RONALD MACKINNON. Do we as doctors always put our patients first?

After his retirement, Dr Chris McCaffrey requested that his gravestone be inscribed:

‘I was always on the side of the patient‘. 

The ten tips for graduates by Emeritus Paediatric Prof. Kim Oates, P&I 12th January are a timely reminder to all of us of the primary reason for our existence – to put our patient first. It should be studied by recent graduates and remembered throughout their life long career.

The exhortations of Prof. Oates are a reminder of the mentoring of Dr Chris McCaffrey when he was superintendent of Royal Newcastle Hospital (1939-1965). I was fortunate to be accepted on his three year rotational resident training program from 1959 to 1961. Little known was his request after his retirement that his gravestone be inscribed, “I was always on the side of the patient”. Such was his zeal, enthusiasm and practical application for this principle that it became part of the DNA of his senior staff specialists and those us fortunate enough to have our early training by them at RNH. It remained part of that DNA for the remainder of our careers, totally influencing and enriching our patient contact. It was forever considered an honour to be invited to be involved in the maladies, the joys and tribulations of every individual brave enough to trust us.

At our first meeting with Chris McCaffrey as undergraduates on an exploratory visit he asked what activity we felt would be of benefit. Of course most wanted to perform an assisted appendicectomy or to become proficient in venesection. He widened our narrow horizons at that time and in the future by suggesting that it would be more in the interest of our future patients if we became proficient in the diagnosis of appendicitis especially in the very old, the very young, during late pregnancy and in patients hospitalised for other reasons. Did we know who could succumb to acute appendicitis? He stated that it was much easier to then be trained in the actual surgical procedure. However if that was the extent of what we wished to experience, he would assist!

In Sydney Hospital as students we observed large vats boiling water for “sterilising” surgical instruments. At that time this was performed in Newcastle by a Central Sterilising Department also using dry rather than wet surgical gloves. Central Sterilising was later implemented at RNSH with Dr McCaffrey’s advice. An ancient and ineffective autoclave in our small rural hospital was therefore early gifted to the local historical society and replaced with quality controlled autoclaving. This was later upgraded with truly expert regional sterilizing 100 km distant for all hospital and consulting room instruments.

Surgical attire was absolutely forbidden outside restricted areas, whereas today the most common offenders are the regrettably the most senior surgeons who as trend setters are regularly observed wearing operating theatre attire in the wards, in clinical meetings and hospital cafes. This is not in the interest of the patient, and persists in spite of the clear direction of hospital administration, Infection Control, letters to editors in the media and Accreditation Committees, and would never have been tolerated by Dr McCaffrey.

He also instituted “Rooming In” with newborn babies handled very strictly only by mothers. Handling by others was to be fully gowned and gloved. Neonatal cross infection was reduced significantly.

On the hospital notice board was a list of surgical teams and their pathological tissue rates. All removed tissue was sent for histological examination. A team with a pathological tissue rate varying from an acceptable average was told to lift their game. I once provided the 76% pathological appendix rate at our small rural hospital at an annual hospital board meeting and challenged the guest regional Director of Health to shame the larger regional hospitals with their unacceptably low rates to lift their game.

When the Director told the public meeting that I would gain the disdain of my regional colleagues by persisting in such a course, I was able confidently able to state that I was firstly on the side of the patient and not on that of my colleagues. I then asked him to state where he stood. He was silent. On another occasion I was chastised by the local area Director and notified that patients with acute myocardial infarction with locally failed reperfusion following thrombolysis were to be transferred to our regional hospital (where there were no facilities for acute intervention) and not by helicopter, as was my practice, to Sydney for facilitated intervention and reperfusion. I responded with an assurance to send him to his regional hospital in the event of his suffering an infarct locally, but intended to continue transfer all other such patients directly to Sydney. I also told him that as this would be unacceptable he should arrange for my replacement to care for patients presenting with an acute coronary syndrome. Such a stand could never have been considered without the early example of Dr McCaffrey. At that time the mortality rate for myocardial infarction for patients with our post code was half that of sufferers with regional hospital post codes albeit with very small and statistically insignificant numbers.

Chris restricted the commencement of any elective surgical procedure which could encroach on theatre nursing staff meal time. Female nursing staff and all female hospital cleaning staff were awarded the courtesy of entering a doorway before any male staff, no matter what their station.

Dr McCaffrey would station himself in the emergency dept. noting the patient waiting time and subsequently requesting from them an appraisal of their management. Sudden large increases in patient attendances were always matched immediately with an increase in medical and nursing staff. There were no general emergency specialists, each team managing their own discipline. Interns were not permitted control of patient management. As doctors in training they were required to make their signed assessment and management which was then made by the staff specialist who was always on hand to revise, teach and to carry out any required procedure in the most appropriate time span and not later at his or her convenience following a day of remote office consultations.

