be a trend away from the strictly full-time clinical professor, which had begun before I left the States, and which, I heard, had continued. I could not see any unification of outlook in the administrative plan of instruction, that is, whether a should have its own hospital or not : the points for being still the freedom of the universities to choose their staff, and the points against the equally good (or equally bad) teaching in non-university hospitals (since few universities seem to interest themselves in the
university
VISITS TO
UNITED
STATES, CANADA AND SCANDINAVIA
51
of their medical staff in teaching methods, and few of the rnedical staffs of hospitals take any interest in methods of teaching) ; together with the freedom from administrative and legal problems enjoyed by universities which do not utilise hospitals of their own. These arguments might equally well be applied in deciding the future policy of British Medical Schools, and to some small extent both policies are being tested at present, as a consequence of the different in England from that which is administration of
training
teaching hospitals
employed in Scotland. As you know, there is
a
governmental
movement in the United
towards a state or federal medical service, and I was often asked if the advent of the state service in Britain had made any difference to our teaching facilities. The answer, of course, is that in at least in Scotland it has not ; but I found wherever I went that the United States and Canada only the difficulties and teething troubles of our service were known to the majority of doctors, who
States
had
rather obviously) with their information Indeed I found the easiest way to terminate these tiresome discussions on our state service was to say firmly that I thought it a very good one, which ensured that we could talk of other been
supplied (I thought
by visiting propagandists.
things
at
once.
such
There was, I found throughout the profession, a state scheme as had been put forward by the
?Pposition Federal Government, although the voluntary to
!t
difficult
hospitals
were
finding
impossible balance their budgets. There is in both Canada and the United States the difficulty in nurses and other non-medical hospital personnel which seems to be widespread ; as a consequence of this, 8^ per cent, of the 385,980 beds in the of the United States are not in use. to
or
finding
voluntary hospitals
The
universities and colleges were taking an active and helpful interest in this problem. I found that in several places it was possible to combine a college education with a nursing course, which seemed to me a sensible to take arrangement. In many universities it is possible a staffs the recruited are which course in medical administration, from is time the office side of student's Part of the spent in
the this
hospitals.
university and part in practical work in hospitals, and I found course a popular outlet for those who had wanted to study medicine
but had
the necessary entrance standard : for ?^?rnerican and Canadian medical schools, like Scandinavian schools, take only the best students. It appears that in the United States 61 million persons are protected from the expenses of illness by some form of insurance (Blue Cross and Blue Shield) or about 41 per cent, of the population, and that the number of those so covered has been steadily increasing. In a Serious illness this insurance will meet at least half the cost. Those
^ho do
not
not
quite
desire
a
reached
state
service wish
to
lower the total
cost
of medical
by using public funds for building new hospitals, and for paying Jare 0r the staffing of hospitals and such ancillary services as the ambulance
SIR
52
JAMES
LEARMONTH
wish to provide centres equipped with all the modern advice will be free. They wish to have school aids where diagnostic And they wish to supply children examined at regular intervals. services.
They
require them with drugs and appliances which are so costly beyond the capacity of the ordinary citizen. I confess that I thought that a considerable part of this programme seemed to resemble state medicine very closely, the only important item missing being the salaries of the doctors, even in the free diagnostic those who as
to
be
services.
parties?those for and those against a state service?were the number of doctors should be increased, and that that agreed The anti-state must be made for their higher education. provision In the United service group do not believe the need is clamant. Both
States, for the present academic than for
year
6986
and the
students were enrolled, of increase of doctors
1948-49, 9 per is greater than the rate of increase of the population of the country. In Britain increases in the number of doctors were at first said to be essential, and indeed in proportion to our population we are training cent, more
rate
doctors than the States, but there do not seem to be any outlets for doctors in this country or abroad either immediately or in the Moreover it seems to me that if one assesses the average future. reduction in number from entry to final examination as from 10 to
more
15 per cent, (without taking into account so-called wastage by marriage), then a better method of selection of medical students could be devised, and this would obviate the need for more so as to avoid this wastage ; medical
schools,
and
might
even
reduce the numbers in the
schools to a more educationally profitable size. I found that this was the view of a section of
larger
university opinion
in the United States. It may interest you to hear the present cost of building a hospital in North America, together with the cost of maintenance of different types of hospital, reduced to our currency with the dollar at its old par value of 4.80, before any of its devaluations : to obtain present values these
sterling figures
should be
multiplied by 7/4.
