History and humanities

Chance and commitment. Memoirs of a medical scientist. Basil S Hetzel. Adelaide: Wakefield Press, 2005 (xviii + 301 pp). ISBN 1 86254 686 7. The title Chance and commitment evokes Pasteur’s statement that chance favours the prepared mind. Basil Hetzel’s story combines good fortune and opportunity with a lifelong commitment to improving population health. Central to this narrative is the author’s 40-year commitment to elucidating iodine deficiency disorders (cretinism, neuromuscular disability and goitre), and pursuing worldwide remediation of this preventable scourge. The “chance” arose in the early 1960s when, as Reader in Medicine at Adelaide University, Hetzel reviewed a manuscript reporting goitre reduction by iodine supplementation of Papua New Guinea (PNG) adults. With his interest in hormones and stress physiology, Hetzel’s interest in iodine-dependent thyroid hormone duly heightened. His team undertook a trial in PNG that showed that pre-pregnancy iodine administration prevented cretinism. Hetzel subsequently made two unorthodox career moves (for a clinician) — first to the (Foundation) Chair of Social and Preventative Medicine at Monash University (1968–1976), and then to head the Commonwealth Scientific and Industrial Research Organisation (CSIRO) Division of Human Nutrition. These moves, fortuitously, facilitated further epidemiological and animal experimental studies of iodine deficiency disorders (IDD), respectively. “Commitment” then became dominant. Hetzel helped establish the International Council for the Control of Iodine Deficiency Disorders (ICCIDD), and, in the late 1980s, as Executive Director of that body, persuaded the World Health Organization to support a program of IDD elimination via iodised salt. By century’s end widespread gains had been made. With detailed recollections of family, friends and colleagues, Hetzel recounts his school days, university studies, early clinical research, stress-hormone research in New York and London, his work at Adelaide University, Monash University and the CSIRO, and, in “retirement”, along with his ICCIDD activities, his Deputy Governship of South Australia and Chancellorship of the University of South Australia. There were highs and lows: the death of his first wife, Helen; his subsequent marriage to Anne (and their travels together); and, along the way, many honours and tributes. Basil Hetzel’s autobiography underscores how, with a little luck and risk-taking, much can be achieved via a mix of optimism, resilience, clarity of focus and commitment grounded in professional and religious conviction. Anthony J McMichaelDirector, National Centre for Epidemiology and Population Health Australian National University, ACT

Anthony J McMichael

Modern medicine’s picture of human nature offers challenges and opportunities to the humanities There is much talk these days about “the medical humanities”, although we still await agreement on its meaning and importance. I think the key lies in appreciating how medicine and the humanities share in an endeavour larger than either alone — the endeavour of understanding the human condition. In this, medicine and the humanities have much to offer each other. My framework begins with an observation about knowledge, scientific and otherwise. All knowledge is to some extent concerned with the knower: our attempts to know things about the natural world are also part of a much larger attempt to understand ourselves (Box 1). Sometimes, this is obvious. For instance, in economics, the laws of supply and demand tell us about how we, as consumers, can be predicted to behave. It is still more obvious in the arts and humanities. Knowledge — about musical forms, the rise of impressionism in painting, Aristotelian influence on medieval Church scholars, or the ambiguous role of the narrator in the psychological novel — is knowledge about how people have tried to make sense of the world, how they saw themselves in the natural order, whether they liked what they saw, and whether they were going to “come along quietly” or were going to struggle. This is true in the natural sciences as well, even if only implicitly. When physiologists study the relations between form and function, when scientists of virtually any discipline attempt to create models of the world, they construct knowledge which not only tells us something about the world, but also something about us. They disclose and specify our need for explanation and prediction: our material need to govern our environment and to harness Nature, and our inner compulsion to understand, dissect and demystify it (Box 2). Enquiries in the natural and life sciences also raise questions about us. What is the nature of observation? How can we contain observer bias? Why do we crave simple explanations? Why do we derive such pleasure from making satisfying theoretical models? This relationship between the known and the knower has important implications for medicine’s role in our culture. Following Raymond Williams, 20th-century pioneer of cultural studies,1 I take “culture” to be the stock of meanings and purposes and shapes in a particular society (which we learn in our education and upbringing) and also the process of challenging these meanings and purposes, and making new ones. So, a “cultural good” is something that helps us learn the meanings, purposes and shapes that our society already embodies, or that helps us create new meanings, purposes and shapes. Medicine itself has a big role in this today. If knowledge implies something about the knower as well as the known, then equally a society’s meanings and purposes tell a story about that society and its members, collectively and individually. Medicine today makes a powerful, uncomfortable and as yet unchallenged claim to supplying part of that story. For me, this conclusion emerges from analysing medicine as a “cultural good”, by which I mean something that gives us resources in reflecting upon ourselves, or in articulating or expressing ourselves, or in developing ourselves, or in criticising ourselves, or in encountering ourselves — all key aspects of what it is to “tell our story”. Art or literature, history or philosophy, politics or theology are initially more obvious resources for doing these things. For instance, to reflect upon ourselves we might read a psychological novel, or study the conventions of classical Greek tragedy. To articulate or express ourselves, we might turn to social history, or to popular music, or to newly commissioned writings or public art. To develop or to criticise ourselves we might cultivate a taste for philosophy, or study the work of dramatists from Aristophanes to Arden. To encounter ourselves we might grapple with expressionist painting, and so on. Western cultures are partly defined by our habitual turning to these particular resources or cultural goods. However, I think that less obvious resources are all around us in scientific and other practices — but they are usually overlooked. And the practice that strikes me most forcefully in this regard is modern technological medical and health care (hereinafter “medicine”). So, how does medicine do these things? Reflecting upon ourselves: Modern medicine has given us new models of our own nature, seen in molecular genetics and in biological psychiatry’s story about our behaviour and character traits. Public health and preventive medicine purport to prescribe our “proper” conduct and spell out our individual responsibility, in line with the unargued assumption that good health is a self-evident benefit, rather than a contingent or instrumental one. The values that medicine presumes — such as the absolute benefit of health — show its heritage and its potency as a “cultural good”. Articulating or expressing ourselves: Medical practice has given us abundant material for artistic, literary or other creative purposes, arising, perhaps naturally, from the linear and “narrative” form that illness, disability, treatment and recovery seem to take. Thanks to the episodic form that clinical medicine acquires in individual clinical cases, intimate and compelling aspects of the experience of being human are explored in literature as diverse as Chekhov’s A case history,2 Camus’ allegorical The plague,3 and John Sayles’ film Passion fish.4 Of course, medicine is not unique in providing material for creative reflection on life’s conditions: all of lived experience does this. I simply want to note that medicine amply satisfies this characteristic of a “cultural good”. Developing ourselves: By contrast with the dominant theological determinism of earlier ages, according to which bodily suffering was seen as a necessary part of our journey through “this vale of tears”, medicine apparently offers a reassuring alternative, placing us within a flawed but eminently improvable natural world, from which we could in principle remove the deadlier stains, be they smallpox or polio or, in utopian mood, congenital anomalies. If, for most humans, life in the time of Thomas Hobbes was truly poor, nasty, brutish and short,5 medicine has already improved the odds and has ambitions to do vastly more. In the process, it has extended the range of stories we can tell about ourselves and about the human condition. It confirms our development beyond fatalism (Box 3). Criticising ourselves: Medicine has given us a vocabulary of criticism, whereby we draw on health, sickness, diagnosis and treatment for images that capture larger areas of our experience — think of “the body politic”, of “healthy” and “unhealthy” behaviour, societies or subcultures. The general idea of “diagnosis” has colonised human affairs, giving us a model of what it is to function well or badly in the social and cultural arena; we commend processes, teams and institutions for their “organic” development, and condemn them for their atrophy, decay or paralysis. Of course, this — sometimes dangerously — implies a rhetoric for action:6 to call one thing a treatment, remedy or therapy is to impugn some other things as a pathological problem in need of change. We now have “remedial” processes in education, in management, in urban regeneration. Certainly, there are grievous problems in these areas, but the vocabulary of remedy and therapy spuriously distinguishes expert agents from lay “patients” in matters where public dispute ought to remain legitimate. Encountering ourselves: This final aspect is perhaps the most interesting and suggestive. One of the conceptual foundations of medicine is the assumption that what lies beneath, or inside, holds the key to what lies outside or on the surface. Gross clinical pathology is explained by disruptive processes at the cellular or even molecular level. The once-astounding optical microscope now seems no more than a feeble and naive beginning: the slice-by-slice scanning of computed tomography, and the “unpeeling” made possible by magnetic resonance imaging, give us a new visual vocabulary for human nature (Box 4). By making the invisible become visible, we invert surface and substrate, seeming to locate the truth about ourselves at the level of physiology and neurology — rather than at the level of the ordinarily visible face and whole body, where we as selves ordinarily function and experience. The “medical body”7,8 is itself a substantial, if incomplete, story of encounter with the human condition, and one that invites critical interpretation and imaginative response. In all these respects, modern medicine is indeed a “cultural good”. The challenge that we face is to find an adequate response to the persuasive power of its reductionist picture of human nature and the human condition. Today, in the West, this picture is virtually unopposed by earlier claimants for our adherence: religious, Marxist or psychoanalytic world-views. We have an opportunity to reinvigorate enquiries into human nature within the established humanities disciplines — prominent among them being philosophy, recently rather coy about asking the real “meaning of life” questions.9 As a philosopher, it seems to me that coyness is no longer a serious option in the face of a story of human nature rooted at the molecular level. If we are to create a more satisfying conception of the human condition, it is time we recognised the need for a re-engagement between the humanities and medicine. All illustrations reprinted with permission from The illustrated history of medicine, by Jean-Charles Sournia. Published by Harold Starke. 1 The anatomist Vesalius, by Pierre Pons All knowledge is partly concerned with the knower. 2 Insulin molecule We have an inner compulsion to understand and demystify Nature. 3 Public health poster, post World War II Medicine’s promise to improve the human condition confirms our development beyond fatalism. 4 Magnetic resonance image of the brain Grey matter appears reddish-brown, and white matter green and blue.

H Martyn Evans BA, PhD

The medical humanities are concerned with “the science of the human”, and bring the perspectives of disciplines such as history, philosophy, literature, art and music to understanding health, illness and medicine. The medical humanities are designed to overcome the separation of clinical care from the “human sciences” and to foster interdisciplinary teaching and research to optimise patient care. Medical humanities have become part of the mainstream in medical education in North America and the United Kingdom, and are now integrated into many medical curricula in Australia. The Australasian Association for Medical Humanities was inaugurated in November 2004; a postgraduate program in the medical humanities began at the University of Sydney in 2003.

