Dr Derek Wylie: St Thomas’ Hospital

In this interview from the AAGBI’s archives, Dr Derek Wylie discusses his life at St Thomas’ Hospital, where he completed his initial training and eventually became Dean of the Medical School in 1974. He was also Dean of the Faculty of Anaesthetists (forerunner of the Royal College of Anaesthetists) from 1967 -1970. Dr Wylie was very involved in the education and training of undergraduates and junior doctors, and met every one of his students whilst Dean of St Thomas’, something that is remembered fondly by many of his former trainees.

St.thomas.hospital.arp.750pix.jpg
St Thomas’ Hospital, c.2004

Beginnings at St Thomas’

I had a typically northern middle-class upbringing in West Yorkshire. My father was a dental surgeon and I went to private prep school, and to a school called Uppingham where I didn’t do very well academically. I went to a crammer and I got in to Cambridge in 1938. I wasn’t set upon a career in medicine, but my father was, and I did as I was told, I suppose like many boys and girls in those days, you followed what your parents hoped you would do. And I must say I thoroughly enjoyed myself at Cambridge. It was shortened by the war; I’d got a year of peace at Cambridge and a year of the war. Then I went on to St Thomas’ Hospital Medical School in London, arriving just after the hospital had been blitzed and bombed.

“I arrived at St Thomas’ just after the hospital had been blitzed and bombed”

I got house jobs at St Thomas’—casualty officer, what we called resident anaesthetist… and then house physician. And then there was this question of going into the services… Some of you went up for another six months; some of you went into the services straightaway. I went up for another six months and another six months after that, and I was really destined to be a physician. I did my membership in what was then the old-fashioned Diploma of Anaesthetics. And I went into the RAF at the end of the war and I was a physician in the Middle East.

I’d done the anaesthetic post at St Thomas’, but I didn’t see myself as a career anaesthetist. And it was only when I got a letter from the senior anaesthetist at St Thomas’ in 1946, asking I was interested in a vacancy on the honorary staff at St Thomas’ when I came out of the RAF… I’d never thought about it.

“There was no senior resident anaesthetist in London; we were left to our own devices…”

There was a full-time resident anaesthetist, but because of the war, St Thomas’ was split into various parts of Surrey. And there was no senior resident anaesthetist in London; we were left to our own devices, which was not very good.

 

Agents and Techniques

The standard of course was ether or chloroform, Evipan, hexobarbitone before thipentone came in, and then cyclopropane, because cyclopropane was this wonderful gas which Michael Noswothy used to demonstrate how he controlled respiration in thoracic anaesthesia for lung surgery.

Cyclopropane
Cyclopropane, 1952

I was taught how to use spinals, but not much with epidurals. Strangely enough, I was taught about epidurals by a physician in 1944. He said the best way to treat low backache is to inject saline into the epidural space.

“The tradition at St Thomas’ was for general practitioners… to be appointed as anaesthetists on staff”

At St Thomas’ Hospital, the honoraries got £50 a year, about £1 a week, to come and give their services. But there was still an emergency medical service after the war, so when I came out of the RAF you were supposed to go and find some private practice, and I did get something. I came out of the RAF in 1947 before the Health Service, and when it started I was delighted. I got a cheque every month after that.

The tradition at St Thomas’ was for general practitioners by and large to be appointed as anaesthetists on the staff, but there was one exception at St Thomas’ because the senior anaesthetist after the war who spent his wartime service in the navy as a whole-time anaesthetist. So, we had a sort of tradition of having somebody who was more interested in anaesthesia than in general practice.

“I hadn’t touched anything to do with anaesthetics for over two years… I was supposed to be training them, having had no training myself virtually”

It was a really dreadful example of how teaching hospitals in those far off days appointed their staff. There were in fact two vacancies after the war, and they gave the other one to a well-known anaesthetist. And they gave the other one to me as a young man who they thought had some prospects. So, I came back when I left the RAF with no knowledge of anaesthesia, I hadn’t touched anything to do with anaesthetics for over two years, and I had to learn. And strangely enough, most of the people who were my junior- registrars and people like that- had served as anaesthetists in the army. I was supposed to be training them, having had no training myself virtually. I had to work very hard to pick it up.

 

A Practice of Anaesthesia

Wylie
A Practice of Anaesthesia, 1st ed. 1960

I had written a previous book for the publishers on pain in childbirth, and after that, they asked me if I would edit a book on anaesthesia as a whole. The contract I signed was also in the name of another well-known anaesthetist, but I think he realised what the task was meant to be after about six months and opted out. At that stage I was rather at a loss as to who to invite to join me, and Harry Churchill-Davidson, who was then a senior registrar but was just about to be appointed to the staff of St Thomas’, joined me.

“The only way we could investigate [new drugs] was by giving them to ourselves and seeing what happened”

Harry did a lot of work on muscle relaxants as a whole. He was really into the research field. I did some clinical investigations into a muscle relaxant called gallamine, trade name Flaxedil. There were other relaxants which various drug firms gave to us and said ‘would you like to investigate?’ The only way we could investigate was by giving them to ourselves and seeing what happened.

Flaxedil
Flaxedil, gallamine triethiodide

 

Deaths Associated with Anaesthesia

I suspect I got involved [in the wider field of anaesthesia] because of the Association of Anaesthetists’ investigations into deaths. I was one of the four of the original committee. I was the very junior member and I think I was probably invited to join because there were people on the council of the Association of Anaesthetists who knew me… I learnt an enormous amount, and that was a national investigation into deaths associated with anaesthesia.

Deaths

It was a totally voluntary exercise and we invited anaesthetists, or the heads of departments, to send all the deaths associated with anaesthesia and around the surgical period [and] the perioperative period.

