Royal College of Physicians Oral History Project

Interview with: Dr Eric Beck

Date: 14th September 2015

Interviewer: Sarah Lowry

[PART ONE]

Q: Today is the 14th of September 2015. My name is Sarah Lowry, I’m interviewing Dr Eric Beck. Thank you very much for coming and for taking part and also for being an interviewer on this project as well. Please could you start by telling me your full name?

A: Eric Robert Beck.

Q: And where were you born?

A: I was born in London in 1934, the joke is that I was conceived in Paris which will become apparent when I tell you a bit about my family history, but my parents were refugees who came to this country in 1934 having been thrown out of Germany in 1933 and given a--, my father was given a year’s scholarship in Paris but was told at the end of the year he would have to move. So it was a notable year for him going to Paris, learning French, conceiving me [laughs].

Q: Why were--, why were your parents thrown out of Germany?

A: Well my father was Jewish, a very non-observant Jew but nonetheless he was, and he was a lecturer in pathology at Marburg University after graduating in Frankfurt and when Hitler came to power in 1933 the first people to be dismissed were Jews working for public authorities which included obviously universities. So he was given notice to leave Marburg and was unlikely to find another place within Germany in the climate that existed then and he was offered this--, I think it was a Rockefeller scholarship to go and work at the Pasteur Institute in Paris and so that’s why they left Germany. My mother was not Jewish she was born a Catholic which didn’t please her family too much when she married my father, but she was a non-observant Catholic as it were. And in true traditional style she met my father when she was a nurse in the infirmary in Frankfurt where he was a medical student. So that’s--, and then years later history repeated itself as will become apparent in a moment. So that’s--, that was their background. They had to get out in a hurry and their year in Paris was partly work but also looking to see what their next step would be knowing that they couldn’t stay beyond the year. And South America was apparently the most welcoming part of the world for refugees in those days, but because of his particular interest and background he was also offered a job in England but couldn’t practice medicine because the British authorities, presumably in response to Nazi Germany, would not recognise a German degree to allow you to practice medicine in Britain. You could do research jobs, which is what he did when he came over, but to get on to the Medical Register he had to re-sit his final exams in a strange

Dr Eric Beck Page 1 of 123 language which he didn’t speak [laughs] to get back on the Register. So my early memories are of him coming home from work at night, going upstairs reading his medical textbooks in English. And the quickest way you could qualify in those days was the Scottish triple exam, the three Scottish colleges ran an entrance exam which he didn’t have to have any clinical work it was just a matter of papers and exam at the end of it. So he spent every evening swotting for his exam which he finally got in 1938 and that enabled him to join the medical register and be, as it were, a fully-fledged doctor.

Q: What was the research that he was working on before?

A: He was, erm--, one of the things he was--, I know he was involved with was the pathology of syphilis because I remember him telling me one of the--, there was no penicillin of course in those days and so the treatments for syphilis were pretty crude and ineffective and one of them was to induce fevers in people by giving them malaria and it was hoped that the high temperature would kill the syphilis germ. And I think he was partly involved in that. He worked originally at the Dreadnought Hospital down in Greenwich, which is the Seamen’s Hospital, of course seamen were likely customers [laughs], and then he moved--, we moved a year before the war broke out to Epsom because his work took him to the local mental hospital in Epsom where there were a lot of people with tertiary syphilis. So that was his particular field then and subsequently he also became interested in tuberculosis, particularly the so called atypical mycobacteria whether they caused disease or whether just incidental organisms that you pick up. So those were his particular research areas and provided an income until he could get a proper job and the proper job was--, his first proper job was as general pathologist in Burnley in Lancashire. And so we upped sticks in 1930 [1939]--, well it was after war had broken out so it must have been, yes, end of ’39 beginning of ’40 we moved to Burnley where my father, as I say, was pathologist based at the local hospital. But I still remember vividly the day war broke out because we were sitting in Epsom in our house at 11 o’clock on a sunny Sunday morning and huddled round the radio and on came Mr Chamberlain saying--, this was after Germany had invaded Poland who were our allies, saying that they had given an ultimatum to the German government to withdraw by midday and this had not happened and we were now at a state of war. I was completely bewildered, as a sort of five year old it didn’t mean very much to me particularly when this was immediately followed by air raid sirens going off and everyone had to blackout their windows on a sunny Sunday morning, that really brought home what we--, what the situation was. September the third.

Q: Can you remember anything about the--, the kind of atmosphere?

A: Well of course the atmosphere apart from dismay, particularly amongst refugees who feared that if Hitler invaded England he would do as he was already--, already did in other countries, would seek out the Jewish population and deport them. So by then my parents had obviously got quite a lot of refugee friends so I think there was considerable alarm about what would happen if--, if Britain were invaded. The war itself, as you may know, was for many months a phony war and then of course Dunkirk came along and then the Battle of Britain and then it

Dr Eric Beck Page 2 of 123 was on for real, but by the time the Battle of Britain happened we were up in Burnley in Lancashire and I think one bomb dropped on Burnley in the whole of the war and planes flying over to bomb Manchester but it was not a target. So in terms of every day involvement it was just the austerity of war and all the changes that happened. Iron railings, I see here looking out of the window, were the first things to disappear to make munitions and so on and so forth. So yes, I lived with the war and every night of course you listened to the radio bulletins to see what was going on as the war progressed into Russia and so on. And I still remember we had a large Daily Telegraph map on the wall behind the radio and with a set of flags with pins and every time some place was mentioned in the news as having been captured or fallen we would pin a flag there so you saw the Germans advancing to Stalingrad and then retreating and so on. And when the war was over four or five years later we took this map down and you could see on the wall behind this pattern of pinpricks of the advance and retreat [laughs] of the war where we’d been sticking these flags in for four or five years. So yes, that was another sort of reminder of the war. But otherwise apart from, you know, rationing and so forth and people going off to the war not many people who we knew actually did go off. The other thing of course that happened to refugees particularly if they came from Germany [was that they had to register] --, although my father had been born in Prague in the old Austro- Hungarian empire, which in 1919 became Czechoslovakia, so he became a Czech citizen so he had a Czech passport, but he was a refugee because he was Jewish and had he stayed on in Germany, if Hitler hadn’t come, I’m sure he would have become a fully integrated German. You know, his whole career would have been there. So, erm, what was I going to say? As a refugee in this country if you had a German connection one of the things that happened to a lot of them, very briefly, was that they were interned in the Isle of Man because people, you know, were very suspicious of German spies and so on and so forth. But because of his Czech passport he was--, Czechoslovakia had been invaded and they were now our allies and so on this, as it were, protected him throughout the war and, to some extent, protected me as well because when I--, as I was starting school although I spoke very little German, in fact German ceased to be spoken in our house the day war broke out. I was brought up bilingually [until then], but the way school children are they noticed I was a bit different from the others. I didn’t speak German but when they said, “Where do you come from?” I said, “Well my father is Czech,” they said, “Czech?” you know, “What’s that?” and then when they realised the Czechs were our allies that put me in good stead. But I think some refugee children, particularly German refugees, probably did have a hard time at school for those sort of reasons. Yes, so the war had--, well of course the other repercussion the war had was on my father’s family. He was one of [four], he had three siblings, two sisters and a brother and they were all interned, sent to concentration camps. His two sisters died and his younger brother Kurt, who had actually settled in Holland before the war and was taken by the Nazis when they invaded Holland, survived Auschwitz and emerged at the end of the war and was killed in a car crash five years later. But one of the other features of the war was, through the Red Cross, people [prisoners] in concentration camps were allowed to send a certain number of letters, which we’ve got tucked away somewhere at home of my uncle Kurt typing in English, because he

Dr Eric Beck Page 3 of 123 spoke quite good English, letters which obviously had to get past the German censors even though it was sponsored by the Red Cross. So he--, he couldn’t give us any detailed account of what was going on other than sort of reassuring us that he was all right. And his mother [Eric Beck’s grandmother, Jenny], who was--, also had been interned, she was in Theresienstadt in Prague and she survived the war as well and lived on for a good few years. And the last twist of her story was that years later we took our young daughter Lucy to Belsen because it was near where my wife’s sister in law, who was German, lived and we were on holiday there. So we thought we ought to go and see Belsen which we did, which has been remarkably well preserved by the Germans as they have other concentration camps, and everything in the concentration camps was very carefully documented. In typical German fashion they would record everybody who came in to the camp, their origins and what would happen to them and of course a lot of them died but others were sent on to other camps. And we were wandering around Belsen and I got separated from my wife and daughter and she came and hunted me down and she said, “What was your grandmother’s maiden name?” so I thought and, erm--, and, “I think it was Radamuker [corrected to DRESDENER] [0:14:57]. She said, “Oh! We’ve--, I’ve just found the book, the register of the people coming in to Belsen and I found her name and she was admitted such and such a date in 1941 but there is nothing about what happened to her.” And so I remember filling in the visitors’ book in Belsen saying ‘to get your records complete you may be interested that Mrs Radamuker [corrected to Beck, nee DRESDENER] [0:15:27] survived the war in Theresienstadt and died of natural causes five years later’. So yes, so that made quite a big impression on our teenager daughter at the time not only seeing the place but seeing someone in her family had actually passed through it. Yeah, so that was a somewhat distorted view of the war that we had.

Q: Did your--, did your parents practice Jewish religion?

A: No. Well my mother, as I say, was a lapsed Catholic and my father was very much a lapsed Jew. His father had become a very orthodox Jew during my father’s childhood, against which my father and his brother rebelled, so no, they--, I mean obviously he--, he was a Jew and he had Jewish sympathies and was very interested in Jewish culture but not in the religion. And of course my mother as a lapsed Catholic had to take that on board with her as well, her family largely renounced her because of her marriage to him. So that wasn’t a very happy arrangement. And I know very little of either of their families although again interestingly the other day a distant cousin on my mother’s side, who now lives in America, sent me a book a little memoir about her uncle Walter who would have been my--, he would have been my uncle, yes, my mother’s brother, who was in the U-boats and was--, was killed in the war. And this arrived, this book which she’s written about my uncle Walter, she said ‘you may be interested because he’s your uncle Walter or was your uncle Walter’ just after we’d come back from a visit to Bletchley to, you know, the codebreakers there and of course that was one of their great triumphs was sinking German U-boats and probably had led to his demise. So that was another sort of interesting personal twist on the war. I’ve become fascinated with the

Dr Eric Beck Page 4 of 123 whole Bletchley story and I consider a remarkable episode in military history which, you know, changed the war and probably killed my uncle Walter, who I never knew I never met him.

Q: Did your parents talk about their life in Germany at all before coming to…

A: Yes, my father hadn’t lived there for very long. As I say, he moved from Prague to study medicine in Frankfurt because in 1919 when Czechoslovakia was created Czech became the official language whereas the Charles University up till that time in Prague was German speaking. So he would have--, he couldn’t have studied medicine [in Czech] because he didn’t speak a word of Czech which is why he went to Frankfurt. And, as I say, if things hadn’t happened the way they did he would have spent the rest of his career there and I would have been a little German. So they weren't in Germany all that long together. Between the time he qualified and the time he lost his job in Marburg was probably only four or five years and, I mean, apart from the reaction of her family, which my mother talked about a bit, they never said a great deal about their life in Marburg for example. Of course when he was studying medicine in Frankfurt it was very institutionalised, he was a medical student she was a nurse living in there. So no, they didn’t say a great deal. And of course as the war unravelled, comments were made about Germany and of course the image I had of Germany by the end of the war, having wiped out my father’s family and so on, was a pretty negative one. And I was very reluctant to go to Germany, to even visit Germany until I was--. The first time I went as a medical student in the long vacation [in 1952] I went with a fellow medical student down through Germany to Italy and I was--, yes, I must say I’m glad I did it but I kept sort of thinking all the time as I went through the country, you know, what had happened. And I was impressed by the Germans’ wish to make good which interestingly did affect my father because having lost his job because of his religion in a state’s institution he might have been eligible for reparations. If he had been a German citizen there would have been no question but the various lawyers who sprung up--, it’s a bit like PFI lawyers now, there’s an enormous industry helping people get reparation and taking their percentage and my father was approached or he approached one of these legal firms and they said, “Yes, you’ve got a very strong case because it was clear from what you said that if you--, or what you did that you would have remained in Germany.” And so this long legal battle, a bit like this Dickensian thing was it in Bleak House where it goes on and on? This law suit went on for over ten--, ten years or so and just before my father died the German government acknowledged that he was a victim of the Nazi regime, gave him a sizeable lump sum and a pension for the rest of his life transferable to my mother but I mean, you know, he was then well into his late 70s. But I think it was a pyrrhic victory and helped in some way as it did for other people, you know, to bring closure with the Germans. And since then I’ve been back to Germany. In fact I was there last summer because my--, one of my great passions is Wagner and I managed to get a ticket for Bayreuth [0:22:18] and so I spent a few days there. And I must say I--, I wouldn’t say I’m a Germanophile but I am impressed by the country, the way it’s run, the way they’ve tried to make good their past and, you know, even the politics of the present day we’ve been talking about Angela Merkel and how Germany had been handling refugees and I’m sure some of this

Dr Eric Beck Page 5 of 123 is a carryover from what happened in the days of Hitler. But yeah, so everything seems connected one way or another in the end.

Q: Have you ever either as a child or an adult had any kind of confused feelings about your own identity?

A: No, I don’t think so. I think--, I was born in England, I was, --, you know, therefore this makes me British with an interesting background. I never thought of myself as German or Czech or anything other than British. I remember years ago I was a great fan of Peter Ustinov the playwright and well sort of polymath and him recounting how when he was in the RAF stationed in Uxbridge picking up a book in the shop at Uxbridge of memoirs by some English--, retired English colonel in the Indian army and the first line was ‘in the lottery of life I had the good fortune to be born an Englishman’. And I just thought well that applied to Peter Ustinov as well and probably applied to me as well. But one of the things I want to just say, we’ve touched on what an irreligious bunch we were, but my parents, again because Hitler was looming on the horizon, were very concerned again if he ever invaded England that I would be a victim as well as them and they got me baptized in the Church of England in Blackheath. I just turned up the other day my baptismal certificate which would have perhaps protected me if the Nazis had moved in that I was a signed up Church of England [laughs] baptised child. And that was purely--, this wasn’t anything to do with religious belief it was purely a preventative measure. So it tells you something about the thought processes that people were going through.

Q: Do you know if they had a plan for if England was--, if the UK was invaded?

A: I don’t think they had. There were various relatives scattered around the world some in America, but I don’t think this was ever a serious consideration that they would leave England. Likewise, at the end of the war when some refugees were dispersed all over the place, including Israel, I don’t think there was ever any question then. I mean my father was--, I think as I said at his funeral, he was an enthusiastic Englishman by adoption. He was a great admirer of the British way of life. And all the refugee business that’s been going on at the moment has an added poignancy because of their background and I’m sure, you know, he would have reacted very strongly to what’s going on.

Q: Was--, did your mother work?

A: No, no, she was a housewife and mother in Burnley. And it was quite a big house to run, old Victorian place on the edge of one of the parks there. Oh, just one final German thing I went to, when I got to the age of whatever it was, seven, to kindergarten, Sunnybank in Burnley and it was quite a journey from the house there and back and I came--, and somebody obviously took me. And I came back the first day and my mother said, “Well how was it at school today?” you know, “Did you enjoy it?” I said, “Yes, it was very nice but, erm, something rather funny happened,” and she said, “Well what was this?” So I said, “Well the teacher was trying to find out how much we knew about objects and was showing us pictures and we had to name the objects,” of animals and so forth. And they showed me a picture of an eule and the

Dr Eric Beck Page 6 of 123 teacher said, “No, no, it’s not an eule it’s an owl,” and I said, “No, no, it’s an eule.” And I’d never learnt the English word for owl and I was giving the German word for eule. And I still remember it was my first day at kindergarten and it never came up again as an issue, but yes, that was--, that was quite something.

Q: Did your parents talk about experiencing any prejudice because of their German accents or…

A: Not really, no. I must say my father spoke with an accent but his English became meticulous. My mother--, my mother’s English was never very good. And I think it’s partly this thing I was saying about being a Czech national I don’t think many people really knew much about Czechoslovakia, as Chamberlain referred to it ‘a far off country of which we know very little’ in one of his famous statements. But, to some extent--, and people knew they were refugees and they had come from Germany but I think his Czech background, even though he wasn’t much of a Czech, as I say he was an Austro-Hungarian, helped to some extent. So I was never aware of any particular prejudices but I think they were careful obviously not to speak German in public to each other although they spoke to each other at home in German. And I picked up a little bit but I never learnt to read or write German; it was purely conversational German and they didn’t encourage me to speak German because they feared that it might have repercussions. So I don’t recall them talking about any kind of prejudices and the good Lancashire folk in Burnley seem to, you know, adopt them as one of their own.

Q: Do you have any siblings?

A: No, I don’t. I’m an only child. Never particularly regretted it [laughs]. Perhaps I should have done.

Q: So you’ve mentioned your first day at school.

A: Kindergarten, yes.

Q: Kindergarten. What else do you remember from your early education in Burnley?

A: Well this was Sunnybank, it was a private school, it was known as Snob’s Academy by one or two of other people around. And then the next step up to secondary education, and this was before the 1946 Butler act, would have been to go on to grammar school. And Burnley Grammar School didn’t have a particularly good reputation but the one that did have a very good reputation was Clitheroe Grammar School and Clitheroe was about 20 miles away from Burnley and they had a preparatory school, a prep school, and quite a few people went from Burnley to Clitheroe prep school and then went on to the main grammar school. And I don’t know how my parents sort of got to hear about this, obviously through friends and colleagues, so my next step from leaving Sunnybank was to go Clitheroe Royal Grammar School Preparatory School at a very early age. And there were so many people going from Burnley to Clitheroe there was a special bus laid on at eight o’clock every morning in the marketplace to take us to Clitheroe and then back again in the evening. So yes, Clitheroe prep school was a happy experience. Two teachers, Miss Grace and Mrs Hudson I think she was called, and they had an 11 plus exam I think to get into grammar school, you know, which I took and duly

Dr Eric Beck Page 7 of 123 passed. So I entered the grammar school and I was saying earlier on that the grammar school and the secondary modern schools which of course the Education Act abolished and merged into comprehensive schools. But certainly one of my memories in Clitheroe, which are very happy memories, I was very happy at the grammar school, was once a week going off to the secondary modern school on the other side of town where people [pupils] were--, if you went to secondary modern it meant you had failed the 11 plus and you were being singled out as a future worker where they taught you practical skills. And we went one afternoon a week to learn woodwork it was thought to be a good thing for us. And this was always a bit of an ordeal because we had to run the gauntlet of the secondary modern pupils who knew we’d come from the grammar school that they’d failed to get into. So that was quite a vivid memory, it didn’t teach me anything about woodwork I’m afraid [laughs]. And so I stayed at the grammar school and it had a particularly outstanding headmaster, Lawrence Hardy, who had won the Military Cross in the First World War and had a large scar on his face. And he was a very enlightened man who was also very interested in amateur dramatics. And the school each year put on a play and this became increasingly ambitious until they put on Hamlet and he happened to have a head boy, I still remember this, Derek Welsh who was an outstanding actor who played the role of Hamlet and this sort of made quite a splash locally that the grammar school were doing Hamlet and one of the boys was doing it. So yes, he was very interested in the arts, he was interested in sport. And being some distance away not being in any of the sort of school teams at weekends I wouldn’t come to support, as it were, the school sports teams, but having moved to Burnley the first football team I ever saw was Burnley Football Club. And I became a very young fan and used to go along there every Saturday and the headmaster, Lawrence Hardy, became aware of this and we--, if I bumped into him he’d say, “Well how did the Clarets get on last weekend and why weren’t you at Highmoor supporting the school team?” So he was a very humane character. And the school itself founded in 1554 by Queen Mary and her Spanish husband Philip, the Royal Grammar School. So it was very aware of its history. And in fact I remember going back there in 1954 when the 400th anniversary celebrations were taking place. So that was a good experience. And interestingly when we moved back to London, because my father then got a job in north west London, and I subsequently went on to medical school, I bumped into people--, two people who had been at Clitheroe Royal Grammar School at the same time as I was, Philip Exelby [0:35:04] and Philip Knowles. So yeah. So yes, the--, my education had to change gear when my parents moved to London. They moved in December of 1946, incredibly cold winter, and none of the local schools were very keen to take me in midyear, as it were, because the first term had already finished. So the local grammar school in Finchley where they lived was Christ’s College were not at all interested and so somewhat reluctantly my parents, not for financial reasons but their reluctance was--, said, “Well we have to try the local public schools to see if they will take you.” And the nearest one was Mill Hill just up the road from Finchley and I still remember being sort of taken there and interviewed and the letter that they got--, my parents got was ‘we are a school for the empire not for the district’ implying that they didn’t want local lads they wanted--, so that was rather strange. And then the other--, the

Dr Eric Beck Page 8 of 123 school that I eventually went to, St Paul’s school, was the other side of London in Hammersmith opposite Cadby Hall, the big Lyons place [factory], and I had the good fortune that they had been evacuated during the war and they had just come back to London to this huge Victorian, since pulled down, building and were low in numbers. And so I went along and had a test which I didn’t do particularly well in but I was given a place as a day boy at St Paul’s school which meant an hour’s journey every day from Finchley to Hammersmith, but again I enjoyed school more and more as I moved up it. And then the old school certificate you had to make a decision about your future, you know, what subjects you were going to do in the sixth form and I really had very little idea of what I wanted to do. Medicine was not particularly an option, I think you find this I think with some doctors’ children, and I had this sort of vague idea I’d like to be a geologist. So they said, “Oh well, you will need to do physics and maths and chemistry.” So I went into the appropriate sixth form (or eighth form as they call it at St Paul’s) and I realised this is not what I wanted to do. And then my father prevailed upon me to look at medicine in the sense that a medical qualification would give you a wide range of opportunities. And so I switched to biology and this was not only a good move in terms of what I learnt but the biology master at St Paul’s was an outstanding man, he’s one of these sort of charismatic masters who make people’s lives and careers. Sid Pask he was called, an ex-army major with a very bad stutter. And he was a natural rebel against the school establishment and one of the first things he said to you when you entered his form was, “I’m going to teach you biology and get you interested in it and if you follow what I’m doing you will have no problem passing the exams but I’m not going to use any curriculum to get you to swot up.” So this was very much his attitude and he was a very hands on strongly opinionated man. Every Saturday he would take those of us who volunteered to go on various field trips so we would go to the Basingstoke canal with fishing nets and pull out leeches and one thing and we’d go all over the place with him. And once a year the--, a small group of us would go up to Millport on the Isle of Cumbrae in the Clyde, the Scottish Marine Biology Headquarters, I don’t know how he had established the connection there, but for a week we would all descend on the labs in Millport and do various projects and be taught marine biology. And this was entirely his initiative and we flourished under it and did get our exams. And also, of course, we had rather striking, looking back, fellow pupils in the sixth form or eighth form, biology eight, at that time, one who I’ve kept up with on and off over the years was Jonathan Miller and his great buddy was Oliver Sacks who died the other day and Eric Korn a little gnome like figure who became I think an [antique] book seller. And then there were other people like Ian McColl who went on to become Lord McColl in the Tory government. And various--, he generally brought out the best in people and he was a remarkable man with very strong political opinions, right wing opinions. I remember him in his stuttering way once instructing us about politics saying, “P-p-politics is a d-d-dirty game and the only c-c-clean party is the conservative party.” And he lived in Harpenden and everyday he came in reading the Daily Telegraph and Harpenden was opposite the--, his house was opposite the Rothamstead agricultural research station so that was another place that we got taken to by him. And he really was a remarkable man and--, but you had to play it by his rules, shirkers were not encouraged as it were. So

