A Geriatrician’s Beginnings: Glasgow, Scotland, 1966
WHERE IT ALL BEGAN
“Dr. Geoghegan, I think you will fit in well here, but, geriatrics is a difficult and demanding specialty —perhaps the most difficult of all. Not everyone can do it. If after a few months working here you are unhappy and feel you cannot pursue it, you must not feel you have failed. Come and talk to me anytime. My door is always open.”
These words introduced me to a great clinician, a great man, and to geriatrics. Specializing in geriatrics had never crossed my mind until unforeseen circumstances made me apply for a post with Professor Ferguson Anderson, the first professor of geriatrics in the world, and one of the most respected and best loved doctors in the country. The year was 1966, the place was Foresthall Home and Hospital, Glasgow, Scotland.
FORESTHALL HOME AND HOSPITAL
Foresthall’s origins were grim. Known as Barnhill, the largest poorhouse in Scotland, it opened in 1850 and was described in 1882 as “a very capacious asylum for the children of poverty and well adapted by its cleanliness, ventilation and position to mitigate the ills of their condition.” “Paupers” who could not support themselves were sent there and were obliged to work at jobs such as bundling firewood, picking oakum (separating tarred rope fibers), and breaking rocks. Able-bodied inmates were required to make up 350 bundles of firewood per day, and stonebreakers were expected to break 5 hundredweight per day. Strict discipline was observed at Barnhill. Any inmate not producing the stated amount was put on a bread and water diet in solitary confinement for 12 hours. Disorderly conduct such as swearing or rule breaking resulted in being put on a diet of bread and water for three days.
The usual fare was oatmeal and milk for breakfast and supper, and bread and meat broth for dinner. The diet of children was more varied, and in 1885, one Malcolm McNeill, Visiting Officer for the Board of Supervision, described their appearance as “satisfactory”—however he urged the substitution of sweet milk instead of buttermilk for them. His comment about the women in the washhouse receiving tea and bread in addition to the basic diet was less kind; he described this as “…an unnecessary, and in some respects, mischievous indulgence.”
Barnhill was renamed Foresthall Home and Hospital in 1945 and was thereafter used as an old people’s hospital and residential home, while continuing to provide food and shelter for the homeless. (By this time, though, they were no longer required to bundle firewood, break rocks, or pick oakum, nor were they put on bread or water for transgressions!) The geriatric section was closed in stages between 1978 and 1983, with the patients being dispersed to local hospitals. Sad to relate, Foresthall was demolished in the late 1980s, and a private housing development now stands on this desirable site.
Foresthall the “village within a city,” on over 30 acres of great natural beauty, had wide, well-tended lawns, a fine backdrop to the blossoms and berries of rowan, laburnum, and hawthorn trees, while in spring, snowdrops, crocuses, and daffodils traced an intricate pattern of color against this green background. A staff of nine Parks Department employees maintained these gardens. The gray lines of the buildings spoke mainly of Victorian grandeur, although with a military influence. Near the hospital paint shop was a 60-foot-deep well, covered with a manhole, which supplied water for the establishment in bygone days.
The many large buildings housed acute geriatric wards, wards for the elderly chronic sick, other wards for the younger disabled and chronic sick, and rooms and dormitories for the homeless (required by law in Scotland). Although a number of vagrants showed up at regular intervals and received a hot meal, delousing, a good scrub, and a clean outfit before returning to the highways and byways, many of the homeless who sought shelter there were families. The usual reason was that a father had lost his job, couldn’t pay the rent, and the family had been evicted from their home. They stayed for as long as it took to get another job and find a place to live. I didn’t see any families take advantage of this—on the contrary, the adults were ashamed to be here on charity, and strove mightily to get back to work and find a home. The staff at Foresthall provided high-quality personal and medical care to all of these people, as well as to the old in the acute and chronic geriatric wards, and the younger disabled patients.
“TEAM WORK”
“Team Work” was the key, an innovative idea in those days of old-style patriarchal medicine. Five middle-grade doctors (called “registrars”) were the foundations of the team. We had the responsibility of the day-to-day care of the patients. In the British health care system, a doctor who decided to become a specialist was required to work his or her way up in the hospital service through the following grades: junior house officer (fresh out of medical school), senior house officer, registrar, senior registrar, and finally, the top of the ladder, consultant. After junior house officer (1-year minimum), several years were spent at each level, and rigorous examinations such as the Membership in Medicine or the Fellowship in Surgery, had to be passed. Competition for promotion was keen, and those who did not make it could return to a career in general practice or public health. Hospital-based and public health doctors had a salary, with consultants allowed to have a part-time private practice as well. General practitioners were paid per capita, with additional bonuses for those who did obstetrics, research, and community service.