Jill Gordon MPsychMed, PhD, FRACGP

Story-telling can help doctors cope with the great catastrophe of illness and death Recently, I was involved in the diagnosis, suffering and, ultimately, death of my friend and patient, “Christie”. When I began to write about this experience, I thought that I was writing her story. But soon, I realised that this is my own story. Narrative, a recital of facts in the first person, has been used as a tool for people who personally experience illness. However, I believe it can be used by doctors as they try to understand the illnesses and sufferings of their patients. Christie’s storyI met Christie in my daughter’s school playground in 1989. She had recently arrived from Melbourne, and, apart from having daughters of the same age, we shared many interests. There was an instant spark. Several years after we met, I opened my own general practice and Christie came to see me as a patient. When I asked her whether she would be willing for me to do her Pap smear, she remarked that had we not already been friends, we would have become friends. She was such a warm, friendly and outgoing person that this theory of hers was probably right, although I think that when someone has been a patient first there is more reserve in the doctor–patient relationship. In September 2000, I fled the sporting mania of the Sydney Olympics and went to New York with a friend. We wined and dined, went to live theatre, saw all the tourist attractions and climbed the World Trade Center. It was a wonderful holiday. It was an abrupt return to reality when, on my first day back at work, I learned that, in my absence, my colleague had seen Christie — and had found a lump in her breast. The biopsy report was on my desk. I knew as soon as I read it that she was going to die. There was not one redeeming feature. The tumour was anaplastic, there were 38 positive nodes in the axilla, and the tumour was oestrogen-receptor negative. Not only did I anticipate Christie’s early death but I also realised that I was going to have to play a difficult, painful role in the process. Already, my self-pity was threatening to overshadow my grief for my friend and her family. The next three-and-a-half years were, for me, a tragic example of the way an aggressive tumour can destroy a human being. Christie, of course, handled the whole affair with flair. She had surgery, radiotherapy and chemotherapy. She passed through an era of hats and scarves that hid her hair loss. Through it all, she remained cheerful and optimistic. I do not try to hide the truth of a difficult prognosis with my patients, but do make an effort to break the news gradually. I also think it important to maintain hope and optimism. So, for me, making sure that Christie understood the hopeless nature of her cause was incredibly difficult for me. After the initial flurry of medical intervention, there was a period of relative calm. For about 12 months the only medical treatment Christie received was trastuzumab (Herceptin), known to slow the growth of oestrogen-receptor-negative breast cancer. She resumed her previously hectic social schedule, and her friends would tell me how wonderful it was that Christie had made such a great recovery from her breast cancer. My secret knowledge ate at me like a personal malignancy. She came to see me as her doctor again in May 2002. She had just had a routine follow-up CT scan and wanted to discuss the result with me rather than her oncologist. There was a mass of enlarged lymph nodes in the left supraclavicular space. The cancer was back. I broke the news as gently as I could, but she was devastated. Her fear for the future was written all over her face. I referred her for radiotherapy and she went through another period of intensive treatment. Without complaint, Christie suffered the accompanying fatigue and the skin burns. This period of intense treatment was followed, once more, by relative calm. I did not know which of Christie’s initial visible fear or her later cheerful front was the more difficult for me to witness. But the gaps between crises were shortening. The next problem arose less than six months after the radiotherapy. Christie was getting short of breath. A simple chest x-ray revealed the problem — fluid in the left side of the chest cavity. A day-trip to hospital was all that was required to drain the fluid, but pathology analysis confirmed the presence of malignant cells. The cancer was on the march again. In July 2003, I made arrangements for my own family to have a holiday — two weeks in the surfer’s paradise of Angourie, on the north coast of NSW. On my last day at work, Christie came to see me. This time, she was really in trouble: she had a constant burning pain in her left arm and marked weakness. The cancer had begun to invade her brachial plexus. Christie wept uncontrollably in my office. I held her and comforted her as she explained the frustration of having a useless arm. She couldn’t cook or hang out the washing. She couldn’t do up her bra or pull up her underpants. I did what I could for her neuropathic pain and referred her to the pain clinic. Then, I went on holiday. During that holiday, I spent many moments thinking about what Christie was going through. Sometimes when I was enjoying a moment in the sun, a walk on the beach, a card game with the family and, once, as I was pulling up my underpants, I thought of her and wept. I wept for her pain and frustration, for the bitterness of terminal illness in those too young, and my frustration in being able to do no more than observe, pity and weep. Over the next three months, I saw less of Christie. She was deep in the clutches of the medical machine. The most important person was her pain specialist. Every possible pain-relieving drug, including huge doses of morphine, failed to relieve her pain. Finally, her oncologist decided that depression was exacerbating the pain and she should see a counsellor. She went once, but informed the oncologist that, although the counsellor was lovely, she would find it much more helpful to talk to her GP. So began for me the most difficult period of all. Christie came to see me once a week. We spent at least half an hour together as she discussed the pain and practical difficulties of her situation, as well as the worsening prognosis. Sometimes we met at my surgery; sometimes I would go to her house. At about this time, she was going away for a weekend with her husband. I think they knew that the end was not far away and wanted some time alone. The day before they left was our counselling day. Christie told me how much she wanted to be sexy one last time for David, but how she was unable to get comfortable enough even to think about making love. Never before had I been required to help anyone with this dilemma and never had I felt so useless. In the following month, the cancer spread under the skin of Christie’s chest and the tumour broke through the skin, erupting into a foul-smelling sore. Nurses came daily to dress the wound and apply antibiotic gel to try to control the smell. I was unable to offer any way of preventing this from getting worse, and I was appalled at the ability of uncontrolled cancer to eat away at the flesh and dignity of such a lovely lady. Christie’s youngest child, “Henry”, who was seventeen, came to see me to talk about the way he was feeling. He had clinical depression. Although the management of his depression was within the scope of my expertise, it was beyond my coping skills. I referred him to an adolescent psychiatrist. Christie was severely distressed about her son’s depression and we discussed her guilt and grief about it. Her worry about dying and leaving the family was now compounded by her fear that something would happen to Henry. She felt it was all her fault. As a mother of teenage children, I knew what it was to worry about the effect that your life might have on them. I had spent a lot of energy dealing with the guilt that my commitment to my patients might have interfered with their capacity to become well-adjusted adults. Over Christmas 2003, Christie’s whole family went to their holiday house at Avoca on the NSW Central Coast. They rang me on Christmas Day and again the following day for help to try to keep her pain under control, but we all had to admit defeat and Christie went back into hospital. Finally, the decision was taken to install a ventricular pump to put narcotics and local anaesthetic directly into the central nervous system. The pain specialist had been promoting this idea for some time but Christie had been reluctant to submit to a procedure that was both invasive and irreversible. Thankfully, it was a successful exercise and, at last, her pain was controlled. Within a month of this step forward, Christie’s oncologist rang me. The tumour was spreading into the epidural space in Christie’s neck and the decision had been made to stop chemotherapy and admit defeat. Despite my knowledge at all times of this inevitable outcome, the news, when I heard it, made my heart race and my spirits sink. The end would arrive within a few weeks, and I was not ready to face that. As I grappled with this news, I found myself able to discuss the theoretical implications of certain types of treatment with the oncologist as though Christie were no more to me than any other patient. It made me angry with myself even while I recognised that I was displacing my anger at her impending death in the only way I knew. Christie died, aged 52. CommentaryIn a society that has attempted to remove much of the pain associated with living our lives, illness and death remain the great catastrophe. There has been a recent explosion in illness narrative — the telling of the facts that relate to a personal experience of illness. Broyard wrote: Always in emergencies we invent narratives. We describe what is happening as if to confine the catastrophe.1 It would also seem that, with patients, this may be because they need to reclaim their illnesses from our increasingly complex, technological and hospital-based health systems, which consider all illness within a biomedical model. Illness narrative can help patients to create meaning from memory, validate themselves as people in the role of patient, and reflect on the significance of the experience on their lives. It also helps them to come to terms with pain, whether the pain is physical, emotional or existential. Illness narrative may also have a therapeutic role to play in their illness, although this is not proven. In The Wounded Storyteller, Frank broke illness narrative down into three different types of stories — the restitution narrative (illness interrupts a life, is fought successfully and life resumes), the chaos narrative (no discernible narrative order, no happy outcome and the most difficult kind to read) and the quest narrative, in which not only does the patient overcome their illness but in the process something is gained either for the patient themselves or for the wider good.2 Chandler, in her essay on autobiography, describes three aspects of healing which flow from the writing: catharsis, restoration and transformation.3 These can be seen to fit into either restoration or quest narratives in the Frank model. Narrative can also be used by doctors. Hunter explains how, from the earliest days of medical training, doctors are taught to use narrative, both verbal and written, to understand and interpret the story of a patient’s illness.4 Medicine is fundamentally narrative...and its daily practice is filled with stories... Much of the central business of caring for patients is transacted by means of narrative... Medical stories are a well established way of sorting through and tackling problems of diagnosis and treatment... In such a scientific discipline it is surprising to find this unexpectedly familiar way of making sense of the facts. 4 True narrative, rather than case history, can be used to understand and explain the complexities of the person and their reaction to illness, as it affects their lives and the lives of those around them. Of course, the doctor will tell a different version of the story than the patient. The patient tells of the effect of the illness on a life, where the doctor tells, at least, the story of the identification and treatment, but perhaps can tell much more. In the same way that the 20th century has hospitalised illness, death and dying have also been taken out of the community and relegated to the hospital or hospice. Segal discusses the way in which the public sees death as part of the human experience, while the medical profession sees death as the failure of modern medicine.5 It is not only hard for patients and their families to face death and dying — it is also hard for doctors: The ability to cope with dying patients does not come easily. Society has not prepared one for such interaction.6 Medical education does not prepare doctors to deal with death and dying. Remen talks about the way in which medical training may even undo some of the inherent life skills that we have to deal with death and dying.7 The emphasis of modern medicine is on cure; and, in a narrative sense, doctors may only want to tell restitution stories. Accepting that death is inevitable for a particular patient usually invokes a sense of failure: People enter the medical profession to help; when they find that they cannot give good news, they often feel terrible and impotent and they tend to retreat.8 Further, discussing the issues that relate to dying and death is hard to reconcile with a professional relationship that emphasises the importance of an emotional distance between doctor and patient. Although there is a more general acceptance of death as a natural part of life in general practice than in hospitals, the myth that modern medicine can always find an answer persists for both doctors and their patients. Kübler-Ross found that specialists in her hospital were reluctant to refer patients to her program because to admit that the patients were dying was to acknowledge a failure to cure.9 It is true that “most of us learn to cope with the life and death scenario with denial”10; but there is a need for doctors to be taught other, better coping mechanisms. Dealing with the dying and death of someone close to you creates special dilemmas. Working with a dying patient can create a special relationship. Contact becomes more frequent as death approaches and there are more physical problems to solve. Contact often takes place in the patient’s home, which can create an emotional closeness, and there is often more involvement with the patient’s family members. McNamara wrote: Facing death, whether it be our own, that of someone we love dearly or someone we feel responsible for, presents us with a unique challenge... Inevitably the frequent contacts with dying people awaken some personal response...if you’ve given a bit of yourself to them, you lose that something when they die.11 Loss and disappointment are common experiences in the practice of medicine, and acknowledging this is important. I think narrative can be a good way to express the loss and at the same time to put it in perspective. Remen strongly believes that grieving is necessary, and not readily undertaken by doctors.7 Crying alone or with the patient is the method that she proposes. I believe that writing the story is another way in which the caring professional can come to terms with the grief and distress. I certainly found the writing of Christie’s story to be both cathartic and helpful in organising my memories. There is a strong sense in which writing it all down allows one to think about it less. Faber-Langendoen obviously shared that experience with me. Even though she was an oncologist and dealt regularly with dying patients, when confronted by the imminent death of her own mother she found herself ill-prepared to face the issues.12 She wrote a narrative as part of the “coming to terms” process, but failed to decide whether she had been able to successfully combine her roles as doctor and daughter. I believe narrative can also help professionals reclaim their caring role in the care of suffering patients. If doctors were to write more accounts of their dealings with patients, it would help people to better understand the issues faced by them as they attempt to manage the burden of sickness. And, doctors who do not write might take comfort from reading what other doctors have written.