Dr Eric Beck Page 9 of 123 yes, so there I was in the eighth form preparing for university and medical school. And unfortunately at School Certificate I had failed Latin and in those days an entry requirement to Oxbridge to study anything was you had to have Latin and if I was going to do Latin it would have meant an extra year at school doing Latin and I was really getting quite restless and wanting to move on. And so I became aware of UCL, University College, I think we must have had a--, yes, one of our neighbours’ daughters was there. So I got shown round UCL and I rather liked the ambiance and the campus and also the fact that if you did a medical degree there, and now this happens in many medical schools but at that time I think only UCL and King’s College, you had the opportunity if you wished to peel off after second MB before going on to the clinical course and doing a BSc and that was one of the--, I think one of the attractions. So I went along for interviews at UCL. Two interesting things happened at the interview one was that we were--, we were given a ‘mini exam’ in rather odd things. We were shown an x-ray and none of us as schoolboys knew anything about x-rays and it was to see what we could--, what observations we would make and we were told it was, you know, an x- ray of a chest and there were various other sort of rather psychologically slanted exercises. And this was a lady called M L Johnson and her husband was [Michael] Abercrombie, the geneticist [corrected to embryologist], and she’d been given some kind of research grant to try and select medical students not purely on their A level results but, you know, on other criteria. And it’s interesting medical schools have--, some of them have reintroduced this kind of approach. So we sat this rather strange exam and then we all in turn had to go off and see the Dean of the medical school to be interviewed by him and he was an old Pauline, Tim Flew [0:43:55], nice man, and I still remember wearing my old school tie which I hardly ever wear, I don’t know whether anyone had tipped me off that he was an old Pauline, but he immediately recognised the tie! And I also had with me because of my enthusiasm for marine biology a copy of the--, in the New Naturalist series, I don’t know if you remember this was a series of books that came out in the 1940s, and this was The Sea Shore by CM Yonge a leading marine biologist which I was reading. So I came along armed, in retrospect I don’t think this was deliberate, with the old school tie and a rather interesting book. So he said, “Oh, I see you’re an old Pauline, what are you reading?” and this sort of dictated the whole of the interview [laughs] and I was obviously ‘in’. So I started at UCL and did the second MB course and the--, that particular year that I was in had a remarkably high success rate of second MB who all had to be found places in the hospital for the clinical course. So they were quite keen to persuade some of us to go and do other things. So this fitted in exactly with my wish to do a BSc and I was given a scholarship to do a BSc in physiology. And in many ways the year of the BSc physiology was the highlight of my undergraduate education because it had a scientific base, it taught you how to use a library, how to think critically not just to stuff you with facts and so on. So I really enjoyed--, and you were part of the everyday life of UCL. So I really enjoyed the BSc and then went on to--, across the road--, across Gower Street [to UCH] to do the clinical course which again I largely enjoyed with one or two--, many pluses and a few minuses. [Pause] So that took me up to qualification in medicine. Again this particular cohort that I was in many of them had done the BSc so they’d sort of creamed off people to do

Dr Eric Beck Page 10 of 123 the BSc and we then did pretty well as we went through the clinical course and got a large number of honours in the London MB. My friend John Francis, who I’d first met at the very first interview to get into medical school, won the university gold medal and several others of us got honours in various subjects, myself included. So it was a--, it was a very successful year. And along the way, yes, one of the other [laughs] things coming back to Tim Flew [0:46:58], was I got involved in the medical school magazine and Jonathan Miller, who had gone off to Cambridge, came down to UCH to do his--, to do the clinical course there and he became the editor and I became the assistant editor of the hospital magazine, which was not-- , you know, a magazine of record and not very exciting. And I was given the task of, er, reporting on the annual prize giving day when some notable person would come along and make a speech and hand out the various prizes. And the person they had chosen for the year that I was asked to report on it was the headmaster of Rugby Sir Arthur Fforde. He spelt his name with two little Fs, F-f-o-r-d-e and he was a rather pompous character as you might imagine and I wrote a rather scathing account of this in the hospital magazine. And I got hauled up before the dean saying, you know, this was a--, “This is an official record magazine and you’ve made some rude remarks about our visiting person. I agree it was a terribly boring afternoon but you can’t say that sort of thing,” and so I--, he said with a twinkle in his eye as it were. So I remember getting reprimanded for my account in the hospital magazine. Yeah, so we all qualified. Very few people failed the exam that year and again there was the problem of finding house jobs for us.

Q: Do you mind if we go back a bit--,

A: No, not…

Q: Back into university time before we go on to house jobs? I was wondering when you made the decision that you were going to study medicine how aware you were of your father’s work and the work that your father did.

A: Well his work was a rather esoteric branch of medicine. He was a pathologist so he had very little dealing with patients although actually pathology was linked with venerology so I think he did one VD clinic a week once in a while, but he was very much a laboratory based person. I remember going and visiting his labs and seeing the guinea pigs being injected with various things but I didn’t really see much of medicine.

[END OF PART ONE 00:49:31]

[PART TWO]

Q: Okay, we’re restarting. So you were talking about your understanding of your father’s work Dr Beck and how--, how you’d been--, I think you mentioned--, the last thing you mentioned you’d been to visit him at work.

A: Yes, at his laboratory in Burnley and I suppose in London as well but it was very different kind of medicine from what I was--, wanted or finished up doing, but nonetheless I think, you know, I liked the atmosphere.

Dr Eric Beck Page 11 of 123 Q: And did you have any experiences of medical care in childhood or…

A: Yes, quite significant in terms of my career--, subsequent career. As a four or five year old I had repeated attacks of otitis media, that’s infection of the inner ear, which nowadays is very easily treated with antibiotics but in those days antibiotics didn’t exist. So this was a rather painful thing where your eardrum gets inflamed and so on and ultimately may perforate to let the pus out as it were. And I spent several--, had several spells in hospital with this and in fact before penicillin the first antimicrobial drug, which technically isn’t an antibiotic, was Sulphonamide, M&B 693 was the trade name for it. And I must have been one of the first people to be given M&B 693 which was effective against the streptococcus pneumoniae which was the bug causing the otitis media. So otitis--, my ear problem for a year or two was quite a significant one and the repercussions it subsequently had came up after I’d completed my preregistration year as a houseman, and in those days everybody had to still do national service. And it was getting to the point of winding down and it was going to be abolished within a year or two and the army was shrinking and they were stuck with the fact of an--, you didn’t have to do your national service until you’d completed your medical course and then you went into the army or whatever service as a doctor. And they were stuck with the problem of having a huge number of doctors in relation to the people they were going to look after and, you know, what to do with them and of course you had to do your national service unless there was some good reason why you shouldn’t. And so I went along with all my colleagues after finishing our--, as we were finishing our house jobs to the recruiting place in Acton, I remember it very well, where we had to have our medical to prepare us to do national service. And in the--, part of the medical was a questionnaire in which one question was have you ever had discharge from the ears or any problems with the ears? And so I wrote down what I’ve just told you and they said, “Oh dear, we may not be able to take you into the army we’ll have to get a specialist opinion first.” So I said, “Oh yes, oh dear.” So I was sent along to see this ENT specialist at the National Temperance Hospital for some reason and, er, I came in and he said, “Well I see you’ve just finished your house job, what are your career plans?” So I said, “Well I think I want to be a physician so I want to get postgraduate jobs and take the MRCP examination, you know, and go up that ladder.” He said, “Yes, yes, that sounds a very sound plan. You don’t want to join the army, do you?” And I said, “Not particularly [laughs].” So he said, “Well we better have a look at your ear.” So he looked at my ear and you can see the eardrum has a healed perforation and it had so happened in this long holiday I’d had with my colleagues between second MB and the clinical course we’d been to the coast in Italy and dived in the sea and one thing and another and I had reopened the perforation by, er, diving in the sea. So I told him that and he said, “Oh yes, I can see your healed eardrum, what shall we say? Liable to breakdown under service conditions?” So I said, “Well I suppose if I was standing next to a cannon when it goes off.” So anyway, he endorsed the fact that I was unfit for medical service--, for national service, which I was quite prepared to have done but many of my contemporaries who did it found it was really a bit of a waste of time although it was part of the university of life as it were. So yes, so that’s the answer to did I have any medical conditions, that’s about the only one and it actually did me some good in the end.

Dr Eric Beck Page 12 of 123 Q: And when you first went to university were you living at home?

A: Yes, yes, that was one of the issues I was getting a bit restless living at home and so I think all through the preclinical course and the BSc I was still living at home in Finchley commuting in to UCL which was no great problem, but once I started the clinical course I was keen on moving out and along with John Francis, who I’ve already mentioned a contemporary of mine, we found a flat in Falkland Road, Kentish Town. So we moved in there--, we moved in there. A third person who we didn’t know called Fred Johnson came and joined us. So the three of us were in this flat owned by Mrs Harrison or Frau Harrison because she was German, a German widow. And yeah, that was a very pleasant existence in Kentish Town and we cooked for ourselves and I had a motorbike and went in every day usually with John on the pillion. So it worked out very well. And I don’t think there was too much, as it were, teenage rebellion involved in it. My parents helped fund it so, you know, I think my mother probably missed me more than my father did but [laughs]--, and I could go home as often as I wanted. So it was a fairly natural sort of break.

Q: And what about the demographic of the students at UCL?

A: At UCL? Well, they came from a pretty wide background much wider than people going to Oxbridge. And I don’t think we had any black students at that time. I mention black as a particular thing in medical education because years later when I became an examiner at Barts where there were again very few black students, there was one who was a borderline candidate in the final MB exam. And what usually happens at examiners’ meetings is that the home examiners are very keen to get all their people through against the objectivity, as it were, of the visiting examiners of which I was one. And I remember this bloke who really wasn’t very good, he was a black student from the east end of London, and the special pleading that went on, you know, “He’s our first ever black student and you’re going to fail him. Do you really want to do this?” So we said, “Well, you know, by the objective criteria he I’m afraid is going to fail.” So he did fail. So it was such an unusual thing in those days--, well that was years on by the time I was an examiner. It wasn’t culturally a very mixed bunch. I suppose most people came from grammar schools, not so many from public schools and very few overseas students or coloured students. So it was a fairly pure, yes, clone.

Q: What about the gender balance?

A: The--, that was--, we had quite a lot of women students. I can’t remember the exact numbers but this was one of the said things which I think was true, to get into medical school as a woman you had to be a lot brighter than your male rivals. So they were all very bright young women. I don’t think they had a particularly difficult time once having got there, I think the getting there was the difficult part. Yes, so I wasn’t conscious of any particular prejudice against people who were there. I think it was the selection procedures which might have been criticised.

Q: And how much were the female students integrated into the course or student activities?

Dr Eric Beck Page 13 of 123

A: Pretty fully. I mean apart from the sports and I suppose they probably didn’t drink as much and didn’t play bridge as much [laughs], they seem to be two of the main occupations--, leisure occupations, but yeah, I think they--, I can’t remember whether they had their own equivalent extramural activities that they went to. I remember going to the UCL film society and seeing all the old classics there, the René Clair films and the Russian films and the membership there was very much 50/50; a lot of women there. I went--, and this was one of the nice things about UCL all the things you could do, the debating society, perhaps women were not very prominent in the debating society. I can’t remember what other things. Well UCL of course had and still has an annual opera production which became more and more professional over the years, again I think women were involved in that as much as men were. So yeah, I think they got a--, having got in they were treated the same as everyone else.

Q: And how much would you say you mixed with people from outside your course?

A: Not as much as I would have liked to because in the preclinical course the medical students had a common room in the basement of the anatomy department and so the tendency was to stick together there and also to take part in some of the activities of the medical school across the road. We were linked by a tunnel in fact under Gower Street. So when it came to sport for example, I was quite a keen footballer, I played for the medical school rather than for one of the university teams and the squash court happened to be in that, an offshoot of the tunnel going to the medical school so I spent a bit of time there. So I think this is perhaps one of the things that with hindsight was not such a good idea to make us a separate faculty from the other faculties of the--, of the college. Although when you--, when I was doing the BSc in physiology, although I retained my sporting links with the medical school, you felt you were much more part of the--, of the college. Of course the other people doing the BSc, I think there were two or three of us who were medical students and the others were pure physiologists and this made it much more interesting that the whole thing wasn’t medically orientated whereas the other big BSc group because of the high pass rate in second MB was in the newly created BSc in anatomy and that obviously was almost entirely made up of medical students. But I mean UCL had a lot to offer. The professor of anatomy was a man called J Z Young, does that ring a bell with you? J Z Young was a relatively newly appointed professor of anatomy at UCL. He came from Oxford, knew nothing about medicine, was totally uninterested in the human body but this chair and the department that went with it suited his research program which was studying electrical transmission in the nerve fibres of the giant squid [laughs]. But he was an outstanding scientist of his day and in fact he’d just given the Reith lectures of ‘Doubt and Certainty in Science’ which was published. And he gave one lecture a week to the medical students because it was part of his job to do so, which was mainly doubt and certainty in science. It was a fairy stimulating totally non-medical lecture. Us callow medical students probably wouldn’t have gone along to it because it wasn’t very relevant to medicine except for the fact we were told that one of the questions in second MB would relate to this course of lectures so we all turned up and I think for the better. So J Z

Dr Eric Beck Page 14 of 123 Young was an outstanding figure at UCL. The other one, and I remember going to his inaugural lecture because he started the same time as I did, was a newly appointed professor of zoology Peter Medawar who went on to do fundamental work in transplants, rejection of transplants and won the Nobel Prize subsequently and he had just arrived and again I remember going to his inaugural lecture in the department of zoology. So he was another inspiring figure there. And then there was a remarkable man called Ernest Baldwin who was a biochemist who had written the most up to date and stimulating textbook on biochemistry which is not the most exciting subject. I’ve forgotten what the title of the book was but everybody read it and it was a really--, you know, it was a textbook that you enjoyed reading which doesn’t apply to many textbooks. And he was a very eccentric character and his big hobby was knitting and somehow I seem to remember him either giving lectures or sat in seminars knitting away while--, what’s his booked called? The dynamics of something [The Dynamic Aspects of Biochemistry]. The dynamics--, so there were some very stimulating people in the non-medical part of UCL and--, oh yes, of course biophysics - Bernard Katz, one of our modules was doing biophysics with him and he went on to win the Nobel Prize at UCL. And then there was a--, because we were doing medicine--, the few of us doing the physiology BSc who were going to do medicine were given a module to do in pharmacology, Otto Schild, again another inspiring teacher with a very Germanic background which he retained but a very nice man and again they had--, this was a purely scientific approach to pharmacology rather than pharmaceutics or drugs and medicine. So the BSc was a good experience educationally and you were attached to one of the research workers as a sort of dogsbody in the lab which was interesting and you got some sort of insight into how research happens in a first rate institution. Oh yes, one of the other stories, a physiology lecturer called [Jim] Pascoe who described his days as a BSc student and that they had set up some experiment in which they needed an elastic membrane, I’ve forgotten what they did with it, but anyway the cheapest and easiest way to get an elastic membrane was to buy a condom. And so as the junior member of the team he was sent to the chemist to buy the condoms for the experiments in the physiology department and the chemist he went to, obviously condoms weren’t such a popular thing as they are now, and the chemist said, “Well I’m very sorry sir, but the only ones we have in stock are out of date and can’t be guaranteed,” to which he replied, “It doesn’t matter we cut the ends off them anyway [laughs].” Yes, that was Jim Pascoe.

Q: Obviously later in your career you became very interested in medical education.

A: Yes.

Q: I’m just wondering if in light of that you had any sort of specific reflections on your time particularly in the--, on the medical quality of the course.

A: Yes, well the--, we had some outstanding teachers no doubt about it. One of the things that they did and still do to a great--, I hope rather more of to try and integrate the course was when you were doing second MB, which is anatomy, physiology, biochemistry, to make you aware of what the ultimate goal was there was one morning, one Saturday morning, when you were--, went over to the hospital and a clinician would talk to you about his field and its

Dr Eric Beck Page 15 of 123 relevance to the anatomy and physiology which you were doing. And I still remember that morning and it was John Nabarro does that--, yeah, who was then first assistant in the medical unit, subsequently went on to the Middlesex Hospital, and he--, we must have been doing endocrinology as part of our physiology and he was an endocrinologist. And I still remember vividly he demonstrated I think three patients: one with Addison’s disease, which is adrenal failure, one with Cushing’s syndrome and I’ve forgotten what the other one was, and how important this was, as it were, to get the troops interested in what they were doing. Yes, so that was a particularly good experience in the preclinical course. In the clinical course, erm, by and large there were some very good teachers and one or two duds. The two professors there Rosenheim was professor of medicine and Nabarro was his first assistant and they were excellent teachers. And the professor of surgery was a slightly dour man called Pilcher who actually was--, had double qualifications, he was an FRCS but an MRCP as well and he had a very good knowledge of medicine which obviously rubbed off in teaching surgery to clinical students. In many ways surgery is a rather dubious thing to be teaching at an undergraduate level, you could say it’s really more a postgraduate subject. So he was--, he was impressive. And then one of the difficult areas for many of us as students was neurology and we had a neurologist called Blake Pritchard who was again a very eccentric man, rather difficult to understand who loved impersonating the neurological problems of his patients that he was lecturing on, but he seemed to have no kind of system by which this was--, it was all largely anecdotal. And the other neurologist was a man called William Gooddy, he was the junior neurologist, and he was completely different from Blake Pritchard and he was very much a sort of touchy feely doctor with great empathy for patients and how--, you know, how was your background, how’s this, well we better just find out a bit more about what’s brought you along here today sort of thing. And he had a very good way with patients and he had a clinic on Saturday mornings which was not a time when medical students normally want to be in medical school and he would have this neurology clinic till lunchtime and then he would get into his car and drive down to Chichester where he was a visiting neurologist and held a clinic on a Saturday afternoon. Anyway, I got to start going to Gooddy’s Saturday morning clinics and they were very sort of relaxed and unbuttoned because it was Saturday and the thing that struck me was his great empathy with patients. And as they described, you know, somebody say with trigeminal neuralgia, which is a very severe unpleasant pain, you could almost see him wincing as the patient described the pain. And somehow this was totally different from his other neurologist colleague. So I became rather fond of William Gooddy and he wasn’t a terribly well organised neurologist--, he didn’t give you a system by which to learn neurology but he certainly helped to show you how to communicate with patients. He came to a rather unfortunate end in later years, er, he--, I don’t know whether you remember a big law suit involving Guinness, Ernest Saunders, does that ring a bell with you? Ernst Saunders had done some big swindle at Guinness and he pleaded that he was unfit to plead because he had early Alzheimer’s disease and William Gooddy appeared as the expert witness for the Defence to say that Ernest Saunders was showing the early signs of Alzheimer’s disease and Saunders I think got off. And a year or two later he was back in full harness and he’s known

Dr Eric Beck Page 16 of 123 as the only man with Alzheimer’s disease who recovered from it and Gooddy had obviously missed the diagnosis. And a certain amount opprobrium fell on Gooddy as a result, you know, it made a nonsense of being an expert witness who diagnosed an incurable disease which is then miraculously cured. Yes, so that was William Gooddy. So he was a very human and approachable person but I didn’t learn much neurology from him. I’ll tell you when I learnt the neurology when we get to preparation for the MRCP. The other people at UCH--, at the medical school one of the weak spots was cardiology and there was a man called Kenneth Harris who was the senior physician, again incredibly pompous and proud man, who had been a pupil and junior doctor under Sir Thomas Lewis. Now Sir Thomas Lewis was one of the great figures in British cardiology before the second world war and of experimental medicine, you know, how to experiment on patients without, as it were, hurting them and electrocardiography. So he was a great figure. The two figures who dominated UCL in recent times were Thomas Lewis the physician and Wilfred Trotter the surgeon. And Kenneth Harris rode on the coattails of Lewis, you know, “I was Sir Thomas Lewis’ house physician,” which he may have been but--, and he was--, he really was a damaging person in the sense that you learnt no cardiology from him. And in terms of his treatment of patients he really was a most unpleasant man and the significance of that was that UCH, like most London medical schools, was trying to build up a portfolio of all the specialties and cardiac surgery was in its infancy. And to have a cardiac surgery unit not only do you have to have a cardiac surgeon, which Pilcher the professor to some extent was and one of his assistants, but you have to have a good cardiologist to work up the patients to pass on to the surgeons and Harris had no feel for this at all. Congenital heart disease was the big thing in those days in cardiac surgery long before coronary artery surgery and he just was hopeless and disinterested. And so cardiac surgery never took off at UCH largely because of Kenneth Harris. And just before he retired they appointed a second cardiologist which I think he strongly opposed because he was the cardiologist, and this was a man called Arthur Hollman who was a UCL graduate who worked at Hammersmith Postgraduate Hospital in a very good cardiologist set up and he got appointed to UCH. And that was a great breath of fresh air but it was too late, as it were, to rescue the cardiac surgery. One of the--, my contemporary registrars at UCH was the registrar in cardiology Harry Meindock [0:28:01], he was a Latvian refugee who finished up in Canada. Anyway, he was a very worldly man far beyond his years and he spent his last few years, which were also Kenneth Harris’ last few years, surreptitiously transferring all the chronic patients that Kenneth Harris had not been doing much for over the years to Arthur Hollman’s clinic [laughs]. I still remember this, you know, Harry Meindock [0:28:31] quietly helping the cardiac patients of north London, but Kenneth Harris really was a bit of a disaster. One of his--, he would arrive to do his ward round--, he had a Harley Street practice I don’t know how many people went to it, but he would arrive at two o’clock, it was a bit like did you ever see Doctor in the House? The--, Sir Lancelot Spratt? Well anyway, he would arrive at the front door of UCH at two o’clock on I think it was a Wednesday afternoon, would walk in, hand his coat to his houseman, pick up his white coat from his registrar, you know, there would be a sort of formal procession as he progressed through the wards. And he--, because

Dr Eric Beck Page 17 of 123 he was a cardiologist and physician he would never refer a patient to another physician for an opinion because, “I know it all.” You know, that was a very damaging thing as well and again one had to find ways--, or when--, as medicine was getting more and more specialised you needed more and more specialist opinions, and how you could manoeuvre patients into the correct slot without Kenneth Harris being too upset. Yes, so he was a not a force for good. I wasn’t on his firm as a student but I went on some of his ward rounds and they were pretty awful.

Q: How much choice would a patient in the NHS have at this time? Would they be able to request a transfer to a different specialist?

A: No, I think the main choice that patients would have, and this was very rarely exercised, was you have the right to ask for a second opinion but in asking for a second opinion you’re implying there’s something wrong with the first opinion. So it doesn’t happen very often. It didn’t then and I don’t know whether it happens now. I think people are much more open about cross referral, but there was something in Kenneth Harris’ generation cross referral was almost an admission of failure that you hadn’t been able to solve the patient’s problem you needed somebody else to do it, but this was very rarely patient led. I think the other way in which patients exerted their choice was, and still do, when you’re referred as an outpatient to discuss with your GP what the options are and there are--, you know, you can go to quite a wide range of specialists. But once you’re in the system it’s not easy to move from one to the other unless you’re in a specialty where there’s more than one consultant and occasionally it would happen that you would be cross referred within the specialty. It just happened yesterday, I mean I was looking this out, I looked at--, I was trying to find the BMJ article I was referring to but there was a letter of complaint about one of my colleagues which probably referred to how his juniors had treated a woman in outpatients and she was very upset. And he must have sent me a copy of the letter because he did write back to her and apologised and blamed it all on his junior staff [laughs] and said ‘but if you would like to have another opinion I suggest you go and see’ me and I remember this lady coming along. But this was, you know, unusual practice for this to happen, but there was the potential for it to happen.

Q: You’ve given two kind of extreme sides in terms of bedside manner and interacting with patients, was it something that you learnt in the course at all?

A: Yeah, well there was no formal teaching in communication skills. You learnt it by example and there’s, as you say, good examples and bad examples. Hopefully you learnt from both. Now of course it’s a very central part of the new curriculum, I mean we spend a lot of time teaching it and examining it which we’ll perhaps come to that later. Can you examine communication skills? The older physicians would have said no but you jolly well can and you do. Yes, so communication you really learnt by example and hopefully you learnt from bad examples as well as good ones.

Q: And can you remember--, this is a strange question but it just occurred to me, can you remember anything about the motivation of your peers on the course? What had encouraged them to go into medicine?

