After attending medical school at St Andrew’s, Prof Jennifer Hunter completed her training at Alder Hey Children’s Hospital in Liverpool, where she began her career in academic anaesthesia. Prof Hunter has been a lecturer at Liverpool’s Department of Anaesthesia, an Honorary Secretary for the Anaesthetic Research Society and was the first woman to become the Editor-in-Chief of the British Journal of Anaesthesia, and the Chair of the BJA Board. For the full transcript, click here.
“I’m going to be a doctor, just like you”
I’m part of the post-War baby boom. My early life was a very happy one… for which I’m very grateful. My father was still in the army when I needed to go to school, so my first school was in an army station in Kenya… But I was starting to talk in the local language, my mother was getting worried. So at the age of nearly nine I was sent to boarding school in St Andrew’s, which was a huge wrench for me.
When I was 14 I came out of boarding school and went to grammar school in Liverpool. But at that time I was very keen to be a doctor. When I first went to school, even in Kenya, my mother took me along for a medical and they asked me what I was going to do when I grew up and, much to my mother’s surprise at five, I sat on the doctor’s knee and said, ‘I’m going to be a doctor just like you,’ and she nearly fell off the seat!
I elected to go back to St Andrew’s to go to university and I was terribly happy. And it was just at the time when they were starting to take more women into medical school. So of 95 in my year at St Andrew’s, 17 were women, but if you’d gone back 10 years earlier, there had only been 10. I loved every minute of it really, I’d do it again!
And then I did my house jobs in Dundee, which was then a college of St Andrew’s, it became a university in its own right when I was there. I had been quite interested in psychiatry as an undergraduate because we were taught it very well, and I did six months psychiatry after house jobs but I very rapidly realised that I couldn’t keep quiet for long enough to be a good psychiatrist!
“There was a mystique about anaesthesia…”
But when I was a surgical houseman I was more interested in what the anaesthetist was doing than what the surgeon was doing actually; there was a mystique about it, how was it that these drugs were putting people to sleep and then they were waking up? And I also was very keen to use my hands in my work. I did enjoy my surgical house job and I was encouraged to take up surgery by those consultants I worked with then, but I don’t think I was ambitious enough then, at that stage, to have succeeded as a woman in surgery because there were still huge challenges for women in surgery then. And I didn’t have the desire to beat everybody else to it, I didn’t have that; I had the desire to do my work well but I didn’t have the desire to beat the next person to it. And I think a woman in surgery in my generation needed still to have that drive.
“After a month of training we were on call… after two month’s [were] emergency caesarean sections…”
So after six months’ psychiatry I managed to get an SHO job in anaesthetics in Dundee, which I thoroughly enjoyed, but when I look back and think of some of the things I did… after a month of training we were on call, and there were several maternity homes where I could be sent out in the middle of the night after just a couple of months’ experience to do emergency caesarean sections. And they did children’s dental work in the back streets of Dundee, where it was thought that children should all have their teeth out for their 21st birthday, that sort of era, and I was being sent to do chair dentals at three months’ experience.
Alder Hey & The Liverpool Technique
I worked in ignorance but it was a good grounding in the breadth of anaesthesia experience. After the Primary I applied for what was still labelled an SHO job in anaesthetics at Alder Hey Children’s Hospital, passed my final Fellowship 1975, and did a year at Alder Hey, which I thoroughly enjoyed. But I still didn’t think I was ever going to be a consultant, I was still at the SHO grade and enjoying myself, and it was very hard work and you got every infection in the book; I used to think I’d have cholera by the time I’d worked for a year at Alder Hey.
Because the Liverpool Anaesthetic Technique was really only still being practiced in its purity at Alder Hey, people came from round the world to Liverpool to train in paediatric anaesthesia. Jackson Rees and Gordon Bush, these were the greats of paediatric anaesthesia and I just lapped it up really. Gordon Bush was the best technical anaesthetist I’ve ever seen in action; he was superb. We’re talking now about the mid to late seventies when they were developing fibre-optic techniques for intubation in these small children with difficult airways and things, so he was leading the way. It was an honour to work with these people.
