RONALD HEPWORTH VARTAN
President of the Nottingham Medico-
Ronald Hepworth Vartan: "Dunlace," Woodstock Street, Hucknall, Nottinghamshire. (Vartan, Fitzgerald & de Costres). M.B., Ch.B. Edinburgh 1928: Assistant Area Surgeon, St. Johns Ambulance Brigade. Appointed Factory Doctor; Treasury Medical Officer; Flight Lt. Royal Air Force Auxiliary Medical, 504 Squadron. Member of the British Medical Association and the Nottingham Medico-
Medical Directory 1959.
Ronald Hepworth Vartan was born in Sandiacre, Nottinghamshire on the 3rd October, 1905. He was educated at Bishops Stortford College and later graduated from Edinburgh University in 1928. At both his seats of learning he was an outstanding student, both academically and athletically. At Edinburgh he was captain of tennis and swimming, and president of the Students’ Union. He was also a successful golfer.
As a general practitioner he practiced single-
In a personal tribute by Dr. Keith Bywater to Ronald Vartan it was said:-
Ronnie was as nice a man one could ever meet and I never heard him say anything unkind about anyone. He was very popular, as was his wife who taught my children to dance at the classes she held at the YMCA in Nottingham.
BMJ, Volume 306, page 138, 9th January, 1993.
Dr. R. H. VARTAN
Delivered Wednesday, 2nd October, 1957
Ladies and Gentlemen,
This is the beginning of a new session and my first duty is to thank you for the honour you have done me in electing me to this high office; secondly, to congratulate you on your fortitude in turning out to listen to me tonight.
You have all received your programme for the session and I hope you will agree that we have managed to arrange an interesting and varied series of lectures by many well-
I don’t know how many hundred million of years life has existed on this earth, but I do know that all through those millions of centuries the one unchangeable rule of existence had been ‘Adapt or perish.’ We have seen some striking examples of this in recent years. Rabbits in this country have had to adapt themselves to myxomatosis. Germs have had to adapt themselves to penicillin. And another lowly form of life, medical practitioners, have had to adapt themselves to the National Health Service.
There are some who think that the National Health Service has been just as deadly for doctors as the big-
The first doctor may have been something like the present-
This Olympian age of medicine, however, came to an end with the first great doctor, Hippocrates, who convinced his fellow countrymen that illness was not sent by the gods to punish slights or wrong doing, but that it was quite natural, and the sort of thing that everybody had to expect. We know very little about Hippocrates himself, but he was probably born in Cos, and in that island off the western coast of Asia Minor, there arose a school of medicine which based its theory and its practice on what Hippocrates taught. So I am going to draw my first picture -
It was a new school. The old-
In Cos, however, the doctors were trained to treat each case on its own merits and to deal with people who were ill, not with illness that had found a temporary home in the bodies of certain people. The Hippocratic method was to observe closely every detail and then to decide what might best be done in each individual case -
You will gather that the school of Cos believed in a physician getting to know his patients. And indeed it is that the doctors of Cos were very much like the family physician thirty or forty years ago in this country. They knew all that was worth knowing about their patients, and this included a vast amount of non-
Unfortunately, the free spirit of enquiry always aroused intense opposition sooner or later in the ancient world -
Medicine was freed from authoritarian handcuffs in the 17th century but it also suffered a serious blow from the philosophers. It is only recently that the serious blow has been realised. Descartes laid it down that man consisted of a material body which worked like any other machine and of a spiritual mind which had quite a different mode of existence. So there was an end to the connection between priest and physician which had been so close in the temples of Egypt and Greece, and also in the monasteries of the Middle Ages. The priest was given the care of souls and monasteries of the Middle Ages. The priest was given the care of souls and the physician the care of bodies, and both professions were expected to stay strictly on their own side of the fence, or at least to make any trespassing quite unofficial.
Yet, in spite of the comparative neglect of the mental side of healing, the position of the G.P. some nine or ten years ago was not so very different from that of the school of Cos. Naturally, he knew a little more, but in his relationship to his patients he had the true Hippocratic approach, and also the Hippocratic conscientiousness. The specialist and the hospital doctor had to belong to the school of Cnidus, and deal with cases of this and that as they came in, but most of the general practitioners still preserved some of the virtues of the old family doctor.