Anne P Hellman MB BS

Your position never gives you the right to command. It only imposes on you the duty of living your life so that others can receive your orders without being humiliated. Dag Hammarskjöld, UN Secretary-General, 1953–1961 awarded the Nobel Prize for Peace I grew up in Canberra in the 1920s and ’30s, then, as now, a planned and favoured town awash with politics, politicians and public servants. Although interested in these dynamics, our caring, skilled family doctor was the person who most impressed me. John James FRCS was our community’s quiet medical leader, later recognised through the John James Medical Centre, now part of Canberra’s teaching hospital system. My parents were typical of their time. My father had emigrated from Britain in his teens and served in France in World War I. He was a public servant with the Federal Capital Commission (which from January 1925 was responsible for the planning and development of Canberra). He had a vocational flair for amateur theatricals of music hall and comedy genre. My mother was a capable homemaker. We became aware of the Great Depression just about the time my sister was born. My parents combined to have our large yard supplement our pantry. Mother became a genius in food preserving with the Fowler Vacola steam preservation kit, providing a great variety of foods. As children, my sister and I had warm and strong emotional, social and aspirational support, but our choices for our futures were our own. My parents offered two aphorisms: “Hard work is not lethal” and “Loyalty and fairness are necessary for success”. I have not found either to be wanting. In choosing a career, medicine held no competitor for me, although I dallied momentarily with veterinary science. I experienced the grief of three of my school classmates succumbing to diseases that now rarely cause death: poliomyelitis, mastoiditis and diphtheria. Polio returned to the class several times, and, although not lethal, it was damaging beyond reason, both physically and psychologically. Polio, in particular, marginalised those it affected. I felt that more could be done to alleviate this unfairness. “The effect of a teacher may be infinite”My undergraduate days during World War II were spent at the University of Sydney and at St Vincent’s Hospital, Darlinghurst. I commuted daily on the on-time “red rattler” (today we say “if only”) and travelled between campuses on the tram. Hospital life as a student was immensely fulfilling, and I matured among competitive peers. Two of my tutors made these days particularly memorable: Justin Markell, the meticulous, kindly physician in outpatients, and Douglas Miller, later Sir Douglas Miller, who became a leader in neurosurgery and President of the Royal Australasian College of Surgeons. Both encouraged and taught a careful approach to physical examination, diagnosis and patient care. They provided a sound basis for my future clinical endeavours. I became a junior resident at Marrickville District Hospital in 1947. At that time, 18 months to two years after graduation saw most graduates enter general practice. I also aimed to do so. Marrickville Hospital was general practitioner oriented, with specialist honorary staff drawn from Royal Prince Alfred Hospital. These included role models like the late Sir Thomas Greenway, a charismatic, thoughtful and instructive physician, and Frank Mills, a friendly, insightful surgeon who had made his reputation in Changi and Sandakan in World War II. He visited his patients often and always left a dusting of his knowledge on the junior staff. Looking further afieldAfter 18 months and still attracted to general practice, it was time to move forward. Two positions presented themselves: one for a medical officer on Macquarie Island, the most southerly point of Oceania in the Australian Antarctic Basin; and the second, for Medical Superintendent at Collinsville, a small coal mining town in north Queensland. My colleague Bob Allison and I applied for both and were interviewed together by the Antarctic pioneer, Phillip Law, in front of the dying embers of the log fire in the common room of the (old) University Club in Phillip Street, Sydney. Bob went to Macquarie Island and I to Collinsville. As the only doctor in town, I enjoyed 18 months of rich clinical experience. Post-term obstetric deliveries, head injuries, critically ill children, motor vehicle accidents and accidents involving horses all hastened my clinical maturity. I remember a young jackeroo with a perinephric abscess after a nasty horse-related accident. As we were stranded by floods at the time, a surgeon in Mackay took me through the operative steps by phone. All ended well. The community was full of reliable, loyal Aussies with enormous hearts. They were openly friendly and had a great bank of skills, and gave their local doctor the comfort often absent today. An outbreak of croup in some young children was the most formidable of my experiences. They desperately needed steam inhalation, but I was a little nonplussed as to how to supply it. One father spoke with his boss at the mine workshop, who rapidly produced a large galvanised watering can with four arms, each capped with a watering-can rose. Placed on a primus stove, this device effectively dispensed steam to four mosquito-netted cots simultaneously. Problem solved! Surgeon by serendipityI was no longer sure that I wanted to pursue general practice and planned to undertake postgraduate work in the United States. I applied for several positions and was appointed to a rotating internship at Albany Medical College, New York State. At my request, it included a term of psychiatry. I arrived to take up my appointment in 1950, just as the Korean War began. Given my previous surgical experience, I was promptly moved from psychiatry to surgery. The experience was life-changing. As the American surgical residents were drafted to Korea, I was promoted after six months, subsequently accepting the offer of five years’ graduated surgical training in the Halsted tradition at Albany Medical Center. William Halsted had been Foundation Professor of Surgery at Johns Hopkins University in Baltimore, and laid the basis for graduated surgical training. This proved to be five years of restricted finances, but top professional fulfilment and growth. My workday would start with 5.30 am ward rounds (before the chief arrived at 7.30 am), followed by a day in theatre, then admissions and lab work before falling into bed. How much more civilised work practices are today. I was embarrassed when my previous senior resident returned from Korea to be my junior, and his view “c’est la guerre” was most generous and the basis of a long friendship. My training was predominantly in general surgery (with much exposure to thyroid surgery) and included my introduction to clinical investigation, which initially centred on bleeding varices and the monitoring of serum ammonia concentration.1 A three-month exchange with the Women’s Clinic at Johns Hopkins in Baltimore allowed me to work under the dynamic Richard Te Linde, Head of the Gynecology Department. Another privileged memory was witnessing the early development of cardiac surgery, as Alfred Blalock, under the watchful eye of cardiologist Helen Taussig, performed his “blue baby” procedure for tetralogy of Fallot and for alleviating the effects of congenital cardiac defects.2 My final 18 months were spent in Albany in thoracic surgery at the time of its greatest development, as the pump oxygenator was introduced. These five years were shared with a global workforce from 27 nations including Japan and Germany. The chiefs of medicine and surgery offered opportunity and education to all, hoping to heal wounds from World War II. This global experiment was clearly ahead of its time, and resulted in many firm international friendships. Being Australian was a significant plus, as Australia was popular after its Pacific role and genuine friendliness to US troops. In 1953, I married Mary Jo, whom I met in the operating room at Albany Medical Center. She has been my loyal supporter and valued confidante since. Return to Australia — spreading my wingsI returned to Sydney in 1955. Many doors were initially closed, but, with recommendations from mentors, I was eventually employed by Frank Rundle, Director of the Unit of Clinical Investigation at Royal North Shore Hospital (RNSH). After six months I received a full-time research fellowship with clinical responsibilities in my areas of interest, giving me the opportunity to be involved in thyroid surgery and studies; isotopes and cancer chemotherapy; a prospective database for thyroidectomy; and ultrasound of the breast. Thyroid clinic: I worked with Rundle in his multidisciplinary thyroid clinic and helped develop an animal experimental facility. This brought me into contact with Ian Monk, a cardiothoracic surgeon, who, with a pump expert, Viv Ebsary, was exploring open-heart surgery.3 The use of animals for experiments caused significant angst, especially when clandestine activity was required — such as transporting anaesthetised sheep by wheelbarrow to a ground floor angiographic facility for experimental studies. From such humble beginnings, the entire unit later evolved to become the Wellcome Laboratories. Rundle was a perfectionist, demanding that our every activity be of the highest safety and quality. The preoperative checklist was instituted (now indispensable in modern risk management) to ensure nothing was omitted in preparing patients. Every operative step was to be as haemostatic as possible,4 and postoperative care empathic and supportive. These requirements became expected of all who worked or trained in what later became the University of Sydney Academic Surgical Unit at RNSH. Cancer chemotherapy: A grant from the NSW State Cancer Council in 1958 enabled me to spend four months with cancer specialists Joe Burchenal and David Karnofsky (known for the Karnofsky Performance Scale for assessing terminally ill patients) at Memorial Sloan-Kettering Cancer Center in New York. I returned to initiate the provision of cytotoxic therapy at RNSH, which later established a formal medical oncology unit. Even then, the need to embrace randomisation and the careful accrual of evidence was seen as crucial.5-7 Thyroid database: On leaving the United States in 1955, I had been encouraged by my surgical mentors to embrace the computer age and “develop a prospective databank to record progress and results” — “outcome” as a word was still aborning. Our first cases at RNSH were accrued in 1957 and, over time, we honed the database into a useful clinical and research resource. All thyroid and parathyroid surgical procedures by the Endocrine Surgical Unit at RNSH are recorded, and at my retirement in 1988 numbered 10 000 entries. Intrathoracic goitre: During the period of compulsory mass x-ray surveys for pulmonary tuberculosis in Australia between 1948 and 1975, many people were diagnosed with intrathoracic goitre. A prevalence study we conducted in metropolitan Sydney in 1953–1956 showed that intrathoracic goitre occurred in 1/5040 subjects examined (compared with 1/750 with active tuberculosis and 1/3500 with lung cancer) (Box 1). Unexpectedly, the prevalence of intrathoracic goitre was about three times greater among people born in England (then the main source of immigrants) than in those born in Australia.8 Diagnosis of intrathoracic goitre improved with the introduction of computed tomography scanning, as did the safety of operative procedures. We used a surgical approach based on embryology — a transverse incision in the lower neck (a collar incision) — delivering the goitre into the neck, which, with appropriate control of vascularity, resulted in minimal sternal splitting and avoided a transthoracic approach.9 This technique was refined over time with much input from surgical colleagues Alan Poole and Leigh Delbridge (and the surgical registrars) and particularly our anaesthetist Bruce White. Superb scrub and bedside nursing helped to ensure success. This led to a rethink in the treatment of recurrent goitre and provided leadership in optimising total thyroidectomy for nodular goitre, now a widely accepted procedure despite earlier controversy.10-13 Breast ultrasound: A visit to RNSH in 1962 by George Kossoff (who with David Robinson in 1961 built the first ultrasound scanner at the Commonwealth Acoustic Laboratories) led to another fortunate and fruitful long term collaboration — ultrasound of the breast (Box 2). Surgery — academic and vascularIn 1961, Academic Clinical Units were established at RNSH, with the support of Sir John Loewenthal, then the Chair of Surgery at the University of Sydney. I was appointed Senior Lecturer in Surgery and subsequently became the inaugural Professor of Surgery in 1974. I believed, like Osler (quoting John Henry Newman), that: “An academical system without the personal influence of teachers upon pupils, is an Arctic winter.”18 Students were involved as far as possible in all unit activities, and teaching students and residents in the operating theatre became a major thrust of our program, although initially we were limited by a lack of full-time teachers.19,20 Graham Coupland was appointed senior lecturer in surgery in 1967 and was as great a friend and associate as I could have hoped for. With fellow surgeon Harry Cumberland, and encouraged by Douglas Piper, Professor of Medicine, he refined the investigation and surgical treatment of peptic ulcer, for which their preferred procedure was highly selective vagotomy.21 Coupland’s untimely death in 1982 came at a time of unit growth, as we taught exceptional undergraduates, trained bright young people of integrity, and produced quality surgery and research. Vascular surgery was developed by Douglas Tracy with my assistance.22 However, with his departure to the University of New South Wales in 1961, this specialty grew very demanding of those remaining — Ray Hollings, myself, and later Graham Coupland. Ruptured aneurysms, which require immediate surgery, became the bête noire of our social and family life. At that time, pagers, which were the size and weight of a house brick, only emitted an alarm, and a telephone call determined the reason for the call. In 1977, RNSH agreed to the appointment of a full-time academic vascular surgeon, Michael Appleberg, an excellent leader who took the department through to substantial strength in surgery,23 research and training. A stream of overseas and domestic visitors and interactive visits between the RNSH unit and overseas units promoted clinical and research strengths (Box 3). RetirementAll these activities have provided a springboard for continued enjoyment of life after I retired from academia in 1988. Elected President of the Royal Australasian College of Surgeons in 1989, I have travelled extensively in Australia and New Zealand. This experience has reinforced my perception that the exceptional compassion and service given in war are still given in peace. Australasian surgery and surgeons stand high with me. I was asked to report on quality assurance in clinical management to the Australian Government Department of Health,24 and now follow with interest the progress of the Australian Council for Safety and Quality in Health Care. As Chair of the working party developing the Clinical Practice guidelines on the management of early breast cancer25 and as a member of the board of the National Breast Cancer Centre (1995–2003), I have found it very satisfying to see women empowered to handle a life-threatening disease. Working with the Cancer Council Australia and the Clinical Oncological Society of Australia to develop the Australian Cancer Network has, since 1994, also kept me happily in contact with clinicians and consumers in promoting better cancer care. I have also maintained a clinical interest through surgical assisting. I have more time to “smell the roses” and travel with Mary Jo to see friends and enjoy our grandchildren in the United States, with side trips to Europe. I read more, but am unable to keep up with all the good books that are published. I also have time to think over the contrasts between then and now and what is to come. Surgery in 1947 was more uneven than today. There were top-level surgeons who performed to their level. A good deal of surgery, however, was done in small hospitals across the community, and too frequently exploratory laparotomy was performed for an obscure diagnosis. The limitations were primarily in training and diagnostic technology. The idea that doctors “owned” the patients was diminishing, but still prevalent. This limited patients in obtaining a second opinion, when perhaps it should have been embraced. I have observed changes and been pleased to have the opportunity to be involved, and sometimes been supportive in promoting change. Strong academic units centred in training hospitals across Australia have, together with the Royal Australasian College of Surgeons and specialist surgical societies, embraced strong mentoring and graduated and proficient training. The quality of surgery and hospitals has been improved by these educational and vocational developments. Australian patients have access to surgery of the highest quality. The future for surgery should know no limits, with increasing precision of diagnosis, limited wounding associated with surgical access, and developments in pharmacological and genetic interventions. Surgeons will be expected to understand and fully explain the complexities of many new approaches to treatment, some of which will not be operative surgery. The psychosocial aspects of surgery will reinforce the benefits patients should enjoy from the science and art of surgery, in which the level of trust between surgeon and patient must remain inviolable. I am delighted that opportunity for betterment for patients expands apace. Fortune has indeed smiled on me. As I look to the future, remembering colleagues, nurses, students and patients, I remain aware that I have gathered a posy of other men’s flowers and only the ribbon which binds them is mine (Sanskrit). 1 Age distribution of intrathoracic goitre detected by mass x-ray surveys for tuberculosis (1953–1956) Source: Reeve et al8 2 Development of breast ultrasound imaging — from weather maps to quality images Initial attempts to develop breast ultrasound involved many women volunteers and a bistable waterpath machine, which provided linear, sector and compound scans. Sonograms were initially derived through a water bath in contact with but above the patient. Water sometimes spilled (Figure A), or leaked (Figure B), saturating staff and patients, but not dampening their enthusiasm. Technology (Figures B and C) rapidly improved the quality of sonograms, and, in 1974, the patient’s comfort (Figure C). With Kossoff and his associate, Jack Jellins, ultrasonographer Kaye Griffiths and her team, surgical registrar Bruce Barraclough, and sonograms from our volunteers, we were able to determine the “normal” sonographic appearance of the breast. It was hard going until Kossoff introduced “grey-scale” contrast into sonography,14,15 which allowed tissue contrast and better identification of breast disease, a principle later applied to virtually all tissues16 and “leading to the widespread adoption of ultrasound throughout the world.”17 Ultrasound now plays a significant role in breast cancer diagnosis — no more wet shoes and soaked patients! A. CAL Closed water bag breast echoscope (1966). The bag was lowered onto the chest, and the transducer moved through the waterbath. Coupling with the skin was incomplete and the breast compressed. B. CAL Open water bag breast echoscope (1968). This method allowed for improved coupling to the breast and removed the problem of compression of tissue. The breast floated freely in a water bath. C. CAL Open water tank breast echoscope (1974). A new approach, patient prone and breast freely floating, thus eliminating the need for coupling drapes. (Photos courtesy of George Kossoff.) 3 International Surgical Week — International Association of Endocrine Surgeons, Hong Kong 1993. Back row: Joe Tjandra (Melbourne), Tom Reeve, Leigh Delbridge (Sydney). Front row: Raj Nambiar, Abu Rauf (Singapore), Martin Liepins (Riga, Latvia).

