Why I left England; E. McNeil, M.D.

"opportunity," "politics," or "cli mate," but if I describe the con ditions under which I found my self practicing medicine in Eng land, the reader m.ay find his own answers. When I qualified as a physician and surgeon, the NHS had been established for five years and there was virtually no private practice of medicine in England. The prac tice of medicine in wartime did not offer any relevant basis for comparison with the system I found myself involved in; nor did the practice of medicine before Dr. McNeil came from England several years ago to the private practice of medicine in the United States. His article is reprinted by per mission from the January, 1971 issue of the magazine, Private Practice. 290 Why I Left England EDWARD L. McNEIL, M.D. 1939 as, in retrospect, that was another era about which the older practitioners were reluctant to talk. (I naturally suspected the old system of private practice wasn't good.) My only knowledge of private practice in the U.S.A. was from a small number of patients and friends who had been there and reported that medical care was very expensive and that one had to establish credit at a hospital before being treated or admitted.

It was not until I had been in my own solo practice in Yonkers, New York, for about two years that I realized the tremendous ad vantages of the private practice system. As a student I had always been more inclined toward the surgical disciplines, so my first "house job" was as House Surgeon in a Lon1971 WHY I LEFT ENGLAND 291 don hospital with two surgical wards, 36 male beds, and 36 fe male beds. There was also a small er ward of about 10 beds which was used to isolate clean ortho pedic cases and serve as a spare ward for overflows of one or the other sex. There was rarely an empty bed and I had the unpleas ant task of turning down at least two out of three requests by GP's for emergency admissions. Selec tive surgery cases had their ad missions arranged through the waiting lists compiled by OPD clinics. I later learned what it was like to be a GP trying to have a patient admitted for an emergency condi tion, telephoning five or six dif ferent hospitals without success, then, in frustration, sending the patient to the emergency depart ment of a hospital that had al ready turned down a request for admission, and hoping for the best.

In later years, London had what was called the Emergency Bed Service to which a GP could direct his requests for admission and they would call all the hospitals for him, then force the hospital they considered most able to adapt to an extra admission to take the patient. (This system was fine in theory, but in practice it would often take the EBS six to twelve hours to find a bed, and some patients could not wait that long.) As the only house surgeon for at least 80 surgical patients, in cluding some in the pediatric ward, I worked very hard but appreci ated the technical experience which I crammed into six months. Within two months of qualifying, I was performing laparotomies in the middle of the night, relying entirely on my own diagnostic abilities, relying on the house phy sician or obstetric house surgeon (also newly qualified) to give the anesthetic, and relying on only one scrub nurse for my surgical assist ance. (Before 5 P.M. I did have an Indian surgical registrar - a senior resident who was an ex cellent surgical tutor - to guide me, and the two attending sur geons did "rounds" every other day and a rushed "round" after their operating sessions.) Clinic Y5. G. P.

What humility I had as a "new boy" receded very quickly with the volume of experience, and I soon found myself agreeing with the other house staff that those doc tors out there in GP land had minimal medical knowledge and no manners. Fancy an experienced GP sending a patient to the Cas ualty Department with a scribbled note saying, "Please see and treat," with no history noted or any attempt at diagnosis; and such bad manners, when I had already 292 THE FREEMAN May told him on the telephone that I didn't have any empty beds and we had seven extra beds up in the corridors and down the middle of the ward! Assisting the Chief and the Registrar at the surgical clinic also put me in the position of ad vising GP's with decades of ex perience about the diagnosis and management of their patients. The conceit of youth! At the clin ics, the Chief would see the least number of patients and those most potentially interesting. The Reg istrar would share the remainder with the house surgeon. From the patients' point of view, it was pot luck whether they saw a real sur geon or me.

(Only a few years later, I found myself as a GP referring cases to the clinic and waiting a few months for a letter from a newly qualified pipsqueak house surgeon telling nle that the diagnosis had been considered to be "so and so," "such and such" had been done, and the patient was referred back to me on "such and such" medi cation.) I quite naturally came to the opinion that a newly qualified phy sician was at the peak of nledical knowledge and know-how and there after it was a steady decline in his knowledge and ability. I took com fort in the excellence of my medi cal training but was repeatedly surprised at meeting situations I had not been taught about and finding patients didn't all respond to treatment as they should. Some thing seemed wrong with the system. Little Prospect for Advancement as a Surgeon As previously mentioned, I was surgically inclined and considered I would eventually become a sur geon. A look at the prospects of surgical colleagues who were five or six years ahead of me in the race made me realize I might as well forget it. I knew many who had spent over five years in the specialty only to quit and go into general practice because the chances of becoming an attending surgeon (known as a Consultant) were so slim. A hospital of over 200 beds would only have one or two surgeons of consultant status and often the same surgeons would cover other hospitals as well. The only vacancies for consultantship occurred when a surgeon died or retired at the age of 65.