By 1966, although I had had four years intensive experience in hospital medicine, my main contact with elderly patients had been the care of a number of ancient, frail women, permanent residents of the “Grannies Ward” in the Southern General Hospital. The other four Foresthall registrars had all been practicing geriatrics for several years and were able and willing to teach me, and help in any way they could.
Other key members of the team were the ward sister and staff nurses of the particular ward we were visiting, physical, occupational and speech therapists, a social worker, and a secretary. Two or three consultant geriatricians accompanied us on our weekly “Grand Rounds,” which I will describe below. An inspiration to us all on these events was Professor Ferguson Anderson, the father of geriatrics.
THE FATHER OF GERIATRICS
William Ferguson Anderson, a tall, handsome, dark-haired man who listened carefully and smiled easily, was born on April 8, 1914. He graduated from Glasgow University School of Medicine in 1936. After junior and senior house officer posts in Glasgow, he became registrar at Glasgow University Department of Materia Medica and Therapeutics at Stobhill Hospital. After serving in the Royal Army Medical Corps in India and Germany as Medical Specialist after World War II ended in 1945, he returned to Stobhill Hospital (at this time, the largest general hospital in Europe) as Assistant Physician and Senior Lecturer in Medicine at Glasgow University. Three years later, he went to Cardiff as Senior Lecturer in Medicine in the Welsh School of Medicine and Consultant Physician at Cardiff Royal Infirmary. He returned to Glasgow in 1952 and took the post of Physician in Charge of Foresthall Hospital and Advisor in Diseases of Old Age to the Western Regional Hospital Board. In 1965, he was appointed inaugural David Cargill Professor of Geriatrics at Glasgow University—the first professor of geriatrics in the world, a post he held with distinction until he retired in 1979. His research articles and books were the stepping stones to a whole new medical specialty. He was an inspiring teacher, a pioneer of preventive geriatrics, and an ambassador for the aged, both at home and abroad. He was successively President of the Royal College of Physicians and Surgeons of Glasgow (1974-76), President of the British Medical Association (1977-78), and President of the British Geriatrics Society (1975-78). In 1961 he was awarded the Order of the British Empire, and in 1974 he was knighted for his outstanding contributions to geriatrics.
GRAND ROUNDS, SCOTTISH STYLE
So, what was “Grand Rounds” Scottish style? Well, once each week the team I mentioned above went together into the wards. (An aside: Perhaps Scots are just naturally gregarious; the large, open ward was, and is, popular. A few private rooms were available in every hospital, for example if a patient needed isolation, but they were not sought after. Camaraderie developed quickly in the ward, recovering patients watching over the sicker ones, and helping the nurses pass out cups of tea and other food items. They felt useful, this boosted their morale, and, I am convinced, speeded their recovery. Also, if any patient’s condition changed, it was noted immediately, and the nurses on duty alerted. I could tell stories about lives saved by this.) During our Grand Rounds, every patient was spoken with, with as much time as needed given to those with complex problems. The registrar assigned to the case would present it to the team, out of earshot of the patient if this was deemed necessary, and each team member was encouraged to comment. The consultants asked and answered questions, and demonstrated clinical pearls for us. Hands-on examination of the patient was carried out where needed (behind curtains drawn round the bed to respect modesty and for privacy), and the weekly event was concluded with a care planning meeting, where we sat together around a large table and discussed the most knotty problems. (Always with tea, coffee, freshly baked cakes and biscuits to fortify us) The family and social situation were reviewed, and plans for home visits by doctor, nurse, and/or social worker as needed, were made. We also were expected to do pre-admission home visits where necessary, a registrar alone or accompanied by one of the consultants. What a learning experience! We learned by doing, seeing, listening, touching, questioning, discussing. Each team member was encouraged to speak up, and was listened to with respect. Ferguson Anderson was our teacher and our inspiration, not only because of the great medical wisdom he shared with us, but also because of his natural courtesy to one and all.
By the time the meeting finished, the secretary who had accompanied us on our ward rounds had typed up the shorthand notes she had taken down as we talked, and they were ready for review and signature. While we were doing this, the notes from the care planning meeting itself were being typed, we reviewed them together, and our team care plans were ready to be put into action.