It is true that modern progress in medicine had gravely undermined the status of the family doctor even before the National Health Service began. He could not keep abreast of progress in every field, and he could not install all the new gadgets which proved so useful, so that more and more of his serious cases had to be passed on to other hands. But he did try to preserve the doctor-
The relationship between patient and doctor, before the passing of the National Health Services Act, was unique. The patient came to the doctor with some physical symptoms of illness, but the doctor knew that he had his mental or emotional lesions as well. And the efficacy of the doctor’s treatment depended almost entirely, not on the medicines or treatment he prescribed, but on the trust and confidence which the patient had in him. In other words, the doctor treated his patient as an individual, different from every other patient on his list, and he always tried to find out as much as possible about him, so that he could treat not just a single limb or organ, but the whole man. He had every opportunity, of course, of building up his knowledge about each patient; he had visited him in his home, and probably seen other members of the family; he had a good deal of the atmosphere of that home. He may have known the patient for years, or perhaps known his father and mother. He certainly knew enough about the patient to treat him as an individual and not another case of soansoitis. And he took a personal pride in treating his personal patients.
But now in many cases what a change there has been! I am not blaming the National Health Service Act for all the deterioration in the doctor-
Here is Kenneth Walker’s description of the ‘service’ of the Mayo Clinic:
“From the moment of his entry there the patient is, so to speak, caught up on a delivery belt and weighed, measured, photographed, X-
I suppose that something like that will happen when we get our new health centres as outlined in the 1948 Act -
The State has become between doctor and patient. The State employs the doctor and expects him to consider the State’s interests as well as those of the patient. He has to spend a lot of time filling up forms of one sort or another. He has little time to practice his art or to apply his scientific skills properly. He can only deal with the simple cases himself, and direct the others to some hospital or specialist for further treatment or examination.
As for the patient, he may, in some cases, retain the old attitude of friendly confidence in his doctor, and, realising how busy he is, he may not call on his services until the need is pressing. But in other cases -
But this natural impulse strikes at the root of the fine traditions of the medical profession. It is symptomatic of the irritations which have been aroused in the profession by the National Health Service. We have all experienced most of them in some degree or other. We all feel the need for more time to keep abreast of modern progress, and we all deplore the waste of time we spend in filling up forms and dealing with people who are not really in need of medical attention -
There are other things in the service which might be improved: notably the inability of doctors to keep in touch with their patients when these have been sent to hospital. Then there is the tendency of big organisations to try to set up their own little machines with the big State machine. A certain nationalised industry, for example, which has a strong desire to be self-
In the old days, indeed, mirabile dictu the patient might well have dealt with the matter himself, and bathed and bandaged the finger when he got home. But the National Health Service as part of the Welfare State, does not encourage people to think for themselves. It tells them all about their rights, but it never thinks of telling them about their duties, or about their moral obligations if they intend to enjoy those rights. Dr Frangcon Roberts diagnosed this difficulty very neatly a few years ago when he said:
“A free and comprehensive health service is a noble ideal, but one which the country cannot under existing conditions attain. When the people realize that the benefits which can be derived from the Service depended primarily upon national productions, and that these benefits are adversely affected by all inflationary tendencies -
Dr. Roberts was thinking of the great mass of the people when he talked about the conquest of ourselves, and about adapting ourselves to changes, but I am going to apply the words to us doctors. For, believe me, unless we do something about it, we shall find the medical profession rapidly being paralysed, and losing all its vitality, in the grip of the Welfare State.
It is my firm belief that the basis or king-
That being so, the family doctor must devise his own protective mechanism in the new and uncomfortable conditions in which he has to live and practice his art. And that brings me to the third of my pictures -
It will of course, have to develop its trade unions. Not one union, but many. For we could not possibly have a single trade union for both doctors and surgeons. Nor would it really be correct for graduates of one medical school to belong to the same union as those from another. Gentlemen from Edinburgh, for example, could not be expected to belong to the same union as fellows from London, and gentlemen from London would be equally averse to being mixed up with these fellows from Dublin. Then again it would be necessary for each kind of specialist to belong to his own special union. The E.N.T. brigade would be one of the first, but the numbers would rapidly multiply, until we had such things as fantastic counterparts of the A.S.L.E.F. in the association of specialists in the lancing of esoteric furnacles, and of the transport and General Workers Union in the Terminators of Gravid wombs or uteri.
Already the trade-
So here is my 1965 dream-
Monday morning surgery is at 9 a.m. and there are already a few patients queuing up outside in the rain as the hour strikes. Dr. Tud (trade union doctor) is very conscientious and he goes and opens the door of the waiting room for them to sit in. “Silly of you to come before time,” he says. “You will only catch cold standing in the rain. And your wet clothes will spoil my furniture.”
