What has been the most satisfying moment of your career?
There have been so many good moments in my 40 years as a doctor that it is difficult to pick out one specific moment. I thoroughly enjoyed my career in paediatrics even though I originally intended to become a surgeon, even up to the time that I did a casualty job after leaving the army following National Service. Most good moments have usually involved making a difficult or unsuspected diagnosis having success with the new techniques such as intubating neonates for the first time, getting the first neonate off the ventilator, performing the first successful jejunal biopsy, liver biopsy, GI endoscopy – usually introducing new techniques or investigations and being involved in clinical research with staff and seeing that published.
One moment I remember vividly was during a study screening newborn babies in the Leeds Maternity Hospital for urinary infections as part of my MD thesis in the Sixties. It was absolutely crucial to determine if the bacteria we had grown from some neonatal urine specimens were from external contamination or actually from within the bladder. Therefore, with great trepidation, I performed a suprapubic bladder aspiration with a needle and a syringe, a new technique at the time and a first for me. I was rewarded with a few millilitres of slightly cloudy urine. I rushed round to the side room, put a drop under the microscope and confirmed there were millions of motile bacteria. It was true bacteriuria.
Certainly, being involved with children who have chronic serious disorders and being trusted by their parents has been a privilege and very satisfying although very sad at times. The continual improvement in the outlook for people with cystic fibrosis, mainly due to better conventional treatment, has been a constant stimulus to improve their care even more. I’ve been fortunate to live through a quite astonishing period of medical progress since the 1950s during which time the outlook for so many disorders has improved. Paediatric practice today is very different from when I qualified in 1956. The development of the Leeds Regional Cystic Fibrosis service, from the first small clinic I started in 1975, success leading to the need for an Adult Service headed by Dr Steven Conway and the continuing development of both under his leadership gives me great pride and satisfaction.
I am particularly proud of two publications which had a widespread impact on practice interestingly both were letters to the Lancet. Our 1988 letter reporting slowing of growth and asthmatic children due to large doses of inhaled steroids was a world first. Although the finding was dismissed by the acknowledged paediatric respiratory experts at the time, it was ultimately proved to be valid and it’s now common knowledge.
However, by far the most important from the patients’ point of view was the undoubtedly our 1985 Lancet letter reporting the successful eradication of the early Pseudomonas aeruginosa infection in CF children with nebulised colomycin. Prior to this the onset of Pseudomonas infection had been regarded as the inevitable start of a chronic infection that would ultimately prove fatal. The value of the early eradication treatment was confirmed in a controlled trial from Copenhagen in 1991 and subsequently by others. Early Pseudomonas infection is now routinely treated and usually successfully eradicated with a course of inhaled colomycin and oral ciprofloxacin.
What is the best part of your job?
Seeing patients and working with expert colleagues was the best part of my job and, since retirement from clinical work in 1997, it is still in working with good colleagues in my voluntary role at the CF Trust. I always enjoyed the challenge of a new problem and was fortunate to have many such problems referred by general practitioners, other paediatricians and hospital colleagues. Working in a huge hospital such as St James’s in Leeds one had numerous colleagues with great expertise in many fields of medicine. I always had a great deal of cooperation with the consultants dealing with adults particular the gastroenterologists and biochemists working in Professor Monty Losowsky’s department, with whom we had many joint CF and other gastroenterological research projects.
On the other hand, I certainly used to enjoy the one or occasionally two sessions of private practice each week. Our private clinic sessions were organised by my wife Ann and who is a qualified nurse. She also organised the database at our cystic fibrosis unit at St James’s for some 15 years on a voluntary basis before we retired in 1997. In the private clinic she organised all the appointments, in the clinic weighed and measured the children, tested and plated the urine for me to microscope. I had an hour with each new patient – bliss!!
I almost feel guilty writing this in the days of an overworked underfunded NHS. But surely this is how a medical consultation should be conducted when it concerns, on occasion, a serious problem with the family’s most precious possession. So I’m quite unrepentant!
What is the worst part of your job?
Latterly the worst part of my job was spending hours trying to persuade some NHS managers (but not all I would add) to provide appropriate facilities and services for treating our patients. Seeing patients getting suboptimal treatment as a result of the gross NHS underfunding is a national problem which I encounter frequently. In the early years it was difficult being constantly on-call and being available for consultation at any time of the day or night for the hospital or for domiciliary visits
What is your biggest regret?