Tom Reeve AC, CBE, FRACS, Emeritus Professor of Surgery, The University of Sydney

A doctor graduates from “blow in” to full-blown artist 1 Barramundi dreaming Sail form, 1400 mm high kiln-formed glass. I seem to be able to ‘think in glass’ and saw this vivid image in my mind before I went on to execute it in glass. 2004 has been a gratifying year for me. Solo international exhibitions in Dubai and Hong Kong; group shows in Australia and overseas; some interesting architectural commissions; and, some proposals for major international projects accepted. A piece acquired by the Ebeltoft Museum of Contemporary Glass in Denmark and another presented by the Governor of New South Wales, Marie Bashir, to the President of China; even a prize in a Queensland fine arts competition. A gratifying year for a glass artist, indeed, but an unusual year for a doctor. How did all this happen? My life began with 20 unbroken years of full-time institutional education, culminating in 1976 with graduation from the University of New South Wales (MB BS). I had chosen to study Medicine with what I now see as probably typical teenage arrogance and ignorance — when faced with an application form for the “rest of my life”, I ticked the boxes for Medicine, Law and Arts, without any real understanding of what any of those choices might entail. I pronounced that I sought a career where I could help people, continue learning and work anywhere in the world. Once begun, Medicine became my life. My choice was unquestioned; I proceeded with no thought of any alternatives. I loved it! In third year, I married Barbara, a fellow medical student. Not having to pursue the dating game, we had plenty of time and energy to devote to Medicine. For the next three years we spent much of our “spare time” in casualty departments and outpatient clinics, improving our clinical and practical skills. A major teaching hospital was the setting for my intern year, but I found myself craving a smaller, more personal environment, and moved on to a district hospital where junior doctors were expected to perform more procedures and accept greater responsibilities. A couple of years later I was lured into an entrepreneurial general practice partnership and lasted three months before accepting that this style of practice was anathema to me. Next came the toughest 18 months of my life. I established a general practice from scratch. I did it the hard way — forgoing all offers (including office equipment, an ECG machine, a nurse for one day a week and having my surgery painted) from pharmaceutical companies, pathology services and the like. I set up a no-frills, old-fashioned practice. One day, sitting at my desk, looking at the wall, I thought: “Well, here I am. I’ve made this practice viable. In 40 years, I can still be sitting here looking at the same wall.” That night I told Barbara that I wanted to sell up and travel. She took about three seconds to agree (even though she was in the middle of a paediatric intensive care term). That night I jumped off the merry-go-round. Although I didn’t know it, I would not get back on. I had dabbled in various arts and crafts over the years of my childhood and even university. I tried many media (including painting, drawing, pottery, leatherwork, copper enamelling and basic printmaking), but none held my interest once I had reached a level of basic competency. When I commenced general practice, I enrolled in a stained glass course at TAFE. The initial class was an epiphany. The moment I picked up a glasscutter and scored my first piece of glass, I knew something important had happened. It was akin to falling in love. I became obsessed with glass and spent any quiet hours between seeing patients drawing designs for windows. When the practice bell rang, I would reluctantly gather up my coloured pencils and be a doctor again. I filled our house with windows and started making them for friends and family. I found that I had an aptitude for the medium and was able to visualise the completed image in glass to begin with. I seemed to be able to “think in glass” (Box 1). I began to fantasise about running a little leadlight shop (instead of a general practice) and becoming a craftsman. This may have been sublimation for a frustrated earlier plan to become an orthopaedic surgeon. Orthopaedics had attracted me because of the variety of problems faced and the innovation and manual ingenuity it demanded. However, I found I could not accept either the requirement that I work overseas to qualify to work in my own country or, what seemed a necessity, to “step on the heads” of friends and colleagues to attain any one of the few available positions. Just before that defining moment when I had literally seen my future on the practice wall, I had faced mortality. I had the tragic misfortune to be involved in an unsuccessful attempt to save the life of my closest friend at that time. He had been stabbed and died, despite my best efforts as part of the resuscitation team. The wall that we construct in order to do the job that emergency medicine demands was breached. I suddenly knew how quickly life could be over. I began to dwell upon the things that I wanted to do but had not yet done and decided that it was time to stop postponing my gratification. So, I sold my practice and we went to Germany, bought a big motorbike and rode off on a great adventure. On our return, I decided to give glass a try. That was 22 years ago. My self-understanding and my feelings about that decision have evolved over the subsequent years. At the time, I talked it over with peers and mentors and received differing opinions. My colleagues told me I was mad to throw away all those years of study. How things change! At our last reunion dinner, I was awarded a prize for “best career choice”. My mentors, who were of my father’s generation, had a very different perspective. Most had a regret: the unwritten novel, unfinished canvases, missed opportunities. One observation was pivotal: “You have a choice. Before you tie yourself down with a mortgage, kids at private schools, the pool and a Volvo, give it [glass art] a try. If It works — wonderful. If it doesn’t, you don’t have to go to your grave regretting what might have been. So, get it out of your system.” The concept that my trial was to be temporary was paramount to my being able to consider it. Practical and emotional support from my parents, and particularly my wife, made it possible. As one of the few people on the planet to have choices, I also felt a genuine responsibility not to waste the opportunity. Becoming a glass artist was a long, difficult journey. I started at the bottom (again) and travelled alone. Going back to college to complete a visual arts degree would have been an easier, quicker path to a new career, but I was tired of institutional learning. I worked briefly as a glassblower, took courses in colour and design, life drawing and various technical methods and set up that small leadlight studio I had fantasised about (Box 2). I soon discovered that there was much more to the medium of glass art than tulip-pattern front doors and was launched onto a steep learning curve. Invitations to master classes in Germany and the USA led to dramatic improvements in my skills. Gradually, over 20 years, I evolved into a glass artist in my own right (Box 3 and Box 4). Every day, working away in my leadlight studio, two thoughts recurred. The first was that, eventually, I would be discovered to be having too much fun and it would have to stop. The old adage “If you find a job you love, you will never work another day of your life” turned out to be absolutely true. The second was that I agonised over leaving Medicine. I felt guilty about having had the benefit of a free university education, and wondered whether the time I had put in had in any way repaid my debt to society. I worried that my medical skills were waning and about how difficult it might be to regain them. I feared that I had failed my family’s expectations. Although working with glass gave me a level of satisfaction that practising medicine had not, my internal debate continued as these thoughts recurred for years, often on a daily basis. It helped that I was able to bring medicine into my work in a variety of ways: a privileged body of knowledge, much of the visual imagery that appears subconsciously in my work and the capacity to research what I do not yet know. And, instead of ministering to the body, I like to think that my work provides succour for the soul (Box 5). Simultaneously, in those early years, I experienced great difficulty in defining myself. I needed to call myself something. I knew I wasn’t an artist, although I didn’t really know yet what makes an artist. I also knew that it would be impertinent to call myself a craftsman, given my beginner’s skills. My dilemma was not aided by the stained glass fraternity, who labelled me a dilettante and a “blow in”. In time, these attitudes changed and some time later I was elected President of the Australian Association of Glass Artists. Recently, all these old, resolved identity problems came rushing back to me when I was compelled to join the non-practising medical register. Twenty years on since stopping work as a doctor and charting another course in life, I finally feel relaxed about calling myself an artist. (I know I am an artist — because I am receiving more critical acclaim and making less money than ever!) However, all this time, I have had in the back of my mind that I am still a doctor and had chosen to maintain full registration. I was surprised by how much this change in registration status bothered me. Although I no longer seriously entertain the idea of returning to clinical practice, I felt something stirring within when the door back (which remained ajar despite having receded further and further away) seemed to have closed on me. Even now, I rationalise that, if I really needed to, I could requalify. So, it would appear that I still have not abandoned the idea, as unlikely as it is. Medicine is a tough habit to shake! 2 Me and my kiln My current studio is much more spacious than earlier workplaces. 3 This land or Song of the magpie dawn Architectural installation, The Galeries Victoria, Sydney. 6 m x 2 m kiln-formed glass. Most of my work is based on Australian geological, social and mythological landscapes. 4 The magic carpet 500 mm x 600 mm kiln-formed glass Recent solo exhibitions in Dubai and Hong Kong have inspired me to address designs based on other cultures, still utilising my own styles and techniques developed over the past 20 years. 5 The Bungle Bungles Giant curved form, kiln-formed glass. Purchased by a doctor. I maintain links with the medical profession through collectors and commissions.

Marc D Grunseit MB BS

If you walked into my surgery in the inner-Brisbane suburb of Highgate Hill, you could be forgiven for thinking you were in an art gallery — paintings, my own works, hang on all the walls (Box 1). Am I a doctor? Am I an artist? I am both. When I left high school, I thought seriously about studying art, but logic prevailed and I found myself with a medical degree. After 6 years at university in Brisbane and three years of hospital work in Townsville, I travelled to Europe. In Belgium, while walking one night in a moonlit field, I was momentarily aware of the presence behind me of generations of European artists with whom I felt an intense personal affinity, including Michelangelo, El Greco, Vermeer, Van Gogh and Picasso. Perhaps it was the result of having immersed myself in art-filled galleries and churches; perhaps it was because I was so far from home. Whatever it was, I experienced a powerful sense of transcendence that took my breath away. And, for whatever reason, at that moment I felt very strongly that I would paint and would become known as an artist. It took some time to realise this grand vision of mine. I studied fine art at Townsville TAFE and then Seven Hills College (now part of Griffith University) while working in various general practices. Then, I set about establishing my own practice and having four children. For 10 years, I drew and produced only occasional works. After I turned 40, everything changed, and I found myself fired by a passion that I felt almost powerless to control. It was as if pictures had been accumulating inside me for years, and the backlog had reached a point where they had to be expressed. Each evening after work, when my family was in bed, I would begin painting — pouring my thoughts, visions and various “unconscious conclusions” onto canvas. I’d get by with little sleep — often three to four hours a night. It was one of the most stimulating and exhilarating times of my life. Painting energised me and charged my soul. Over the next 10 years, I held 10 solo exhibitions in Brisbane and Sydney and painted eight minor series, as well as “one-offs” (Box 2). Over this same decade, I continued to work in my practice, finishing work around 2 pm and employing other doctors to see the rest of the patients. My concurrent practice of medicine gave me many ideas to use in my art. For example, a patient waxed lyrical about her nephew’s wedding just when I was painting some women in white dresses. I decided to make them the bridesmaids and my exhibition “Tying the knot” was born. Each painting in the exhibition represented something people might bring to a marriage, from company and consolation, friendship and family, jealousy and acrimony, even alimony. Because my nights were so creative, I was glad to be sensible Dr Byth by day. Earning money by practising medicine gave me the freedom to paint whatever I liked, as I did not have to necessarily sell paintings (although this happened). Having studied medicine and having to deal with the body and its function on a daily basis, I feel at ease with the artistic “discussion” of the flesh, sex and sexuality, and I’ve used this knowledge freely in some of my exhibitions. Being a doctor adds credibility to this artwork, and even humour. After seeing my exhibition about the uterus, fertility and the power of female sexuality (“Up front, On view”), a patient joked as she had her Pap smear done: “So, whose cervix are you painting tonight, Dr Byth?”. My love and practice of art has helped me become aware of the broader social picture in medicine. “Normalising” illness, helping patients to become focused on good health outcomes and minimising the impact of setbacks have been some of my main patient management tactics in general practice. I know that painting provides me with relaxation at the end of a hard day’s work. It’s therapeutic for this doctor. When I begin each canvas, I have no idea what I will be painting. But I know that I’m a logical person; capable of working something from A to B — I guess this is the bedrock of medicine. Similarly, a painting represents thousands of small decisions (brushstrokes), each one dictated by what has gone before. Each and every painting “happens” when I am lost in this open-ended process. I paint almost exclusively in acrylics, beginning with an abstract colour field in which the painting gradually shows itself; I’m often surprised by the distance travelled between the final form and the original. The final painting will usually represent something I’ve been trying to say but for which I’ve often had trouble finding words. In my depths, there is a fount of ideas that are a mystery to me; their nature is unpredictable. I am able to give substance to these concepts in my paintings. In my art, I feel as though I can express many ideas and many layers of perception simultaneously and without discomfort, even though some of them are contradictory. For example, in Head of the river (Box 3), the composition of the painting separates “them” (over by the river) from “us” (our school) and lends weight and excitement to the picture. (Some boys, however, are completely uninterested.) As with medicine, I think I will never stop learning and developing in my art; I enjoy spending time with other artists in workshops, exchanging ideas and refining techniques. I think I’m a very Australian artist — my work has its roots in the land and people of this country and in what I’m doing. I began by painting Australian landscapes with my own perceptions and style. I love the messy edge of town where things are left behind, like wilting tennis courts, Hills hoists and car bodies (Box 4). In my early days, I used a lot of collage. Then, I did a series on Australians and sport called “Recreations”. Seeing lots of mothers and babies in my practice inspired the exhibition “Modern Madonnas”. Small fish swimming across and within some of the paintings in this exhibition gave them a dreamy quality (Box 5). Love of the sea, and in particular the coast of northern NSW, has led me to depict Cook Island and Fingal Head in many of my paintings (Box 6). I’ve painted schools and children, as my own children have been educated (Box 3). And, after a friend’s sudden cardiac death, a series of 12 black drawings evolved using stethoscopes, electrocardiograms and some religious imagery — heart beats representing life, followed by the stark silence of death. I want people to know that I am a three-dimensional person, not just a doctor. I hang my less confronting paintings in the surgery, and I enjoy having my patients tell me every day how much they enjoy them. Not only my patients, but also relatives of patients, other doctors, art lovers, people off the street (and even drug reps!) have bought my paintings off the walls. When I sell a painting, I replace it with another. My general practice has evolved over the years. As the elderly have died, younger families have moved into the area. Migrants and students are ever present, and more residential units mean more young people who work in the city. I love this variety. But I have had to meet other, more challenging changes: accreditation and continuing education requirements, as well as computerisation and the business aspects of practice. After about five years of painting nightly, two of my “right-hand helpers” at the surgery moved on, and I decided to return to full-time work for a while. As a result, I’ve painted a little less in recent years, but still manage two or three nights a week. Medicine and art, my two passions, have always intertwined, shaping my life. I can’t imagine practising medicine without my art or creating art without my medicine. The real skill (which I know I don’t always get right) is to strike a balance between them: the logical, precise and ordered thinking of medicine and the unstructured, unpredictable and creative flow of art. Together, they help me to appreciate the beauty of each moment and give me the practicality and resilience to get on with life. 1 My waiting-room (and art gallery) 2 Night duty 3 Head of the river 4 Renovations 5 Mother and child 6 Surfer