Dr Eric Beck Page 18 of 123 A: Not a great deal although I do remember the first day in the preclinical course our first visit to the dissecting room and I think there were about six or eight of us each allocated to a body and I remember the--, one of the group of six of us who was an ex [serviceman]--, he’d done his national service he was a bit older and more mature than the rest of us, and he’d come along with a very fancy set of dissection instruments, almost like a surgeon’s full regalia. And he said, you know, “My name is so and so--, xxx”, I don’t know what’s happened to him since, and “I’m going to be a neurosurgeon,” this was day one of the preclinical course, “So when we come to dissect the brain I hope you will agree that I will be the one who will do it.” That’s some sort of confidence on day one. I think he finished up as a general practitioner somewhere [laughs], he certainly didn’t finish up as a neurosurgeon. So it was very clear why he was there. Why had the others come to medical school? I don’t know. It’s a question you could even ask today and I--, of when I see first year medical students. I don’t think too many of them did it because of the money as it were because it was the national health service and you were--, only a few would finish up with significant private practice. So this was--, I don’t think the financial rewards as such, although of course the financial security that you had working as a doctor. I don’t think too many of them came along wanting to make great discoveries in medical science either, a bit of that may have come later in the course when you did your BSc and you actually saw medical--, or scientific research going on at first hand. No, I imagine some of it was parental pressure and we see this today and that can be a very disastrous thing if you get pushed into it and a certain number did drop out because of that. I suppose because medicine was seen as a good career for men and increasingly for women as well, but I don’t remember any sort of people coming along with real determination that they wanted to heal the sick any more than I do today. Sounds disappointing.

Q: And what would you say you enjoyed most about the preclinical course?

A: The preclinical course, well the bit up to second MB was a pure grind of anatomy, physiology and so on. The preclinical course the highlight was the BSc when you could stop and think and learn how to use a library and that was--, that was the highlight and it made up for any regrets I might have had about not going to Oxbridge which I suppose, you know, would have been my first choice. Whenever we went--, as a football team we played some of the Oxford and Cambridge colleges and always had a very nice day out there, you know, that sort of rekindled the wouldn’t it be nice to be there and then you thought, well, you know, it’s not so bad being a BSc student at UCL. UCL is unlike many of the London medical schools which were purely catering for trainee doctors and were very narrowly focused, UCL did have that breadth of being a multi-faculty [college] and then to become an independent university. I think King’s College was probably similar, but I don’t know whether that answers the question [laughs].

Q: And what about your--, when you moved on to the clinical work but still as a medical student, what was some of your early clinical experiences?

A: Right, well I can still remember the first patient I saw on the first day as a medical student on the medical unit. A farmer from Dorset who had been referred up to the big teaching hospital

Dr Eric Beck Page 19 of 123 in London because he had a rather mysterious disease which turned out to be sarcoidosis which is a--, still a bit of a mysterious disease and actually came--, comes up later on in relation to Guy Scadding. Yes, so the first impressions were of the--, yeah, talking to patients because we had had no practice in this whatsoever in the preclinical course. And some people I think found it very difficult and awkward and also asking some of the very sort of personal questions with you as a callow youth, you know, asking women their menstrual histories and obstetric histories and so on. So that was a pretty steep learning curve. The housemen on the firm—[were approachable and interested in teaching], and this is perhaps where the medical education interests began with me, we had very good housemen ‘cause the medical unit house job was the crème de la crème and I still remember how helpful the houseman was and allowing us and supervising us over simple--, doing simple procedures like catheterising a patient and so forth. So yes, that was important. And the other people of course were the nurses and the ward sister. The ward sister really ruled with a rod of iron and most of the clinicians were--, even the consultants, you know, didn’t--, didn’t cross them lightly. And then of course the nurses they would be the qualified nurse, the SRN, staff nurse and then nurses in training who like medical students in the training of the School of Nursing. And one of the things that they did and I think they still do do was that in our first three months I think one day a week after hours we did practical nursing, we went on the wards and joined the nurses in changing the beds and emptying the bed pans and getting the patients in and out of bed. And that was--, that was obviously an important--, it doesn’t sound a big deal but looking back people who haven’t done that sort of thing I think lose out on it. And it’s where I met my future wife who was a nurse on the, --, on the ward where I was doing my practical nursing one day a week.

Q: So tell me more about meeting her.

A: Well she--, she of course wore a nurse’s starched uniform and seemed to be far more knowledgeable about what was going on than I was and she--, she lived in Kettering, that was her family home. So she’d come up to London too. So she lived in the nurses’ home. And yes, so that would have been--, what time of the year did we start the clinical course? We started it in the autumn that’s right because we’d done the BSc that puts us six months out of kilter with the others. So over the coming year, yes, we got to know each other and had our first holiday together up in the Lake District which I still remember very well, catching the overnight bus from Victoria up to Keswick and then down to Borrowdale and staying in Borrowdale. Yeah, so everything went pretty--, pretty smoothly. We then, erm--, we got married while I was still a medical student 19--, yes, I think I was still--, I must have been in my final year and she was--, she was by then a qualified nurse and one of the rules of the nursing profession in those days was you couldn’t be a nurse if you were married. Simple as that. And because she had got her SRN they--, and she was marrying a medical student, I don’t know whether that influenced them at all, they created a post for her in the chest clinic, a sort of day post as a nurse in the chest clinic which was quite a magnanimous thing to do. They could have just said, you know, ‘goodbye’. And yes, so she worked in the chest clinic and then we found a flat down in Brixton opposite the town hall which chimed out every quarter of

Dr Eric Beck Page 20 of 123 an hour 24 hours a day. So that worked pretty well and then unfortunately in my final year as a medical student when we were already married she developed Hodgkin’s disease. And not so much was known about Hodgkin’s disease as now but it was essentially you did a biopsy of the gland [an enlarged lymph gland] to confirm the diagnosis and then the treatment--, which was really before chemotherapy came along, the only treatment was radiotherapy which she had a course of and it seemed to go away but over the subsequent years she had several relapses. And finally, erm--, well almost 20 years later it caught up with her and she died down in Wales where we had rented a cottage for many years. Yes, so--, but despite this when the disease was in remission we had two children which she went through as it were unscathed, it didn’t seem to do anything to her underlying illness and well she was a--, a good and much loved mother by her children. And then the irony of it all was that our daughter Helen at almost the same age as her mother found almost the same lump in her neck and she had a slightly different form of Hodgkin’s disease and this was treated again initially successfully but eventually caught up with her last year when she died of the effects of the radiotherapy on her heart. Yeah, so that was the--, that was how I met Pat and how our children [grew up] --, who I don’t think were too aware of their mother’s illness during their early childhood. Obviously in the months immediately before her death they were and so I was left with a teenager daughter and a son who was 11 or 12 and don’t think I handled it particularly well. We got a series of au pairs to--, we were living out in Bushey then, I was a newly appointed consultant at the Whittington. Yeah, so that was not an easy time they were finishing school and so on. And then I subsequently met my present wife Pam who moved in and acted as sort of stepmother and took on perhaps more than she had bargained for with that.

Q: Your hospital and your colleagues were they supportive when your wife was ill?

A: Yes, I--, yes, they were. I mean I don’t know how much, as it were, support I needed. Certainly the treatment was all at UCH so the people treating her were people who I knew as a student who I obviously had confidence in. Yeah, and I don’t remember whether I had to take much time off. When Pat eventually died years later yes, they were--, I was at the Whittington by then and, yeah, they were pretty supportive and said, you know, “Come back when you feel you want to and we can cope,” which they did. Yeah, so I think it--, I don’t remember any sort of notable event but the general atmosphere was one of support.

Q: You were saying that nurses were an important part obviously of your career as a medical student when you were a medical student and you said there were--, there were some people with quite strong personalities.

A: Well the ward sisters, yes.

Q: I was wondering if there was anyone particularly that you can remember.

A: Well there was one sister, Sister Whitow [0:47:47] who was the--, by then quite middle aged who was the ward sister on the [ward]--, where the medical unit had its beds. And that was Rosenheim was the professor of medicine, I think Nabarro had moved on to the Middlesex by

Dr Eric Beck Page 21 of 123 then and Spencer--, there was a chap called Spencer who subsequently went on to Barts who were the two medical unit consultants and Hawksley whose firm I was on were also on this ward. And Sister Whitow [0:48:26] obviously had been in love with--, in a platonic way with Professor Rosenheim the archetypical bachelor all her career and so, you know, everything revolved about it ‘had to be right for Professor Rosenheim’. Anybody else working for him in the team was nobody. And I remember one particular incident when I don’t know what had happened, I think somebody had been rude to her about Rosenheim, and she got very upset and Spencer, the first assistant, came in to the ward that morning and she said, “Oh, Dr Spencer, Dr Spencer, a terrible thing happened to me last night,” and he looked at her and said, “Was it a black man?” And he had that sort of sense of humour [laughs] which yes, I--, so he was a nobody as far as she was concerned. So yes, she was pretty powerful. Then there was a sister on the--, oh golly I should remember her name, on the ward where Pat finished up as a staff nurse after she got her SRN and she was a very--, she was the complete opposite to Menny [0:49:44] but one was--, Menny [0:49:48] was the male ward and what was her name? Anyway, she had the female patients and, you know, it was chalk and cheese and she was such a nice lady, I’ve forgotten her name now. And then one of her underlings became Sister Hall, Sister Hall, who we still see from time to time because her husband became the chief executive at the Whittington, he was a nurse in management. Yeah, so they were pretty good. One of the wards that we had at the medical unit where I was a student and subsequently where I worked as a registrar was the metabolic ward.

[END OF PART TWO 00:50:40]

[PART THREE]

Q: Okay.

A: Yes, one medical ward that was very different from all the other wards at UCH was ward 1-1, the metabolic ward. And this was the territory of two outstanding people, one Charles Dent, professor of metabolic medicine and the other was Eric Pochin who was a registrar and subsequently became--, and the reason they were--, Pochin was down there was that he was a pioneer of the treatment of thyroid cancer with radioactive iodine which had to be administered under rather careful conditions. So I was involved with Pochin and his radioactive iodine patients and Charles Dent was the ‘major shareholder’ doing studies on calcium metabolism. And the whole ward was geared, as it were, to medical research and the patients who came in would have all kind of studies done on them, some of them with rather obscure or rare diseases. And it was made very clear to them in terms of his communication with patients he was very good at explaining what he was doing, why he was doing it and it might not be of immediate benefit to them but, you know, would they--, would they like to participate. So that was a rather unusual ward and it comes up again later in relation to human experimentation. And he [Dent] was a staunch Catholic, Jesuit Catholic who had a very strong, as it were, moral sense and you often wondered how he managed to reconcile his outstanding scientific approach to his very strong religious approach but it obviously--, although he didn’t, as it were, flaunt it, it obviously formed an important part of the ethics of

Dr Eric Beck Page 22 of 123 medical research as he practiced it. And I--, although I didn’t, as I say, work for him I was very much aware of what was going on--, what was going on there. But this was mainly after I qualified I don’t think I saw much of [Ward] 1-1 as a medical student.

Q: So we were talking earlier before we began the interview about Maurice Pappworth and some of the ethical issues.

A: Yes.

Q: Where there things that you saw when you were either a later medical student or in your early jobs that surprised you about medical practices at this time?

A: No, I can’t think of any outstanding bad practices. One of the dangers of course in a teaching hospital is that patients are sort of held up as objects to be taught on rather than as individuals and this is a problem in medicine in general, but it’s heightened I think in a teaching hospital atmosphere. I remember there was one particular demonstration we used to have a clinical theatre on the third floor of UCH where instead of going on a round--, round the beds all the students would sit there and the patients would be brought in and, as it were, demonstrated. And I still sort of can’t quite work out in my mind what was wrong with this, but it was--, and I can’t remember the actual physician involved, but it was a patient with hysterical conversion syndrome, that’s to say a person who was physically perfectly well but who thought he had some bizarre condition which caused a paralysis which didn’t fit, as it were, in the orthodox textbooks. And this man, I think it was a man, was brought in and demonstrated to us and asked to tell us about his symptoms and he was examined and it was all done in a seemingly very proper fashion. And then the clinician, erm, he having demonstrated, you know, he couldn’t do this, he couldn’t do that and it didn’t make sense, suddenly said something which completely switched off his hysteria and he walked out a normal person. You know, it was almost like magic as it were. And we were enormously impressed about the power of the mind over the body which was the gist of the demonstration. And then it sort of occurred to me and some of us what thought had been given about why this man was doing what he was doing and that he was very much held up as a prize example, which he was, of a rather unusual condition. So that left me and several of my colleagues I think a little uneasy as to what exactly had been going on.

Q: Can you remember what they said to bring him out of his state of hysteria?

A: To bring him back--, to bring--, I’ve forgotten what--, I’ve forgotten what the trick was. It was something about--, it might have been as simple as, you know, almost a form of hypnotism, “I’m going to count to three after which you will raise your arm,” that--, something like that because these people of course are highly suggestable or often are and quite like being the centre of attention. And so the patient, you know, they’re an unusual lot of patients and it’s very difficult to know how to handle them. I don’t think anyone had seen anything like it before and I can’t recall having seen anything like it since although you read about it. But yes, so that--, I don’t know what the ethics of that were. But by and large I think I don’t remember any

Dr Eric Beck Page 23 of 123 outstandingly bad examples and I do remember some, you know, good examples of William Gooddy and his Saturday morning clinics despite his misdiagnosis [laughs] in later years.

Q: What other--, you’ve mentioned sarcoidosis and the work on the metabolic ward what--, at this stage in your career, so before you qualified or while you were practising in a clinical setting, what other kinds of patients do you remember seeing? What other illnesses were people presenting with?

A: Well as an undergraduate during the clinical course this was governed by the special interests of the firms I was working for and of course emergency admissions that would come in. So I suppose I saw a fairly broad spectrum of patients with heart attacks, strokes, pneumonia. Hawksley was a sort of gastroenterologist but very much of the old school so he would have some patients with abdominal problems. Who else? Which other firms was I on? Hawksley, the Medical Unit. Well the Medical Unit, yes, were interested in blood pressure and in those days there were very few--, very little medication for blood pressure. There’s now an enormous amount. And one of the first drugs that came along was the first beta-blocker which was I think Propranolol and I remember as a student getting involved as a pair of hands in taking people’s blood pressure at 15 minute intervals round the clock and doing it in shifts, as it were, to see whether these--, how effective these drugs were. So yes, the beginning of the beta-blockers I suppose was one of the things I became aware of. The other big thing that was coming in in those days were steroids. And Cortisone and its derivatives were being used more and more in all kinds of conditions where it might help some conditions. It was wonderful in people with active rheumatoid arthritis it could and still does transform their lives. I don’t know whether the man with sarcoid was treated with Cortisone. It was about that time that Cortisone was coming in and then of course its use in asthma became aware of that. Yeah, I think those are the main disease patterns that, you know, common every day diseases.

Q: What other drugs or treatments do you remember using regularly in your early career?

A: Well as a medical student, as I say, Cortisone was just beginning and people hadn’t really explored the breadth of its use or the--, or the side effects. The acute side effects were recognised because they were the same as having Cushing’s syndrome but the long term side effects took some while to sink in. And I think as--, there was a rather gung-ho attitude that, you know, these are wonder drugs we must use them and it’s only in recent years that people have become much more cautious about their use. The other thing of course that had already come in, penicillin, as we mentioned earlier had been [developed] in Oxford at the beginning of the war so--, but alternatives to penicillin were already being looked for because penicillin resistance was beginning to show up. I don’t think the message about misuse of antibiotics as we understand it today had been very clearly formulated then it was just sort of bad luck if your infection didn’t respond to penicillin, thank goodness we’ve got Tetracycline, or something like that. The other drug advance I suppose that I saw happening as a medical student was in the treatment of tuberculosis. The first drug that had come along in the treatment of tuberculosis was Streptomycin and in fact one of the outstanding clinical trials using Streptomycin was by

Dr Eric Beck Page 24 of 123 the Medical Research Council under Richard Doll at the Central Middlesex Hospital and this a was [probably the first] very carefully studied controlled study. So Streptomycin was in. PAS and INAH [0:11:19] came along more or less at the same time so Strep, PAS and INAH seemed to be the end of tuberculosis but of course it made a huge impact but then drug resistance began to appear there. And streptomycin was a fairly toxic drug, could cause deafness and balance problems. And so tuberculosis treatment was constantly looking for newer drugs, Ethionamide and I’ve forgotten what the other ones were. But tuberculosis was very much in decline and you saw some of the old--, older people with wrecked lungs from the disease or from the surgical attempts at collapse therapy, the mutilating things that had happened. They still had--, because Pat my wife worked in the Chest Clinic, they still had what was called a pneumothorax clinic which is where you deliberately introduce air into the chest to collapse the lung to rest it, as it were, and then the air would be gradually removed [corrected to ‘absorbed’] and you would have to come in and have a new pneumothorax. So she was involved in a bit of that and that’s I think virtually gone out. There was one other form of collapse therapy which I may just come back to when I’m talking about my MRCP exam because it was a key thing in a patient I saw [laughs].

Q: Do you remember seeing anyone or having patients that had illnesses that just don’t happen anymore or just…

A: Er, what diseases--, well a lot of the infectious diseases of course I don’t think I ever saw a case of diphtheria in my life. We were seconded as part of our clinical training, I think we spent a week at the South Middlesex Isolation Hospital and there was nothing too esoteric happening there. Diseases that have disappeared.

Q: Did you have any polio patients?

A: Right, active polio no but we certainly saw the after effects of that. Actually mentioning polio you were asking me about my own medical history. One summer--, in fact it was a summer when my mother had had her jaw broken by a dentist and was--, so she was--, I think she was away having surgery to repair her jaw, I’m sure it was a terrible sort of medical accident. I had obviously developed some kind of [transient] fever and I was confined to my bedroom for several weeks; and I never knew what the reason for it was and subsequently my father told me, “Oh, there was a lot of polio around at the time and we thought you might be having the prodromal illness.” This was never [confirmed] --, I don’t know whether I would have known about polio then it was--, I was still a schoolboy but I always thought this was a bit odd that my father, the microbiologist the pathologist--, I don’t know whether it was--, I think it was largely his diagnosis although I think a GP sort of came along and said, “Well we better just be careful.” And there I was sitting in a hot summer in my bedroom getting increasingly frustrated and then eventually I was released. And I remember I went off with my [father]--, because my mother’s jaw had been broken and the summer had been rather wrecked one way and another my father took me off on a camping holiday and we went to the Savernake forest and somewhere else and I’ve forgotten exactly where. Yes, so that was a--, that was a weird summer, but in answer to your question I don’t remember. Did I see any new cases or polio?

Dr Eric Beck Page 25 of 123 Probably not. Rheumatic fever that’s another thing which of course had virtually disappeared and there was a special unit at the Red Cross Hospital in Taplow in Buckinghamshire where we went on an afternoon visit from the medical school to see people with rheumatic heart disease and I think there might have been one or two cases of acute rheumatic fever but that’s virtually disappeared as well. Yeah, I don’t know what else has disappeared. Or what--, and new ones have come along of course, no one had ever heard of HIV when I was a lad but that came much later.

Q: Absolutely. I’m just wondering whether we should stop for a bit--,

A: Yeah.

Q: And…

[END OF PART THREE 00:16:16]

[PART FOUR]

Q: So I think Dr Beck before we move on to your house jobs you wanted to say something about- -, something more about your medical student days.

A: Yes, well one of the things that the medical school did in common with many others, and couldn’t provide the whole panoply of medicine to teach onsite, was the use of other hospitals- -, other hospitals which might not then have been teaching hospitals. I think I mentioned earlier going to the South Middlesex Hospital for fevers; some people went away to hospitals for obstetrics because there weren’t enough babies going round UCH for everyone. And one area where UCH, being in the centre of Bloomsbury, was somewhat deficient was paediatrics in that it had specialist paediatric interest but every day paediatric conditions were hard to come by as it were. And to compensate for this the medical school had set up an arrangement with the Whittington Hospital with a paediatrician there called Simon Yudkin and his colleague Joe Luder and Whittington, as you probably know, is right sort bang in Islington and very much a working class district with lots of children as patients. So we got sent out to the Whittington for I think about a month of our course and this was a real eye opener moving to a district general hospital and this was one wing of three old infirmaries where the paediatric unit was located. And the whole atmosphere of the hospital was very different from the teaching hospital where we [coughs] were being taught in that it was very much a hands on down to earth practical approach and learning as you went along. And so along with many of my colleagues our time at the Whittington, albeit very brief, left a deep impression, so deep that I finished up spending the rest of my life there eventually. So that was a particularly good experience going out to the Whittington. So having completed the various appointments within the clinical course I took my finals, which we’ve referred to already I think, failed my medical for national service which we’ve referred to already but before then, of course, I had to do house jobs. And I was appointed to St Pancras Hospital which was again an old infirmary and ‘workhouse’ [0:02:50] hospital to UCH which had acute units, it had a geriatric unit, it also had the mental observation ward which I’ll say something about in a moment and also the hospital for tropical diseases had been located there. So it was a sort of mishmash of different

Dr Eric Beck Page 26 of 123 hospitals and specialties with very little acute medicine coming in apart from one month one summer when UCH A&E department closed and things were diverted to the Whittington, which happened while I was there so that made the job more interesting. Just to say a word about the mental observation unit there, I haven’t mentioned much to do with psychiatry in our training and we didn’t--, if truth be told, didn’t get much training in [everyday] psychiatry, but to make us familiar with acute psychoses (people going acutely mad and how to deal with them) we used to go along for a series of Saturday mornings to the mental observation ward, with locked doors and clanking chains and so on. And a rather odd consultant called Dunkley who was in charge of it, who was very deaf, who had a hearing aid which was constantly peeping and beeping and the story was that he heard voices through his hearing aid and that’s why he was a psychiatrist he was hallucinating all the time. And on these Saturday morning sessions again patients would be brought in who had been there a day or two acutely psychotic with schizophrenia or suicide attempts or whatever, it was really the raw end of psychiatry, and again it was quite an eye opener coming from the protected wards of UCH. And Dunkley had been ‘taken over’ by UCH when they took over the mental observation ward so he wasn’t, as it were, a teaching hospital consultant as such but had been made one and I think he suffered a bit from, you know, not being fully recognised in any way in a specialty which people didn’t really want to know too much about. And it seemed that an awful lot of the acutely psychotic patients that we saw on Saturday mornings always seemed to be Polish and this was before the common market and freedom of movement. And I think somebody must have asked him that once he said, “Oh well, all Poles are paranoid,” but that’s something that has stuck with me ever since [laughs]. So that was him. The other thing about the mental observation ward was that the two more respectable psychiatrists on the staff at UCH had to do certain shifts there and one of them was a--, in fact, a very nice man, Roger Tredgold, a very tall thin athletic man who taught us the little psychiatry that we did get to know and he happened to be also a first class fencer of Olympic standard. And in 1948 when the Olympic games were held in London he was chosen to fence for the British Olympic team and I think he was at that time a senior registrar working in the mental observation ward totally absorbed in his work, looked at his watch and realised that he was fencing for Britain in half an hour’s time. And so rushed out of the mental observation ward and hailed a taxi because taxis were often circulating and said, “Quick, quick take me to Wembley, I’m fencing for Britain.” So the taxi driver drove him once round the block, back to the front door and knocked on the door he said, “I think this is one of yours [laughs].” This was Roger Tredgold, fencing for Britain. I don’t know whether he won a medal but it was a lovely story.

Q: That’s a fantastic story [laughs].

A: So moving to St Pancras was…

Q: Sorry, can we--, can we just--, can I just ask you one or two questions about your work in the mental observation ward your experiences there?

A: Well this was a student.

Dr Eric Beck Page 27 of 123 Q: Were people beginning to use some of the early drugs for treating psychoses [0:07:20]?

A: I think Chlorpromazine had come along. ECT was certainly around and I remember seeing this as a student and thinking, you know, how awful it was but it did seem, as it still does, to produce results from time to time, but--, and there wasn’t much ‘talking treatment [therapy]’ going on in the mental observation ward because people were too disturbed to talk as it were. So I think Chlorpromazine probably was the main drug that was in use and a relatively new one.

Q: Were there any other treatments that people were using at this point?