“People came from round the world to Liverpool to train… It was an honour to work with these people”
In Dundee when you went into work on the Monday morning, the first conversation was about how successful your shooting or fishing had been over the weekend or your sailing; whereas when you went in to Jackson Rees on a Monday morning it was to talk about residual volumes and airway trapping in paediatric cardiac patients. It was just a different world. And that was late seventies, the end of the first Professor of Anaesthesia in Liverpool, Cecil Gray’s reign. Whilst he was still working the Liverpool Technique had to be practiced and hyperventilation and profound neuromuscular block and analgesics, but limited use of inhalation agents, and it was just coming to an end as I got there. So in adult practice I didn’t really ever use the pure Liverpool Technique, although some of my supervisors were still using it.
And then I got an SR job in Liverpool; those were the best years. The Fellowship was out of the way and the pressures weren’t on and I was enjoying contributing to the teaching of the postgraduates. I was working at a very good cardiac unit led by a bit of a maverick of Cecil Gray’s era, Dickie Richardson. Dickie Richardson was a superb anaesthetist and also superb at using four-letter words and telling people where to get lost; he didn’t like people to question him too much. So it was always considered a bit of joke that he encouraged me to apply for a lecturer’s job, because it was thought that I might apply for his job in his unit and I’d give him too much hassle!
“I got an SR job in Liverpool; those were the best years”
So I applied for a lecturer’s job just as the second Professor of Anaesthesia, John Utting, was appointed. He was appointed to the Chair in ’78 and in November ’78 I went into the department as a senior registrar/lecturer and this was probably my main bit of good fortune.
John Utting was approached to do work into atracurium, and that was a huge opportunity for me and meant doing clinical research which I liked, dealing with patients and collecting data. And the door opened because atracurium and then vecuronium came along and for the whole of the next decade that was my research interest, and I became a senior lecturer. I was even then thinking particularly of an academic career but Professor Jones and Professor Utting, started to put the pressure on for me to do a higher degree. So I did my PhD based on the work we’d done on atracurium and vecuronium.
Research in the USA
And I had three sessions in the States during the eighties, at Boston, in Nashville, Tennessee, and in Oregon and Portland.
The way research in America was carried out was very different. There were many differences ‘cause there was an infinite supply of cash to do the work, so all the facilities were there. That’s probably the main difference. You could get staff, laboratory staff, clinical staff; you could get the space to have your laboratories, and in that sense it was another world. They seemed so well off compared with universities in the UK; you didn’t have to fight for money all the time and support. But the actual work that was being done wasn’t that different. It was just the whole ambience of doing it was different. Getting grants was much easier than getting research grants in the UK. And in the eighties, of course, the pharmaceutical industry was supporting a lot of our work, but it was only the easy way to get research money.
Women in Anaesthesia
By the early nineties I’d established my own research group… [and] I was still doing quite a bit of teaching of the veterinary and medical students, and setting up modules for veterinary anaesthesia study at undergraduate and postgraduate level. And so by the early nineties you might have thought that perhaps I’d exhausted atracurium and vecuronium, but then mivacurium and cisatracurium came along and I was freewheeling. By the early nineties I’d presented at the Anaesthetic Research Society a significant number of times and so my first national appointment was as Honorary Secretary to the ARS; I was the first woman to do that and the first woman on their council, and I was involved with the ARS for a long time.
“By the early nineties I’d established my own research group…”
At that time Alistair Spence officially wrote to me to join the ARS Committee and was also Chairman of the British Journal of Anaesthesia board then. At that time, so we’re into the early nineties, there were a few members of the BJA board who I’d had, for various reasons, contact with. John Edmund Riding was the fifth editor of the journal, and he was one of my big mentors in Liverpool. He was an NHS consultant but he’d been Dean of the Faculty of Anaesthetists and he actually had a wife who’d struggled to get a consultant appointment in her time with young children, so he was hugely supportive of women in anaesthesia in Merseyside and when Dr Riding was Dean of the Faculty of Anaesthetists, he had been involved with the instigation of part-time training for women, and so in Merseyside… we started the ball rolling, we got some very good, slightly older, married women with children taking up part-time training in anaesthesia and thanks to him we led the way.
I was then Deputy Regional Advisor for Mersey so I was instigating the administration of this with Dr Riding. But I think that there was a lot of discussion when Dr Riding put my name up to be a member of the board of the British Journal of Anaesthesia because they’d not had a woman and it was a bit of an old boys’ club. I must mention at that stage in my career, that Jimmy Payne was in the BOC Chair at the Royal London, and he too was quite a supporter of women and because he’d done neuromuscular work and presented at meetings alongside me, he stopped me once on the doorstep of the College when we were in Russell Square and the Chair was advertised in Liverpool and he said to me, ‘You must apply for this Chair for women in anaesthesia, and there’s no excuse, you must apply for it!’ And so I had support from him and by a slim majority I was elected in ’89-90 onto the BJA board.