Susan Byth MB BS

A doctor–artist discovers that her art and her medicine may be not so different after all . . . 1 What the doctor prescribed Tubes of oil paint (not for ingestion). Last year, after 20 years in hospital practice as a paediatrician, researcher and clinical geneticist (and a daily witness to lives unravelled), I took six months’ leave to paint full-time. Institutionalised, I needed some time “out of captivity”, in exile from the medical cocoon. The conformity of the hospital system was suffocating me. I found little there to nurture the soul or guard against dampening of the spirit. I needed time to reclaim my individuality. Doctor, heal thyself . . . my prescription, my antidote: art, in hefty doses (Box 1). I have always been passionate about art, but, as the daughter of immigrant parents, I knew that I was destined for university. Art school was not really an option. I studied music and medicine simultaneously. My internship completed, I promised myself that I would try to incorporate the practice of art into my life as a doctor. I enrolled in a series of night art-classes — in life drawing, watercolour and oil painting, ceramics, leadlighting and mosaics. I fell into training programs in paediatrics and genetics, and then a doctorate. There were stints abroad, working in Houston and Manchester — my time, gobbled up. The study of undergraduate and postgraduate years proved a stark contrast to the creativity of my childhood days. Childhood. I remember lying on my stomach in the change room at a dance studio in Adelaide on a Saturday morning, busily drawing in my scrapbook as I waited for my ballet class to start — pink stockings, black leotards, hair pulled back; the softness of ballet slippers, shininess of ribbons, smell of sawdust; the big mirrored room; standing at the barre. Equally vivid is my memory of sitting on the laundry floor at home, having unwound balls of Turkish rug wool with my mother and cutting the lengths of richly coloured yarns. Making knots, one by one, I watched with wonder as, from humble threads, a rug magically materialised. Recollections of my mother at “work” in the kitchen — a feast for all the senses. The agility, the deftness, the sheer brilliance of it all dazzled me. All that creativity, bursting at the seams. I had already been painting seriously for seven years before my six-month sabbatical, and had held several solo exhibitions. I thought of art and medicine, my two great passions, as diametrically opposed — a dichotomy — and looked forward to stuffing my now “free” days full of artistic pursuits (Box 2). The degustation menu included abstract painting, printmaking, sculpture, and a course in professional practice for artists. It was a time of experimentation and renewal, revelation, unpredictability, self-directed learning, unexpected experiences, serendipitous discoveries and precious slivers of enlightenment. 2 Works-in-progress for the solo exhibition “Hieroglyphs and heartbeats”, April 2003 Left: Free-falling through my grandmother’s whispers. Oil and beeswax on board, 1.2 m x 1.5 m. Right: Mapping my own landscape. Oil and beeswax on board, 1.2 m x 1.5 m. When I paint, everything rests on intuition. There are no preliminary sketches, no navigation points — just me and the bare surface. What transpires is unknown, and I have learned to trust in that. It is like a dance, like music. There are many stories I could tell about this time: of being duped by one gallery owner and well treated by another, and of shocking indifference to trespass and violation after some of my paintings were vandalised with shards of glass on Jewish New Year. Here, I will share with you two stories — “Sitting duck” and “Of intimacy and interplay”. Each story, in different ways, shows how my time out of captivity has dispelled forever any misconception about the cleavage between art and medicine. Sitting duckJust before preparing for a group exhibition, “Sitting duck”, I was asked to be an expert witness for a family suing a hospital for allegedly negligent care of their son. He had become quadriplegic after surgery for scoliosis. I trawled through reams of medical reports, deeply affected by the accounts of the denouement of an able-bodied teenager to a ventilator-dependent quadriplegic adult. The words, the terminology, the descriptions in the reports were all so sterile, so lacking in compassion. Was I truly part of this fraternity? Sitting duck. My original intention was to create three sculptures (a new artistic pursuit for me), all light-hearted and frivolous, a celebration of my release from medical confines into the playground of creativity. I had very clear ideas about the works. One was to be a plaster cast of my torso and arms, with paintbrushes in either hand — the brushes of my conductor. The second was to be a hardened, hollow, shell-like, three-dimensional form of my torso modelled from an old T-shirt smothered in oil paint from my wiped brushes. This was to be gaily mounted on a plinth, with all the colours from my palette smeared irreverently on my own outer surface. The third was to be a transparent hollow form of my head, filled with empty tubes of paint, in playful acknowledgement of those six short months when paint, not medicine, was uppermost in my thoughts. However, the final sculptures bore no resemblance to their points of origin. The pieces took control, imposed their own will and directed me, a mere player in their grander scheme. 3 Winter 2003 Freezing cold in a garage as Ken Bowrey applies alginate, and we wait for it to cure. I can’t see, I can’t hear, and I can just breathe. My senses are all diminished. Ken makes body parts for film and television. Look carefully in the background and you’ll see some body parts . . . Unwittingly, the young man’s tragedy became the catalyst for the creation of sculptures that ushered me through a process that paralleled his own. Entrusting myself to strangers, I became my own palette. I was bound in fibreglass. My head was cast, and a mould made from it in a freezing-cold garage in mid-winter (Box 3). Unable to move, see or hear, my own vulnerability sensitised me to that of others. The sculptures developed their own integrity and autonomy. They became about altered and lost senses, loss of the recognisable self, fragility, vulnerability, dissociated states, disembodiment, about ability and disability, and the loss of self-expression. So much for light-heartedness and frivolity! I was outside comfort, outside what I knew. A sitting duck. I learnt that this is when self-discovery happens. All three pieces had morphed into an exploration of quadriplegia, its inertness, muteness and isolation. Disability, such an indelible mark on life, challenges and makes us rethink our own mortality. The first sculpture affected me the most. I wanted to mould the T-shirt into a form resembling my torso, harden its external surface, and then remove the inner stuffing. It sounded simple enough. Despite my research at hardware stores and dry cleaners, and a foray to the beach to collect a backpack full of sand (for the stuffing), the garment simply refused to be hardened. All my attempts were thwarted. While battling with the sculpture’s stubbornness, I temporised by sewing closed the neck and sleeve openings, filling the garment with cotton wadding, and arranging it into a shape that I liked. I left it propped on a chair. I was still determined, somehow, to harden the exterior. The next morning, I was confronted by what seemed to be another presence in the room, a palpable living, breathing thing, slumped on its chair, silent and motionless. Keen to photograph it outside in natural light, I unlocked the back door and lifted the torso on its chair. With the chair raised, the torso tumbled towards me — a moment of astonishing poignancy. I had just identified with quadriplegia in a very intimate way, through an inanimate object. How does that happen? 4 “Slumpy” Slumpy, relegated to his own room, with screens drawn around and a hospital blanket overlain. Autumn leaves are sprinkled on a bare palette (no paint for the artist), which doubles as a hospital food tray (Slumpy has lost his appetite). For days afterwards, the torso was so confronting, and the symbolism so potent, that I could not look at it. I had to move it to another room. (Isn’t that what society does with the disabled?) Each time I tried to reposition it, it defied me and would slump, just like a flaccid quadriplegic. I never did harden the exterior. I left it as it was (Box 4). Affectionately, I named the torso “Slumpy” in an attempt to diffuse the gravity of what it had come to represent. A year later, I still find him unnerving. What do we do with the parts of ourselves or of someone close to us that, through mental illness, malformation, accident, physical deformity, burns, or paralysis, are no longer recognisable to us? What is it like to look back at your own image and not recognise it (Box 5)? How do we incorporate this into our concept of self? Of intimacy and interplayA large part of my practice of genetics involves caring for disabled children and distressed parents. Pattern recognition is quintessential to syndrome diagnosis and requires a highly developed visual memory. It is not uncommon to see children over many years, to review and research, go back and look again, to interrogate the literature and databases, before a correct diagnosis is eventually made. This process, perhaps more so than in other medical disciplines, mirrors the artistic process, where constant questioning and reworking is the norm, and intellectual curiosity is crucial. In retrospect, it seems no accident that I was drawn to this subspecialty, the practice of which rests on many of the same skills that I employ as a practising artist. Like a metaphor for life, painting is about the search for relatedness and connectivity. I liken the process to standing in front of a mirror, completely naked, all flaws exposed. There is push and pull, tension, uncertainty. Images are lost and refound. Slowly, a painting starts to speak, as paint breathes life into the work. This marks the beginning of a dialogue, after which the painting itself directs my mark-making. From this, intimacy develops. The process echoes the way in which we ourselves form connections with others. Think of the vulnerability of our patients — medicine, too, is steeped in intimacy. 5 My own death mask The positive plasticine mould of my head. I cannot recognise myself in it at all — it isn’t lifelike; somehow neutered. I am forced to confront my own mortality. I will never forget my amazement when, on two separate occasions, a woman stood in front of one of my paintings and wept. Then there was the time when a small child, less than two, carried in his mother’s arms, looked at one of my paintings, pointed jubilantly, laughed out loud and exclaimed “woo WOO!”, having recognised a dog in the imagery. Relatedness and resonance. Touching another soul. How can marks on a surface do that? There are both similarities and contrasts between painting and doctoring. Putting on armour, for example. Sometimes work feels like that: steeling oneself for the day ahead, the bureaucracy, the demands and deadlines, the difficulty of yet another undiagnosed child. Sometimes painting is like that too — hurtling myself at a canvas only to be spat out, ricocheting backwards to the opposite side of the studio, then rolling my sleeves up for the next advance and flinging myself back again, the canvas unrelenting, with me solely accountable. The clinical practice of medicine demands adherence to rules and regulations; there is a dictated way of thinking, order, structure and logic. Unpredictability and experimentation, factors pivotal to the practice of art, might be seen as the antithesis of medical thinking, yet both are paramount in medical research, where advances often depend on novel ways of seeing and thinking. The practice of medicine, so laden with pathos, grief, love, regret, sadness, joy, struggle, tragedy, courage and humility, has informed me as an artist from the very beginning. In turn, creativity fosters new and different ways of seeing, broadens my understanding, nurtures me, assuages my soul, deepens my compassion, and heightens my empathy (Box 6). I believe that I am a better doctor for all this. So, for all my years of bearing witness, painting is, for me, part catharsis and part desire to give something back. On returning to work, my first memory is of a profoundly dry mouth, my heart beating outside my chest as I stand in the corridor, unable to open the door to my office. Back in captivity. “Doctor, schmoctor”, I tell myself, “we are all our own works in progress”. 6 At work in my studio

Lesley C Adès MD, FRACP, CG (HGSA)

Frederick Grant Banting (1891–1941), the Canadian Nobel laureate responsible for discovering insulin, had a less familiar side. As an artist he exhibited under the name Frederick Grant.1,2 Having enjoyed art at school,3 he took up painting again in 1920, as a relaxing way to fill in time between patients in his struggling medical practice in London, Ontario. He later wrote: “My happiest hours of this period were spent thus trying to copy pictures mostly from old magazines or books.”1 In the long gaps between patients, he also read the medical literature, which gave him the idea for his research. Within 3 years, he had isolated insulin and received the Nobel Prize.2 Throughout his life, art continued to be his favourite form of relaxation. As his confidence and skill as an artist grew, he began to paint the Canadian landscape. In the late 1920s, Banting’s introduction to the Canadian artists known as the Group of Seven provided him with encouragement that had a lasting influence on his work, and forged lifelong friendships for this enthusiastic amateur. Banting was intending to retire from medical research at 50 to paint full time, but his plans were foiled by his accidental death, at 49. (Paintings reproduced with permission from the Estate of Nelson Banting, Alliston, Ontario).

