Why medicine?

When I was in my last year at school, my father needed an operation for cancer, and this turned my thoughts to medicine as a career. If I could not be a farmer, then I would be a country doctor.

Why research?

After graduation I worked as a Junior Resident Medical Officer at the Royal Melbourne Hospital. The Honorary Medical Officer in charge of the medical ward was Dr John Bolton, whose twice-weekly ward rounds were unusual in a number of ways. While there was much talking with (definitely not to or at) the patient, and physical examination was done when needed, there was no medical discussion in the patient's presence. That took place in the side room during afternoon tea, a ceremony presided over by Sister in which everyone, including the lowly students, participated. After discussion, a member of the team was sent back to tell each patient the results of the deliberations. Dr Bolton himself then went around again to make sure no patient had further questions.

During one of these ward-round afternoon teas I asked if patients who had had a long history of angina did better after a heart attack than those who did not, reasoning that those with angina might have developed more collateral circulation to prevent some of the damage resulting from the occluded artery. Dr Bolton suggested that I should find out by conducting a small research project using the hospital records. Under his guidance I studied the medical records of 100 consecutive patients admitted with myocardial infarction, correlating the presence of pre-infarction angina with the outcome of their hospital stay. He assisted me in formulating the research questions, in coping with the limitations of hospital records for the research purpose, in revising my rudimentary knowledge of statistics, writing up the results, and having the final paper published.

"Shock in myocardial infarction" was my first research paper, published in the Royal Melbourne Hospital Clinical Reports in 1959.⁴ I disproved my hypothesis, as there was no evidence that a longer history of angina led to less shock or fewer deaths in hospital, but I did find that the overall death rate in hospital following myocardial infarction was an enormous 34%.

Is research possible in country general practice?

The first question I addressed with my practice index was "What are the commonest conditions seen in my general practice?". It was soon obvious that these were acute respiratory infections, so I decided to investigate these, conscious that then, as now, there was great controversy about how these should be diagnosed and managed. I started by considering the epidemiology of acute respiratory infections, and presented the results at the 1963 Annual Convention of the Australian College of General Practitioners in Sydney.⁵

A seminal idea arose at a football match. Several of my friends there had colds of varying degrees of severity, coughing and spluttering amidst the cheering for our team. During the following week some of them came in for a consultation. However, it was not necessarily those who had seemed most sick who came in. It set me wondering, why? It was obviously more than just severity of symptoms that made sick people seek medical attention. What were the other factors? It also made me aware that my research into respiratory infections was biased towards conditions for which the patient sought attention. Were those who didn't consult a GP different?

These questions led me into the fascinating realm of the sociology of medicine via David Mechanic's book Medical sociology.⁶ A statement that particularly caught my eye was: "Studies which begin with known or treated cases of particular disorders risk confusing aetiology with social and psychological processes leading to care unless the relationship between treated cases and untreated cases is known." I did not know this relationship in Traralgon, but hoped that I could find out.

Since I had study leave due after five years in the practice, I used it to spend several months in the United Kingdom in 1966, meeting people who were doing the sort of research I now wanted to do. I visited the people I knew of already, and they recommended many others. At the end I reflected ruefully that some of their incisive and critical comments about my own research and ideas had been a little deflating, but that the depth of concern shown for a fellow researcher was encouraging. I was ready to go on.

In 1966, the (by now Royal) Australian College of General Practitioners' Council advertised "one long-term Fellowship for conduct of a major research project approved by the College". I applied and was awarded it. From that time onwards my professional life included paid research time.

We recruited from our practice 56 families with children, comprising 258 individuals, who were to keep a daily health diary for each family member for a year, and were willing to allow me to access details of all medical attention they received during that time. I was thus able to learn about all illnesses, particularly respiratory infections, including those for which no medical attention was sought.

In 1968, I met Basil Hetzel, newly arrived at Monash University as the inaugural Professor of Social and Preventive Medicine. He was most interested in the research I was doing in Traralgon, and extremely supportive, inviting me to use the facilities of his department, the most helpful of which was access to the university computing centre to analyse my results. He also encouraged me to write up my study as an MD thesis, something that had never occurred to me.

In the same year, I became Honorary Secretary of the Royal Australian College of General Practitioners' Research Committee of Council, a position I held for nearly 20 years. I was involved in the 1969-1974 RACGP national morbidity survey, which led me into research and development of appropriate classifications and to membership of the World Organisation of Family Doctors Classification Committee.

In 1970 I commenced a new project, the Traralgon Health and Illness Survey. This was to be a major undertaking, based on my previous studies but much more representative of the community and more sophisticated. It preceded and in many ways foreshadowed the later triennial Australian Health Surveys that are now undertaken by the Australian Bureau of Statistics, for at that time there was relatively little information about community health status. The survey occupied me for the next three years, and three major articles resulting from it were my first publications in the international arena.^7-9

All this time I had been a busy and fulfilled country GP, treating my patients in hospital and in the community. I loved the personal interaction with patients and the continuity of care that led to long-lasting relationships. It surprised me that so much of my research work was now a matter of epidemiological surveys and classification, as I did not see myself as a number cruncher, an academic theoretician.