Soon after that Alistair Spence became president of the College, and so he left and George Hall became the Chairman of the BJA board. He was at St George’s Hospital in London, and was very supportive of girls too. By the nineties there were certain guys who were helping women quite positively to progress, and it was up to the girls then to take the opportunity.
Editor in Chief of the BJA
George Hall immediately made me Secretary of the BJA board which was like being thrown in at the deep end, because I knew nothing about the structure, but it meant that I had to write down everything that happened so I very rapidly learnt the game. And Graham Smith was editor of the journal at that time and when he got to the end of his 10 years, he and George Hall cornered me when we were in the World Congress in Sydney in 1996 and strongly advised me to apply to be the next Editor-in-Chief, which came as a bit of a surprise actually! I was willing to do more for the journal, I was enjoying the journal enormously, but I didn’t really expect this, but I think again, this is a rather female’s fatalistic sort of streak, I just took it. Once they said, ‘You should apply,’ I applied, and so in 1997 I became Editor-in-Chief of the British Journal of Anaesthesia, which was a huge task, which I did for the following eight years until in 2006 I became the Chairman.
But the editorship of the journal takes over your life, you know, it’s so busy that you can’t really say you enjoy it, but I feel that that was the major achievement of my life really, because I’ve met so many people, both physically and electronically, I mean names of people round the world whose faces I never met but I feel I know because I’ve edited their work. And I learnt a lot about areas of anaesthesia that I didn’t practice because I was having to edit their work, like cardiac work, pain and things like that, and I met a lot of people who I’d never otherwise have met and I’m very, very grateful for that. In fact, when I retired from clinical practice and had to step down from the journal, it was the biggest break to make really because they were my professional friends and I enjoyed it so much.
“The editorship of the journal takes over your life, it’s so busy you can’t say you enjoy it, but… [it was] the major achievement of my life…”
When you apply for the editorship, you have to produce an equivalent of a business plan on how you’d run the journal. Up till that time there’d just been one editor, there hadn’t been an Editor-in-Chief as such, but the editor had help doing all the reviews in the journal which was a substantial amount of work, and each editor tended to have a local anaesthetist supporting them. We changed the system when I started to four editors independently working on manuscripts assisting me, because by the time I took over we were getting about 850 manuscripts a year, so one person couldn’t do that. And I set up the electronic handling of these manuscripts so we could send them electronically to each other and edit them accordingly. So it was a time of change and by the time I passed on to Charles Riley in 2006 we were getting over 1,000 manuscripts a year and now it’s up to 1,500. Interestingly enough going electronic has attracted more manuscripts to be submitted from round the world, because it’s easier to submit a manuscript electronically than to post a paper copy!
There’s a public side to being Editor-in-Chief as well because you’re seen as a spokesperson. I don’t think I realised that when I started really but in some ways even more than the President of the College, dare I say it, or the President of the Association, when you go round the world everybody knows who the Editor-in-Chief of the British Journal of Anaesthesia is. The contacts round the world are significant and of course we were trying all the time to improve the international standing of the journal by having Chinese issues and South African issues similarly. And we still do Portuguese issues. We tried hard to get into South America, which I’ve thought about a lot with the Olympic Games, but we didn’t succeed in that respect because Anaesthesia and Analgesia have got a grip over Spanish and Portuguese translations for South America. When I went to medical school I never thought I would learn so much about publishing and all this sort of thing… I learnt a huge amount and I’m very glad I did it, but you go on holiday with a pile of manuscripts, there isn’t a day when you don’t work.
“When I went to medical school, I never thought I’d learn so much about publishing!”
It is difficult to do both but by the time I took over the editorship of the journal, I’d got a research unit that was swinging, and I had research fellows who kept going and I continued to write, but by the end of that eight year period I realised that if I didn’t stop editing, my research would grind to a halt. But very fortuitously soon after that, sugammadex came along so the research on this reversal agent for antagonising neuromuscular blocking drugs, aminosteroids in particular, was a new start really and that came just as I took over the chairmanship and stopped editing the journal. The chairmanship was work but nothing like as much work as being Editor-in-Chief. In some ways I wonder if I was a better chairman than Editor-in-Chief but that was probably because I set my standards higher as an Editor-in-Chief, keeping everybody happy as an Editor-in-Chief is almost impossible.