Joanne C Elliot

Snow-capped Mount Kilimanjaro, in Tanzania, stands 5895 m (19 335 ft) high and is the highest mountain in Africa. The hike up the mountain, although considered arduous, is attempted by dozens of people each day. About one in four actually succeed. A few years ago, we set out to climb it, planning to get to the summit and down again in six days. We had pre-arranged an experienced guide and, rather than carrying tents, chose to stay in huts provided on the mountain. We hired some down-filled clothing and sleeping bags with the help of our guide — but, when offered crampons and ice axes for hire, we both laughed at the idea. “This is just a walk”, we joked, “not a real climb”. View of Mount Kilimanjaro (5895 m, 19 335 ft), Tanzania, from the road leading to the park entrance. It is two vertical miles higher than Australia’s highest mountain, Mt Kosciuszko. For years no one believed the early reports that a mountain near the equator had snow on its summit. The first two days of climbing were moderately hard and it became progressively colder. At one point, our guide spent some time talking intently to a colleague who was on the way down. He then explained that a group of hikers, two days ahead of us, had been climbing through a thunderstorm when a young American woman was struck by a bolt of lightning and killed instantly. She had literally “blown up”, with lightning bolts arcing down her body and out through her torso and limbs to the ground, leaving huge flesh wounds. This macabre event caused us some anxiety. Our guide thought she had been struck because she was wearing a red parka, believing that red objects “attract” lightning. We pondered whether there was some scientific rationale for red gear being more likely than other colours to attract lightning. Trying to warm up in the sun outside one of the huts on our rest day. We eventually reached the first hut and stayed overnight. Next morning was initially cold but comfortable. But then we struck rain, a strong wind blew up, and the chill factor sent the thermometer plunging. It became so unbelievably cold that we had to put on every piece of cold weather gear we had. This was our first sense of just how cold it can be at high altitude. As we sat on a rock to rest, one of us noticed a scrappy piece of red plastic on a bush and began to deride those nuisance climbers who “show a complete lack of respect for the beautiful mountain surroundings by leaving behind plastic rubbish to contaminate the pristine environment”. We then saw another piece of red plastic, then another, and soon realised that there were dozens of such pieces in a circle of about 10 m diameter. We then noticed a carefully constructed mound of rocks adorned with fresh flowers. It suddenly dawned on us that this must have been the spot where the young American woman had been blown apart by lightning. The rough rock memorial must have been constructed by her fellow climbers. We were both awestruck by the frightening power of lightning. We continued climbing fairly easily, and had decided in advance to spend an extra day at Horombo hut (at about 4000 m) to help us acclimatise. It was hard to watch our fellow climbers leave without us — people we had met in the first few days and who would probably reach the summit before us. As events unfolded, our decision to spend that extra day at Horombo set us up for life-theatening situations near the summit. On our fourth day, we reached the highest hut, Kibo, at 4700 m. The views were quite beautiful, with a pink sunset on neighbouring Mount Mawenzi and absolutely pristine clear skies. We had a small meal — no one has much appetite at altitude — and turned in for a few hours’ sleep before the final hike to the summit, with the aim of being there at dawn. We set off for the summit at about 12.30 am. It was a moonless night, but at that altitude the sky was filled with millions of stars that appeared so close we felt we could pluck them from the sky. Amazingly, the starlight was sufficiently bright to illuminate Kilimanjaro and adjacent Mount Mawenzi. It was unforgettably spectacular. We were climbing with our guide and a trainee guide on his first ascent. We felt fairly confident that this last section of the climb would not defeat us. We had both tried to get fit enough by running up and down 50 flights of hospital stairs three times a week, and had taken precautions to avoid altitude sickness — climbing slowly, drinking plenty of water, taking prophylactic acetazolamide, and taking the extra day to acclimatise. As we began, I was surprised to find that I was extremely breathless despite walking slowly. The snow was hard and, as we had not brought headlamps, we stumbled in the frozen boot marks of previous climbers. Recovering from each stumble required much energy and produced marked breathlessness. We found the climb extremely arduous, and experienced effort-induced nausea plus the bitter, penetrating cold. I felt certain that I would not make the summit. In lucid moments I cursed my oxygen-dissociation curve for its failure to “shift to the right” and be more generous in donating oxygen. The physical and mental struggle to reach Hans Meyer cave, a third of the way up to the summit push, was monumental. I had seen published photos of Hans Meyer cave (named after the first man to climb Kilimanjaro) — which show it as virtually dry. But we found the cave totally ice encrusted, with large icicles hanging down from its roof. The temperature was −20°C to −30°C. We rested briefly at the cave, which allowed me to recover somewhat. As we pushed on laboriously, we noticed the bright stars disappear and within a few minutes we were enveloped by cloud, strong winds, and then driving, icy snow. The blizzard made climbing treacherous and reduced visibility to almost zero. To our surprise, and alarm, virtually all of the other climbing groups had turned back. The only person who didn’t was obviously an experienced mountaineer, who rapidly passed us wearing crampons and swinging his ice axe rhythmically to cut steps in the snow. To see the other groups stop and then turn back made us a little concerned that we were taking a considerable risk in pushing on. Nonetheless, we were both determined to continue up the mountain. At this point, Mark, a cardiothoracic surgeon whose hands generally prove fairly useful in his profession, hadn’t been able to move or feel his fingers for some time and was convinced he had significant frostbite. This did not change his determination to continue the climb. He thought that, as he already probably had some frostbite, going on to the summit was unlikely to make it worse. It is hard to describe how much emotional effort was required to keep climbing. Taking each step required every bit of mental endurance and concentration. It would not have been so bad if we had crampons, but we only had boots and so we slipped a lot. And every slip was exhausting. Everything in our lives — our families, our professions and all our previous life experiences — faded into a vague, dark background as our whole world was reduced to the small space between our ice-encrusted eyes and the snow slope in front of us. Dawn began to break and we were able to see a little more clearly in the faint light through the billowing ice and snow. It was around this time that we had two frightening experiences. First, I lost my footing and began to slip backwards down the mountain. It crossed my mind, with surprisingly lucid mathematical precision, that my slide down the mountain may increase in velocity and end by my crashing at near terminal velocity into Kibo hut 915 m (3000 ft) below. However, I managed to roll over and, aiming for a large rock, slid feet first into it. This life-threatening event produced marked and unrelenting breathlessness. I recovered slowly, and we continued to struggle on up the steep slope towards the summit, kicking our boots as deeply into the snow as best we could to gain precarious footholds. Then the second frightening event occurred. Mark slipped and began sliding down the mountain. He frantically grabbed at a rock protruding from the snow and this stopped his fall. He hugged the rock above his head with both hands, his body hanging down, and his feet flailing helplessly, unable to get any foothold. Every effort to kick a hole in the snow to try to gain a footing caused the snow to just fall away down the slope. I tried to help him, but couldn’t do much. The guide retreated down to our position, kicked a foot hole himself and then helped haul Mark above the rock. Mark lay prostrate in the snow, unable to catch his breath for 10 minutes or so. He later described this sensation as what it must feel like to die of respiratory failure! The guide encouraged us to keep going if we wished, although he later confessed that on a number of occasions he had decided that neither of us could possibly make it to the summit. Doggedly, we pushed on. We reached the top at about 8.00 am. It was an anticlimax — we were unable to see much. Although the blizzard had eased off slightly we were still besieged by falling snow and mist. The only reason we realised we were at the summit was that there was a small sign welcoming us to the top of the mountain. With blue fingers, I am attempting to video at – 30oC without gloves. The video camera, laboriously carried to the summit, only worked for a few seconds in the cold, but that visual record of our achievement is very precious to us. We shook hands and joked with our guide. However, he was more interested in leaving the summit as quickly as possible, warning us that “the weather is going to get bad”. Mark remembers thinking at the time that this was a somewhat superfluous statement. It didn’t seem conceivable that it could get any worse! We hiked, slid, crab walked, and glissaded down the steep slope through the whiteout. It didn’t look like the same route that we had come up on — it looked even steeper and we both felt that our guide was completely lost, and that at any moment we would glissade over the edge of one of the cliffs. We had read that 10 people die on Kilimanjaro each year, some by getting lost and falling over ice cliffs, and we thought that the same fate was destined to befall us. Eventually, we reached Hans Meyer cave and began to feel that we would safely descend the mountain. What should have been a physically demanding, but easily manageable, hike turned out to be an unexpectedly dangerous adventure for us both. The disappointment at not being able to see the famous dawn view from the Kilimanjaro summit was minor compared with the sheer adventure of the experience, the knowledge that very few hikers made it to the summit that day, and the experience of two close friends struggling together against exhaustion, cold, fear, danger and disappointment. We were inexperienced mountaineers. But we were both able to help each other when we each faced danger, and we felt a very strong bond with each other. We felt an incredible sense of achievement because we had overcome all of the difficulties. Snowbound descent — this spot was totally dry and barren on the ascent. And we learnt some lessons: Get very fit by walking and running up stairs (not just on the flat) before undertaking a climb up Mount Kilimanjaro. Get professional advice on cold weather gear, especially modern thermal underwear, wind-resistant but “breathable” jackets, and good-quality down-filled gear. It can make the difference between being miserable or comfortable. (Many times as we climbed I said to myself that I would pay $10 000 to anyone who could have given me any of that gear, right there and then.) Take anti-altitude sickness precautions. Hire a reputable, experienced guide — inferior guides may not be primarily interested in getting you to the top — the earlier you turn back, the less work and less risk it is for them. And we did meet someone who could have died for lack of a good guide. As we descended through the storm, we found her stumbling along, severely hypothermic, disoriented and unable to speak. Her guide had let her set off up the mountain without gloves and other warm gear, and had not followed her into the storm. Hire crampons and an ice axe. We scoffed when we were offered crampons, but if we were doing the climb again we would undoubtedly hire these climbing aids, even though it is rare for Kilimanjaro climbers to strike a blizzard. Take digital cameras, including a video camera, with you, even though they are heavy and inconvenient to lug at such an altitude, and the exhaustion produced by climbing reduces one’s motivation to take photos. The resulting pictures are irreplaceable and worth every effort. A useful website is www.climbingkilimanjaro.com But, in the end, the experiences and rewards we gained from our adventure were such that neither of us could possibly have anticipated how much it would enrich us as individuals and friends.

Bruce W S Robinson MD, FRACP, FRCP · Mark G Edwards MB BS, FRACS, FRCS

Much has been written about false memories — memories that are a distortion of an actual experience, or a confabulation of an imagined one. Memory and its reliability or otherwise have profound implications for us all, not only in our daily lives, but clinically and medicolegally. How often does a medical negligence or misconduct allegation boil down to “he said, she said” evidence? And we have all experienced the mismatch of memories of events shared in the distant past by more than one person. This personal anecdote records the same event as recalled by two people. Quite fortuitously in this instance, objective contemporaneous evidence settled the disagreement. Being a borderline student in Chemistry I, my poor performance in the practical examination was enough to secure a fail mark and a repeat of first-year medicine. During my rerun of Chemistry, I consistently failed to identify the colours of certain metals when held in the Bunsen flame. The Ishihara chart confirmed partial red–green colour blindness. Four years later, in 1959, I bumped into a medical school colleague in Paris, and we visited an art gallery together. Throughout the ensuing 45 years, my memory has been that the gallery was the Louvre. I have a clear memory of our standing before an impressionist painting by Manet, with mainly blue to purple hues, of Paris in the rain. My companion commented how wonderfully the red roofs contrasted with the overall bluish colours. I asked, “What red roofs?”. I could not see them until she pointed them out, and was intensely disappointed by this aesthetic consequence of my red–green handicap. That night I recorded the unhappy event in my diary. I have since visited perhaps no more than two or three art galleries, and then only as a reluctant companion to my wife. Van Gogh’s bedroom in Arles Van Gogh’s bedroom in Arles (oil on canvas — Musée d’Orsay, Paris; photo RMN © Gérard Blot) — one of three versions of the same painting, and most likely the one I saw. This one, painted while Van Gogh was voluntarily confined to a mental asylum in Saint-Rémy, includes a self-portrait as one of the paintings above the bed. In a letter to his brother, Théo, Vincent wrote “. . . it’s just simply my bedroom, only here colour is to do everything . . .” Fast forward to 2002. By chance, I re-established communication with my student colleague, now a psychiatrist in England. I commented how she had been someone I had always remembered, in large measure because of our joint experience at the Louvre. She replied that our gallery visit had made its mark on her, too. In subsequent decades of lecturing, she had taken care, when preparing slides, overheads and PowerPoint presentations, to avoid colours that might be confusing to men like me. However, the painting had not been in the Louvre, she said, but at a museum of impressionist art near the Place de la Concorde. Furthermore, the red I had not been able to see in the painting was not Parisian roofs in the rain, but the red heads of birds! Quite fortuitously, at the time of this correspondence, I was transcribing my 1959 European travel diary into typescript. I quickly checked my entry for the day at the art gallery. Yes, my colleague was right: it was a museum at the Place de la Concorde, not the Louvre. (The museum was, in fact, the Musée du Jeu de Paume at the Place de la Concorde, which housed the collection of impressionist paintings of the Louvre before they were relocated to the Musée d’Orsay in 1986.) But the painting in question? No red roofs in a rainy Paris. No birds with red heads. It was the famous Van Gogh painting of his bedroom in Arles, with the large, red coverlet on his bed! I had been familiar with Van Gogh’s bedroom painting for many years before going to Europe. But my memory, over nearly five decades, remains of rainy red roofs. No matter that I have searched the catalogues of the Impressionists and have not found such a painting. No matter that I now know that the painting with the invisible reds was the Van Gogh pictured here, my memory remains undiminished — red roofs in the rain! I still “see” them clearly. As for my colleague, despite my presenting her with the contemporaneous evidence of my diary, she, in turn, “knows” that the picture was of birds with red heads!

