22 NOVEMBER 1963, Page 29

Pride . . •


'IF a doctor's got 3,000

patients on his back, it's

not medicine he's prac- tising, it's witchcraft. In fact, that's exactly what I was doing before I came here; passing out prescrip- tions with magic formulae on them.' Thus a young English doctor in practice in a medium-size, medium- attractive town in On- tario, one of the steadily increasing number who have left this country for Canada every year since 1947. In one evening in Kitchener I met five English GPs and was assured that the num- ber in practice in the town and surrounding countryside was nearer a dozen. These young men aren't part of the brain 'drain proper; they haven't been lured away by the siren charms of research nor even by prospects of huge finan- cial gain. Obviously money does come into it and they do make good money faster than they would at home, but, as they would admit, even under the health scheme doctors form one sec- . tion of the community which isn't likely to come within cringing distance of the breadline.

The reasons they left England are interesting, partly because they confirm what so many general practitioners seem to be feeling here, but mainly because they were trained at consider- able cost by this country and should be working here. To be fair, most of them had done so and apparently. found the experience so dis- heartening that there was a chorus of 'Hear. hear!' when one doctor in his early thirties was moved to exclaim: 'All I can say 'is that I hated general practice at home. I dreaded 'the morning surgery.' Most of them seem to have gone to Canada because the details of day-to-day medical practice there make it more interesting and professionally rewarding.

At the root of it all, perhaps, is the scope for self-esteem, the way the doctor himself regards his position. Listening to the average doctor talk, one. is tempted to dismiss this as a question of petty self-regard, but, as in any other job, a doctor's pride is an important factor in the way • he regards his work. Since his work is sick people, it's all pretty important to them. 'I trained to be a doctor, not a civil servant' was another remark greeted with loud agreement.

Admittedly, the medical profession has always been notoriously grandiose in its delusions about the priestly functions of the doctor 'assisting at the mysteries of life and death and has felt that this aura is necessary to gain the confidence and respect of patients. The best practitioners will always gain confidence whatever the framework because of their 'own authority, but many doc- tors do feel that they are no longer their own men, but bodies in a go'ernment department, their judgment and work constantly open to out- side interference. We've probably been subjected to an overdose of all that Hippocratic mystique, but it's also quite possible that a small bit of the mystique is quite good for doctors and patients alike. At least, after experience of de- feated English GPs whose immediate solution to a sore throat is to get one out of the surgery with a letter to a specialist as quickly as pos- sible, I think there's some case for preserving their self-esteem, even if we do have to take their self-importance at the same time. So much for status, or proper pride, or what- ever. There is also the medical framework. It's academic to talk about this, since surely not even the most reactionary wing of the medical profession would now want to exchange the concept of the Health Service for the piecemeal insurance schemes of North America. These are inadequate just because they're not automatically all-enveloping, and in any insurance scheme which doesn't include everyone, it's always those who need it most who get left out. Doctors in Canada, particularly the English ones on whom the burden of justification lies very heavy indeed, work hard at proving that no poor person goes untreated. I'm still puzzling over a piece of casuistry about the doctor/patient relationship which ended, 'It's just because we don't have to worry at all about money that we can always take poor patients. We don't have to think about how they'll pay.' The patients, knowing. that after a period their debts will be put in the hands of a debt-collecting agency, view the doctors less rosily. 'Businessmen' is the kindest epithet generally applied to doctors in Canada, and the more usual comment is a swift obscenity, fol- lowed by the work 'sharks.' But the time the doctor/patient relationship there does conic into its own, and everyone agrees that it does, is when it comes to the actual business of being sick. And this, after all, is when it matters. For most people in England the time the doctor/patient rela- tionship comes to grief is when they have to face the doctor's surgery feeling like death. The attention the patient receives in Canada is swifter, more personal and more constant.

Partly this is due to the hard truth that if a patient is a business client who must be satis- fied if he's to pay his bill there is more incenti■e for the doctor to follow his case with care. But there are .besides the workaday details of general practice. For example, the GP there attends his patients in hospital and does much of the work assisting at operations, etc.---which is done by housemen over here. Most CiPs in Canada can do a great deal more in the way of specialised treatment in their own surgeries of cases which they would hand on to hospitals here ('As soon as a case got interesting at home I had to hand it on to a hospital specialist and never heard any more about it'). And, most important, there is the question of time. None of the doctors I talked to thought of having a list of more than 1,000 patients, which means the GP can probe a patient's .personal as well as medical history.

The doctor in Canada may be regarded as. a tough financial proposition with his eye on the main chance, but he is obviously relied (upon absolutely as a doctor. In this country I think he's probably regarded as a good man working against heavy odds, but with less and less con- fidence as a reliable healer. And his own ob- vious sense of defeat doesn't help. If any scheme -is to run well, the doctors must be happy in it and the general practitioners aren't the least bit happy with their own situation. We tend to feel in this country that if a job is socially useful the people who practise it must be men of vocation to whom virtue is, in the main, its own reward. Professions like politics and teaching should have shown us that this is not only un- reasonable but unrealistic, because there just aren't that many idealists around and it's silly to plan as though there were. After a furious slanging match about English medicine, I said to a young English doctor in Canada that surely the health scheme was a valuable idea worth staying around to achieve. His reply in retrospect seems reasonable enough, If it's a good scheme it shouldn't need idealists to make it work.'