 

The Status of Anaesthesia and Anaesthetists

From the point of view of my own hospital, there was no problem at all. This was what upset me when I became Dean of the Faculty [of Anaesthesia]. Quite frankly, I thought the surgeons were extraordinarily arrogant about anaesthetists as whole, nation-wide, but I have to say that I had nothing but support from my surgical colleagues in St Thomas’ from the moment I got on the staff. There’d been a war, many of them had served in the forces, and they knew the value of having somebody competent dealing with the patient as whole, rather than just a part of the patient.

“Anaesthetists knew the value of having somebody dealing with the patient as a whole, rather than just a part of the patient”

Although I didn’t know much about anaesthesia when I started, there were a tremendous support, and when I got onto the board of the Faculty, I realised this was not the position around the country, and I think I understand why. We were at the stage then when a great many anaesthetists were not very well trained at all, and they were perfectly content to walk into the operating theatre and give an anaesthetic irrespective of the state of the health of the patient and walk out again and not bother about the patient any more.

I think the big problem the Faculty had was to raise the status of anaesthetists, ensuring that the quality of those who practised anaesthesia was of the highest possible. You had to retrain young men and women to be not only competent practitioners in the operating theatre, but to have a wider knowledge than giving an anaesthetic. Preoperative care, postoperative care leading into intensive care, all the things we take for granted now, were emerging then.

I think that there was a succession of people who were able to ensure that the training system in hospitals throughout the country was improving the whole time. ‘Anaesthetists in training’ were being used as a pair of hands. And if you raised the standard of training too high, then they couldn’t get pairs of hands, because people in training had to have more time to read their books and to learn more about medicine as whole. So, we did succeed I think in getting the standards to rise, but it’s taken a very long time to get to where we are now.

 

Education

“I’ve never been convinced that pure academic ability makes a good doctor”

I’m no politician myself; in fact I’ve always had a great distrust of politicians and of medical politicians in particular. I don’t know really what it is that makes one land up holding these sorts of positions. I think it is just that perhaps your colleagues think you could do that job better than somebody else would do it. Of course, I’d been on the staff at St Thomas’ for a long time, I think that I got on fairly well with the young doctors and helped to teach undergraduate students something about anaesthesia, and perhaps my colleagues thought that I would do the job reasonably well. But I did develop quite strong views about medical education, undergraduate selection in particular.

I’ve never been convinced that pure academic ability makes a good doctor. Not a popular theory to have… The only really objective method of assessment is perhaps the results of examination, and that has its limitations, but that doesn’t make you a good doctor. And I saw every single potential doctor or student at St Thomas’ over my period of deanship personally, but always with other people when we came to selecting them.

“There’s never enough time… you can’t train a doctor in five years… it goes on the whole of your working life”

Because I did a lot of medical legal work at the Medical Defence Union before I was Dean, and of course while I was Dean, I was well aware of the fact that many doctors were pretty good at their job as doctors, but they didn’t have much of an idea of how to handle patients. And that’s a contradiction in terms. If you are a good doctor, you have to handle patients, but a lot of them were awfully arrogant and didn’t like being questioned about what was going on. Perhaps they still are, I don’t know, but I felt it was very important that potential doctors knew a great deal more about that side of medicine than just the purely clinical side where you learnt how to listen to the heart and prescribe drugs and things like that.

I never really got round to changing the medical curriculum in St Thomas’, because you had to work within the guidelines put down by the General Medical Council. But even adding to that, there’s never enough time, and we all know now that you can’t train a doctor in five years of undergraduate training, it goes on the whole of your working life.

 

The Medical Defence Union

I retired in 1979 from the Health Service, and I think I left the Medical Defence Union in about 1990, finally, when I was President for about five or six years. Incidentally, the Union of course if a world-wide organisation, so you were also trying to help doctors in other parts of the world. The problems were different. In some countries there were no problems because the patients as a whole did not sue, and they didn’t have a media telling them what doctors shouldn’t be doing. I mean, at the moment of course the media are very intrusive.

I think a lot of the medico legal problems related to anaesthesia, well some of them of course were a group of just bad doctors, doctors practising bad anaesthesia and making culpable mistakes. But I thought that perhaps not enough anaesthetists were prepared to look at the patient as a whole and foresee what might happen then they administered anaesthesia in the circumstances of surgery. They were not prepared to take a wider interest in the care of the patient.

“I’m an optimist and I think the media does an enormous amount of harm to medicine by intruding and giving the wrong impression”

You sign away as a patient your rights when you go into hospital, and the surgeon is supposed to give a description of what he’s going to do to the patient, and give them some indication of what might happen. The anaesthetist is just included on the consent form, saying ‘And I submit myself to an anaesthetic, general or local as maybe’. I have thought for a long time that the anaesthetist should have to explain what the implication of that anaesthetic might be.

I’m an optimist and I think the media does an enormous amount of harm to medicine by intruding and giving the wrong impression. I strongly suspect from talking to people who are still in the hospital service or in general practice… I get the impression that life is very busy but much more efficient in the hospital service. But this is a big teaching hospital. I’m not disposed to think that there is something wrong with the Health Service… I have very little experience before it started, but I know I was very pleased to see it start and I accepted the changes. I do recollect that my senior colleagues at St Thomas’ at that time thought it was awful to have this new system imposed on them.

I became Dean of the Medical School at St Thomas’, just when the socialist government at the time had abolished the Board of Governors. Our independence went. Again, we lived though it and the service didn’t deteriorate or anything like that. I don’t know whether the expectations of patients have changed. All the ones I’ve talked to in the country who have been in hospital are full of praise, quite contrary to what one might think listening and reading what’s in the media.

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