Peter C Arnold BSc, MB BCh, BA

Doctors’ concerns in 2004 look remarkably similar to those they were expressing more than a century ago Doctors often yearn for the good old times when governments didn’t interfere and economic security was matched by an unfettered freedom to practise their skills, but did these times ever exist? Delving into the Australian Medical Journal (AMJ) from 1870 to 1879 suggests that the medicopolitical issues confronting the profession have changed very little. Medicine today is more sophisticated, but the politics is not and has lost a certain character-forming robustness. Premises of Dr William R Pugh, surgeon and oculist, 131 Collins Street, Melbourne, circa 1865. © State Library of Victoria. The political issues confronting doctors in the 1870s included: The number of doctors entering the colonies with questionable overseas qualifications and uncertain language skills, and the failure of medical boards to control this;1 Poor remuneration for general practitioners and control of doctors’ remuneration by health funds (lodges and friendly societies);2 Specialist intrusion replacing general practice;3 Inadequate funding of the public and charity hospitals;4 Competition from pharmacists and alternative medicine;5 and Litigation, an unfair legal system and poor expert witnesses.6 It sounds familiar! The qualified doctorIn 1870, Australia had medical schools in Melbourne and Sydney. A reputable British degree was a prized qualification, and England was fondly referred to as “home”. Medical Acts governed the registration of doctors, a privilege which was jealously guarded. In 1873, there were 469 registered practitioners in Victoria with degrees from 48 universities, “not to speak of 10 who hail from no College at all, but by good luck were practising in the colony before 1853”.7 Valid proof of 3 years of equivalent study was enough to gain entry to the Medical Register, but there was doubt that medical boards were able to adequately check overseas qualifications. Frequent stories appeared of unlicensed medical practitioners being prosecuted, as did editorials calling for better screening of international medical graduates, exemplified by the case of Dr Myers, of the University of Lima, Peru, who rated an entire editorial, as he was accused of “sneaking into the profession”.8 The editorial castigating Dr Myers and the Medical Board was a gentlemen’s tiff compared with a stinging editorial in August 1875 on American degrees:9 “. . . the Americans who do everything in a hurry, educate their doctors in their usual fashion”, implying that a fat fee to an American university could purchase a pass in a fast-tracked medical degree. This, in turn, was mild compared with the disdain shown towards Chinese degrees and to those of Asian descent who attempted to gain access to the Register. The comments from an 1875 editorial10 would today earn a trip to the Anti-Discrimination Tribunal: “Because they speak in an unwieldy tongue and because any system of medicine they may have studied is at the opposite extreme of intelligence” and “. . . whenever an opportunity has been afforded them of submitting their medical knowledge to a reliable test, they have shown an incompetence . . .” The failure of the Medical Board of Victoria to protect the public from overseas-trained doctors of dubious quality caused great agitation. Criticism in an editorial using the subtle genre of the time expressed the view that “The Medical Board . . . is, in reality, only the mockery of an authority. They have no option in registering the most objectionable holder of a valid qualification and . . . what they know to be the most insufficient evidence of a proper medical education.” Have these all-too-similar sentiments been more gently expressed in our own medical and popular press of late? Remuneration of GPs“A person will go to a specialist and joyfully give a guinea . . . while the poor half guinea of the general practitioner is uniformly begrudged”, lamented an AMJ editorial from April 1876. The standard fee for a GP consultation was 10 shillings, but most GP visits were house calls. This period saw the rise of the medical clubs and friendly societies. GPs were invited to tender a competitive price and were paid by the club, essentially a health insurance fund. To ensure a busy practice, the price competition was fierce. As the price of general practice was driven down to meet the demands of the funds, GPs complained frequently about their poor remuneration.11 There were several attempts to form cartels to stand up to the clubs and bring the prices up, but doctors would always break ranks and offer to undercut their colleagues to ensure the security of their own practices.11 Attempts to improve GP remuneration usually failed because of lack of political unity. Successive Medical Society presidents expressed great concern about the emphasis on low cost, high volume medicine, which meant that it was “impossible that they [doctors] can devote sufficient time to each individual case. They must hurry along . . . and this continued hurry must lead to a kind of practice unsatisfactory alike to practitioner and patient.”12 State remuneration of “medical men” was considered a “disgrace”. The vaccination fee of 2s 6d “was ludicrously inadequate”,13 and state health officers were “mocked by their paltry salaries”.13 Compassionate discounting in private practice was common, but many GPs felt their charity was abused by the wealthier who could afford to pay. Informed financial consent was the subject of an editorial in November 1875:15 “Patients are often obtuse on the fees for operations and it is better there be no misunderstanding afterwards”. However, the popular press often made reference to high medical fees. Such a story in The Argus, a Melbourne newspaper, so raised the ire of one GP that he was moved to write In reply:16 “Of the 30 medical men residing there [Collins Street, Melbourne’s equivalent of Harley Street in London] . . . and [who] visit their patients in expensive vehicles, drawn by thoroughbred horses, driven by fat coachmen in gay livery, seven have no carriages at all, and eight drive but one horse, and their coachmen are not in livery . . . albeit I have no carriage and cannot quite make ends meet.” Doctors and their cars in the 1870s! The specialist and the generalistAn 1878 editorial entitled “Special practice” stated: “There is not much left for the General practitioner to do in these days of specialism; at least there is not much the public think he can do. Every organ of the body is appropriated by those who give their attention to regional diseases so that the general practitioner is looked upon as a kind of pathological poacher if he extend his treatment greatly beyond catarrh, colic or fever. In surgery, especially, he is forbidden to meddle, and there are certain instruments which it is a kind of professional crime for the average [GP] surgeon to use.”3 Public sector fundingThe public (or charity) hospitals were chronically underfunded. Outpatient waiting rooms were crowded with patients waiting many hours to be seen. There was a need for more public hospitals, and the decade saw the completion and opening of the Alfred Hospital in Melbourne. It was initially a free hospital, but it wasn’t long before a debate started about the merits of increasing its income by taking in “pay patients”. As the charity hospitals received minimal government funding, there was continued and strident criticism of those patients who could afford to pay for their hospitalisation but took advantage of the free system. The question of paying patients in public hospitals was a vexed one, with lessons we could learn from today. The medical profession was divided, as it gave a competitive advantage to the full time clinicians and honorary specialists at the hospital. An editorial entitled “Pay hospitals” in March 1877 summed up the position well: “It is a mistake to endeavour to associate gratis patients and pay patients under the same roof. So far as we know, wherever the experiment has been tried, it has failed . . . the difficulty continually arose, of pay patients complaining they did not receive attention and accommodation sufficient to distinguish them from the gratis patients, while these latter were of the distinct contrary opinion, that the pay patients were unfairly preferred.”17 Melbourne Hospital circa 1870. At that time honorary medical staff were elected every 4 years by the hospital’s subscribers. Doctors expended considerable effort and expense to win these prestigious positions.14 © State Library of Victoria. Competition for honorary posts was fierce. Appointment was by elections, the voters being the subscribers to the hospital; such ballots were a cause for much angst and legal action after the results became known. Petty jealousies abounded between doctors, and tension existed between the hospital administrators and the medical staff over budget control. The Melbourne Hospital’s budget was saved in the nick of time by a zealous administrator who publicly called the medical staff to account in no uncertain terms for their over-prescribing of meat extracts as dietary supplements, thereby nearly breaking the pharmacy budget. In May 1878, the whole medical staff of the Sydney Infirmary resigned because of dissatisfaction with the conditions at the hospital: “Week after week it has been found necessary to turn away applicants for admission there, partly for want of room . . . there are many instances in which patients cannot be properly treated at the infirmary at all.”18 Access block in the 1870s! The competitionThree groups provoking the ire of the profession in the 1870s were pharmacists, homoeopaths and quacks, a basket into which all other alternative healthcare providers also fell. The prescribing pharmacist caused the most concern, and some doctors were most rigid in their views. One GP was fined for refusing to attend to a child who had been kicked by a horse because a pharmacist had already applied some sticking plaster to the child’s head! Pharmacists drew this comment in an 1876 editorial: “They [the public] seem to entertain a belief that a knowledge of drugs implies a knowledge of disease and he who can compound and dispense can also prescribe.”11 How did the medical profession fight this competition? They considered dispensing medicines and charging for their own drugs. Doctors insisted on charging a consultation fee when issuing repeat prescriptions, and this was a source of frequent public complaint. These complaints particularly aggrieved the profession, which felt that there was some intellectual property in the potions and mixtures that they designed to treat various diseases — intellectual property which then stayed profitably with the pharmacist.19 Patent medicines, which promised a cure for everything from alcoholism to scurvy, were also a problem, particularly when promoted by snake oil merchants. However, it was humbling to see one of the major academic tussles of the day was a written war between The Lancet and the AMJ on the benefits of intravenous ammonia for the treatment of snakebite, a cure promoted by a Professor George Halford, one of Melbourne’s leading academics. Homoeopathy was especially hated by the profession. This hatred was fired by the repeated attempts by homoeopaths to gain admitting rights to the Melbourne Hospital and to set up special homoeopathy units. This was a move as fiercely resisted then as it would be today. Homoeopathy was described in an AMJ editorial in 1877 as “an irrational heresy” and homoeopaths were described as “immoral, dishonest and promoting a system of charlatanry”.20 The homoeopaths were well organised and very adept at answering public criticism and mobilising their supporters. The public seemed to find no shortage of cash to pay their homoeopath or herbalist, but were very reluctant to pay their GP, a source of serious irritation to the profession.21 “Quacks” encompassed a wide range of practitioners, and even included the odd member of the profession whose views did not match the thinking of the day (which seemed rather rigid despite proud claims that it was consistently evidence-based). Certainly, unqualified practitioners abounded, as did cures using cupping, blistering, electricity, patent medicines, chiropractic techniques, and herbal medicines. The disdain of the profession towards all of this was evident, and doctors bemoaned the general public’s support of alternative therapy, as shown in an 1871 editorial: “A sympathetic public would be up in arms to protest against the inhumanity of repressing a benefactor of mankind who got his knowledge of disease from nature and who, like a poet, had not been licensed to practise, but had been born with a diploma.”22 Medicolegal problemsOur profession’s dim view of their legal brethren was not shaped in recent times. Doctors in the 1870s felt hounded by an unfair, biased and poorly administered legal system. Most of the AMJ issue of November 1871 was devoted to the unjust nature of a verdict for malpractice against a doctor who missed a fractured neck of femur.6 The patient was awarded damages of £230. The opinion of the AMJ was: “It is hardly possible to imagine a verdict more unjust, or more directly contrary to all the facts as they were presented.” A public fund was set up to help the defendant pay the damages, medical defence organisations not being available at the time. The AMJ was scathing about the expert witnesses who testified against their colleagues, especially as they were of the view that the whole unjust action was begun after a doctor consulted for a second opinion implied the treatment by the initial surgeon was defective and so “encourages the belief in the patient’s mind that there has been neglect in her (first) attendant.” Doctors were frequently in court as witnesses and experts but were also exposed to the rigours of a jury in the Coroner’s Court. Deaths frequently resulted in coroner’s cases, and the outcomes of these cases were extensively reported in the popular press. Manslaughter charges against unfortunate practitioners were not uncommon. An editorial in the May 1875 issue of the AMJ called for coroner’s juries to be replaced by expert panels so medical men could be tried by their peers, who more fairly understood the complexities of medical practice.23 Court fees paid to expert witnesses were low and their experiences were unpalatable: “That a medical man should be kept in attendance for a whole day at a court of justice, and probably bullied into the bargain, and then, for all this trouble and annoyance, get a paltry pound, was monstrous.”13 This was a litigious age and legal actions against medical practitioners reported in the Journal made spicy reading, with actions for slander and libel being not infrequent. Lessons from the 1870sThe politics of the time was robust and intemperate, not ruled by genteel Victorian manners. Consider these quotes from the AMJ in 1871:24 “The autocrat who rules Geelong hospital . . .” “The committee of the Alfred Hospital are a very paltry one” and “Some opposition can be expected from an unimportant section of the profession which makes up in obstreperousness and bad language what it lacks in numbers and intelligence”. How better to end than with an obituary in the all-too-plain language of the day, expressing regret at the passing of a Melbourne specialist, who died on holiday in England: “For, although as a contributor to the sum of medical knowledge, Mr Whitcomb cannot be said to have taken a prominent position, he had practised long and successfully in this city . . . and at the Medical Society dinners . . . could be relied upon . . . to take part in the more convivial division of the festivities”. It seems the secret to successful practice in the 1870s was very similar to today’s — work hard, look after your patients, control your own fees and stay out of court. A little advertising didn’t go astray even in those times, and many speeches deploring medical men appearing in the press to announce their latest breakthroughs and triumphs were disdainfully reported. Ego was never far from the surface, often manifested as professional pride. Doctors tempered their independence with compassion and were more caring than commercial, as well as irascible, difficult to lead and organise, contemptuous of government and very opinionated. What has changed? Alfred Hospital circa 1875. Nosocomial infections were never as rife at The Alfred as at Melbourne Hospital. In the 1880s the Herald newspaper advocated that people carry cards reading “If any accident should happen to me do not on any account take me to the Melbourne Hospital”.14 © Alfred Hospital Archives.