Costs.? Provincial Hospital
Per bed
Capital
(U.S.A.) (County) Teaching Hospital (U.S.A.) Veterans' Hospital (Canada) Teaching Hospital (Canada) (Children) .
.
.
.
.
.
.
^2500 ('12,000) ^3130 (15,000) ^2800 (13,000) ^3130 (15,000)
Cost?Day.? Provincial Hospital (U.S.A.) Urban Hospital (U.S.A.)
.
.
.
^1
17
6
.
.
?2
15
o
In ninety years, the cost of hospital care in the United States has increased twelve times, and it is of great interest that the same Is true of the value of income for each inhabitant. An unfamiliar feature to
me
were
the
and the United
large States,
and
both in Canada with ex-service men^
well-equipped hospitals,
which dealt
exclusively
VISITS TO
UNITED
STATES, CANADA AND SCANDINAVIA
53
the Veterans' Hospitals. Their existence is a political matter, and therefore not for any comment : but both in Canada and in the United States they had been usefully incorporated into schemes of post-graduate
training. As in other
usually gets what one high capital costs and running expenses reflect not constructional increases but also increases in the provision only ?f ancillary facilities such as radiological and laboratory services. It seemed to me in North America, and also in Scandinavia, that these increases were viewed in a better perspective than in this country, because though presently expensive, they will lead to a reduction of expense in the future as a result of more rapid service and shorter stays in hospital ; although it is arguable that the bottlenecks in hospital investigation might be abolished by a substantial extension of the Polyclinic system, in which a high proportion of investigations can be done while the patient is an out-patient. A hospital can be almost too palatial. Of all the new hospitals which I saw, I liked best the Victoria General Hospital in Halifax. This 400-bed hospital is built on the T-plan, which makes for ease of Pays for ;
and
of human
activity,
one
initial
administration,
little
spheres
and
of reinforced concrete.
space had
not
been put
to
good
It seemed use,
yet I
to
me
thought
that very the wards
roomy enough for comfort and for nursing. This took from 1944 to 1948 to complete, and the cost of building including the cost of medical equipment) was ? 154? f?r each
rooms
quite
hospital
(not bed (7400
dollars in
By invitation,
Congress
1948).
I attended in
of the American
the Sixth Inter-American
Chicago the Thirty-fifth Annual Clinical College of Surgeons, with which was held Congress of Surgery : the latter includes
SlJrgical
societies from the countries of Central and South America. be noted that the Congress of the American College of Surgery in addition to meetings which correspond roughly to our Association
It is
ls
?f
to
Surgeons
of Great Britain and Ireland.
This Congress is remarkable in the first place as a feat of organisation, for it was attended by between six and seven thousand surgeons,
^umbers
as these cannot be occupied other than sectionally, and for the week that the Congress lasted, day every day, there was an almost embarrassing choice of meetings which one could attend. These were divided into seminars, at which a broad topic f?r example, nutritional problems including the use of fluids and considered in all its aspects ; symposia, in which
such
and all
e^ectrolytes?was
rather
narrower
Wlth ;
and
specialties.
Congress.
subjects (for example, anticoagulants) panels, which dealt with certain problems in I
was
interested
f thought this
note
the wide field covered
dealt
surgical by the
It included certain aspects of post-graduate education : and of nursing education, matters which might well be discussed on occasion at surgical meetings.
hospital administration,
ln
to
were
the
country.