A: Erm, well I don’t think there was any psychosurgery going on like leucotomy although we were told about it; interesting story that it is I don’t think anybody within the UCH complex was doing anything surgical. Insulin coma had been tried as an alternative to ECT but I think it was not very effective and rather dangerous. So I think it was essentially ECT and a drug. The other thing I should say, because I had slight contact with it later on, was that in the basement of St Pancras Hospital was the electroencephalography unit, EEG, for measuring or recording ‘brain waves’. And that was one of the rather false dawns in neurology and psychiatry. People thought when you could see people’s brain waves it would have the answer to everything and the answer sadly, apart from epilepsy where it is useful, is that it hasn’t fulfilled its promise, but that was something I got marginally involved in as a houseman. So I was appointed houseman at St Pancras to Hawksley who had been--, whose firm I’d worked on as a medical student, nice man, bit of a casualty of the war he’d come back post war sort of burnt out. And another nice man rather in the Gooddy mould called Burt, Hugh Burt, who was a rheumatologist and physical medicine doctor, long gangly man and he was another one who had this quality of listening to patients with often rather unpleasant and painful symptoms and empathising with them. And so--, and he taught me one or two things like how to inject knee joints with steroids for arthritis. So that was a pleasant experience working for the two of them. And being at a hospital without an acute admissions, except for the one month, it--, the pressures there were not all that great. However, in the hospital next door, the hospital for tropical diseases with whom we shared a mess where there was an academic unit, Alan Woodruff and a couple of other consultants, they had a registrar called Philip Marsden, now he was really quite a character. Philip Marsden had a Boris Johnson-like laugh, he was a very sort of ebullient extrovert character but he just couldn’t pass the MRCP exam and I suspect partly because when he got into a viva situation he probably got up the back of every examiner. But anyway, he kept failing this exam and until he got the exam his career had to be on hold. So what he organised was--, with a similar group of people around London who were trying to work for the MRCP exam they arranged a weekly rota of going to each other’s hospitals and showing each other interesting patients and acting as the examiner and so the HTD [Hospital for Tropical Diseases] was one of the venues and as someone who wanted to do the MRCP, even though I was the lowliest of the low, I was allowed to tag on to these membership rounds. And that gave me considerable insight into the kind of cases, the kind of talk, the paranoia that it induced in people who failed rightly or wrongly and seeing some very

Dr Eric Beck Page 28 of 123 interesting patients. And one of the patients I saw again comes up later on in my career in a year or two’s time who I always remember, and this was a general practitioner working in the New Forest who had been referred to the Hospital for Tropical Diseases which may seem rather odd because the New Forest isn’t all that tropical, but they tended be a place that people were sent with unexplained but definite physical illness. And he had an illness comprising of lung problems and abnormal liver function and, to cut a long story short, the--, and he was in the New Forest and he was very fond of eating watercress which he would go and pick in the New Forest. And the New Forest has got downland sheep who graze in the New Forest and defecate in the rivers on to the watercress and the watercress he had eaten contained the eggs of a liver fluke called fasciola hepatica and he had got fascioliasis. And the HTD doctors diagnosed this and it was quite a coup and it was written up as a case report in the BMJ I think. And this sort of struck firmly in my mind this case of fascioliasis amongst the many other interesting cases that they had. So I began, as it were, my preparations for the membership in my first house job and we also of course had medical students coming down from UCH to St Pancras and I got involved a bit in teaching them as well as learning myself and…

Q: Can I ask you, sorry, before we move on from the Hospital of Tropical Diseases, did you have any patients that were coming there that had illnesses that were left over from being on active service in the Second World War or…

A: Not that I can specifically recall. I mean I remember as a student in outpatients seeing people who had been gassed in the First World War with chronic lung disease, there were a few of those still surviving, but I don’t remember any specific Second World War disease casualties.

Q: Or people from national service perhaps.

A: With tropical disorders? Well they came from anywhere and everywhere but again I can’t on the spur of the moment think of any specific ones like that. The other thing I should say was that they--, one of the consultants there went out to the only remaining leprosarium in Britain. There was still a hospital for cases of leprosy some were longstanding and chronic ones, one or two acute ones still and they would sometimes come up to the HTD. So I did actually see a few cases of leprosy and the sort of social attitude to leprosy came over as well. So having the HTD there was certainly a bonus and having Philip Marsden striving to pass the membership, which eventually he did and went out to Brazil and did some really fundamental work on Chagas disease, trypanosomiasis. It’s a parasite that causes something a bit like sleeping sickness. So his potential was waiting to be unlocked by passing this wretched exam and it took him years to do it. He had this incredible laugh, as I say, like Boris Johnson and I--, our paths had crossed, Marsden and mine, although he was a few years ahead of me, at medical school where we had to go to a short set of lectures by the coroner about forensic medicine. And the coroner at that time for Islington was a man called Bentley Purchase who achieved a little notoriety at the end of his career by being not only the coroner for the Royal Family, so if anybody royal died he had to conduct the inquest, but for some reason that was

Dr Eric Beck Page 29 of 123 never properly explained he died falling off the roof of his house at home. How he ever got on to the tiles no one quite knew. And he was a remarkable oddball character who had a great collection of the most gory illustrations of how people had died including front pages of the Daily Mirror sort of showing mutilated corpses and during his lectures he would put up pictures of this and then he would laugh this very loud laugh and Philip Marsden in the back row, the laugh would ricochet off him and these two laughing [laughs]. Anyway, there I was in St Pancras coming to the end of my first six months house job. On the last day, this is just to illustrate how tied junior doctors were in those days, there was no official time off you worked 24/7 and Hawksley, my very nice boss, said to me, “Well thank you for your work for the last six months,” and I said, “Well thank you for having me,” as it were. He said, “Well I think you should take a holiday.” And I said, “Well I would if I could but tomorrow I’m starting my surgical job [laughs],” which I literally did. So I did my second six months as a house surgeon at St Pancras and on the first day I made two--, no, I made one error which was the senior registrar who ran the show and the UCH consultants would come and do operating lists but the day to day work was this chap Frank Ellis, I think was his name, and he sat me down, he was a blunt Yorkshireman and he said, “Well what are you going to do?” So I said, “Well I want to do the MRCP and become a physician.” “Oh,” he said, “Well what do you want to do surgically?” So I said, “Well whatever is necessary.” He said, “Don’t you want to do operations?” So I said, “Not particularly,” and I was sort of written off as a failed surgeon from day one. Day two was interesting ‘cause it was a Sunday and the--, one of the surgeons who had a list on the Monday would come in to see the patients he was going to operate on the next day and so would his anaesthetist and his anaesthetist was a senior registrar, very nice quiet man called Peter Verrill. And Peter Verrill sort of sat me down and I was going to be working for four or five different surgeons and he explained the idiosyncrasies of each of these five to me which was, you know, a very helpful thing to do. And Peter Verrill later became Dean of the Medical School and his daughter, Jane [nee] Verrill, is our president of the College of Physicians. So I got to know her at a fairly early age through her father who was--, had by then become a consultant anaesthetist and then become Dean of the Medical School. So it’s just how one thing gets connected with another. So I had my six months doing different bits of surgery including an interesting bit in the second three months working for the neurosurgeon, a very nice thoughtful man called Bernard Harries who had been in the Japanese prisoner of war camp and was a very sort of thoughtful and thorough in his methods, very slow. Neurosurgical operations could take up to five hours and all kinds of techniques were used to, er--, to, as it were, immobilise the brain while you were operating on it, one of them was cooling the patient to a very low temperature by putting them in a huge tin bath full of ice and so their temperature went down to whatever it was, 15 or something, and it was then safe to operate on them. So I remember being involved in that. In fact, I was involved in one lengthy operation like this in the second six months which was end of October [corrected to October 29th], and I think we’d started at ten o’clock at night and it was about two o’clock in the morning and I was there holding the sucker or the--, which you didn’t do much as a house surgeon. And a nurse came in and whispered in my ear and Bernard Harries looked

Dr Eric Beck Page 30 of 123 up, he said, “What’s that about?” and I said, “Well the nurse has just told me that my wife has just entered the second stage of labour at the obstetric hospital in Gower Street.” He said, “Oh, you must go, go immediately, take my car.” Well I had my motorbike. So I always remember Helen, my eldest daughter, was born in the middle of a lengthy neurosurgical procedure. I got there in plenty of time. So that was--, that was Bernard Harries who was in many ways the nicest of these five surgeons. But there was a rather mad one called HRI Wolfe. Very eccentric, emotionally labile character with some rather offensive views who had- -, who was surgeon to the hospital of tropical diseases and once a week he would have a list for any patients that they had there, which were very few, and that was a bit of--, and he had this curious belief that his hands were sterile. And so most surgeons when they prepare for operation they wash, they gown up, put gloves on and gown and so forth, HRI Wolfe would come in I think he wore the surgical cap and a gown, he would then wash his hands and he would ask the theatre sister to provide him with a bowl of absolute alcohol, a tin bowl and he would then rinse his hands in the bowl and start to operate without gloves. And people obviously, you know, questioned why he was doing this he said, “Oh, I find I can get a much finer control on my instruments when operating if I don’t wear gloves,” and so people would say, “What about sterility?” He said, “No, no problem, I’ve had my hands swabbed by the microbiologists and there are no bacteria on my hands.” And he had this weird belief that he had sterile hands and all he needed to do was wash them in alcohol [laughs] before he operated. He was a--, he was a rather unpleasant bit of work, he was another staunch militant Catholic and one of my subsequent housemen a few years later when I was at the Whittington was almost destroyed by Wolfe. He was--, the houseman in fact is dead now, he died under tragic circumstances in Plymouth, called Roland Levinsky. He was a--, had become by then an eminent paediatrician but he became because of the luck of the draw house surgeon to HRI Wolfe and Levinsky, as his name implies, was Jewish and not particularly observant Jew but Wolf immediately took a dislike to him and made his life hell for the next three months of his job. And I remember Levinsky coming along to me and saying, you know, “I really can’t take any more of this I think I’m going to give up medicine.” And I remember, you know, talking to him saying, “Look, it’s only three months stick it out and--, which he did. So--, but I mean he was--, Wolfe was such a personality that he could destroy people. And during the time that I was working for the neurosurgeon he went off on holiday and HRI Wolfe, who had some neurosurgical training, took over the neurosurgery and everyone was in fear and dread what happened or what would happen. Fortunately nothing much because he didn’t have much to do. So those were my surgical--, that was my surgical job and, at the end of that, I went off to be failed for national service and had to find--, with a bit of my appetite whetted for the MRCP by Phil Marsden and his rounds that I had to find a job which would help me in further preparation for the MRCP. Now the scene in those days in terms of postgraduate training or membership training was one of pure luck and a certain amount of influence. There were no SHO training programs as such. What you hoped to do was to get a good job where you would get good experience, where your bosses might be membership examiners even and there was a recognised circuit of jobs like that in London and also outside London, part of

Dr Eric Beck Page 31 of 123 it was called the golden triangle which was the hospitals of the Brompton, Hammersmith Hospital and Queen Square, these were all postgraduate institutes. And if you could get a job at any one of those you were well on the way to preparing for the membership, but there were other hospitals which had good reputations and the Whittington was one of them and the Central Middlesex was another. And the reason the Whittington had a good reputation in postgraduate medicine was that it was this huge hospital, 2,000 patients [corrected to beds], the largest in Europe, three wings, three former workhouses and taken over by the LCC as a single hospital and then became an NHS single hospital and had to have a unifying name. It had been called Highgate Wing, St Mary’s Wing, Archway Wing [added: each at the apex of a London Borough, Hampstead (now Camden), Islington and Hornsey (now Haringey). And so it’s because the pub the Whittington Stone is in Highgate Hill with the stone where Whittington sat and heard the bells of London telling him to turn again that somebody had the bright idea of, “Why don’t we call these three wings now forced together the Whittington Hospital?” So that’s how it got its name. Anyway, the early physicians there from the early NHS days realised it wasn’t going to be a terribly attractive place for attracting good junior doctors unless they had something to offer and what they had to offer with 2,000 beds, although it rapidly shrunk, was lots and lots of interesting patients. So the Whittington was one of the first places to start a postgraduate course for the MRCP, an evening course, to which of course their junior staff could go. So people were perfectly happy to put up with the workhouse surroundings if they could come to the Whittington course. And people came from all over the world, which has been one of the pleasing things in my later career going around the world and saying, “I’m from Whittington,” and hearing the president of this or that college say, “I was there.” So anyway, the Whittington was the place--, one of the places to go. So I applied for an SHO job at the Whittington thinking, you know, with my good finals results and having been at UCH and so on, anyway, to cut a long story short, I got turned down at the Whittington for one of the six jobs. I was really rather miffed particularly as one of the characters who got it was a complete no hoper conman, you know, contemporary of mine at medical school [0:27:55]. So the first job I had ever applied for and I failed to get it. So I licked my wounds and the Central Middlesex jobs were coming up in the next week or so so I applied for the Central Middlesex and got appointed there as post registration or SHO [corrected to house physician] to Horace Joules and Keith Ball and this, you know, would have many of the things that I would have liked to have had at the Whittington. And that was a very happy six months at the--, at the Central Middlesex, again bit like St Pancras because of all the other things that were going on around me. The MRC had a Clinical Research Unit there attached to Avery Jones, one of the father figures of British gastroenterology and Richard Doll, the epidemiologist who I already mentioned worked in his department. So they were doing clinical trials in a scientific way which was then relatively unknown, the idea of having control groups and so forth. So that--, although I didn’t work on that unit every Tuesday afternoon they had a sort of open session to which anyone could go and lots of people came from other hospitals for it and there it was sitting on my doorstep. So that was one good thing about the Central. The other thing--, well--, and there were medical students from the Middlesex and in those

Dr Eric Beck Page 32 of 123 days the Middlesex was a separate medical school and the Middlesex had invested in the Central Middlesex from the late ‘30s onwards partly because of the problem I mentioned at UCH as a central London teaching hospital they just didn’t have enough patients to teach--, with which to teach their students and the Central Middlesex was bulging with them. And so again it was an extremely popular place for medical students to come and the clinicians there were all very good teachers and were partly selected on their ability to teach. So yet again I got exposed at a fairly early stage to the importance of clinical teaching at a fairly junior level. But of course the overriding need while there was to go on preparing for the MRCP exam which I wouldn’t have been eligible to enter for another six months until after I’d left the Central Middlesex but I wanted to have a go as soon as I could. And this is how I and many others, on I think it was Tuesday evenings or Thursday evenings, finished up down the road from here at the [Marshall Street] swimming baths. What do they call it just round the corner? Where the magical Pappworth had his weekly sessions and so we all traipsed off to Pappworth who really was a remarkable character, a highly flawed character but nonetheless, you know, is an important figure in the history of the MRCP--, post war MRCP examination. And Pappworth was just a brilliant teacher and his lectures I’ve forgotten how long they were supposed to be but we usually finished up after two and a half hours it was time to go home. And he for the first time--, I mentioned it already the difficulty I had understanding neurology and he just made it so clear and how you--, you know, the system of thought you had to have to understand neurology but it wasn’t just neurology it was the whole of medicine. So he was a brilliant teacher and his teaching methods--, in fact he subsequently published in a book called the Primer of Medicine which was very dull compared with his lectures, somehow, you know, the lectures didn’t come over. Now what motivated Pappworth was that he had fallen foul of the medical establishment and I’m not exactly sure why, I suspect knowing the kind of combative character he was it might as well have been his own fault as that of the establishment, but he had got on the wrong side of people. He had never progressed beyond the senior registrar. He never got a consultant post. And it seemed quite likely that whenever he applied he was being blackballed or, “We don’t want a rebel like this,” and he--, his bête noire was the College of Physicians who he thought were behind his failure to advance his medical career. So a lot of his teaching I think was motivated by a wish to defeat the College of Physicians in the MRCP exam. It became his sort of personal crusade and added fire to his--, to his teaching skills. And added to which there were all kinds of other things which immediately antagonised the college one of them was he would give you thumbnail sketches of the medical establishment, many of whom were membership examiners, most of whom he had a very low opinion of with one or two exceptions. So if there was somebody Pappworth approved of he really had to be a good egg as it were. And so that was amusing and entertaining. And just to mention his heroes, he was a Liverpudlian and he had been to Liverpool Medical School where Henry Cohen was the professor of medicine, subsequently Lord Henry Cohen, and Lord Henry Cohen was god as far as Pappworth was concerned. He had--, he was Jewish Pappworth as I imagine Cohen must have been. Another person he had a high regard for was Max Rosenheim the professor of medicine at UCH who, you know, in his

Dr Eric Beck Page 33 of 123 quieter way was an outstanding figure and became president here. He--, another person that he had admiration for and I think this was more practical, was the radiologist at the Central Middlesex Hospital where Pappworth had once worked as a locum senior registrar, a man called Frank Pygott who I think supplied him with lots of interesting x-rays for his teaching, but Pygott was god. And that was about it and the people for whom he had particular disdain weren’t just the Harley Street consultants for whom he didn’t have too much time but it was Du Cane Road, Du Cane Road is where the Hammersmith Hospital was. So it was these eminent medical scientists at Du Cane Road which upset him and he never was very clear as to why he disliked it. He didn’t like their style of medicine, the fact that patients who went there were nearly always entered into whatever research program was going on at the time but he never actually spelled this out in his lectures why he didn’t like Du Cane Road. Oh, and one other person for whom he did have a high regard was Guy Scadding. Guy Scadding was--, he was a Du Cane Road product but had gone on to the Brompton Hospital as professor of respiratory medicine there but retained one session a week at the Hammersmith Hospital but Pappworth forgave him that because he thought Scadding was a good chap, which he was and I’ll tell you more about him in a moment.

Q: Can I ask you a couple of questions about him before you carry on? Can you describe to me what he looked like?

A: He was a short squat rather turning to obesity man with a good head of hair as they would say and very restless, always on the move and no respecter of persons or rank, you know, he treated everybody equally which made him very popular with--, many of his pupils were overseas doctors who were coming to do the MRCP and although I don’t think he had any strong feelings against racism nonetheless they felt comfortable in his presence. I mean he wasn’t beyond making racist remarks, he wasn’t beyond making remarks about anybody and anything. So I think they regarded it as all part of his personality rather than anything individually aimed at them. And now I never went on any of his ward rounds but he had managed to inveigle himself into the Friern Hospital, the mental hospital in north London where there--, because of their long stay patients, quite a lot of them had chronic medical conditions and so he built up a dossier of these patients dotted around Friern Hospital to which he would bring his membership candidates and teach them bedside medicine. And I never went on one of these ‘cause I had plenty of patients around me to see, but apparently he would give the patients a bar of chocolate at the end of the session as a sign of his gratitude. And he did actually come back and teach as--, not teach, practice as a locum at the Royal Northern Hospital which was allied to the Whittington and I think his doctor/patient communication was not very good.

Q: And you mentioned that he taught in a particular room that was quite close to here.

A: Yes, is it Marshall Street baths round the corner from here?

Q: Could you describe it to me please?

Dr Eric Beck Page 34 of 123 A: Off Marylebone. It’s on the Marylebone Road and you--, he had hired a room it was just an ordinary room but it happened to be in the swimming baths. I think it was Marshall Street baths, it’s the ones in Marylebone Road. And you would always pay in cash and I don’t think the Inland Revenue saw too much of it and--, but, as I say, it was a remarkable experience and what is rather sad is that a lot of people now in high places who greatly benefited from him are not prepared to acknowledge it or even rather critical of him afterwards, after he had materially helped them through the exam. Now the one thing that he did do which was a bit naughty but was all part of his campaign against the college was if you as one of his pupils passed the exam or even if you didn’t pass the exam he would ask you to feedback your experience in the exam. So he built up a large dossier of patients being used in the examination centres around London not only of their diagnoses and their physical signs but in the dossier would be the questions which the examiners asked and the answers that were expected of them and these were the same patients with the same questions and same answers time after time after time. And he would feed this through in his lectures. He’d be, I don’t know, talking about cardiology and he’d say, “Well if you go to St Mary’s Hospital they will show you a patient with this, that and the other and they will ask you this and you should answer that,” and it was all true and of course he was praying on one of the disgraceful things about the way the college ran its exams it just trotted out all the same patients, all the same examiners and he benefited from this as I did I’ll tell you in a moment, yes.

Q: Did he used to tell you about the examiners as well?

A: Yes, yes, the examiners were largely boring old farts, as it were, following a ritual with not much original thought. He--, he--, again one or two of his approved people were excepted from this and one of them was this chap Guy Scadding, the professor of respiratory medicine at the Brompton whose son John Scadding is a neurologist at Queen Square, came a few years after me. Yes, so he was pretty disparaging about the medical establishment but what wasn’t all that apparent in his lectures even though it may well have been in his thoughts, because I think he was quite an observant Jew and had a strong ethical code, again none of this came over in the scurrilous stuff that he was dishing up, was when he wrote this book called Human Guinea Pigs. And this did focus largely on what was going on in Hammersmith Hospital in the immediate post war years. I mean I think it’s all changed and changed for the better now, but there is no doubt that some of the pioneers of British post war medicine who were working at the Hammersmith were developing techniques with dubious ethical support for it. I mean one of the examples was Sheila Sherlock, a famous hepatologist doing liver biopsies. Now, no one had done liver biopsies where you stick a needle into a patient’s liver and take a sample out to look under the microscope so she developed that technique at Hammersmith Hospital. Normally you wouldn’t anaesthetise the patient but you would sedate them and put in local anaesthetic so that probably wasn’t the worst of things that went on, but cardiac catheterisation was just beginning where you have to pass a catheter up the [brachial] artery, back into the heart and make measurements and I don’t think there was too much concern for the patients in that. And a whole general atmosphere at Hammersmith which I think he latched onto and objected to was that patients are coming to a centre of excellence,

Dr Eric Beck Page 35 of 123 which they were, and the price they pay for it is they help us to progress the excellence and, you know, we don’t ask them for their consent to do it we expect them to do it. And it was this kind of thing and then he found examples from other places as well but it was very much Hammersmith focused his book and of course when it came out it created a furore. In the popular press people said, you know, ‘at last a doctor speaks out about the unspeakable’. In the medical establishment it was divided, some people said, you know, “How can he speak of his colleagues like that?” one or two thoughtful people said, “Well, you know, yes we should be doing things better and differently,” and this is where Charles Dent comes in again. The professor of metabolic medicine at UCH, the staunch Catholic who was doing similar things to Du Cane Road in his own 1-1 ward but doing it in a much more ethical way. And he contacted Pappworth, the staunch Catholic to the practising Jew and said, you know, “I’m disturbed with what you’ve written in your book, would you like to come along and see how I do the similar things?” So he invited Pappworth to 1-1 to go on his ward rounds, sent him home with a large packet of x-rays like Pygott used to do [laughs] and Pappworth was very impressed, you know, that one can do these sort of things but to do them properly. I think Dent was acting partly defensively to make sure he didn’t get tarred with the same brush but, nonetheless, this was an important coming together of these two unlikely characters and things did change after that. And hospital ethics committees, there may have been a few informal ones but they gradually developed and became de rigueur, every hospital now has them and any research project has to be put up to the ethics committee to be cross examined about how they’re going to do it, what they’re going to tell the patients, how they’re going to fund it. I was the first chairman of the Whittington Hospital ethics committee some years later when I was a consultant there and we would have lay members on the committee as well. You know, so Pappworth did initiate a major reform. I don’t think he proposed ethics committees should be set up but this was one of the reactions of the medical establishment. And I don’t know what the--, whether the College of Physicians took a particular line on Pappworth’s book, I would imagine that they were probably divided some for and some against, but I don’t remember anybody here, as it were, publically speaking out against Pappworth even though they had plenty of grudges against him because of his activities getting people through the MRCP exam. They were aware of this sort of dossier of cases that he had assembled to tell the candidates.

Q: So in terms of influence, given his involvement both in ethics and in the MRCP exam, where would you kind of rate him in terms of influential physicians of this period?

A: Well in terms of ethics I mean I--, you know, he started off something, he didn’t follow it through necessarily, I think it was partly his raising two fingers to the medical establishment saying, “Not only are they a corrupt bunch but look what they do to their patients,” so I think having got that out of his system he wasn’t involved in setting up ethics committees or anything like that. He’d done his bit there. In terms of--, sorry, the other?