After this gracious and gratuitous advice, he retires into the surgery where he clocks in by opening his case book, and time keeping it 9 a.m. Then he puts the kettle on and makes a cup of tea for himself and his very attractive and moderately efficient secretary.
At 9.20 he opens the door and announces that he is ready to receive the first patient. It is a man, so the first question he asks is: “What is your union?”
“I don’t belong to a union.”
“You don’t belong to a union? What do you do for a living?”
“I’m a Clerk.”
“Well, what's wrong with you?”
“I’ve a pain here” (touching epigastrium). “Makes me feel sick sometimes.”
“Comes on before meals, I suppose?”
“Yes, a long time before sometimes.”
Here Dr. Tud places a thermometer in the patient’s mouth and feels his pulse. No fever is apparent. He pushes back his chair and stands up.
“Sorry I can’t treat you. You’ve got a bad duodenal, and duodenals are caused by worry. You’ll have to go and see a psychotherapist. Here’s the address.”
“But I'm in pain, doctor. Can’t you give me something to stop it?”
“Sorry. I could, of course, but that would be interfering with Dr. Flanagan’s work. He’s your man and your his pigeon. My union won’t let me. And you ought to join a union yourself, you know. That’s the best advice I can give you. Take some of the worries off your shoulders.” And then, with a faint touch of compassion for a man almost at the end of his tether, he adds: “Look, its a long way to Dr. Allen’s and his surgery might be over by the time you get there. Here’s a couple of tablets to suck on the way. But don’t tell him I gave you them.”
The second patient comes in. It is a woman. Complains of dysmenorrhoea. Dr. Tud scribbles down ‘Prescription No. 13’ and says: “Take this to the chemist’s around the corner. That’ll put you right. Good morning.” Total time occupied with this case is 15.7 seconds, helping to bring the average time of each case down to the statutory one as laid down by the Executive Body.
The third patient is a hefty fellow looking very fit. But one of his eyes is rather red and inflamed.
“Boilermakers’ Union,” he says before the doctor can utter a word. Evidently there is some sort of freemasonry among the union members. Dr. Tud smiles. “And what can I do for you, mate?”
“Well, its me eye, doc. Think I must have got a bit of steel in it at work. It was a bit sore yesterday, and when I was having a couple of pints last night one of my pals said I ought to have it seen to and quick. He’d been off for a month, he said, and it all started with an eye no worse than mine. And it does feel bad this morning.”
Dr. Tud makes a careful examination but can see nothing wrong embedded in the cornea. There is some conjunctivitis which might be due to dust or drink. He looks grave, and after writing out ‘Prescription No. 19’ and adding ‘One eyeshield,’ he says: “You did right to come and see me. You can’t be too careful with your eyes. I’ll sign you off work for a few days. Take this prescription to the chemist round the corner and bathe your eye every two or three hours. Wear the shield if you go out and come and see me again about the end of the week. I may have to send you to an eye specialist if it does not get any better, mate.”
One or two more patients come in and then the clock strikes ten. Dr. Tud clocks out by time stamping his case book again. But he continues with the surgery. He believes in looking after his patients, especially the union members.
And besides, he is now on time-
The next patient is a young mother with her son. The young lad has been complaining of earache. That is easily dealt with. It just means prescribing No. 23 on Dr. Tud’s list of 24 which are all he uses, and which are now ‘official,’ not only at the chemist’s round the corner but all over the country. Anything outside this list has to be prescribed by a specialist. Then Dr. Tud looks at the mother, and another touch of the unfashionable humanitarian feeling shakes him. After all, his father was a real family doctor. “And how are you feeling, yourself?” he asks.
“I’m all right” is the answer -
“Not Dr. Nervo,” says the woman. “He asks too many awkward questions and I don’t like strange men asking me questions.” She looks pathetically at Dr. Tud, but his moment of human weakness has passed and does not accept the unspoken offer. He hurriedly writes ‘Prescription No. 1’ (Mist. Bromoval) and sends her off to the chemist around the corner.
Dr. Tud’s surgeries on the following days are very simular, but by Thursday afternoon he feels that he has done enough and earned enough for one week, so he fastens a printed notice to the outer door: ‘No Surgery till Monday morning’ and goes off for a weekend’s golf at Woodhall Spa. Woodhall Spa sounds better if he has to explain his absence, but that is very unlikely. It might lead to a strike.
At Woodhall he meets several medicos from neighbouring counties, and one of them says to him: “I say, Tud, do you ever see anything of old Dr. V. these days? He used to enjoy a game of golf as well as anybody, but I never see him nowadays. What’s happened to him?”