So I was chairing a board, by which time we’d got two other ladies on out of 25, one was a scientist, Helen Galley, Professor in Aberdeen now, and a lady from Denmark, Anne Møller, and so getting women onto the board of the BJA was occurring, but it wasn’t because we were turning the women away, and this is an important point to make at this time, I think, that now there is no hindrance to women coming on but it’s up to women now, if they want to do it, they can do it now … I mean some women are ambitious, they must be to be PM and President of America, but I think there are fewer women who have that drive to get to the very top compared with men. I think there is a bit of a difference here because I strongly believe now that if women want to they can do it but the demands are such that they mightn’t always choose to. But chairing a board of 25 people, 23 of whom were all quite intelligent men and perhaps thought they were more intelligent than they were is not an easy task, though one had to treat it lightly and with humour otherwise you’d have gone under.
“I strongly believe now that if women want to they can do it, but the demands are such that they mightn’t always choose to”
When I was on the Board of the journal I had a personal view that there was a conflict of interest if you were on College Council and the Board of the journal as well. And I think this probably applies to the Association of Anaesthetists as well, because you must make decisions as editor of the journal or chairman of the Board, which are purely beneficial for that journal and if you’ve got the College Council business hanging over you as well you can’t make an independent decision. Now I would be in a minority of views over that because there are many members of the journal board who are on College Council as well. There are more academics on College Council now and I think it’s now becoming more important. But that was just my view and also the amount of time I was committing the BJA when I was editor, any other time I had had to be committed to Liverpool University and my clinical commitment, not to college council, I felt.
When I’d done my 40 years, I decided to retire from my clinical responsibility. I wanted to go when the going was good, I dreaded having a clinical disaster at the end of 40 years of luck and a good run. Because of my Emeritus title in the university, I still have access to all the university facilities and still spend at least two days a week doing academic work. In fact, it’s the serious end of the academic work now, it’s not teaching undergraduates which you can do when you’re half asleep, but it’s still writing manuscripts and preparing international lectures and those requests still keep rolling in. I’m at the stage where I can say no if I want because when you’re working you can’t really say no to teaching undergraduates when you’re in an academic role, even though it’s a bit tedious when you’ve been doing it for decades.
I applied three times to be an examiner in the Fellowship. I was the first female clinician to examine for the Part 2 of the Fellowship, when it was three parts. I very vividly remember it, it was still held in the Royal College of Surgeons in Lincoln’s Inn Fields, in the Pathology Department.
And the first time I applied to be an examiner I was about 35 and I was told to go home and come back when I was 40! And so eventually, I was appointed a Part 2 examiner and I did my 12 years but during that time the three part exam went down to two parts, and I was examining in the first part, all the time fighting to try and raise the academic standards because I felt that the academic standards were sinking really. By doing away with the Part 2 of the exam, the science was disappearing from the exam. But I did my 12 years of that, and again I enjoyed it because I met so many people in my specialty who I wouldn’t have otherwise because they worked in different parts of the country and their specialist interests weren’t mine, and I enjoyed that too.
“I was the first female clinician to examine for Part II of the Fellowship”
I examined abroad for several reasons. The Fellowship at that time had sittings in Cairo, in Columbo, and actually I never made the Iraq sittings because when the first Iraq War broke out they had to stop, but they did until then. But also, because of the Liverpool course which was one of the first courses after the war in anaesthesia in the UK, we had people coming especially from Commonwealth countries to Liverpool for decades. The first three professors of anaesthesia in Malaysia trained in Liverpool and did their fellowship there, so we continued to examine for their Fellowship when they tried to set up their own. There was always an external examiner from the UK, frequently from Liverpool, and so I examined a lot in Kuala Lumpur. I went to Hong Kong to examine but I think that was the Fellowship exchange system with the UK college.
The standards compared with standards in London were variable; I would say in Hong Kong it was the same as here. It’s very difficult when you were taking our exams and there’d be about 50 candidates and the average standard was undoubtedly less but you had to pass somebody, whatever the rules said, so the top 5% of the candidates probably would be equivalent to average candidates here. Of course a lot of these people were trying to get to Britain to work for the rest of their training because they didn’t have the equivalent of senior registrar jobs as it was then in their own country, so the standard was more variable. But when the College were going out to examine the standards were set, but my main memory is that it was hard work. In these countries they work very well, they’re hard… because all these trainees were having to work long hours as well as study.