When, after 1974, advertisements began to appear for Chairs of General Practice or Community Medicine in Australian medical schools, I found the idea irresistible. I applied for several, although I felt torn between the challenge of taking up an academic position and the wish to remain in the country. I was going to miss the generosity of a country community and the space.

Why Sydney University?

It started with a phone call answered by my wife, Anne, one morning at home. She was impressed that the man at the other end introduced himself with perfect etiquette as "Richard Gye, Dean of the Faculty of Medicine at the University of Sydney". Did I realise that in phoning a stranger at home one should always introduce oneself with one's first name, Anne asked me when I came in to lunch. No, I replied. On returning the call, I was invited to come to Sydney to share my ideas about teaching general practice in universities. It never occurred to me that this might be an approach inviting me to apply for the Chair there, but I accepted the invitation to visit Professor Gye and his colleagues. One evening he took me to dinner, where we discussed many things other than professional issues. I had not expected to find an eminent neurosurgeon — narrowest of narrow specialties, I thought — an interesting human being, but I did. My formal interview must have gone well (I don't remember much of it), as I was offered the Chair. I had ascertained that, although it was a Chair of Community Medicine, its focus would be general practice.

I was fortunate in being able to start a new department and ensure it had a clinical emphasis. To that end, the acquisition of a university general practice was important and rewarding. Here was a base from which we could initiate further research into medical records, respiratory infections, and emergencies in general practice. It was a great disappointment when the practice had to close in 1990 because a high quality teaching and research practice could not be made financially self-sufficient.

Teaching came easily to me. It was also "organised curiosity", but in this case there was already an answer to be shared. We built a closeknit team of staff and emphasised experiential learning and small-group interaction. We established a widespread network of teaching GPs in both city and country whose support was invaluable. Our course always rated well in faculty teaching evaluations.

My first major research task as an academic was to edit a report of the 1969-1974 RACGP national general practice morbidity and prescribing survey.¹⁰ This reinforced my interest in surveys and classifications and the international links that were to develop and provide so much interest and stimulus over the next 20 years, alongside the international friendships and travel in which Anne and I delighted. The evolution of the International Classification of Primary Care¹¹ was one lasting achievement. The 1990-1991 general practice morbidity and treatment survey¹² not only updated such information, but led to the continuing national BEACH ("Bettering the Evaluation and Care of Health") survey now contributing to information about Australia's health.¹³

There was even opportunity for creative activities. I was one of the editors and contributors to the book General practice in Australia,¹⁴ one of the last publications of Sydney University Press in 1986. About the same time I initiated and helped edit a video produced by the university about people living with terminal illness. I chose the title, A changed kind of reality, from a quote of one of the participants. We not only used it in our teaching program, but it also won a Penguin award and was broadcast by the Australian Broadcasting Corporation.

Reflections

References

1. Eimerl TS. Organised curiosity. J R Coll Gen Pract 1960; 3: 246-248.
2. Pennycuick SW. The Arthur E Mills Memorial Oration. The secret of living. Med J Aust 1952; 2: 261-264.
3. Pickles WN. Epidemiology in country practice. Bristol: John Wright and Sons, 1939.
4. Bridges-Webb C. Shock in myocardial infarction. Royal Melbourne Hospital Clinical Reports 1959; 27: 26-29.
5. Bridges-Webb C. A three-year study of respiratory infections. Med World 1965; May: 381-389.
6. Mechanic D. Medical sociology: a selective view. New York: The Free Press, 1968.
7. Bridges-Webb C. The Traralgon health and illness survey: method, organisation and comparison with other Australian surveys. Int J Epidemiol 1973; 2: 63-71.
8. Bridges-Webb C. The Traralgon health and illness survey part 2: prevalence of illness and use of health care. Int J Epidemiol 1974; 3: 37-46.
9. Bridges-Webb C. The Traralgon health and illness survey part 3: illnesses and their medical and hospital care. Int J Epidemiol 1974; 3: 233-246.
10. Bridges-Webb C, editor. The Australian general practice morbidity and prescribing survey 1969 to 1974. Med J Aust 1976; October 2(Suppl): 1-28.
11. WONCA International Classification Committee. International classification of primary care, ICPC-2. Oxford: Oxford Medical Publications, 1998.
12. Bridges-Webb C, Britt H, Miles D, et al. Morbidity and treatment in general practice in Australia 1990-91. Med J Aust 1992; 157(Suppl): S1-S56.
13. Britt H, Miller GC, Charles J, et al. General practice activity in Australia 1999-2000. Canberra: Australian Institute of Health and Welfare, 2000 (AIHW Catalogue No. GEP 5).
14. Anderson N, Bridges-Webb C, Chancellor A, editors. General practice in Australia. Sydney: Sydney University Press, 1986.

Authors' details

Reprints will not be available from the author.
Correspondence: Professor Charles Bridges-Webb, University of Sydney, Sydney, NSW 2052.
cbridgesATmail.usyd.edu.au

©MJA 2001
Make a comment