Is not having kept a diary even with an entry every few days. I also regret not writing a short note about every house physician when they moved on. Over 30 years it is impossible to remember everyone.
If you didn’t work in medicine what do you think you would be doing instead?
I have no idea. I’ve been so involved in medicine for the past 40 years that I’ve never had time to think about doing anything else and it’s a bit late now anyway! My wife says I would have drifted around the world playing my trumpet!
What’s the best advice you have ever received?
The best general professional advice on being a consultant was from a senior Leeds family doctor when I was appointed an NHS consultant paediatrician in 1968. In the 1960s many consultants did some private practice even paediatricians. I was proposing to see patients in my own home. He was against this and advised me to start to rent a consulting room where other successful consultant surgeons and physicians worked. Also, to be available at all times for both private and NHS consultations and to give the same high standard of service to both – whether private or NHS. This was really sound advice for which I was able to thank him personally many years later when, both now pensioners, we met recently in a local supermarket.
More specific advice, I think from Professor Craig or Dr Buchanan, my first paediatric mentors in the 1950s, was to always examine the whole child which included chemical testing and microscopy the urine. Paediatric patients have a tendency to have double pathologies – for example tonsilitis and appendicitis! Ears throat and urine – the general paediatrician’s Father, Son and Holy Ghost!
Finally, always finish a consultation with “Have you any more questions?” and ”Please ring me at any time if you’re worried or he/she doesn’t improve”.
With particular regard to cystic fibrosis, I was profoundly influenced by the advice in an 1974 paper by the late Dr Douglas Crozier who was director of the Toronto CF clinic. He considered “the success of treatment will depend on a complete assessment of the patient and then continue attempts to attain normal bodily function and maintain it”
It was this advice which prompted me to start Comprehensive CF Assessments of our own patients in 1980 looking for potential areas where their care could be improved.
The many areas in which their treatment and condition could be improved surprised us. Offering this Comprehensive Assessment service was the basis of a Regional Service which was officially recognised by the Region in 1983. Eventually we had over 600 patients referred from many parts of the UK and abroad for a Comprehensive Assessment by the team at St James’s. Now Annual Reviews are routine in all major CF centres.
What is the best advice you have ever given?
It is always rather humbling when a young doctor says “I always remember you said this or that” when frequently one has little recollection of making such a wise remark and probably it was originally someone else’s anyway. However, advice which I do remember giving to many doctors, and also reminding myself of it, is to always think of the worst possible explanation for a child’s symptoms. For example, if it is acute abdominal pain – has the patient an appendicitis or intussusception? If a headache – is it meningitis or a cerebral tumour? This is a good rule for a consultant whose raison d’etre is surely to avoid missing rare and serious disorders.
The sign on President Harry Truman’s desk warned – “The buck stops here!” and also a wise professor of medicine of my acquaintance made the same observation. Don’t be afraid of over-investigating a patient provided you are not harming them – the usual mistake is to under-investigate. Also, for heaven’s sake listen to the parents and the patient! Also, if the parent raises the possibility of a particular diagnosis, such as leukaemia or cystic fibrosis, exclude it if at all possible. Finally, always treat a colleague’s, doctor’s and close friend’s children exactly as you would any other patient. If you think they need admission to hospital – admit them; if they need a blood test or other investigation – do it. Finally, in any situation consider what you would wish for your own child.
What is your biggest fear?
This is an easy one that haunts a clinician throughout his career. My biggest fear was to miss an important medical condition that then resulted in the death or permanent handicap of a child.
Name your one big ambition that you haven’t yet achieved.
My big ambition is to be still involved with the CF Trust when a really major breakthrough in treatment of cystic fibrosis is achieved.
Addendum in 2020
The introduction of CFTR modulators in 2011 and in particular in 2019, the combination of three (tezacaftor, ivacaftor and elexacaftor) presented as Trikafta (in USA) or Kaftrio (in Europe), although not a cure, is generally regarded as a major breakthrough. So as Honorary President of the Cystic Fibrosis Trust in 2020 I still have some, albeit indirect, involvement with cystic fibrosis at the time of “a really major breakthrough – my stated ambition in 20.2.01!