Changes in Anaesthesia
Of course I’m bound to say the introduction of atracurium and vecuronium has changed clinical work the most, but probably of isolated clinical contributions, the laryngeal mask airway must stand out for our generation, mustn’t it? I mean it’s just amazing to me, I’m very proud of the fact that the BJA published Brain’s first paper on the laryngeal mask airway in ’82 and that was marvellous, but it’s amazing that Portex declined to produce it for him, but that must be a major contribution of our time.
“The laryngeal mask must stand out for our generation… It’s just amazing to me”
And then the areas related to anaesthesia, I think development of acute pain services post-operatively by anaesthetists has been a major step forward. But a lot of my clinical work was in intensive care in general adult intensive care, and that has just exploded in size, hasn’t it? When I was a houseman and an SHO in Dundee there was a three-bedded intensive care unit and the equivalent of the recovery room of the theatres, and now we have 25-bedded units with full-time intensivists and from my personal, clinical work, the development of intensive care to a freestanding specialty of high scientific calibre has been superb, I think. And out of hospital services that have been generated from that when you see these helicopters flying into major accidents and things. So the spread of anaesthetic interest beyond the operating theatre is very important, politically but also clinically, so it’s been great to see that explosion.
But of course the other main thing is the increasing numbers of anaesthetists, isn’t it? The profession has just exploded, it’s marvellous. But it’s still got some way to go from an academic point of view in equating with general surgery or all the sub-specialities in medicine. This specialty in society [needs] to be acknowledged in the same way as surgeons or physicians by the lay public… it’s still got some way to go.
“The profession has just exploded, it’s marvellous”
And if I might say on a purely personal level, this is why I’m hugely supportive of medical graduates still doing anaesthesia because I think if we allow non-medical people in to provide the service then this will certainly harm our standing in the layman’s eyes. I realise there’s an argument at the moment that there aren’t the trainees out there wanting to take up the specialty but that applies across the board. People aren’t just leaving Britain because they want to do anaesthetics elsewhere, they’re leaving because of disillusionment with medicine generally.
There’ll be ups and downs, we’ve seen a circle of political views go 360 degrees in our professional lifetime and it will happen again. That’s why I think I’ve never been attracted to medical politics because you just see the same old thing go round and round. Now I know it’s very important for anaesthetists to be represented in hospital administration locally and at national level and I want other people to do it, don’t get me wrong, but my interests have been more academic really.
An MBE [is] a bit like getting a third-class degree! I went to Buckingham Palace last autumn and there were 125 of us and I think I was 120th to go up! It’s an interesting experience. It was an interesting mix of people from the Princess Royal’s charities and from her other special interests, equine interests and the like. But she does her homework, she knew who was coming up, and she said, ‘Oh yes, there’s huge pressure, isn’t there, to get more awards for anaesthetists, I feel it every time I walk into your college!’
That’s an example of where our specialty is… to get national recognition from the lay public we’ve still got a long way to go, the surgeons and physicians are getting Knighthoods and anaesthetists are getting the MBE, there’s still a long way to go there.
I don’t regret being an anaesthetist… [or] have many regrets professionally at all. When I was at school there was a great pressure on me to apply for Oxford or Cambridge to do biochemistry. Apparently the year I was doing A levels, Oxford took just five girls to do medicine, and they were well-connected. But they wanted me to apply for biochemistry or natural sciences because they thought I’d get in but I was desperate to be a doctor! I wanted to go to Scotland really, back home, so I applied for Edinburgh and St Andrew’s and St Andrew’s offered me the place first and I took it but sometimes I think would my life have been any different if I’d have gone to Oxbridge? Academically I probably would have benefitted from that, but I’d still wanted to be a doctor, I’d still have had to get into medical school!
There’s always been a feisty side to me and at school I probably wasn’t that easy to handle because I was full of energy and I wasn’t being worn out sufficiently to settle down. And I think that’s probably why I’ve enjoyed a medical career, I think the burden both physically and academically managed to temper my energies sufficiently, but I would have got up to no good if I wasn’t kept fully occupied.