POST-MORTEM LEARNING
Attendance at post-mortems was another valuable learning experience. This was required of the doctors in every hospital in which I worked. We went to the Pathology Department at least once each week, listened to case presentations from the attending physician plus a description of causes of death by the pathologists, and were shown the damaged or diseased organs. Where relevant, the microscopic appearance of diseased tissues was projected onto a screen for us to view. The discussions that ensued taught us a great deal, and we slowly but surely became better equipped to help our living patients. In those days, lawsuits were not an issue in Britain, and families were eager to add to the total sum of knowledge in any way they could, so it was more usual than not for a hospital death to be followed by a post-mortem; there was no charge to the family for this.
SHARING CALL
We five registrars made sure there was always one (at least) of us available, 24 hours a day, 7 days a week, with consultant backup. One night each week and every fifth weekend we took our turn living in Foresthall. Events in most settings tend to cluster, and if a lot of sick elders were admitted to the acute wards, we could summon the second-on-call registrar and could ask advice from our consultants as needed. They were quick to come in to see a sick patient with us at any hour of the day or night, since we all knew how essential a hands-on clinical approach was to reaching the correct diagnosis. Ferguson Anderson never hesitated to join us and help in any way he could. Being able to discuss a complex case with a trusted colleague was invaluable—to this day, presenting a case in this way helps me put my own thoughts in order.
A wonderful aspect of this on-call system was that when you were off first and second call, you really were off, and could go home to relax, recreate, and of course, study. Communications among the team members were superb and ongoing, and I count myself lucky to have been involved in geriatrics at its best.
ROSE-COLORED GLASSES?
Now, if you are wondering if rose-colored glasses are tinting my vision, I want to assure you I am telling it like it was. It truly was as good as I describe. We had supportive senior, experienced doctors and other health professionals always available. Although we worked hard and stayed there each day until our work was done, we had time off. But most important, from the very nature of our leader, Ferguson Anderson, all the people who worked in Foresthall were there because they wanted to be. He had built a team of competent, caring health professionals, who had the highest level of satisfaction with their work, who rejoiced together in triumphs, and wept together over losses and failures. (Genuine, having-tried-everything failure was acceptable; sloppiness, lack of caring, discourtesy, not having explored every possibility was not. Such a health professional would not have lasted long there.) Since we all took a salary (equal for men and women), there was no competition to build a practice or recruit patients; paperwork was minimal; we competed only for excellence in patient care. Also, since medicine was a highly regarded profession, not a business, advertising was anathema, and didn’t happen. In fact, a doctor would be disbarred from practicing medicine if he or she transgressed this rule.
I moved on from here to Aberdeen, marriage and family, and many years of geriatric practice in Britain, and then to America. To this day, I carry with me, and try to fulfill, the vision given to me in Foresthall, Glasgow, Scotland, all those years ago.
TRIBUTE TO A GREAT MAN
Sadly, Professor Sir William Ferguson Anderson is no longer with us. He died on June 28, 2001. Excerpts from his obituary in the Journal of the British Geriatric Society read:
“Ferguson Anderson was a pioneering protagonist and living exponent of the central, fundamental role of specialist medical and medical academic innovation, advocacy and leadership in improving the health and independence of older people. In an era intellectually stifled by political correctness and commercial expediency I think his message needs to be rediscovered and widely restated.” “As Visiting Professor he contributed to the improved care of older people in Canada, Israel, Denmark, New Zealand, Australia and Japan. He was appointed Adviser to the World Health Organization on the medical care of older people (1973-1979). His famous partnership with Dr Nairn Cowan in the Rutherglen Health Centre was the first effort at prevention of decrepitude among elderly subjects anywhere in the world. His determination to distinguish between ageing changes and diseases to be treated was finally rewarded when geriatric medicine was recognized as a specialty of medicine and taught to undergraduate and postgraduate students (in Britain). Sir William gave countless lectures with an infectious enthusiasm and was never too busy to talk to anyone who wished to make an observation or to ask a question. He liked people, and particularly liked and respected older people, for whom he was a powerful advocate.”
Final words, though, must come from the great man himself, speaking about his career in geriatric medicine:
“The rewards have been the delight of having a career which fulfilled my training as a general physician concentrating more on the individual as a person than on the chemical construction of the human animal. This was combined with the realization of the intertwining of the physical, mental and social aspects of health and disease and the almost limitless teaching opportunities and the enthusiasm of so many young people anxious to learn.”
We shall not look upon his like again.