SIR
54
JAMES
The
general standard of the presenting them, usually
LEARMONTH
was high, and the many young forum, had clearly taken great care with their One of these papers and with their presentation. young men, I am glad to say, was Mr A. I. S. Macpherson of Edinburgh. It is true that sometimes an old subject turned up again, and that it was occasionally quite impossible for all the speakers on a subject to be right, so divergent were their views. I am quite sure that these exercises in giving papers form a valuable discipline for young surgeons, and that even though there may not be anything startlingly original in their papers, they are at least good practice in assembling views and in pronouncing them. It was most interesting to find out how much these young men It seemed to be agreed that three years of general training were paid. were essential before embarking on any specialty, and naturally there were considerable variations, partly geographical and partly depending on the amount (if any) of government grants to ex-service men. In one centre, in addition to room and board the salary was, for the first year 25 dollars a month (about ;?8), for the second year men
50 dollars
papers at
a
month and for the third year 75 dollars a month. long waiting list for these positions. In another centre, living accommodation was not provided, the salaries varied 150 to 200 dollars a month, and here too there were many
was
a
a
applicants than places ; monthly allowance of up
ex-servicemen
these salaries with those of
our own
of factors
to
cost of
(exchange, substantially
70 dollars.
There where from more
have an additional It is difficult to compare
might
registrar grades, because a number living, etc.) must be taken into account.
smaller than ours ; and I do not think that the average rewards of practice in America differ materially from ours. There were, of course, operating sessions during the Congress, if one were disinclined to move about the and city one could sit in the of most the were hotel in which held, and watch some of the meetings operations on a television screen, transmitted in colour. I thought these remarkably clear, but?like cinema films?a possible temptation But
they
for the
are
more
adventurous.
also a large display of instruments and appliances. My uppermost feeling when I left Chicago was of gratitude for the great kindness and hospitality with which the College and its individual Fellows treated a guest. I thought the College took a broad and most enlightened view of its activities, and that they were really positive activities, which could not do other than maintain the high standard of American surgery, and give its Fellows every opportunity for adding to primary advances by way of the basic sciences. The experience that the conviction I strengthened my suggestion diffidently made to the Council of our College some years ago, that it might hold an annual congress, might still have something in it. It was intensely interesting as well as intensely moving to revisit the Mayo Clinic where I had spent so happy a part of my life. Moving There
was
VISITS TO UNITED STATES, CANADA AND SCANDINAVIA
55
because of the dread of missing poignantly so many who had been both mentors and friends, after an absence of seventeen years, years during which so much had happened : interesting not only because of the I wanted to talk
but also because I myself the increase in work of the clinic of which I had been told : and because it would be intriguing to learn what was the strategy of the Board of Governors for a future in which a state medical service was possible. As I pointed out in my obituary notice of the brothers Mayo in
many people Would
to
and learn
from,
for
see
the British Journal of ment
was so
their
retiral.
Surgery,
their supreme administrative achieve-
to arrange matters that the clinic continued its work after
This was quite fundamental to their plans, which had the Clinic and all its clinical and financial resources to the of Minnesota. I found the Clinic grown out of all knowledge m its volume of work, and still growing, so that some sections were housed in temporary buildings, and I got lost both in the Clinic and
hnked
University
in the rapidly
expanding town. It seems of significance that the have decided to proceed with the building of a new Clinic to with the growing demand for the services of its members, of whom
Governors
deal there
262 on the permanent staff and 500 Fellows undergoing So great a concentration of clinical material makes it possible f?r any visitor to see the management of almost any surgical condition he cares to choose, during only a brief stay. I need not detain you With particular observations. are now
training.
In the Clinic I found that the plan for integrating the fundamental
sciences
with surgery had altered very little since my
day
:
it was,
course, on a greater scale. There were pure scientists physicists and chemists and physiologists?who had known something of surgical
Problems the
war.
and had in
some cases had their experience broadened during There were doctors who visited the hospitals from their and who took an active part in the management of patients. elsewhere in America, and in Britain, there was a shortage of
laboratories, ^ere,
as
first-class physicists
who were not already at work on problems of ?reat interest and importance. Their difficulties were the same as ^me, and their solution of them a compromise. My old colleagues Were very good to me, and accepted me again in a way that I shall cherish for the rest of my life. So completely was I reabsorbed that ?ne day in hospital I found myself automatically taking up a telephone answer my old signal tick "?1-4- In Rochester, too, as I shall "
Presently tell, had
I found
set out to
a
clue to the
problem, which,
study.