Dr. Tud glances round and then buttonholes his questioner and leads him into a quiet corner. “I’m afraid V’s in a bad way,” he says in a low voice. “You know how old-
“How disgusting,” says the other. “Why did he not send for the ambulance?”
“He did ring up, of course, but they had all been rather busy that day and the only driver in had to have his statutory rest before he could go out again. So V. got fed up with the delay and stitched them up himself.”
“He ought to be reported.”
“Yes, and he ought to be watched, too. He’s a positive menace to medical progress and to our standard of living.”
At this point I woke up, as you can well imagine.
You might think my glimpse of the future rather far-
The old family doctor could deal with the difficulty because he knew the patient so well, and because the patient trusted him, and felt that he was on his side. A psychological examination could be carried out without the patient being aware of the fact; in his view the doctor was just being polite and friendly, and hidden worries could be brought out to the surface without upsetting the patient or spoiling the friendly relationship. I do not mean to suggest that any deep examination could be carried out, but the family doctor could often learn to bolster up his physical remedies with some sound psychological advice, and so give his drugs a much better chance of doing their stuff.
Now what is the prognosis? I have diagnosed this compound fracture in the doctor-
I think it is absolutely essential for the health of the people to maintain the old family doctor relationship as the basis of the National Health structure. That can only be done by limiting the number of patients on each panel, and by paying the doctor a more reasonable capitation fee. At present, there is usually plenty of money for specialist gadgets and new medicines and drugs, but less money for the G.P. That is wrong. If the G.P’s were better paid for smaller panels they would be able to take far better care of their patients, and a lot of the consultations and special treatments would be unnecessary. After all, a National Health Service is supposed to preserve the health of the people, and it is on the prevention of disease, or on the treatment of disease in its early and vulnerable stages that we should concentrate our forces. As it is we let the enemy gain a foothold without opposition and then have to bring out all our heavy artillery to dislodge him.
I have given you my nightmare version of what the G.P. might develop into if he succumbs to the prevalent social diseases of our time. But in my present position of family doctor, if I may so term it, to all the doctors in the district, I feel that I ought to give you some reassurance and hope as well. I found this myself in the Utopian picture painted by Dr. Balint in a recent book in which he recorded the results of the research done at the Tavistock Clinic on the psychological implications of general medical practice. (The Doctor, the Patient, and His Illness: Pitman Medical, 1957.) I ought perhaps to tell you that Dr. Balint is a psychiatrist, and that the mental side of illness -
In his final chapter, Dr. Balint declares that “the more one learns of the problem of general practice, the more impressed one becomes with the immense need for psychotherapy.” Therefore, in his Utopia the general practitioner has had some basic training in the art not psychiatry or deep analysis, but in what might be called ‘minor psychotherapy.’ Economic limitations and professional jealousies have also been eliminated, and the doctor is able to respond freely to the patient’s ‘offers’ or suggestions of what might be wrong.
In this Utopia the G.P. is the king pin of the State medical service. He deals with the human problem and calls in the help of the hospital specialists only to help with the scientific problems. The specialist will not be a ‘super mentor,’ but general practitioner’s expert assistant. The G.P. will “no longer be able to disappear behind the strong and impenetrable facade of a bored overworked, but not very responsible prescriber of drugs and writer of innumerable letters, certificates, and requests for examinations; instead he will have to shoulder the privilege of undivided responsibility for people’s health and well-
He will have learnt that the ‘clinical illness’ so well understood and treated in hospitals are only episodes in a long history, and it will be his duty to keep a watch on his patient even while the hospital treatment is in progress. For he will know that in many cases (here I quote): “any such episode represents only one of the several ‘illnesses’ that a patient ‘offers or proposes’ to his doctor. The way the doctor ‘responds’ to these ‘offers’ has signal consequences for the patient’s future. Much more is meant by this than the possibility of overworking an organic process, the frightening bogy that our present training system has so successfully implanted in every doctor’s mind.”
Yes, the Utopian General Practitioner is in full charge of his patient, and he has the time to follow the medical history of every one of his patients in health or illness. Indeed, he will find that his patients coming to him in the very early stages of any illness, before it has become ‘organised.’ He will know when to treat the clinical illness, and when to concentrate more on the underlying mental conflict.
Obviously, if we are going to progress, the G.P. is going to have to shoulder an immense amount of responsibility. But he will also feel free once more, and be able to take that pride in his work which was ours before the National Health Service organised us into scribblers of prescriptions and certificates. And I am sure that you will agree with me that the burden of extra responsibility will be gladly shouldered if we can get back to our former status, and make the school of Cos at least the equal of Cnidus . . . I wonder?