David Molloy FRANZCOG

Quotes from MJA contributors in 2004 Much that is written for the Medical Journal of Australia is never intended for print. Volumes of correspondence, for the editors’ eyes only, flow into our in-trays — notably reviewers’ forthright opinions and authors’ robust rebuttals. Paradoxically, at times these missives seem better written and more suited to publication than the related manuscript! Straightforward, simple and clear, concise and precise, they are an editor’s delight. This Christmas, as always, we want to wish our contributors “Happy reading and all the best for your writing in the New Year!”. In this vein, we share with you some of the most memorable manuscript-related remarks received this past year. They reinforce general words of advice often given to aspiring writers. Respecting the various authors (and protecting ourselves), these quotes — now in print — have been de-identified. Make your point“The act of writing down guidelines always promotes debate and criticism, but it is important to ensure that the debate moves forward rather than in circles.” “On reading this paper, I wondered whether I was losing my mind. This is for you to judge. I cannot see a coherent argument.” Time matters“The feeling obtained on reading this paper is that a lot of time and effort has been expended and many trees felled for no particular reason.” “I’m sorry that I’ve been slow with this opinion. I don’t think, however, that either science or medicine will be damaged by the delay.” “I happened to have some spare time this afternoon, so I have undertaken the review already (if there is a prize for most rapid review for the Journal, then I want to be considered).” Declare conflict of interest“It is tempting to give it [this manuscript] a glowing review, which it indisputably deserves, but some degree of bias might be alleged since, unless the paper’s authorship has changed since the last draft I worked on, I am one of its authors!” Aim high . . . . . . but temper hyperboleReviewer: “The final section of this article is somewhat evangelical...” Author: “The article’s ‘somewhat evangelical’ tone is part of a desire to make people notice the enormity of the task, to stimulate debate and, possibly, more effective action.” Be scientific“I do not think a show of hands at a conference is scientific evidence to support an argument.” “The statement that a result can be clinically important but not statistically significant is nothing other than wishful thinking.” Be fearless“I look forward to drawing swords against your referees.” Be yourselfWe like Letters to the Editor to be short — no more than 400 words in length. Sometimes reviewers’ well-intentioned suggestions can seem impossible to accommodate. One author responded with individual flair. Reviewer: “... Point 8. It would be useful to summarise the current . . . constraints . . . in a box so that non-Australian authors will understand what is being discussed.” Author: “In 400 words, mate? Your sense of humour is even better than the editor’s.”

Ann T Gregory MB BS, GradDipPopHealth

While shopping one evening at the local supermarket, I did a double take when I came across this startling item. Lethal viruses on sale to unsuspecting consumers!? As the product claims to be “premium quality” SARS, I am sure that if it actually did contain the SARS virus it would be enough to potentially kill thousands of people. SARS in a can (aka sarsaparilla) is made from carbonated water, sugar, caramel, flavours, food acid and a preservative. Strangely enough, sales of this product actually increased in New Zealand during the SARS epidemic, with a BBC news website reporting that some people were asking, “Is this a medicine for SARS or protection against SARS?”.1 In another report, a New Zealand spokesman for the manufacturer said that the company was not thinking of changing the name of the drink and was unlikely to do so if current sales trends continued.2 The company also used to sell Double SARS, but I understand that this product has been discontinued.

Guy D Eslick PhD, MMedSc (Clin Epi), MMedStat

The elegant simplicity of Indigenous dot painting, and how it belies a structural complexity within the story of each work, has long fascinated me. I began experimenting myself, but “dot doodles”, with no story, were unfulfilling. A request for artwork from the Day Procedure Unit at my hospital led to the idea of combining work and art. My workday revolves around human anatomy. As a surgeon, I must understand the spatial relationships of structures. I see the apparent simplicity of their position, and yet still marvel at the boundless complexity of their function and the developmental process that has led to their arrangement. A marriage of this art form and these subjects seemed logical, with the parallel of elegant simplicity and structural complexity allowing me to feel comfortable and respectful in using this method of expression.

Iain J Skinner MB BS, FRACS

With the advent of semi-automatic defibrillators, public access to defibrillation has expanded like never before. Here we see an Adélie penguin at Mawson’s Hut, Cape Denison, Antarctica, being trained by Dr Geoff Couser to administer life-saving defibrillation therapy to a collapsed Weddell seal in the background.

Geoffrey A Couser FACEM

Our initial shock on seeing the sign in the foreground was alleviated when we noticed other nearby signs advertising motor spare parts!

Dhushan Illesinghe MB BS, MD, FRANZCP

A 22-year-old man presented to our accident and emergency department an hour after a motor vehicle accident. He had no history of seizures. On examination, he was alert, haemodynamically stable and his Glasgow Coma Score was 15/15. Both pupils were normal in size and reacted to light. His left eye was slightly protruded, and a rigid radio antenna about 12 cm long emerged from below the left lateral canthus (Figure 1). His visual acuity was normal, and he had no diplopia. Skull x-rays showed the antenna in the left anterior fossa (Figure 2). A computed tomography scan showed it traversing behind the left globe (Figure 3) as far as the left anterior cranial fossa, with the tip embedded in the region of the left sylvian fissure. There was minimal subarachnoid haemorrhage over the surface of the temporal lobe. The patient underwent emergency left frontotemporal craniotomy. At surgery, the antenna was seen to penetrate just lateral to the superior orbital fissure and reach the dura and the temporal lobe (the left sylvian fissure). The antenna was removed, and the patient was discharged from hospital several days later without any visual or neurological complications. Penetrating intracranial foreign bodies at low velocity characteristically enter via the orbital roof, the temporal squama or the cribriform plate. In this case, the antenna penetrated the orbital roof — one of the thinnest areas of cranial bone — without injury to the globe of the eye, or any neurological complications. We recommend that in cases such as this, with minimal external findings and normal neurological examination, simple external traction should be avoided.

Hossein Sanaei-Zadeh MD · Kamran Aghakhani MD · Mansour Parvaresh MD

A woman presented with a “roaring” headache and claimed that she had been chased all day by a lion. After a thorough assessment, I advised her that there was no lion and that it was all “in her head”. A computed tomography scan confirmed the presence of the lion and the woman went home reassured.

Steven R Doherty MB BS, FACEM

Re the article “Are current playground safety standards adequate for preventing arm fractures?”, by Sherker S and Ozanne-Smith J, in the 7 June 2004 issue of the Journal (Med J Aust 2004; 180: 562-565). In Box 2, the slope of the head injury trend was reported as “0.030”. The correct slope should be “–0.030”. The html and pdf versions of the article published online were corrected on 15 November 2004.

Shauna Sherker PhD, MSc, BSc · Joan Ozanne-Smith MD, FAFPHM, MPH

Percy James (“Jim”) White was born on 8 December 1919 —“delivered on a kitchen table by an alcoholic midwife in Murphy Forest, Benambra”, or so the story goes. He spent a life successfully combining his love for farming, medicine and family. He attended Benambra state school in northeastern Victoria, St Patrick’s College (Sale), Trinity Grammar School (Kew), then Melbourne Grammar School, where he rowed in the victorious crew at Henley on the River. He graduated in medicine from the University of Melbourne in 1944. Jim did his residency at the Royal Brisbane Hospital, then, in 1945, became a flight lieutenant in the Royal Australian Air Force. After a period in Melbourne conducting medical examinations on Air Force personnel, he was moved to Darwin as Principal Medical Officer North-Western Area (Darwin). He married Louris Larsen-Disney in 1948 and, a year later, returned to farming at “New Metunga”, in Benambra, later moving to the town of Wooragee. Returning to Melbourne in 1953, Jim began work at the Victorian Health Department as a District Health Officer, covering, at first, his beloved Gippsland area. Later, he was appointed Senior District Medical Officer (Metropolitan), and occasionally took on the role of Acting Head of Department. He was also a Member of the Faculty of Community Medicine of the Royal Colleges of Physicians of the United Kingdom and a Foundation Fellow of the College of Medical Administrators, established in 1967. In 1979, Jim retired from the Victorian Health Department to work part-time in the Department of Veterans’ Affairs. (One day, while examining a veteran, he found notes he had written when examining the same person 40 years earlier!) From 1982 to 1987, Jim was a board member for the Greenvale Hospital. He also lectured as a Foundation Member of the Early Planning for Retirement Association. He was a key player in several Probus clubs, being President of both the Brighton and Toorak clubs. Jim died in his sleep on 16 August 2004. He is survived by his wife of 57 years, Louris, and children Donald, John, Diana, Robert and Andrew.

John C White

Doctors as patients Is an ill doctor still a doctor, or a patient, or both? If he consults no one other than himself, he is both. If he consults a colleague and accepts his or her advice, he is a patient. If he argues with or rejects his colleague’s advice, he remains to some extent a doctor. Doctors choose a colleague to look after them to complement the role they prefer as patients. Those who feel they know almost everything and feel they must remain in control will choose a doctor who will do as they ask. So my father, a very experienced internist, chose as a GP a kind friend whom he had known for many years, but always considered his intellectual inferior. When my father was aged 85 and his GP 82, my father needed a certificate that he was still fit to drive a car. The GP thought it would be a terrible deprivation if he could no longer drive, and so signed it. Soon afterwards my father drove into another car without noticing it, and left the scene of the accident, and after that his licence was taken away. Those who are ready to trust a competent colleague, who understands them, are content to let him take the responsibility. That’s what I prefer, though when it comes to the use of drugs I want my opinion to be respected — and usually followed — because I am a clinical pharmacologist, and it is I who will have to take the drugs. Perhaps I am not so very different from my father. We all need a good doctor whom we trust, respect and like, who will listen to us but is not too close to us and not in awe of us, and will make his or her own independent judgements. When we find such a friend, we are in good hands.

Andrew Herxheimer

Doctors know many things, but mothers know best The daycare centre will never know. Three-hourly paracetamol through the night at double the recommended dose, a couple of shots of chlorpheniramine and a bit of leftover amoxycillin from the last bout of otitis media thrown in (never mind that it was for a different child). This medical mother is free to face the fully-booked day ahead. School days begin and shrink the working day. First it’s school drop-off; then cramming a 10-hour work day into six; spending the next three running between music, sport, and playing at a friend’s house; and stealing 10 minutes to buy some food for dinner — all conducted with efficiency and alacrity. Nothing more, really, than a long day of appointments and housecalls, with a twist. Adolescence hits the household and it’s not quite so simple. All those refined counselling and negotiation skills, the wisdom so often shared with concerned parent patients and with adolescent patients themselves, somehow get lost in the dirty underwear and half-eaten lunches that have decorated the teenager’s bedroom floor for the past three weeks. Still, life hums along on autopilot, with only the occasional interruption of a sleepless night caring for a sick child, or worrying about a patient — the suicidal teenager, the unwell infant, the bad news I have to break. I suppose there’s a selflessness that comes with both job descriptions; it passes unnoticed, almost always. But there are times when being a medical mother hits me in the face. My first-born arrived 10 weeks early, not long after I had completed six months as a paediatric registrar in neonatal intensive care. Despite the panic, fear, grief, delight and excitement, the irony didn’t escape me. As I watched my baby fail to thrive, the mother and the doctor in me started fighting one another. Doctors make terrible patients, and medical parents are particularly neurotic about their own offspring. I knew these as medical facts. The vaguely smug expressions on the faces of the hospital staff every time I asked a question reinforced the fact that I fitted the medical mother stereotype. But the mother in me eventually won. She made a fuss, and a new diagnosis forced a change in my child’s care that should have happened two weeks earlier. I learned a lesson about medicine that I haven’t forgotten: mothers know best. Becoming a mother changed the way I understood the practice of medicine. Intuition can be as powerful a diagnostic tool as a battery of expensive medical investigations. Empathy takes on a whole new meaning. “Treatment” becomes a limiting concept in the light of real people with real lives, like the lives of my children. And when I start to forget what day it is and who I am, I remember something that happened years ago. I had taken the two oldest children, then four and five years old, into work. One said, “This looks like Dr Phill’s (their GP’s) room!”. “Yes! It’s a doctor’s office, just like Dr Phill’s.” “But you’re not a doctor! You’re a mummy!”

Melissa S-L Kang MB BS

First used in 1967, the drug levodopa has rescued many patients with Parkinson’s disease from silence, rigidity and tremor. Parkinson’s disease is called an extrapyramidal disorder. It results from damage to black brain cells aggregated beside the pyramid-shaped tracts of motor nerves. Stephen Leeder, 26 February 2004

Stephen R Leeder AO PhD, FRACP

Barry E Christophers Retired General Practitioner, 1/12 Tollington Avenue, East Malvern, VIC 3145 To the Editor: I write concerning the recent article about my letters to the MJA in the 1950s and 1960s drawing attention to Indigenous health issues.1 Mention is made in the article of the campaign waged by the Federal Council for the Advancement of Aborigines and Torres Strait Islanders concerning the exclusion of Queensland Aboriginal patients with tuberculosis from the generous allowance paid to other TB patients. This campaign was successful. The Tuberculosis Act was amended so that Aboriginal people were not excluded from receiving this allowance. The Australian Medical Association supported this campaign. Without its support it would have failed.

Barry E Christophers