Harvard is one of the American medical
hospitals
I have told you,
for its clinical
teaching,
schools which
and not
voluntary university hospitals as do uses
great state universities ; but its two professors of surgery are each his own hospital. One of them is so over-burdened teaching and administration that he does little or no
chief surgeon in by the work of
?Perating himself; CHIR.
the other is
an
accomplished biophysicist t?
and
SIR JAMES
56
LEARMONTH
biochemist. Boston is a particularly useful centre in which to study the new technical approaches to medicine and surgery. The great Massachusetts Institute of Technology, which is a model of such
for medical men which familiarise them with applications of these new and powerful additions to our
institutions, has the
possible
courses
armamentarium.
My last transatlantic visit was to Halifax, on an errand of interest Edinburgh men, for I had the privilege of delivering to the Medical Society of Nova Scotia the first John Stewart Memorial Lecture. Stewart was a Nova Scotian who qualified at Edinburgh and who accompanied Lister to London as a dresser. He spent the greater part of his life in Halifax as professor at Dalhousie University, and was both an LL.D. of Edinburgh and an Honorary Fellow of our College. He was a man of great intellectual and spiritual fibre, and his example was a most beneficent one in Nova Scotia. The medical school in Dalhousie University is modelled on that of Edinburgh, to
and the town possesses in its new hospital one of the best of its kind. After my return I received an invitation to lecture in the three Swedish universities : Lund, Stockholm and Uppsala, and I also visited Copenhagen and Oslo, delivering eleven lectures in nine days, two
of which
navian
were
hospitality
system of
These activities and traditional Scandilittle time for any detailed study of the training in Scandinavia, but I was anxious
Sundays. left
me
post-graduate
how the new Research Council had influenced work in Sweden, and I found that although it had been in existence for only a short time it had provided much equipment and some posts. Stockholm is> as some of you know, a city noted for palatial hospitals, and beside the Karolinska there has just been finished a large institute under the charge of Dr Anna Schwarz, who had been professor
to see
experimental
of medicine.
The institute
was
full of young
men
and women, including
graduates, working very hard at a large variety of problems, with the help of admirable equipment. I found there was no lack of applicants for the junior posts, from trainees in all branches of medicine, and that although the salaries were relatively low. In fact, in Sweden (as in the other Scandinavian countries) to be eligible for a senior post in a hospital of standing it is essential to have written a thesis, many of which are on preclinical subjects. These are published as additional numbers of the Acta?till recently a very considerable financial undef taking for these poorly paid young men. One of the most interesting things about post-graduate work in Scandinavia is the concentration of clinical material for study by both juniors and seniors, who seem happy to pass it on to one another, their happiness being derived fron1 the knowledge that the material will be well studied and duly reportedI am sure that this is a far better method of intellectual training f?r the young surgeon than a more scattered experience, particularly if it15 largely operative in content. science
VISITS TO UNITED STATES, CANADA AND SCANDINAVIA I have
not
said
saw very little of it.
In Rochester I
57
about undergraduate training because I And I shall now try to summarise what I learned.
anything
saw the quotation that Dr William Mayo used to have " which read, Take of my experience, but give me of Your dreams." I thought that I learned, from my two trips, that the ?nly useful surgical dreams would be dreams of the future, dreams ?f a vastly different approach to surgery, even to the restricted surgery will then be. Dreams of past glories and of present achievement
?n
his
desk,
are not
generally productive. A professor's task would be, first, to catch the dreamer from the recruits to surgery ; then to see that he has already?or can be provided with?the new and thrilling stuff of his dreams : and finally to detach the dream from the dreamer in
the
half-waking
state, when dreams
are
so
elusive and
only
too
often
escape. Meantime the professor's experience will
?f his
department.
assure
the
day-to-day
work