His Unit Medical Record system, universal today, and his medical records department was at that time an exceptional innovation in that a typed record of both routine and emergency admissions was dictated in the presence of the patient and a typed transcript then reached the ward with the patient. Operation reports were dictated typed and handed to the patient post operatively. Post operative relative interviews about acutely ill patients were conducted in a special room outside the intensive care and recovery ward by the most senior surgeon again attired in street clothing, irrespective of the time of day or night or the patient’s classification. Ongoing relative interviews were standard. Ward rounds were accompanied by a trolley containing full patient records with progress notes and all necessary stationery, completed at the bedside. Signed progress notes and discharge summaries were always made by the senior staff specialist unlike today when as previously stated this is a rarity and with ward rounds by unaccompanied specialists giving verbal assessments to patients and then disappearing without confirmation to nursing staff and the subsequent nursing time lost in accessing telephone confirmation. With a resident Staff Specialist system patients suitable for discharge on a Friday or weekend never occupied a bed until Monday – a major contribution to our current bed shortage.  Nursing staff performed nursing duties only, never cleaning or delivering meals – a system used today and implemented in our small rural hospital after the most extraordinary opposition.

While today there is little or no transparency concerning outcomes from the private health system and poor information from the public record system – the paucity of the latter relying on the opinion of internes in training – we were required to attend regular sessions to assist clinicians in collating patient audit and quality control studies from the records for transmission to computing agencies in America in order to document and publish individual clinical outcomes. Today it is difficult to determine outcomes in the public system and is impossible in the private system

Nor was Chris reticent in challenging even the most prestigious visiting clinicians. For example, a very famous British gynaecologist was giving a paper to us advocating prophylactic hysterectomy in women of the child bearing age for cervical pre-cancer. When Chris challenged with the observation that his operative mortality was far greater than the all recorded deaths from cervical cancer with supporting figures from the British Registry, the visitor could only observe that “statistics were like a woman in a bikini, what they reveal is interesting and what conceal is vital”. He then angrily and silently left the meeting. This, an example of our many such experiences forever empowering us to boldly question if our proposed management was evidence based and in the best interests of the patient. Some of us even encouraged our patients to consult published literature about their malady and to feel free to challenge our view – an excellent facet of our continuing education.

Requests were made to relatives of all patients who died in hospital for an autopsy and the results were then the subject of compulsory weekly Clinical Death Meetings. Deaths from which salutary lessons could be learned were discussed and debated in detail.  All requests for antibiotics were vetted by a clinical microbioloogist for suitability before administration. One would never consider an antibiotic for a viral infection as is currently commonplace. Today, a copy of any edition of “Antibiotic Guidelines” is uncommon in most consulting rooms.

He pioneered community care with a team of doctors, nursing staff and social workers in their fleet of VW Beetles all mechanically serviced in house. His innovation is an accepted and vital aspect of today’s health care.

Dr McCaffrey had the ability to recognise innovations important for improving patient care and unlike many current administrators, he implemented them and personally supervised their progress for the benefit of his grateful patients and for those of us privileged to have known him.

Although much has been written about him, his wish to be remembered as being on the side of the patient is his fondly remembered legacy.

Graduated in Medicine from University of Sydney in 1959 (with Kerry Goulston). Undergraduate years at Sydney Hospital. Three year formal rotational training at Royal Newcastle. Decided to go to England on advice of Emeritus Prof. McClure Brown to study Obstetrics and Gynaecology but was told by Superintendent Dr McCaffrey that I should have some short exposure to general practice. He sent me to Walcha in northern NSW, a place I had never heard of, for two weeks. The Walcha folk harassed me almost daily for the next year to return. I did return and spent the next 29 years there serving those wonderful New Englanders. And in retrospect this was a fortuitous decision because my wife Ruth developed a very acute form of Multiple Sclerosis cared for for seventeen years in the Walcha Hospital.

Comment by John Menadue

I first met Chris McCaffrey on a visit to the Royal Newcastle Hospital with Gough Whitlam in the early 1960s. We were both very impressed, particularly by Chris McCaffrey’s concern for patients and the need for high quality clinical services for all.   He spoke of the clinical checks and reviews at all stages. He told me, then a young private secretary, that if I was interested in health policy I should regularly read the New England Journal of Medicine.

It was quite a novelty to hear from a senior health superintendent about excessive treatment and poor quality of care by some doctors. He mentioned that from time to time he had to cull surgeons out of the Royal Newcastle Hospital because of unsatisfactory performance.

As Ronald Mackinnon points out, Chris McCaffrey always put patients first. Most clinicians do that. But when it comes to policy and politics in health the provider organizations don’t always do that.

The ‘public debate’ about health is invariably between provider organizations and the minister with the community ignored.. The structure of the Department of Health and Ageing in Canberra is designed to manage the interests of providers rather than develop good policy for the community.

Chris McCaffrey never forgot that patients come first. He was a pioneer and trailblazer. 

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