Q: The MRCP exam.

Dr Eric Beck Page 36 of 123 A: The MRCP exam well now one of the things that college held against him was this information system he’d set up, which was their own silly fault they could destroy it overnight by changing the patients and the questions, but the other thing was although he had passed the MRCP exam in his junior days for some reason or other he wanted to become a fellow. I don’t know why he would want to become a fellow of a college he had so much distain for. And he--, and a lot of people who had passed the exam were now getting on in life and moving up the ladder and, you know, probably thought yes he should be a fellow whether it would disarm him or not I don’t know. But he took the--, made the fatal error against college regulations of canvassing to be made a fellow and this is rule something or other, thou shalt not--, and so that immediately made him--, you know, this just emphasised the college establishment’s view of this rather unpleasant man who nonetheless wanted to be a fellow. And the irony of it is, I mean quite a few subsequent presidents have probably been to Pappworth’s lectures, he died of a--, I think he died of colon cancer at St Thomas’ Hospital, something like that and almost on his deathbed I think the college did make him a fellow. Why he should ever have wanted to be I don’t know because, you know, he was--, he was the ‘rebel with a cause’ and that was his great strength. So he probably wasn’t a very nice man, he was obviously a principled man, he was a bigoted man but he was a brilliant teacher and he exposed, if only the college had taken more notice of it, many of the weaknesses of the existing college exam. So when reforms began in the college first in the London exam before the MRCP UK, some of these changes were certainly brought about as a result of Pappworth’s activities. Well so I went to Pappworth’s lectures in the autumn of that year that I was at the Central Middlesex.

Q: So this would be 1960, is that right?

A: Er, yes. Yes, that’s right. And I had to think of my next job, it was only a six month job at the Central Middlesex but having got a foot in the door at the Central Middlesex this opened the possibility of the golden triangle. So I got a job at the Brompton Hospital, a ‘peculiar rest home for tired Harley Street chest physicians’ in those days because there was very little going on in chest medicine apart from Guy Scadding interested in sarcoidosis, interested in measurement and evaluation and he was totally different from all the other chest physicians. I worked for two one called Jimmy Livingstone and the other called Neville Oswald and Livingstone was an ex-army consultant with--, interested in, I don’t know, chronic bronchitis who used to sit there in front of his patients smoking saying, “If you don’t give up smoking [coughs] it’s going to [coughs] kill you.” He was a nice man though. And Neville Oswald was a classic sort of Harley Street conman who always wanted to appear to be one move ahead of everyone else including his junior staff. And I remember him coming along to do his weekly ward round the day that the Nobel Prize had been awarded to Macfarlane Burnet, an Australian who was very much in the--, I think Medawar was the co-recipient of immunosuppression being used in transplant. And Oswald came up and he said, “Seen the papers this morning, this chap Burnet got the Nobel Prize,” and then gave us a completely garbled and false account of what he’d got the prize for and we knew better than he did and then he would come out with these rather weak aphorisms. And we had a particularly creepy senior registrar who had failed job application after job application because this was a difficult time to make the jump from senior

Dr Eric Beck Page 37 of 123 registrar to consultant and he was getting more and more desperate and Oswald was one of his referees. And Oswald would come out with these terribly sort of weak statements and [0:51:07] XXX would say, “What I say sir is never a Friday morning goes by without me learning something from you,” the ultimate creep [laughs]. So the Brompton chest physicians apart from Scadding were really not up to much. Scadding just another word about him was that he was interested in sarcoidosis, this rather mysterious disease which had been linked with tuberculosis but probably wasn’t, and there was only one other man with a similar interest in London which was Sheila Sherlock’s husband Gerry James at the Royal Northern Hospital. So each of them had a large collection of patients with sarcoidosis, a chronic disease of which they could describe the manifestations but for which there was really no treatment. And the diagnosis really was based on histological criteria, you had to see certain things in a biopsy to prove that it was sarcoidosis or to suggest it was sarcoidosis. And the thing that impressed me about Scadding was the story, the true story, that one Saturday morning he got out all the slides of the sarcoid patients in his clinic and got his senior registrar to get out a matching set of slides from tuberculosis patients which was very similar to sarcoidosis and went through them ‘blind’ to see whether he could diagnose them correctly which by and large he did. I mean it was this kind of approach which impressed me whereas Gerry James would say, “Well I can tell a sarcoid patient a mile off,” he was a rather blustering--, well I won’t say too much about Gerry James he suffered from being ‘Mr Sherlock’ the husband of Sheila Sherlock living in her shadow. So Guy Scadding was the one impressive chest doctor there, but the Brompton also had a cardiology department with cardiac surgery and the great cardiologist there was a man called Paul Wood, I don’t know if you’ve heard of him. He was Australian by birth but practiced in this country and he really was the god of cardiology and he wrote the standard textbook of cardiology which went into several editions and he had a clinic every Thursday afternoon to which all the junior staff if they wanted to could go. And going to Paul Wood’s clinics was a brilliant experience in medical deduction. To be--, most of his referrals came from here, there and everywhere and he made it a precondition that before he spoke to the patient the patient should have a chest x-ray and an electrocardiogram and when he had looked at these and read the doctor’s referral letter in would come the patient. And he would already have discussed before even seeing the patient the sort of differential diagnosis of what this might be, what questions we need to ask, involving the--, his audience of junior doctors in this and it was quite uncanny, you know, how much he could read before he even spoke to the patient. And I don’t think I--, I’ve never met a person of such analytical skills as Paul Wood and anyone who worked for him, you know, thought he was god. The only blackspot he had was a lot of his heart patients were patients with congenital heart disease and rather complicated abnormalities and he wasn’t quite so hot on coronary artery disease and for which there wasn’t very much treatment, coronary artery surgery I think had hardly begun. And if you had a heart attack you were usually put on anticoagulants to prevent you getting a pulmonary embolism and deep vein thrombosis. And he was dead against anticoagulants. I think he’d once seen in one patient it go wrong, which it can do and patients can then bleed to death. So he had this blank spot about anticoagulants which came back to bite him years

Dr Eric Beck Page 38 of 123 later when he had a heart attack himself and refused to have anticoagulants and died, not that he necessarily would have been saved by it. But that was the only sort of illogical thing in the whole wonderful superstructure of cardiology that he had created. Odd man but a great man. And they had some very good cardiothoracic surgeons at the Brompton as well so they worked together very closely the cardiologists and the surgeons. One particular one a New Zealander who also worked at the Hammersmith Hospital who was no mean cardiologist himself. So it was a very good relationship. So at the Brompton Hospital within a few weeks I was entering the MRCP exam armed with Pappworth’s teachings.

Q: Before we go on to that--,

A: Yes.

Q: Can you just go back, sorry, just to follow up a few questions I had? When you were doing your house jobs I think you were married by this point--,

A: Yes.

Q: Is that right? Did you live in the hospital?

A: I had to, yes. Certainly at St Pancras you had to. Occasionally because it was pretty quiet there was no acute admissions, informally the other housemen doing the same job we would cover for each other and, as it were, get an unofficial night off but this is why my boss at the end of six months thanked me for being there every day and every night [laughs]. And a lot of it was true. So I got more time off probably because of the nature of the job than I would if I had been working up at UCH which was a much more acute place.

Q: So where was your wife living at this point?

A: We had got this, er, flat in Brixton, yes, Acre Lane, number four Acre Lane, opposite the town hall, yeah.

Q: So did you manage to see her at all?

A: Well, as I say, we engineered nights off which were not strictly in the--, allowed but it’s--, it was perfectly safe and nothing untoward happened.

Q: Were there any married quarters at all at the hospitals?

A: No, no, no, that was--, I mean nurses didn’t marry, junior doctors didn’t marry and if they happened to marry each other [laughs] the marriage was null and void. So…

Q: And how did that affect your relationship do you think, the fact that you had to spend so much time at hospital [0:58:06]?

A: Well it--, yes, I mean it did. I mean in--, as I say, during my second house job our daughter was born but that was just a few weeks before I came to the end of the job and from then onwards the subsequent SHO jobs you did have proper time off. So yeah, so it did affect that and parents on both sides were involved in supporting her, her parents were up in Kettering and mine in north London. And we shared the flat with a fellow student Norman Todd who

Dr Eric Beck Page 39 of 123 didn’t get--, have a house job in London but his wife had--, I subdivided our flat in two, they had the upstairs bit and we had the middle bit so she had Pat Todd onsite as it were. Yes, so it wasn’t all that easy for me. I think when she had Helen she had already given up her job in the Chest Clinic. She did continue that for a while until she became pregnant but she didn’t work again after--, well of course she had her illness and so becoming pregnant with Helen was, I don’t know, a thing we had to think about very carefully and talk to the radiotherapists and was it a safe and proper thing to do? So anyway, in the end she became pregnant and that was the end of the argument. And four years later we had a son but by then I was already on the registrar ladder.

Q: So at what point did you actually move out of the--, move out of living in the hospital?

A: At the end of my second preregistration job, after I’d finished my job at St Pancras. I didn’t live in at Central Middlesex or Brompton or anywhere like that. There might be the odd night when you were on call when you--, you’d have an odd night there but no, essentially it ended with the preregistration house jobs.

Q: And what would you say the feeling was of you and your peers at having to work these kind of hours?

A: Well it was the system and there wasn’t any sort of sign of rebellion. Junior doctors were a pretty cowed bunch because they were highly dependent on the patronage of the people they worked for and if they were going up the medical ladder wanting to become a consultant physician it was a very tight pyramid and you didn’t want to put too many feet wrong along the way ‘cause you might never make it beyond senior registrar like poor old Pappworth. So there was very much a bottleneck in permanent consultant posts which sort of filtered back through the whole of the medical tree and to be constantly told, “Well it was like that when I was a young doctor so, you know, you can jolly well do the same.” The other thing which bedevilled it all, which again came up a few years later when I was more senior in the registrar, was there was no proper admissions policy of a unit being on take one day and taking all the emergencies and then perhaps twice a week. And the bizarre system which they had at UCH, and I suspect in many other hospitals, was that there was a person called the resident medical officer, the RMO, who was an experienced registrar who technically was responsible for every medical admission to the hospital. So I mean that was a--, that was a 24/7 job if ever there was one and he just couldn’t, it was nearly always a ‘he’, just do it on his own. So if it happened if it was the daytime he would invoke the registrar of the unit where the patient was most likely to go to deal with the admission. So it became partly an administrative post but he would have to do a certain amount of acute medicine. It was a great experience and at night time technically he was the only person there at night so he would have to get up several times in the night for medical admissions. And this--, there weren’t all that many things you could do with acute medical illnesses in those days but this was becoming an increasing anomaly and places both outside Britain and within Britain--, outside London were developing some kind of medical admission rotation which was strongly resisted by the consultant physicians at UCH and which was one of the things I had to battle for when I became senior

Dr Eric Beck Page 40 of 123 registrar. I’ll tell you about that in a moment [laughs], but this was almost the norm. So the expectations were ‘we did it when we were lads, you can do it and it hasn’t done us any harm’ kind of attitude.

Q: You said that there weren’t many things you could do with acute admissions at this stage, can you elaborate on this?

A: Well if you came in with an acute myocardial infarction, bedrest was the main hope and pain relief if they had bad pain. It then became obvious that if you put the patients to bed for 15 days, which was fairly normal, that roundabout day seven some of these patients would suddenly sit up, cough, and die, and they were dying of pulmonary embolism from deep vein thrombosis from being immobilised in bed. So one small quite important advance was to put patients on an anticoagulant when they came in to prevent deep vein thrombosis. Another was to mobilise them earlier rather than 14 days strict bedrest so they would sit in a chair and move their legs about. So that and pain relief and if they were in heart failure you used the conventional heart failure treatment, there was no specific way of reversing a myocardial infarct and the idea of doing that came much later in the day during my later career. So there wasn’t that much you could do for myocardial infarcts which were common. Stroke, it was the luck of the draw if you had a stroke as to whether you would recover or you would not. And one of the interesting things was various causes--, briefly there are three causes of stroke you may have a cerebral haemorrhage where you bleed into the brain which is pretty serious and poor outlook, you might have a cerebral thrombosis like a coronary thrombosis where a blood vessel would gradually block off and this could do a varying amount of damage from which some recovery was possible or you might throw off an embolism from the heart into an otherwise normal system and this embolism would block the artery and cause a stroke. Now some of these emboli then broke up and the stroke would get better quickly. And there was this idea abroad that a cerebral embolism had a better outlook than a cerebral thrombosis and when I became a house--, an SHO at the Central Middlesex Hospital Keith Ball, the cardiologist, when this was still the orthodox view, said, “Why don’t you as a research project as an SHO do a follow up of patients with cerebral embolism?” Because he was the cardiologist he was more likely to have patients whose hearts were throwing off emboli. And I- -, this was about the only research project which again didn’t come to any firm conclusion but which was interesting to do. I spent my spare time and weekends going round to the homes of people who had had cerebral emboli, had gone home with some degree of paralysis or not as a follow up to see whether this was true, whether their outlook was better than other forms of stroke. And so I would take a history and examine them and draw my conclusions which surprisingly were not very strong. It certainly didn’t favour the idea that an embolism was no great danger, some people’s lives were wrecked by a cerebral embolism, others did get away with it and I’m afraid it was a rather inconclusive bit of research. I think I presented my findings as then at one of the clinical meetings at the Central Middlesex but I didn’t do it long enough or thoroughly enough to--, as perhaps I would have done later on in my career. Yes, so strokes you--, tender loving care and hope for the best, as it were, with some anticoagulants if they were going to be immobilised for a long time. Pneumonia well you--, we

Dr Eric Beck Page 41 of 123 had antibiotics so that was fairly straightforward but you didn’t need a genius, as it were, to diagnose somebody with pneumonia and put them on an antibiotic. Those are most of the acute illnesses. Meningitis of course was important but rare diagnosis which meant you--, somebody had to do a lumbar puncture in the middle of the night which would almost certainly be getting the RMO out of bed and treating that but there weren’t many cases of meningitis. So that was more or less the--, oh abdominal things. Well most acute abdominal conditions were surgical anyway so they were dealt with on the surgical side, is this appendicitis or isn’t it? If it isn’t and we can’t find the cause we’ll ask the physicians to come and have a look. I mean I’m paraphrasing but this is I think how the workload was dealt with in A&E departments. Yes.

Q: Thank you. So do you want to go on and talk about--,

A: Well now--,

Q: MRCP?

A: The MRCP. Finally the great day arrived and I went along to--, in those days they had examination halls in Queen Square opposite the, er, neurology hospital and sat down and two papers each with a foreign translation at the beginning of it. It used to be Latin and Greek but the college had progressed now to German and French and you only got I think one mark so it was not compulsory because it was considered to be discriminatory for overseas candidates to have to do it, but I did the French and the German because they were both quite easy and answered the papers--, wrote the essays in the papers. And the next bit you would automatically get for your money after the papers was the clinical exam and I was sent to St Mary’s Hospital where the--, now who was--, one of the examiners was WDW Brooks, I can’t remember who the other one was. And I was the first candidate after lunch, that’s sometimes held to be a favourable position because the examiners are still enjoying their--, and I--, my long case was a slightly complicated lady with a stroke who was able to give quite a good history and I was reasonably all right on that I felt quite comfortable after it. And then I was taken to the short cases and they again were fairly straightforward until I got to this one short case who I shall never forget partly because I already knew her from Pappworth, and this was a little old lady with chronic chest problems and the telling thing in her was that she had all the abnormal signs of lung disease on the right hand side of her chest, the left hand side was perfectly normal, but the trachea, the windpipe, was deviated to the opposite side. Now this made no sense at all because normally if you have shrinkage or collapse of the lung it pulls the trachea over to that side so part of the examination of the chest is first to feel for the trachea to see if that’s a clue as to where things were going on and then listen to the chest and hope to put it all together. And she had clubbing of the fingers was the other thing. And so there I was finding all the abnormal signs on one side and the trachea going to the ‘wrong’ side and she had clubbing so it was obviously chronic chest problem. And the examiner said, “Well what did you find? I don’t want a diagnosis I just want you to tell me what your findings are.” And obviously this was a test case in the sense that people who couldn’t make sense of it would say the trachea was either not moved or was moved to the abnormal side when what

Dr Eric Beck Page 42 of 123 the examiners wanted you to do was have the courage of your convictions to say what you had found even though it didn’t make much sense. And then it dawned on me Pappworth had mentioned a case at St Mary’s Hospital of a little old lady whose signs are all on one side and the trachea goes to the other side and nobody knows why it is but that’s what they want you to say. And so this gave me enormous support and I said, “Well, it’s rather puzzling in that her trachea has deviated to the,” whatever it was, “The right [corrected to left] but all the abnormal signs are on the left [corrected to right].” He said, “Right, yes, it is puzzling, isn’t it? Next case.” All they wanted was for you to stick to your guns. And so the clinicals went pretty well and the final question which one shouldn’t ask but was often asked in those days if you were a respectable white candidate is, “Where are you working?” and so I said, “Well I’m at the Brompton Hospital.” Brooks was a senior physician at the Brompton Hospital who didn’t know one person from another but when he heard Brompton Hospital and I’d obviously done quite well he sort of, you know, purred and didn’t quite pat me on the head but said, “This is the sort of person we have at the Brompton Hospital.” So the next step then was you went on to the path viva, this is where this room comes into relevance. And in the path[ology] viva you would have--, you went--, you had two 20 minute--, I think they were 20 minute or 15 minute vivas from two pairs of examiners, you moved from one table over to the other and again in the examination halls in Queen Square. And I went to the first table I can’t remember--, I remember one of the examiners was Lord Evans the Queen’s physician who’d written the standard medical textbook but I was asked some fairly innocuous questions. At the second table one of the two examiners was Donald Hunter whose picture we were looking at a moment--, before we came in, and Donald Hunter was the great teacher, he was--, he’d created the special--, the speciality of industrial medicine, he’d written a standard textbook on industrial medicine, all kinds of weird and wonderful diseases that happened all over the world and he just loved teaching. And he asked me a question about somebody with a rash in their- -, on their legs and what was the likely diagnosis and I said, “It could be secondary syphilis or erythema [marginatum],” something or other and that obviously suited him. And then he--, I’ve forgotten what the object was, he was notorious for having brought bits from his industrial medicine experience, he would sort of show you a--, I don’t know, a reverberating sprocket valve or something like that. I’m joking but something to stimulate the conversation. And he handed me something which was no great problem and then he launched into a little seminar for the next ten minutes about the disease [laughs] because he was just so enthusiastic about it. And so I realised I must have done quite well in the path viva. And then the ultimate thing was the final viva. The college was still in Trafalgar Square in those days, the censors’ room upstairs it was on the side facing Trafalgar Square facing east, January morning, sun rising, stained glass windows, president sitting in his chair in his gold and black robe, three censors either side and then a chair for the candidate to come in. And as I was waiting to be called in to the censors’ room out of curiosity the bedell, who had a list of all the candidates for the day, I was just curious to see who was going to be examined in the final viva where, you know, you had to get enough marks there to get through the exam if you hadn’t already got them. And I noticed looking at the list that there were--, I think there were about 30 people on the list and

Dr Eric Beck Page 43 of 123 several of them, myself included, had two minutes after our name and the others had ten minutes after their name and so it clicked, I’d already passed. And I also knew all the other people who’d passed or names of all the other people that--, because I was at the beginning of the list. So I went in and not nearly as fearful as I’d been waiting outside and there was Robert Platt sitting in his chair with his gold gown, the sun shining through the stained glass windows. I mean he looked like god with a charisma around him. And I sat down and he said, “I want to congratulate you on passing the examination and we have no questions for you.” And then you were ushered into a little side room off the side of the censors’ room, I don’t know whether it exists here, in which sat Ina B Cook, the formidable lady, you’ve probably heard about her, who was not in the least bit interested in you as a successful candidate but was interested in getting you to sign direct debits for the bank for all of--, so Ina B Cook brought you down to earth again. And I had, you know, passed the exam and was obviously very happy. I went back to the--, no I didn’t--, yes, one of the people in the afternoon was Betty Priestley I don’t know--, a paediatrician now in Sheffield or was in Sheffield and I saw her name down for four o’clock with two minutes and so I thought,’ oh good, good old Betty’, you know, we’d worked together at the Central, she’s passed. And when it came to the admission ceremony a few weeks later 23 people had passed the membership exam that time, I think it was the lowest ever pass rate for years, and I said to Betty, “Of course I knew at nine o’clock in the morning that you’d passed the exam.” She said, “You knew and you never told me!” she said, “It was the worst day of my life waiting till four o’clock in the afternoon to go in for the final viva.” Yes, so that was the two minutes and ten minutes. Yeah, so that was the end of my engagement as a candidate.

Q: What did you do to celebrate your success?

A: Not a great deal. Well I think we opened a bottle of champagne that evening I--, Pat was at home with young daughter Helen and--, very young daughter Helen. No, perhaps we did go out for a meal but it was a bit of an anti-climax in a way and the thing really looking back had been a bit of a doddle. Just to finish up on Donald Hunter who had been examining for years and years and went on examining for years and years because he was the only sort of occupational medicine physician around and he was a great teacher and a great man. And his son Peter Hunter when I--, when I first came to the Whittington was an SHO there and he was full of stories of his dad examining in the MRCP and he told me one which I imagine is true that his father was very broad minded in terms of candidates’ origins and so on. And he said his father was examining one day with a co-examiner and in came an Indian candidate and his co-examiner opened his mark book and wrote in the mark book before a word was exchanged plus two and was rather surprised at this. And they--, they both asked questions and the candidate went out and had passed because, you know, Hunter had passed him and his co-examiner had passed him and he said to his co-examiner, “I noticed that before the candidate even opened his mouth you had put down plus two in your mark book, you know, what was all that about?” and his co-examiner said, “Well I do recognise I have something of a prejudice against Indian doctors and I try to compensate for this [laughs] by--, in my mark book.” Hunter said, “Oh well, that’s very interesting.” And as the morning wore on apparently,

Dr Eric Beck Page 44 of 123 (this was the era of miniskirts), along came a rather attractive female candidate sat down in front of them hitched up her miniskirt a bit further and Donald Hunter opened his mark book and very ostentatiously put in minus two, according to Peter this is a true story [both laugh].

Q: Excellent. So after you passed the MRCP what was--, what was next on your…

A: What was next? Well I--, as I say, I was at the Brompton Hospital, I’d got the MRCP, I realised I could apply for registrar jobs with the MRCP because it was a sine qua non as it were, but having got one foot on the golden triangle I thought well I’m in no hurry and I--, next jobs I get are going to be of much longer duration wouldn’t it be nice to go to Hammersmith Hospital ‘cause I’d heard so much about it? And so I applied for Hammersmith and applying with the MRCP I wasn’t the only one quite a lot of--, you know, Hammersmith was a very plum junior post. So I got appointed to Hammersmith Hospital where my boss was Fletcher, the television doctor, a Knife in Your Glands chap, with the diabetes who had to be given sugar every so often. The second one was Hugh-Jones who I never saw anything of and these were all people who had appointments at other hospitals as well. And to my joy the third person in the chest team was Guy Scadding my hero from the Brompton as it were. And so that again was a very happy time at Hammersmith which is a remarkable--, was and still is a remarkable hospital, there was nothing else like it in the UK in those days and everything going on all the time, everybody of the highest possible calibre and a very high quality junior staff who, you know, had given their eyeteeth to get there. Lots of people from the commonwealth and no pressure on me at all. So that was a thoroughly enjoyable time at the Hammersmith.

Q: Why didn’t you have any pressure on you?

A: Well I’d passed the exam and all I had to do was sort of think about the next job, I’d got the MRCP, I’d worked at two prestigious hospitals. You know, I didn’t foresee too many problems getting my foot on the bottom rung of the registrar level, in terms of getting to the top and becoming a consultant was for another day as it were.

Q: What were you actually doing at the Hammersmith?

A: I was--, I was the house physician or SHO to Fletcher, Hugh-Jones and Scadding. So this was--, again it was a mixture of acute medicine and chest medicine and the research interest on--, every unit has a research interest at the Hammersmith, was slightly boring of chronic obstructive pulmonary air disease, chronic bronchitis, trying to define it and categorise it and that wasn’t particularly inspiring but what was going on in the rest of the hospital was. And every night as I--, I had to live in much of the time, I had a bedroom looking out on the boundary of Hammersmith Hospital straight into Wormwood Scrubs which is bang next door to it, which the wretched floodlights were on all night because people sometimes wanted to hop over the wall. So that--, that was--, so Hammersmith I was coasting as it were and absorbing and seeing what was going on and there were some remarkable things. And I had this remarkable coup thanks to Philip Marsden while I was there and this was--, Scadding, who I mentioned was one of the people I worked for, came one day a week because he was at the Brompton the rest of the time and he would come on a Wednesday morning and the firm had

Dr Eric Beck Page 45 of 123 always been on ‘acute take’ on the Tuesday. And his role was to do a post take round on the acute admissions which he loved doing because it was his one contact with acute general medicine. And so we’d get round the acute admissions of the previous day and then we’d sit down and have coffee in the sister’s office and Scadding would usually lead the conversation he would always have something interesting to say and quite often about patients who had been referred to him at the Brompton. And one Tuesday morning--, Wednesday morning he said, “We’ve got this very puzzling patient at the Brompton, er, from Cumbria and he’s a middle aged man, he’s a farmer and he’s, erm--, he’s got some chronic chest problems and he’s got these abnormal liver function tests and in his blood count he’s got an eosinophilia.” Actually [01:25:52], well I’ll mention it again in a moment, eosinophilia is a white cell which tends to be elevated when you’ve got some form of parasitic disease but there are other causes of eosinophilia. He said, “I wonder what you chaps all think about it.” And so the senior registrar chipped in first and said, “Well could it be polyarteritis?” “No, no we’ve excluded that with a biopsy.” The registrar said something else and being very thorough they had biopsied everything and so it came to my turn and I said, “Does he eat watercress?” and Scadding goes, “I don’t know, why do you say that?” So I said, “Well your description,” and Scadding was a master of clinical description, “So strongly reminds me of a patient I saw years ago in the Hospital for Tropical Diseases,” and I told him the story of the GP in the New Forest who ate watercress. And so he said, “Well I’ll go back and ask him,” and sure enough this chap had got fascioliasis from eating watercress in Cumbria. And of course being Scadding at the Brompton and also being at the Hammersmith the story spread like wildfire about this diagnosis made in the coffee break at the Hammersmith which obviously did me no harm.

Q: Was there anything you--, did you treat liver fluke?

A: Yes, there’s an anti-fluke--, I’ve forgotten what it is, there is a drug which--, which is used in veterinary medicine. Yes, so that was my--, another thing I was grateful to Philip Marsden for all these years later, the liver fluke. So…

Q: Before--, sorry, before we move on, you mentioned that you were working for Charles Fletcher.

A: Yes.

Q: And I know that you and I were talking about him earlier--,

A: Yes.

Q: But we weren’t recording, could you--, could you describe your time working with him a little more?

A: With Charles Fletcher? Yes, he was a slightly aloof remote figure, handsome man, he was primarily a chest physician. He had the misfortunate to suffer from type one diabetes and he was very keen on very tight control, which in those days was not all that fashionable in diabetes, you know, you gave yourself enough insulin to stop any--, to keep the sugar down

Dr Eric Beck Page 46 of 123 but--, and because of his personable manner, I don’t quite know how he’d got into it, but the BBC had selected him as the ‘television doctor’. And every week there was a BBC program called ‘Your Life in Their Hands’ which was some medical topic and he was the sort of presenter and chairman of it. And this soon became known as ‘Their Knife in Your Glands’. So he was a well-known public figure. He was okay as a chest physician. He was nothing great but his other great love in life was music and he was a very active member of the Bach choir in which he sang. So--, and one of the problems working with him was because he’d kept his diabetes under such strict control if he was late in having the mid morning biscuit, as it were, with the coffee break he might get a hypoglycaemic attack so all his junior staff were warned to look out for early signs of hypoglycaemia. If he started saying something irrational or began to sweat you rushed in and gave him a spoonful of sugar that sort of thing. So that was my memory of Charles Fletcher as a nice personable man from whom I didn’t learn a great deal other than how to treat impending hypoglycaemia [laughs].

Q: Is there anything else you want to say about working at Hammersmith before we move on?

A: Well I mean there’s so many things one could say. I mean the Hammersmith had just opened a huge lecture theatre which got known by the junior staff as the Hammersmith Odeon and they had weekly grand rounds and again it was taken in turn by different units to present cases. And presenting a case at the Hammersmith grand round was quite an ordeal, you know, because you had so many people focusing on you and Scadding always came to--, the round followed on his ward round and coffee before we went to the grand round. And one of the things about Hammersmith because there were a lot of Australian and New Zealand doctors there was no great respectance for people of authority. And I still remember a case being presented I can’t remember what the case was and Scadding was asked to make a comment about the case and he said something fairly bland, I’ve forgotten--, again I don’t remember the details of the case but what I do remember is that a rather brash Australian registrar standing at the back of the Hammersmith Odeon shouted out, “That’s a load of balls professor Scadding [laughs].” That’s the kind of place that it was you could--, you could say things like that.

Q: Did you ever present a case yourself?

A: Yes, I did. I can’t--, it went reasonably well, undramatically. The other thing about the Hammersmith which was a habit which I then saw in other places was after you’d had your lunch you went to the post-mortem room to see, as it were, the corpse of the day. And this was a very effective bit of teaching. The pathologist would be doing an autopsy much in advance of the audience coming and the houseman would present the history of the case of the person who died and the pathologist would then demonstrate what he had found which usually fitted in reasonably well with the ante-mortem diagnosis but occasionally revealed some very striking conflicts. And again it made the point, you know, the importance of teamwork and people talking to each other and how much you learned from your colleagues. And we had a similar set up for--, with the radiologist that we would take along x-rays from our patients which had been reported on but, nonetheless, were interesting and we would discuss

Dr Eric Beck Page 47 of 123 the cases of the x-ray we were looking at and the radiologists appreciated it as well because they got much more clinical detail. So it sharpened up both our--, both of us. So that was the kind of, you know, ethos of the Hammersmith that people were fairly brash, very bright but also there was a lot of interdisciplinary contact which again I think probably rubbed off on me in terms of my future career, how valuable this was. Totally different from the Kenneth Harris as a medical student who wouldn’t let any other doctor see one of his patients because he knew it all. But yes, so that was the end of Hammersmith. And so I applied for the last part of the golden triangle and it was almost a given that having done what I’d done so far that I would be appointed to Queen Square which I was and Queen Square was another kind of, well, national referral centre on the one hand but a rest home for tired neurologists from other teaching hospitals to come and do a session or two a week. And I worked for three people, Elkington, er, Michael Kremer and Hamilton Paterson. Now Elkington, who was the senior neurologist and also at St Thomas’ Hospital, had a rather nasty disease which had been diagnosed very late, he suffered from haemochromatosis which is excess deposition of iron in the body and one of the reasons why it often gets diagnosed late is that your skin becomes very pigmented and makes you look very healthy. It stimulates the melanocytes so you look as if you’re permanently sunburnt or had been out in the sun but it can also wreck your liver, cause cirrhosis and all sorts of other things. Anyway, he had been diagnosed rather late in his illness of hemochromatosis and was not there when I first started the job. The only treatments then available, I don’t think there’s all that much that more now, is to extract iron from the body by various chemical methods. So the main person--, or two people I had--, well the main person was the senior registrar who ran the show basically a chap called Leo Lange [01:35:00], a South African, but Kremer would come along and Hamilton Paterson would come along and do a ward round and eventually Elkington returned. And I--, the reason I mention this was again rather relevant to his diagnosis, and we were going up in the lift to the ward and he said, “You know, after all these months off away from work I’m beginning to feel rather rusty,” and of course feeling rather rusty iron, he’s suffering from iron deposition [laughs], it was a wonderfully perceptive but innocent--, I mean he had no idea what he was saying but I always remember Elkington with haemochromatosis saying he felt rusty. So that stuck. The other thing that the way Queen Square was organised there was actually very little one could do for patients with chronic neurological disorders so it was a very kindly hospital, patients got treated very well, staff got treated very well and they had quite a large outpatient clinic and the convention was that you [the SHO] worked for a different consultant in outpatients from the three or so that you worked for on the wards. And I was--, I was allocated to work with what’s his name? Roger--, my memory! My memory. Ah! Erm, [pause] I must have written it down here somewhere. Erm, Gilliatt. Roger Gilliatt. And I don’t know if the name Roger Gilliatt means anything to you.

Q: Somebody mentioned it in another interview about Queen Square.

A: Yes. Roger Gilliatt was a very establishment neurologist, friend of, I don’t know, the Royal Family and so on, married to Penelope Gilliatt. Penelope Gilliatt was a very extrovert rather promiscuous television critic for the Observer who engaged in a very public affair with John

Dr Eric Beck Page 48 of 123 Osborne, you know, the playwright and all this was happening while I was Gilliatt’s assistant in the outpatient clinic. And poor old Gilliatt, who was a very honest kind of man, he had a very-, he didn’t have a very good reputation [with the juniors] because he was said to have a very bad and short temper and didn’t suffer fools gladly. And one example that was given of his short temper was he had had difficulty in passing the MRCP examination because his attitude to the examiners was possibly a bit like Pappworth and apparently in one clinical exam they had taken him up to a patient as a short case covered in a sheet, I think you could just about know it was a woman, and he was asked to feel the pulse of this patient not seeing anything else of the patient. And the woman had a very rapid pulse rate and that was really what they wanted him to say and to then discuss the possible causes, you know, it was over 100 and there she was resting. So he felt her pulse and I think sort of rather fumbled his way through causes of rapid heart rate and the examiner apparently said, “Go on, go on,” and then whipped the sheet away and this woman had florid thyrotoxicosis and eyes popping out of her head, she--, and that was why she had such a rapid pulse rate and Gilliatt hadn’t mentioned thyrotoxicosis and so the examiner sort of rather insultingly said, “Well, you know, it’s obvious what the cause of her pulse rate is, isn’t it?” And Gilliatt allegedly said, “If you’re going to play silly buggers I’m not staying,” and walked out of the exam [laughs], which if that’s true was a pretty brave thing to say in the generation before me as a membership candidate. But of course he was obviously quite right, you know, if you want to know the cause of a rapid pulse you don’t go through the drama of covering a patient in a white sheet and sticking the arm out. So I rather liked Gilliatt and there was a sort of basic honesty about him and the bloke was going through a terrible time because every tabloid newspaper had the latest goings on of Penelope Gilliatt and John Osborne. And I remember him coming along one day and he said, “I don’t know what it is but every Saturday I seem to get a terrible migraine attack,” and I thought ‘well if you don’t know I can’t tell you’ [laughs]. Anyway the divorce ended and--, he went through the divorce and he married the neurologist senior registrar I think and all lived happily ever after as far as I know. I don’t know what happened to Penelope Gilliatt and John Osborne but it was, as it were, a very public affair. So memories of Queen Square were a very leisurely, because neurology tends to be that way, learning, seeing a lot of very interesting patients because they were all coming from here, there and everywhere so you got a very concentrated view of neurology which was always one of the areas I’d been worried about. And there was one particular neurologist Sir Charles Simons who had retired some years ago and must have been in his 80s or 90s who lived--, had retired to Hampshire and every six weeks he would come up to Queen Square and all the registrars, who were pretty experienced characters, would fish out cases for him to come and give his opinion on. And going on Sir Charles Simons’ rounds from one ward to another, and usually neurology was a matter of recall, pattern recognition and Simons who was bright as a button and, as I say, he must have been in his 80s then would nearly always have something perceptive to say. And again it sort of heightened one’s feeling of the importance of acute clinical observation which is a trend which, you know, golden oldies like me today feel rather sad that this is no longer given the importance that it should when we’ve got wonderful machines for imaging this, that

Dr Eric Beck Page 49 of 123 and the other. And then the final thing was Christmas came up at Queen Square which was a rather jolly occasion and on Christmas day we were all invited into the boardroom for Christmas dinner, more or less all the junior staff and the--, I’ve forgotten what his name was, the chairman of the board of governors would do his conjuring tricks, he was a Magic Circle Member. So that was a very happy time at--, short time at Queen Square and so I was now well armed to apply for registrar jobs having done the golden triangle, having got the MRCP and what’s more natural than to apply to my old teaching hospital UCH for a registrar post which I got. And it was first to--, working for Pochin the chap--, the radioiodine man who was good at radioiodine but not much else. So he left it very much to his registrar to deal with the general medicine.

[END OF PART FOUR 01:42:51]

[PART FIVE]

Q: Today’s the 22nd of September 2015, my name is Sarah Lowry and I’m carrying on the interview with Dr Eric Beck. Eric, I think I was just asking you at the end--, towards the end of our last session you said that you had some very interesting patients at Queen Square and I wondered if you could say a little more about them please.

A: Well it all revolves around the nature of what Queen Square was and I think still largely is, a national centre of neurological excellence but with hardly any acute admissions. So most of the patients came from other hospitals referred or from other clinicians and nearly all the consultants at Queen Square, like other postgraduate institutes like the Brompton, would have had posts in other London teaching hospitals. So some patients came via that route. So it was really a matter of a lot of wise neurologists seeking patterns to recognise the diagnoses. One of the things about my time there was that this was before the current availability of scanning so we didn’t have MRI, we didn’t have CT scan, we didn’t even have ultrasound. So investigating patients with neurological disorders the tools available were really plain x-ray of the skull which didn’t take you very far and if you really were inquisitive about the substance of the brain you had to do one of two procedures. You either did carotid angiography where you showed up the blood supply to the brain or you did a particularly unpleasant thing called air encephalography where you had to do a lumbar puncture and then inject air into the spinal canal for it to track up into the brain and outline the brain in that way. So neurological diagnosis really didn’t have much other than the great memory of many of the people who practiced it. One of the interesting things that also happened was that even the present day consultants there, who were pretty knowledgeable, still had respect for their greater elders and one of these was a man called Sir Charles Simons who had retired some time before I ever arrived there and I think he had retired to the country in Hampshire or something like that, but he still came up periodically. I don’t know whether it was once--, perhaps it was once a month because I wasn’t there all that long. And the consultants or their senior registrars would select particularly difficult cases on the wards and he would come along and say, “I remember in 1923 [laughs] seeing something very similar,” that kind of thing. So that was how neurology was practiced and sadly of course there wasn’t a great deal, somewhat similar to today, that

Dr Eric Beck Page 50 of 123 one could do therapeutically for many of the particularly chronic neurological disorders. So TLC, as it were, was the order of the day and this was--, the hospital had a very nice atmosphere about it, it was fairly relaxed and patients and staff were treated very well. The only really active part was one of the later appointed physicians called John Marshall and he was really rather different from all the other physicians. He didn’t have their sort of London teaching hospital background I think he came from Scotland and he started up a neurological intensive care unit. Now you might say why if they’re all chronic patients did you need that, but a certain amount of neurosurgery went on at Queen Square and so it was back up of that. And the only really important neurological conditions, apart from diagnosing brain tumours and removing them, the only emergency was if you had a subarachnoid haemorrhage which could be fatal and again Queen Square would have a certain number of patients admitted with that but most of them would be dealt with in the hospital to which they were originally referred. So John Marshall was a bit different from the rest and I think that [laughs] without being too judgmental or indiscrete he wasn’t really seen as one of them, he was seen as a lone spirit doing something which didn’t--, which many of the traditional consultants didn’t really fully understand or appreciate. So yes, John Marshall does stand out a bit in that.

Q: Could you tell me a bit more about intensive care? Was it something that had been available since you started as a student?

A: Well there had always been the problem of postoperative--, particularly postoperative patients requiring, as it were, intensive care which usually meant [mechanical] ventilation. So ventilation really took off I suppose when poliomyelitis was still around and if the respiratory muscles were involved in the polio the patients would have to be, as it were, rescued on a ventilator. The big problem that arose with polio, as opposed to other more transient conditions, was they might never fully recover their breathing and there was this remarkable thing which I think I saw and they may have had one at Queen Square called the iron lung, have you heard--, are you aware of the thing called iron lung? Which was a bit like a modern scanner you put the patient in it and pressure was intermittently exerted on their chest to, as it were, force their breathing and of course once you got onto an iron lung your chances of getting off it weren’t very great and with the disappearance of polio I think the iron lung disappeared and also because direct ventilation became more and more sophisticated. But intensive care initially was very much in the hands of anaesthetists and many anaesthetists would, as it were, have one or two sessions in their contracts to provide this service whereas clinicians, cardiologists and chest physicians particularly were the ones likely to be involved, would either be called in for advice or might have one or two [dedicated] sessions there as well, but the whole speciality of intensive care really took off many years later. And there is now, I think, a faculty of intensive care. In fact I--, many years later I was seconded from the college to the newly forming faculty to advise them about assessments and examinations and so on. So it’s become now an important speciality and every hospital has got one to a greater or lesser degree but some are very sophisticated and patients may still be moved from one ICU to another.

Dr Eric Beck Page 51 of 123 Q: So when you were a very junior doctor what would be the process for a patient requiring that level of treatment?

A: Well I think patients in coma from whatever cause and probably the commonest cause would have been a form of stroke either subarachnoid haemorrhage or a bleed into the substance of the brain. Yes, so I think it was--, and postoperatively where patients, you know, had had major surgery on their brains and couldn’t breathe spontaneously and needed circulatory support, but that usually would have had a good outcome if the patient survived in the sense they wouldn’t have to go on having it forever, but one of the worries raised, as it was by the polio cases, was what do you do after the acute phase? And that is still partly a dilemma and of course one of the dilemmas is if you’ve got someone, say, who’s brain dead or appears to be brain dead who’s only alive because of the support machines how long do you give them before you switch off and the whole sort of ethics of switching off and how you do it. And that inevitably comes as an issue with an intensive care unit. So clinicians whether they like it or not may be involved in these kind of decisions and communicating of course with the family. So it’s a very fraught area and I speak with some experience because we had--, I think I mentioned earlier on my daughter died last summer in just those sort of circumstances and she had been on a ventilator for--, in Manchester but the time came to make the decision whether to carry on or not because she wasn’t going to breathe spontaneously. So it’s an ongoing issue but I think we’ve become rather better at handling it than in the early days and it does raise well legal issues as to when is a person brain dead, and that’s now been fairly clearly defined. And a physician may be called in as one of the opinions to, as it were, certify that it’s happened. But the bigger ethical situation still remains and there are still people on ventilators with various forms of locked in syndrome you may have heard of, and it’s a difficult area and it was only in its infancy certainly when I was at Queen Square.

Q: Thank you. So in terms of the chronic conditions that people had who were coming to Queen Square can you say any more about that?

A: Well I mean the most chronic condition in many ways is multiple sclerosis and sadly neither at Queen Square nor elsewhere has there been much progress as far as I’m aware now of treating the disease other than treating the symptoms. So a certain number of patients would have multiple sclerosis. Also of course other congenital disorders and muscular wasting and they would tend to congregate there, again with not much prospect of improving the situation. And then of course people who’d had complicated strokes might finish up there although usually would be treated in their own local hospitals. So I suppose those. Yes, and there were one or two other interesting conditions that people had an interest in. Myasthenia gravis which is a muscle disorder due to faulty transmission of nerve impulses to the muscle and this is a field where there has actually been quite a lot of progress and somebody--, there was somebody at Queen Square I think who had an interest in it but my feeling is that most of the advances in myasthenia gravis have come from other places. One of the things that was being explored and I think is still done is the removal of the thymus gland which is a rather

Dr Eric Beck Page 52 of 123 mysterious and generally considered useless gland [laughs] in the--, inside your chest which somehow interferes with the immune abnormalities that are found in myasthenia gravis. And so one or two patients would be having thymectomies which you had to, as it were, explain to the patient, “We’re opening your chest to take out a gland which may affect the course of your illness.” And in fact I have a feeling that one of the pioneers of this was a lady neurosurgeon, which was rare enough in itself, at the Middlesex Hospital who was called Beck, no relation of Diana Beck. Yeah, so it was a mixture of things a bit like my experience at the Brompton Hospital, although chest disease could be more actively treated nonetheless it tended to attract difficult complicated cases where--, which might be dealt with better in an expert situation. And I’ve just remembered also who the--, Roger Gilliatt’s second wife was, she was called Paddy Fullerton and she was the senior of the senior registrars. So she was--, at the time when I first came there and she went off and did something else I think and was replaced by Roger Bannister who became the senior of the senior registrars. So because there were--, most of us were on very short term appointments apart from the senior registrars there was a sort of interesting flux of people going through the place, but we weren’t terribly hardly worked and it was a very pleasant atmosphere. I was there at Christmas I seem to remember and we all had dinner in the boardroom--, Christmas dinner in the boardroom. And the secretary, I’ve forgotten what he was called, of the board of governors was an amateur magician and I still remember this magic show following Christmas dinner in the boardroom at Queen Square. So that’s the kind of place that it was.

Q: What was it like having patients that you couldn’t really do much for?

A: Well, as I say, this is where I think the tender loving care bit came into it in the sense that whereas sadly many doctors might, as it were, write off a patient and say, “Sorry, I can’t do anything more,” at Queen Square I think there was much more a feeling of, you know, “How can we treat them symptomatically?” Because even though you can’t cure the disease all kinds of nasty consequences from bedsores upwards, as it were, can occur in chronically disabled patients. So yes, I very much got the flavour of that. I think the nursing staff were obviously orientated that way. I’m just trying to--, and physio--, plenty of physiotherapists, occupational therapists, speech therapists, you know, therapists for--, psychotherapists for everything. And I can’t remember whether there was a particularly strong social work department to try and help people when they left hospital to set up facilities. There must have been but I don’t recall the--, who the social workers were. Yeah, so it was rather different from a district general hospital. And you sort of stored away in your memory all the unusual or odd presentations and diseases that you saw there but came away slightly dissatisfied that for all this intellectual powerhouse that it was there wasn’t really a great deal of progress in treating or diagnosing--, well diagnosing yes, but treating the chronic diseases.

Q: You mentioned your golden triangle the Brompton, Hammersmith--,

A: Yes.

Dr Eric Beck Page 53 of 123 Q: And Queen Square, what do you think was--, where do you think you had your most positive experience?

A: Er, well I’ve rather suggested that Brompton and Queen Square were sort of rest homes for [laughs] teaching hospital consultants who came along there and with very little acute medicine. I suppose Hammersmith probably was the most impressive and it stood out from all the other hospitals in the UK at that time, it was very much the American model. And although it was a--, mainly a centre for referral from other places there was a significant acute intake as well at Hammersmith and the staff were rather different, rather brasher some would say, certainly more experimental as Pappworth would say. And the junior staff came from everywhere not just London based golden triangle people like myself but one of my fellow housemen was from Birmingham and he was quite a highflyer and there were quite a lot of commonwealth SHOs and registrars and I mentioned earlier I think the disrespectful remark from the Australian registrar at the grand round [laughs]. So--, and Hammersmith had a very sort of questioning atmosphere about it whereas Brompton and Queen Square, you know, you accepted what you were told and what came down from on high. So yes, it was a very different atmosphere at Hammersmith and of course an enormous amount of research going on most of which I probably wasn’t familiar with or thought too much of.

Q: So after you finished at Queen Square, what next?

A: Well then I applied for a registrar job. I could have applied for one sooner because I’d already got the MRCP under my belt, as it were, but I used the MRCP as a means of completing the golden triangle because I realised it was very unlikely in my future career that I would have the opportunity to spend six months at Hammersmith or six months at Queen Square. So it meant that when I applied for a registrar job at my old teaching hospital the UCH that was a fairly comfortable shoe in as it were. You know, I didn’t have too many sleepless nights over whether I would be appointed or not. So I was appointed and I was appointed to work as the medical registrar with [Eric] Pochin, and I mentioned Pochin earlier as the radioiodine thyroid cancer treatment person in ward--, in the metabolic ward but he also ran an acute medical firm. And I think it’s fair to say his--, his acute general medicine very much had ended years ago so he relied pretty heavily, when patients came in on acute take, on the registrar to run the show. And it was an interesting structure the Pochin firm. He was a consultant physician at UCH but he was also the head of the MRC clinical investigation unit which was a carryon from Sir Thomas Lewis’ famous units which I think I’ve already referred to. But he was not a cardiologist like Sir Thomas Lewis was but the MRC who had set up the unit with Thomas Lewis wanted clinical investigation to go on in whatever form and obviously Pochin and his interest in radioiodine was something they wanted to back and he developed a considerable expertise in this. And attached to--, or as part of the firm there were two other consultants. It was a rather curious firm structure altogether. One was called Rowlands who seems--, who was a gastroenterologist who I hardly ever saw because I think he was mainly at the Central Middlesex, and the other one was David Edwards. There were a lot of Edwards around but he was DAWE, David--, or David ‘the gullet’ Edwards because he was particularly interested in

Dr Eric Beck Page 54 of 123 oesophageal disorders. And in terms of mentoring I think I learnt a lot from David Edwards not only the beginnings of gastroenterology but also in patient management. And he was--, he was considered rather eccentric by his colleagues, he also had sessions at the Central Middlesex Hospital, this is the Avery Jones unit which I had mentioned earlier, an MRC unit at the Central Middlesex so these were sort of joint appointments between the two MRC units. But two of the things--, well I learnt a lot from David Edwards and one of them was his manner with patients. He was a rather shy man but he had this quality which I think I’d always seen in someone like William Gooddy though a much more extrovert character, of listening to patients and he showed an interest in irritable bowel syndrome. Now this is the--, is always considered the graveyard of gastroenterology. If you become a gastroenterologist you’re going to have to deal with irritable bowel because people will be referred to you. Not a great deal is known about the pathogenesis of it except that lots of theories and people act upon them because there’s nothing else to do, like food intolerance which probably isn’t a great feature in causing the symptoms of irritable bowel but also psychological factors so it’s regarded very much as a psychosomatic disease. And if you’re going to get anywhere with it you’ve got to listen to the patient not only to reassure them and rule out all the other diseases which might be mimicking it but to explain to them, you know, what the ‘dos and don’ts’ of irritable bowel and what the prospects of it were. And all these finished up largely in David Edwards’ clinic which would often go on for hours and hours to the impatience of the nurses wanting to go home, but that was very impressive. And when I eventually became a consultant some years later I knew I was going to see a lot of patients with irritable bowel I became more and more interested in it and tried to follow his precepts as it were. And just by listening and talking to people about the details of their lives you can actually help to a certain degree and reassuring them that they haven’t got something terrible or they haven’t got gluten sensitivity which I may come back to later on. Because once a patient believes that they’re sensitive to gluten and haven’t--, and you’ve shown them they haven’t got coeliac disease, which is the disease caused by gluten sensitivity, you may have to do a lot of sort of negotiating with the patient saying, “You really don’t need to be on a gluten free diet and, you know, look at other things that might be triggering off your symptoms.” So that was one thing I particularly learnt from David Edwards and he was very interested in the oesophageal disorders which again were a bit of a sort of Cinderella area in gastroenterology, for many gastroenterologists the gut begins in the stomach and not in the--, not in the gullet. And he got particularly interested in gastroesophageal reflux, that’s to say acid regurgitating into the lower oesophagus causing usually chest pain but a rather atypical chest pain but overlapping with heart pain as it were, hence the term heartburn which is due to acid not due to the heart. And he devised--, and I still remember he had a--, he had a metal locker where he hung up his coat and with a series of magnets and labels attached to them. [By moving them around] he developed an algorithm for diagnosing gastroesophageal reflux. I mean algorithms now are--, everybody knows them and uses them in all sorts of context but in those days having a branching [Yes or No] system of questioning and investigating a patient was a rather novel approach. And he would fiddle around with [the magnets which had labels of symptoms or findings and arrange them in a

Dr Eric Beck Page 55 of 123 logical, branched order], you know, if the answer to this is ‘yes’ do that, if the answer is ‘no’ do that, and he would move these magnets around on the back of his locker in the lab where he worked. And algorithms subsequently have taken off not only in medicine but in everything, but when I--, my colleagues, and we’ll perhaps come to this, came to write a book on diagnosis we borrowed his algorithm for the oesophagus and tried to devise one or two others for other symptoms as well and he was very pleased, as it were, to see us following this approach. But he was considered a rather eccentric character, he wasn’t much involved in the acute medicine. As I say, this was very much left to the registrar to do. So I probably saw as much or more acute medicine than my fellow medical registrars because my consultants were all off doing different things!

Q: So by acute medicine can you give me some examples of the sorts of things you saw?

A: Well the--, you know, the everyday admissions of myocardial infarct, heart attacks, strokes, asthma, the everyday but very important acute presentations. And I think I may have mentioned, or perhaps I haven’t, that the structure of the junior staff at UCH and I think in many other teaching hospitals who had very few people in the SHO grade you were either a preclinical houseman [corrected to pre-registration house physician] or you were a registrar. And so there was this sort of slight gap of junior doctors getting experience in acute medicine and the person who it all revolved round in terms of acute admissions was called the resident medical officer, the RMO, who was a registrar who had been there in post for quite a long time having difficulty getting his MRCP exam, which I think I mentioned the effect it had on Philip Marsden and the Hospital for Tropical Diseases. But his--, the expectations of him were that he provided a 24/7 service to see every acute medical admission that came through A&E which became increasingly a nonsense in terms of the increasing complexity of the cases and the treatment of them. So he would ask quite reasonably registrars to cover for him for part of the time, but there was no admissions rota where you--, you know, each firm took it in turn for one day to deal with the acute admissions, they were the RMO who would then call in the appropriate registrar to deal with the patients that he couldn’t deal with himself. And this--, and this was a time when rotas and admission systems were not commonplace but were beginning to happen, as they needed to happen as medicine changed. And there was a lot of resistance amongst the senior staff to the idea of having a rota where your firm would be on take one or two days a year--, a week. And later on when I’d moved a bit further up the registrar ladder I and several of my registrar colleagues sort of started badgering the consultants and we didn’t quite present a petition but we sent a proposal to the [Consultant] Physicians Committee that we should, like many other hospitals, now have a proper admission system. This came a few years after my arrival. And I still remember us meeting the Physicians Committee who met, I don’t know, every month or every two months and putting our proposals to them. And some of the younger consultants were very supportive of the idea but some of the older ones weren’t and surprisingly one of the people I’ve mentioned Max Rosenheim, the professor of medicine later president of the college, who was a great influence--, a great influence for the good but he was very much the old school. And I still remember him at this meeting saying, “I would be very sad if I was rung up in the middle of the

Dr Eric Beck Page 56 of 123 night to be told that one of my patients--, that something has happened to one of my patients and the person ringing me was not my--, one of my team,” was not the registrar or the houseman, and he sort of looked around and nobody was going to say much then he gave a deep sigh, said, “But I suppose I need to keep up with the times [laughs].” So he, as it were, acquiesced to it and the RMO was greatly relieved in many ways. He still continued to function but not in such onerous fashion.

[END OF PART FIVE 00:31:11]

[PART SIX]

A: So my role as Pochin’s registrar was really very much to deal with the acute medicine while he got on with his radioiodine treatment of thyroid cancer and the other two, Edwards and Rowlands, were much more interested in gastroenterology and were linked with the Central Middlesex gastroenterology MRC unit there. So it was--, I was a bit different in that respect from the other registrars. And the next thing that happened was that in the--, I think I’ve got the sequence right here, was in the course of the rotation--, no, what was it? I got lifted out of my--, out of my registrar position because the--, there were two resident assistant physicians so called RAPs along with the RMO but neither of them was resident and they were almost like supernumerary senior registrars who filled in when consultants were away, you did the ward rounds and clinics and so on. And there was a senior one and a junior one and it so happened that the junior one was going away I think on a sabbatical for a year so they had to find somebody to stand in for the junior RAP which was a senior registrar position. So it was, as it were, above the other registrars. And they asked me if I would take on the RAP role for a year, which in many ways was very flattering having only been a registrar for a year or two perhaps at the most to become a senior registrar. And my only hesitation was--, and this did have knock on effects, was if I’d been a senior registrar for a year and then had to drop back down to being a registrar, you know, this was a fairly backward step. So they said, “Oh, we will look out--, we will look into that when the time comes.” So I became the junior RAP.

Q: Before we go on to that, could you--, I’m sure you didn’t have anything that sort of resembled a typical day, but could you--, when you were actually a more junior registrar in your first position as a registrar could you give me an idea of what your day would have been like in terms of timescales?

A: Well in terms of the inpatients you were--, as I say, even though you were fairly junior you were very much in charge of their management along with the houseman, who was a preregistration houseman, who needed quite a lot of support because he or she wouldn’t necessarily get it from above. So you would start an average day, I suppose as a registrar, at the leisurely time of about nine o’clock in the morning and you’d go up to one of the two wards where your patients were and really go round the patients with the houseman talking about what investigations, what treatments and so on you would carry out. And then at least two afternoons a week or perhaps it was an afternoon and a morning--, no, I think it was two afternoons a week you would go to the outpatient clinic where you’d see a mixture of follow up patients but also quite often, particularly because of the nature of the firm structure, you would

Dr Eric Beck Page 57 of 123 see new patients referred to the outpatient clinic and, you know, initiate their investigation and treatment and occasionally have to admit them as well. And then the third arm, as it were, of the job was that we, like all the firms, had medical students attached so supervising their teaching. And an extra dimension that became quite important in the effects, looking back, that it had on my career was that there were junior doctors [ changed to ‘The effect it had, which was informal teaching of the other hospital junior doctors]. There were some SHOs but very few of them and they were people who were trying to get the MRCP and there was really very little in the way of membership teaching. It was a teaching hospital, fine that was for undergraduate doctors, and there were also some fairly sophisticated postgraduate meetings within each specialty but in terms of what was required for the MRCP there really wasn’t a great deal going. And having come along with the MRCP fairly recently behind me, and I think I mentioned at the time when I got it I felt there were a lot of things wrong with the MRCP, it was far too exclusive, only 23 people had passed at the time I did it and my own preparation had been very much ad hoc but actually had been very enjoyable with Marsden at the Hospital for Tropical Diseases, Pappworth, blah, blah, blah. So several of--, I got several fellow registrars and myself to set up informal teaching rounds for the MRCP and we would take this in turn and there were quite a lot of people attached to the hospital, some from overseas, some from elsewhere who all had in common the wish to pass the MRCP. So I, as it were, informally started organising the teaching of junior doctors for the MRCP and this seemed to fill a much needed gap. And one of the big boosts to this was the appointment of the cardiologist Arthur Hollman, I think I mentioned him earlier in context with Kenneth Harris, the awful cardiologist who had laid his dead hand on UCH for many years. And Arthur Hollman came fresh from the Hammersmith, again a disciple of Sir Thomas Lewis because he’d trained at UCH, and was very keen on teaching and he set up a weekly cardiology round which was mainly aimed at the junior doctors, I don’t think other consultants came to it. And the format was that you--, you would bring along to him interesting or puzzling cardiological cases and you’d go and see the patient or talk about the patient and these rightly became very popular. And I realised that we needed more and more of this but he was really the only one on the consultant staff who was particularly taking an interest in the MRCP because most people, unless you were a preregistration houseman, by definition would have the MRCP to be appointed there in the first place. In fact this was one of the rather unfortunate rules that you couldn’t be appointed a registrar and be paid as a registrar unless you had the MRCP exam. So there were one or two registrars who’d been appointed, one I particularly remember Peter Toghill [0:07:57] who went on to Nottingham, was a good friend and colleague, who had--, had struggled with the MRCP, had passed the Edinburgh exam because in those days if you didn’t pass in one college you went on the circuit of London, Glasgow, Edinburgh. And although he’d been appointed as a registrar perhaps because he had the MRCP Edinburgh he was paid as an SHO and it wasn’t until he subsequently got the full MRCP that he got full pay and this seemed a ridiculous thing to discriminate not only against the person but against another college’s exam as not being as good as your own exam if you were working in London. So that was something that just sort of stuck out about the MRCP. Subsequently, erm, two

Dr Eric Beck Page 58 of 123 colleagues of mine, John Francis, who I think I already mentioned who I’d seen when we were originally admitted to medical school and gone on and won the university gold medal and was the best person qualifying in that year and Bob Souhami, who was considerably junior to both of us. In fact I had coached him [Bob] on the side coming up to finals exam, not that he had any need to be worried, but he and another student, Peter Whybrow [0:09:32] sort of cornered me one day and said would I do some tutorials with them in preparation for the finals exam, which I said they didn’t really need. Anyway, by then he was back on the--, he’d passed his exams and--, junior exams and the MRCP and he was a junior doctor. So the three of us, John Francis, Bob Souhami and I were all involved in this--, in these informal ward rounds. And one of the things that we did was to, as it were, reinforce the bedside teaching was we devised a series of case histories which we would sit down and discuss with the would be candidate. Not that they were going to be exactly examined in this [it wasn’t part of the MRCP exam at the time] but it seemed a very good way of teaching to give somebody a case history and then ask, “What’s the differential diagnosis? What investigation would you do?” blah, blah, blah. And we supplemented this with showing them x-rays and showing them ECGs and, you know, any relevant material that would get them talking partly because in the MRCP exam at that time there was a so called path viva, which I think I mentioned earlier on, where you might be questioned on these things. Anyway, this seemed to go down rather well and the three of us then wondered whether we, erm, might expand beyond just doing the rounds at UCH. And I’ve said there was a dearth of sort of postgraduate teaching from the membership, some hospitals, the golden triangle and so on, obviously prepared you for it but the other thing that people used to do in those days were correspondence courses on how to pass the--, or prepare you for the MRCP. And I think all three of us or certainly two of us had worked for people who ran the correspondence courses marking the work that the people paying for it sent in. And we were--, we were rather unimpressed by the content of the courses we marked for or their relevance and we thought with the--, rather arrogantly perhaps, that with what we were doing every day perhaps we could set up our own correspondence course. Anyway, to cut a long story short we did and so we founded a thing called Medical Tutors and this was a series of I think you paid for 20 lessons and each one was related to a subspecialty and in these lessons we would give them multiple choice questions that we devised because that was already part of the MRCP UK, but we also thought that this--, this sort of case history and data interpretation was a useful thing in preparing for the MRCP and so we devised a whole lot of case histories and data. The one thing we lacked and would find--, and you could photocopy ECGs but how could you send people x-rays on a correspondence course? And I mention this because at the time the drug firm Lederle were selling I think it was Tetracycline, and they had got a rather novel form of advertisement which was a sort of cellophane thing with a picture of an ECG on it which looked--, of an chest x-ray which looked rather realistic and this, you know, appeared in the journals as part of their advertisement. So we wrote to Lederle and told them that we were starting this correspondence course and what its content was going to be but the only thing we’d dearly like to do would be to send out these sort of cellophane paper copies of x-rays and would they be prepared to fund this. And surprisingly

Dr Eric Beck Page 59 of 123 they said, “Yes, as long as we can put compliments of Lederle at the bottom,” that was no problem to us. So we sent them a whole batch of x-rays, they turned them into these transparencies which was obviously going to enhance our correspondence course because nobody else was doing it. And, at the time, I was--, one of the--, in fact I think it was the senior physician at UCH was John Stokes, very well known in the college here, you know, and I’ll be coming back to him as well. And he was--, I think he was senior censor and he--, and he was also very conscious of the need to reform the MRCP exam. And so we showed him the material we were going to use in our correspondence course just to get his opinion as to whether we were doing the right thing. And, to my amazement, he turned round and said, “How did you know?” and I said, “Know what?” He said, “At this very moment the college is looking into the possibility of extending the exam to include the sort of things that you’re already doing.” So we’d, as it were, second guessed the new MRCP exam. And that had quite a lot to do I think with my [laughs] connections with the college. So he said, “Do you mind if I take your material along and show it to my colleagues in the London College?” you know, which for a registrar or a senior registrar was quite an accolade. I’d also been involved as the registrar in helping to organise the clinical exam. The MRCP exam was held in different London teaching hospitals so I got increasing insight, as it were, into the exam. Anyway, to cut a long story short, we had second guessed the new exam. I as a--, I was still only a--, by then a senior registrar, I was invited to join the question group to help devise the new material for the new exam. Rosenheim was president and he was consulted as to whether this was a proper thing for (a) a registrar rather than a consultant to be doing and (b) a registrar who was involved in a correspondence course for the MRCP. I mean looking back although we kept the two very separate nowadays it would have been on the front page of Private Eye a conflict of interests. I remember Rosenheim coming along and saying, “Well as you’re inventing all the cases and the data I don’t really see that there’s a problem [laughs].” So we had the unofficial--, he didn’t put it in writing but, you know, the college knew what we were--, what we were doing. So Lederle came up with the goods which greatly enhanced the correspondence course, which was never financially a great success but people, as it were, got to know what we were doing. So because it was, you know, reasonably well thought out people accepted it and even approved of it and then the problem came round of we were running out of x-rays would Lederle provide [0:17:19] some more for us? So we contacted Lederle and they said, “Well yes, we certainly would like to help again but we’d like something a bit more relevant to medical education than just putting ‘with our compliments’ on the bottom of every x-ray. Why-, would you like to think of some educational activity that we could sponsor?” And in those days there was a fairly new, I think it was a monthly journal, called the British Journal of Hospital Medicine which was funded by advertising but had high quality review articles, many of them relevant to the exam. So lots of junior doctors read the British Journal of Hospital Medicine or it was called Hospital Medicine for short. And Lederle said, “Well we’re going to book advertisements every month in the centre pages and we want you to--, in that advertisement to put something of educational value in which people might be able to collect in a folder,” and anyway, so we devised a whole series of case histories which were then beginning to register

Dr Eric Beck Page 60 of 123 as being part of the MRCP exam as well [Each one focused on a presenting symptom which was then discussed before the diagnostic answer was given]. So people would read them and they’d tear them out and Lederle provided a binder to keep them in. And of course you couldn’t help noticing that it was Lederle who produced it. And you had to write in to the British Journal of Hospital Medicine if you wanted to get the binder to keep the articles. And after I think about a year we asked the Journal how many people have actually bothered to do this. I can’t remember the actual number but it was quite a significant number, several hundred people anyway. So we thought--, and our contract with them to do it was coming to an end, I think we did it for two years and what we particularly had focused on in these diagnostic problems was symptoms rather than diseases, that’s to say patients don’t present with subarachnoid haemorrhage they--, well they do but they present with a severe blinding headache and fall over as it were. So what are the causes of severe headache? What are the causes of chest pain? To use this approach, which is what doctors do every day, but of course textbooks it’s a rather messy way of writing a textbook it’s much easier to write about coronary artery disease, myocardial infarction, the pathology. So we were--, we had chosen to emphasise the presenting symptom as the teaching point leading to diagnosis and management rather than making the diagnosis the all being thing. And people seemed to like it because they’d written in for it. So we thought well perhaps these rather ephemeral articles and a few binders we ought to turn this into a book. And so we approached the Pitman Press which was--, I don’t know why we chose Pitmans and said, you know, “Would you be interested in us writing a book on symptoms?” and the lady there was Betty Dickens whose husband was a great great grandson of Charles Dickens [laughs]. Anyway, they were very supportive and said, “Yes, we will publish it and we will make sure every postgraduate medical institute in the country gets a free copy of it.” And so we sat down to write what we called Tutorials in Differential Diagnosis, a rather unwieldly name, but which dealt with I think it was 24 or 30 common presenting symptoms which we discussed in the chapter and then each chapter ended with a case history relevant to the symptom. So that was an additional, as it were, selling point that you would get a case history similar to what was in the MRCP. And again we showed it to John Stokes and asked him to write a foreword to the book because it did overlap with the MRCP and we wanted, as it were, to plug the fact that it would help people doing the MRCP as well as a lot of other people. Anyway, so the book got published, the first edition and--, which went very well. We didn’t make a great deal of money out of it, you don’t as medical authors and we hadn’t made a great deal of money out of the correspondence course either but it had sort of raised our profiles a bit. So, you know, if you went somewhere and said you were Eric Beck and they’d say, “Oh, Tutorials in Differential Diagnosis.” And this began--, later on in my career with the college when I started going round the world again this was a sort of visiting card that people had read it. And I still remember going out it must have been the first time I went to Hong Kong and to teach on the postgraduate course there and the book had been--, the first edition had been out for a year or more and I thought I’d go and see the Hong Kong Pitman representative to see how the book was going there. And I still remember going to this rather seedy office in Kowloon, climbing up

Dr Eric Beck Page 61 of 123 several flights of stairs and knocking on the door of a lady called Jacqueline Sin [laughs], now Sin is quite a common surname in--, and introducing myself as the--, one of the three authors of Tutorials in Differential Diagnosis and she was amazed. She said, “I’ve never met an author before [laughs].” Anyway, so we sat down and chatted about the sale of the book and she said, “Would you like to see the sales figures?” So I said, “Yes, of course,” and there they were slowly going up and suddenly there was a big boost and I said, “Oh, what was the big boost due to?” She said, “Ah!” I changed my--, now what was it? No, she hadn’t changed What had changed is that photocopying had come in as a technique and lots of canny Chinese--, no, that’s right, sales had gone up and then they dropped, yes, and they had dropped because the Chinese were photocopying the book. You know, it was just one place where the book was being sold around the world and I thought that was rather nice that people were going to the lengths of photocopying it. And then when I went to other countries abroad I always looked in the library to see if the book was there and they’d say, “I’m afraid it’s been stolen.” So it was a much stolen book which [laughs]--, and Jacqueline Sin every time I went to Hong Kong for the next few years I’d go and look her up and, you know, we’d go out and have a meal or go somewhere. So yes, the first author she’d ever met. So all these things were happening, as it were, at the periphery of my career as registrar which had taken a bit of a jolt by this sudden promotion to being RA--, junior RAP. And the year came to an end and I was going to be, as it were, thrown back into the registrar pool but I was, you know, a bit uneasy about taking this backwards step. And so Pochin came to the rescue as one of the physicians by suggesting that I should become an attached worker to the MRC unit not the radioiodine things he was doing but more the gastroenterology, and that I could do this for a year or more if I wanted to. And it sounded, you know, like a great offer to be offered a post working for the MRC. In fact it didn’t turn out like that at all because I was thrown into it without any experience of doing research or hardly any. I think I mentioned the thing I did at the Central Middlesex the clinical follow up [of cerebral embolism patients]. And the assumption that I must know exactly what I wanted to do and how to do it and there were some other rather esoteric things going on by then in the unit, one was Charles Edmonds, who then went on to be a physician at Northwick Park, was doing some very fancy biophysical work down in the basement. And, you know, I said, “What shall I do?” And so partly to link in with his work which was to do with the way the gut handled electrolytes, so potassium and so on, one of--, the idea was that the bowel in disease might behave differently in relation to the handling of electrolytes from the healthy bowel. And that two ways one might look at this, and they encouraged me to do, was one to try and measure the electric potential of the surface mucosa in the bowel, there had been some American paper which had caught their eye. So I had a rather desultory time trying to devise a way of doing that and didn’t get very far. And a simpler thing was to analyse the electrolyte content of the fluid that came out with the stools, a rather messy thing. And there was a technique [used by Oliver Wrong, who later succeeded Rosenheim as Professor of Medicine], again they’d spotted and it had been devised somewhere else, was that if you made little bags which were semi porous and had in them--, what did we put in? Something to make them pass through the gut and attract the water from

Dr Eric Beck Page 62 of 123 the stool into the bag then you’d fish out the bag and analyse the water. These faecal bags. So I started making these faecal bags [laughs] and collecting them and the stools and so on. And again I didn’t get very far partly because I really got very little guidance and the ethos was, you know, if you got an idea it’s up to you to do it and we will help to provide the facilities, but I really got very little advice. I got rather disillusioned with what I was doing; built into the job because the Pochin firm still needed clinical input I was given clinical responsibilities for some of the patients as well which I of course enjoyed doing. And--, but the actual great research never--, never happened. And that’s been one of--, in many ways one of the regrets of my career that although I--, after my BSc earlier on, you know, the idea of research had appealed to me I’d never had any proper training or perhaps I didn’t have a proper aptitude for it, but it seemed sad in a way that having done--, taken the steps that might have got me there I never did get there. Anyway, after a year of this--, oh yes, the other experiment that I did do with a colleague called Neville Conway, who finished up as a cardiologist in Southampton, was on the--, relevant to what I’ve just being doing five minutes ago, the diuretic effect of alcohol [laughs] and--, or the opposite, the anti-diuretic syndrome. It was well recognised that some patients after surgery would go into a state where they wouldn’t pass enough water and this was due to release by the pituitary gland in response to the stress of the operation, and this was thought to be the idea, anti-diuretic hormone. So patients would have very small urine outputs and what urine was produced would be very dilute because the sodium had all been drawn back by the kidneys. And it was well known that alcohol causes diuresis by mechanisms which are not clearly understood. There had been a physiologist at UCL when I was a student there, Grace Eggleton, who had been a bit interested in the diuretic effect of alcohol and had written papers in the Journal of Physiology. Anyway, Neville Conway and I had both actually seen patients in whom this anti-diuretic syndrome, the syndrome of inappropriate ADH secretion, SIADH, had occurred. Anaesthetists were familiar with it because it occurred postoperatively. Most people got over it after a week or two but sometimes because of the fluid retention could run into problems. So we thought we would study the diuretic effect of alcohol in healthy people by recruiting medical students and giving them a drink of alcohol and collecting their urine all in an afternoon. And then we thought it was quite--, I’ve forgotten how we settled on the dose of alcohol but it was a dose that probably would have made you ineligible to drive your car home. And over in the college UCL again there was a psychopharmacologist called Hannah Steinberg and we--, and who was interested in the effect of substances on people’s behaviour. And we said, “Look, we’re going to recruit these medical students, give them alcohol or give them placebo,” it was a proper controlled trial so they didn’t know whether they were having alcohol or not, “And we’re going to observe them acutely over a three hour period before they go home. Would you be interested in seeing the acute effects of alcohol on them?” and she got quite interested and said, “Yes, I’ll devise a series of psychometric and psychological tests that you can do on them while you’re sitting there waiting for them to pee.” So it became a joint study of collecting their urine for a few hours and while they were, as it were, not entertained and amused but kept busy doing these tests. And the outcome was totally inconclusive both in terms of whether it

Dr Eric Beck Page 63 of 123 was a diuretic or whether it had a profound effect on their psyche. And I never wrote it up and Neville Conway had gone by then to Southampton and he was a bit disappointed that we never, as it were, got any further with it. Again it was perhaps a matter of us doing it off our own back without having proper advice as to how to do it. So that was something else I did do in my year in the MRC investigation [laughs] unit but, by the end of the year, I was getting pretty restless to move on.

Q: Before you move on Eric, sorry, can we go back a little bit, is that okay ‘cause there are--, you’ve obviously talked very interestingly about your teaching which I’m quite keen to follow up on? You mentioned that there were various correspondence courses for the--,

A: Yes.

Q: For the MRCP exam, was--, and was Maurice Pappworth still…

A: No, he was not a correspondence --He was still doing his classes but he was not a correspondence course he was much better than correspondence course! One of them was called J Arnold and this--, in fact it had been started by a physician in Dulwich called Frank Rackow [0:34:05] and I marked and I think the other two may have marked for him, and it was okay but, you know, it could be improved upon. And the other one, the other rival as it were, was part of a much larger family of correspondence courses. It had some grand name, Imperial Education something or other and that was somewhat inferior to Rackow [0:34:31] and to us. So there wasn’t that much competition and…

Q: Did you get a sense of rivalry at all?

A: Not really. I--, no, I think ‘cause they probably withered away ‘cause I mean what was happening all the time of course was people were getting more interested in postgraduate teaching at hospital level in the teaching hospitals and of course the golden--, not only the golden triangle but up and down the country. I think I already mentioned there were some posts recognised as being posts where your boss and his colleagues would teach you. So correspondence courses became increasingly irrelevant although the overseas students still did them for a while. I don’t know whether any exist any longer now because, you know, membership teaching has become much of an industry and of course even the college now has its MRCP course which I might say something about later on because I had a slight run in with the college over that. This was years after our correspondence course but I felt that if you’re the college setting the exam you shouldn’t be the college teaching you how to pass it. And George Alberti was the president at the time didn’t agree with me [laughs] and the Scottish colleges didn’t. And we had a--, I remember at a meeting of the three RCs [Royal Colleges], which I used to go along to as chairman of the MRCP Part 2 [0:36:11] board this issue came up. Glasgow and Edinburgh were critical of what the London College were doing and Alberti was defending it and I didn’t support Alberti in what he was doing because I thought the Scottish colleges were probably right to have their objections. Anyway, that’s jumping the gun a few years.

Dr Eric Beck Page 64 of 123 Q: I just wondered as well because you were obviously doing a lot of additional work beyond the clinical work that you were being paid to do at the hospital, how did you manage to fit everything in?

A: Well the MRC thing was a bit of a side track [0:36:46] in that I did very little clinical work, I’d rather insisted that I should go on doing it in case I didn’t get up to my eyes in research which turned out to be the case. So that was a rather fallow year and in many years I wouldn’t say I regretted it but I was looking forward to getting back to full time medicine again. So there wasn’t too much difficulty fitting that in. As far as the Medical Tutors is concerned we hired an office in, er, what is the road that goes up to Finsbury Park? Oh, I forgot.

Q: Holloway?

A: No, it’s not Holloway it’s off Holloway Road it goes up to Finsbury, but anyway halfway along it there’s a petrol station and above the petrol station the building belongs to the Co-op Insurance Society and we hired a room on the first floor above this garage in which Medical Tutors would function. We employed, when it took off, one of our retired secretaries from UCH, Edith Bellenger to run it on a day to day basis, we bought a Gestetner machine for [printing]--, because we didn’t--, you didn’t have photocopies easily available then to produce the material. And we would go along and as the customers came in and we would mark their papers and send back comments and I think we even--, yes, we employed one or two junior doctors to help us out when it--, when it started to expand. But it was never really a money making effort but it was the spinoff from it which led to the--, through Lederle to the transparencies to the book to tutorials that people noticed much more the fact that we were Medical Tutors Limited. And I can’t remember how many years we did it for but I think Edith Bellinger must have retired and then various other people came and helped. We thought this really isn’t the life for us so we wound it up. Can’t remember exactly, I think when all three of us had become consultants, I was the only consultant at the beginning of the project. Yeah, so that was…

Q: And just finally before we move on to the next stage of your career, when you were an RAP--,

A: Yes.

Q: That year as an RAP, can you just describe a little bit more what your actual duties were in that year?

A: Well it was largely a matter of deputising and with a fairly large physician body there was nearly always somebody going off somewhere. So I--, I would, you know, take over the Hawksley firm, say, for a fortnight and run it in his absence. And I was also there as--, the senior RAP was the most senior of the senior registrars I was the junior senior registrar and there weren’t any other senior registrars in the setup. It was quite different, say, from Queen Square where they had senior registrars. So I was there to help and support the registrars and the housemen beneath me and I had a nice little office perched in that funny building at

Dr Eric Beck Page 65 of 123 the front of UCH that overlooks the college, it’s still there. And there was also an RAS, a resident assistant surgeon, who did very much the same for surgeons when they were not there. So I got a fairly broad experience albeit in small chunks of a wide range of the medical specialties and I got to know the wards and the other staff. So yes, it was an interesting but not terribly onerous task and, as I say, my concern was, well, having been a senior registrar for a year what do you do then? And that’s why I went on to the MRC thing. At the end of the MRC thing I didn’t want to go back to being an ordinary registrar. Anyway, I then applied for the senior registrar post which I got and so that was the next step, a rather unorthodox step up the ladder.

Q: And were you beginning to feel your interests crystallise at this point in a particular direction?

A: No, I think that was one of the faults in the system then was that we now have specialist registrars all of whom do general medicine but are being trained in some specialty, cardiology, gastroenterology and so on. That just didn’t exist at UCH and I suspect it didn’t exist in many other hospitals. So if you were interested, say, in gastroenterology you would have to find your way and hopefully make contacts and find units where you would get experience of some but it wasn’t a formal--, a formalised thing which it has now become. I mean specialist registrar training quite rightly is now with rotations and assessments is a--, is great progress. It was partly due to the fact, again coming back to the dear old MRCP, that the MRCP was seen by the colleges as an exit exam, you know, when you’ve got this you’re a physician young man/young woman, whereas increasingly around the world, North America and Europe, the way you became a specialist was to have a specialist training and a specialist exam at the end of it. And the college for many years resisted the idea of having specialist examinations. They belatedly come into this now, but it should have done so many years before because this was having a back effect on the training in the specialties and it was almost a throwback to Kenneth Harris, who was also a famous physician like his brother, who felt as a physician he could deal with anything. Well 50 years ago that might have been true but it wasn’t. So I think the--, the MRCP although it was an important thing to get to get into the registrar grade and into specialist training subsequently did very little in the way of specialist examination itself.

Q: So you became a senior registrar.

A: Yes, and the next--, and the senior registrar at UCH was a rotating post and you rotated between UCH and the Whittington Hospital and I very soon after appointment, I think it must have been straightaway ‘cause, er--, I got seconded to the Whittington Hospital senior registrar to another important influence in my life a physician called Alan Jacobs, AL Jacobs, who was by then a senior physician at the Whittington. A man of very strong left wing political views which went down all right with me and by then the politics was not a big issue when working for him, but he was another person who very much put patients first. He was a general physician who rather unusually after he’d become a consultant, I think it was at a rather early age, decided to do a MD thesis and usually by the time you got to be a consultant MD as a help to progressing your career was not required. You should have done it earlier if you were going to and I never did partly because of my bad research record. But he had

Dr Eric Beck Page 66 of 123 purely for the intellectual stimulus, as it were, and to make him a more complete person had done this study on arterial embolism and got his MD in Oxford many years after qualifying. So that was impressive. And he was a--, he again put patients first. He was a rather frightening figure, not many jokes and rather critical of his colleagues who--, if he felt they were dragging their feet. And one thing that was going on--, one controversy that was going on at that time when I became his senior registrar was in the treatment of patients with myocardial infarction, with heart attacks. And the conventional wisdom was that you--, that bedrest was really the only thing that would help the heart to heal and some physicians, like the cardiologists at the Whittington, would have complete bedrest for patients for 14 days and then they would start to get up and hopefully get better. But the big bugbear of keeping someone in bed particularly after an acute illness is your blood becomes more likely to clot, you’re more likely to get deep vein thrombosis, you’re at risk of getting pulmonary embolism and there was a significant number of patients recovering from myocardial infarction on complete bedrest who were then suddenly dropping down dead with pulmonary emboli. And Alan Jacobs was very aware of this. The--, one of the things that was done was to put them on--, then put them on anticoagulants to try and prevent this happening and that did help. He was very much in favour of the early mobilisation of patients after heart attacks, so within 48 hours they’d be sitting in a chair if they were not in heart failure. Obviously if they were very ill they couldn’t. This was an anathema to his colleague a few wards down who wrapped them up in cotton wool and Alan Jacobs suggested to his colleague that--, recognising that their approach was very different in these two common--, to this common disorder which both of them saw, that they should actually do a follow up study to see whether one group of patients treated one way the outcome was any different from the other. And the--, his fellow cardiologist absolutely point blank refused. He said, “I know I’m doing the best for my patients and I have no need to.” And that, you know--, that again left quite an impression on me about both his cardiological colleague and about Alan Jacobs’ foresight in what he was doing. He was also--, had been one of the people who had set up--, when the Whittington was converted from a large LCC hospital into--, under the NHS into a district general hospital it was a huge hospital on three wings by Archway, the Highgate wing, the St Mary’s wing and the Archway wing. It had 2,000 beds, I think it was the largest hospital in Europe which was again totally unnecessary in the changing pattern of medicine. And it was three workhouses, in fact each one had been a workhouse that’s why they were geographically in the location where they were. And Alan Jacobs and several of the other physicians at the time, Arnold Bloom who was--, became quite a figure in the college, a diabetician, and actually realised that if they were going to get junior staff, erm--,

Q: Sorry. I’ll just…

A: If they were going to get junior staff to look after the large number of beds that each of them had to look after that they had to make these workhouses rather more attractive places for junior doctors to want to go and work in. And they set up--, very early on after the hospitals were merged or transformed from LCC hospital to NHS hospital they set up a Whittington membership course, evening membership course, and again one of the few in town or

Dr Eric Beck Page 67 of 123 anywhere for that matter. And their great asset was not only the keen physicians doing it and their motive for doing it but it was the 2,000 beds. The Whittington had an enormous pool of very interesting largely loyal patients who would come along and help in the teaching. So the Whittington--, which is why it became part of the triangle. I referred earlier to my disappointment at not having been appointed there as an SHO. And the Whittington’s reputation very much began with the--, with the MRCP course and Alan Jacobs was involved in this. And then while I was there I’d already mentioned as a student we went out to do paediatrics there with Simon Yudkin and occasional students would go and do sort of elective periods, but there was this vast potential which was being used for MRCP teaching which undergraduates might also benefit from. Anyway, it came to pass that an acute situation arose at UCH I think they closed the--, erm, a major chunk of it and suddenly were worried about where their clinical students would get clinical experience. So they looked to the Whittington and they had to, as it were, negotiate with someone at the Whittington. And the Whittington had always felt slightly sort of looked down upon by the teaching hospitals down the road even though they were doing a good job and although I--, erm, yes, this actually happened after I’d been there as a senior registrar, but there was this, as it were, shortfall that the Whittington had the potential to teach medical students but hardly ever did. So working for Alan Jacobs again very much general medicine, thoroughly enjoyable year, his outlook on medicine, I’d like to say he was a great communicator with patients he was a good listener but he was--, his intellectual level was rather too high almost to engage with. But the whole atmosphere of the Whittington was--, even without medical students or with very few medical students was very different from the atmosphere in the teaching hospital. Very few of them did private practice so that didn’t become an issue whereas at--, in any London teaching hospital you just accepted that your--, that your boss would be there occasionally visiting, honorary visiting. Of course in the old system they were unpaid the consultants at teaching hospitals because their income came from their private practice. So they felt they were doing the hospital a favour coming along and teaching, which in terms of finances they possibly were but, you know, the whole ethos of a teaching hospital was very different from that of a district general hospital where you had full time or maximum part time consultants paid by the NHS and the NHS was just beginning to expand and flourish. So I had a year of that with Alan Jacobs and then the senior RAP at UCH got an appointment in Aberdeen and I was asked, because I was already a senior registrar and had already been the junior RAP, whether I would come back and become the senior RAP at UCH. So I only had about a year as a senior registrar albeit at the Whittington. So I went back to UCH a little reluctantly because I was already senior registrar grade which would eventually make me eligible to apply for consultant jobs to this slightly ‘non job’ of senior RAP. And I did that I suppose for about a year and then I thought well, you know, I’ve been senior registrar or equivalent of long enough to start thinking about consultant jobs. And there was quite a bottleneck still in those days from senior registrar to consultant. I’d seen along the way and I’ve mentioned one or two sort of time expired senior registrars who still couldn’t get a consultant job. It was beginning to ease up a bit. Anyway, to cut a long story short, I started applying for--, or I thought about applying for

Dr Eric Beck Page 68 of 123 consultant jobs and the--, in fact I didn’t apply very much. I applied for a job in Peterborough, a new hospital in Peterborough linked with Stamford and, erm, this came up before the--, a job at the Whittington for the person who had been physician with an interest in gastroenterology Tom Norris. So I applied for both and the Whittington one was advertised after the Peterborough one but while it was sort of going through all the machinery I had two applications in. And I went and looked at the set up in Peterborough and Stamford, a nice part of the world to live in and so on, a new hospital being built which was an exciting prospect, but after the--, well I wouldn’t say the sophistication of a medical job in London but it was obviously you were going to have to work quite hard to make it--, make a go of it. And then, as I say, the Whittington job came up, Norris’ job, I was known at the Whittington because I’d spent a year there and so on so I applied for that. And sod’s law would have it the--, I was selected for interview for both the jobs on the same day. So I had to pull out of one and obviously [laughs] was to pull out of Peterborough even though I knew there were a lot of people up for the Whittington job and some fairly high powered people had been shortlisted including, er, Sheila Sherlock’s former registrar who was in New York who was flying back from New York for the interview and that rather impressed me. And I was also slightly worried that Sheila Sherlock was on the appointments panel [laughs]. And so I still remember setting off to the regional board offices in Paddington to go by train from the UCH and--, oh, and another person up for the job was called Michael Newton, he was a colleague of mine at UCH and I can’t remember who all the others were. But as I was leaving the hospital to catch the tube to Paddington I bumped into Hawksley, the person on whose firm I’d been a student, on whose firm in St Pancras I’d been his houseman and who I’d stood in for as RAP. So Hawksley was, you know, a benign senior figure and he said, “Oh,” as I walked out the front door, “You’re going for your consultant interview.” And I thought good heavens, how would he know that? I think I had given him as one of my referees and I was quite sort of surprised that he should actually know what I was doing walking out of the front door. He said, “Yes, yes, I was asked to give a reference on you and also on Michael Newton who’s been my registrar which created some difficulty. So I’ve given you both very good references but I did take the liberty of adding at the bottom of your reference that if there were a choice in the matter I would choose you [laughs].” And, you know, not the sort of thing a referee normally tells you. So I went along enormously chuffed to Paddington having bumped into Hawksley on the way out of UCH. And so there we sat for a long afternoon, Jonathan Levi, the chap who’d flown in to Heathrow that morning and had to fly out again that evening was interviewed. Sheila Sherlock, as I say, was one of the people on the panel. I can’t remember all the others. And anyway, to cut a long story short, I got the job. So second time I’d applied for a job at the Whittington I’d got the consultant job having been turned down for the SHO job! And that was in August and I was due to start the following January. So that was a major chapter in my life moving on.

Q: And what was the actual job title?

A: Yes, well that was the problem, I was replacing Norris who--, and they were all labelled physicians with interests which they’d developed to a greater or lesser extent. And Norris had

Dr Eric Beck Page 69 of 123 an interest in gastroenterology, he was not really trained in it, he hadn’t--, he wasn’t doing for example endoscopy. And because he was responsible for all the emergency admissions with gastrointestinal bleeding who needed to be gastroscoped, the thing had moved--, you know, progress in gastroenterology was such that if a patient came in bleeding you had a look as soon as it was safe to do so to see where the bleeding was coming from. And he didn’t do any of that. So there was no great gastroenterological tradition, but as far as the bleeders were concerned he had a working relationship with a surgeon called Savage, a good name for a surgeon Savage. But in fact Savage delegated the bleeding function and the gastroscopy of them to a very nice man called Tony Strange. Tony Strange was a funny and in some ways rather sad figure because he was not a consultant he was this outmoded grade which we had fought against years ago to stop the BMA promoting, he was a senior hospital medical officer, SHMO. So it was a sub consultant grade above senior registrar ‘cause it had permanence but it didn’t have all the responsibilities of a consultant. And his particular strength was gastroscopy. So he was the one who did gastroscopies on every patient virtually who needed one in the Whittington. Acute bleeders but chronic ones as well. So this was his niche. So when I came I was obviously going to work very closely with Tony Strange, as I did, and I just felt uneasy that I was not doing gastroscopies [for which I wasn’t trained] on the patients that I was responsible for, but the surgeons somehow saw it as their fiefdom the way this had evolved and were not particularly keen in getting me to do gastroscopies. So we had this rather unusual system of dual management of patients who came in bleeding. I would deal with their medical problems and resuscitate and so on and Tony Strange would come and do the gastroscopy which would help us decide whether they should be treated medically, as most were, but would pick out the few who needed emergency surgery which he or Paul, his senior consultant Paul Savage, would then undertake. And the whole thing worked very well largely because Tony Strange was such a dedicated person. He’d been a missionary in China and for many years and obviously when he came back he’d reached an age where he was not being--, not applying for or not getting consultant jobs but somehow his personality was such he didn’t want the responsibility of being a consultant and all the other things that went with it. He just wanted to deal with the patients and this, as it were, suited everyone very well. And it worked very well but it was a somewhat anomalous situation because when you went to gastroenterological meetings at the BSG [British Society of Gastroenterologists], as I did, all my--, all the fellow members in my position were of course doing gastroscopy all the time and gastroscopy was advancing in terms of the techniques and things you could do. But while Tony Strange was doing this and I was reasonably happy sitting back doing general medicine as well as seeing gastroenterological patients and seeing patients with irritable bowel. And people thought I was mad that I should be interested in this--, what many people saw as the millstone round the neck of gastroenterologists. And again I had had thoughts which never came to fruition of doing--, knowing I was going to be a consultant for some years there of trying to do some kind of follow up in depth study of what happens to patients with irritable bowel because usually, you know, it doesn’t do them any harm although it may plague their lives. And I even went and spoke to Martin Vesey who had been a colleague of Richard

Dr Eric Beck Page 70 of 123 Doll’s, you know, about how--, how I could usefully use my--, the clinical experience I would be gathering into a study. And anyway, it never happened but I did have lots of patients with irritable bowel and also with other more serious conditions, inflammatory bowel disease, peptic ulcer. Helicobacter hadn’t been discovered then. So there were a lot of patients with duodenal ulcers and quite a few with gastric ulcers. And of course the other thing that appealed to me in applying for the job at the Whittington was the postgraduate course. And one of the first things that happened, I don’t know whether it happened after I came or it happened before, but we set up at the Whittington a daytime postgraduate [three month] course as well as an evening sort of intensive membership thing. And the daytime one was sort of an introduction to British medicine from which you can gather a lot of the people coming to do it were from overseas.

Q: Before I--, definitely we should talk about this more but before we go on to the teaching side do you mind if we talk a little bit more about the clinical work that you were doing?

A: Of course.

Q: Is that okay? So you’ve listed some of the--, the problems that people were coming in with, can you talk a little bit about the treatments that you had available to offer them at that time?

A: Yes, well of course we had a proper admission system of taking things in turn. So again myocardial infarction, heart attacks…

Q: Sorry, I mean particularly for the gastroenterology--,

A: Oh the gastro!

Q: That you were doing.

A: Well, the main acute admissions for gastroenterology were the bleeders and hospitals around the country hadn’t all got round to yet having a dedicated unit that would deal with the bleeders 7/24, whereas the Whittington had, partly because of the dedication of Tony Strange. So that was the main emergency--, gastrointestinal emergency and, you know, I would have to go in at night, later when I was doing gastroscopy I would go in obviously more often. Inflammatory bowel disease, patients with severe ulcerative colitis or Crohn’s disease although most of these would be managed as outpatients. Patients, as I say, with duodenal ulcer, gastric ulcer, rarely got admitted. So most of the beds that I was responsible for--, and there was still a very large number of beds ‘cause they’d shrunk down but I think I had two wards of 40 patients each. So most of the patients in those wards were, erm people recovering from medical diseases other than gastroenterological ones. And again there was very little pressure on getting them out or getting them home which is very much the opposite of today. So it was, yes, a very--, what would you call it? A relaxed atmosphere if you were an inpatient in the ward. No one was chivvying you to--, for early discharge and so on. And yes, so one of the problems that then arose was extra consultants were appointed at the Whittington so extra--, so the beds had to be reallocated. And, as I said, I was in charge of two 40 bedded wards--, were there 40 beds? Five bays, yes, and there were eight patients.

Dr Eric Beck Page 71 of 123 Yes, so I had two wards with 80 patients and I think I shared some of the beds with another consultant but essentially they were mine. So there was very little pressure on beds. When the new consultants were appointed I shrunk down to--, or it was proposed that I should shrink down to one ward which would have suited me fine but if it was going to be a mix--, in those days mixed wards were not acceptable, you couldn’t have male and female patients next to each other. And I remember I suggested that the solution to this should be that the first bay of eight in the ward of 40 should be--, become a female bay and would be physically a bit more separated from the other bays with partitions or whatever [and a separate bathroom]. And the matron at the time was horrified at the thought that this 40 bedded male ward would have 32 males and eight females or whatever. And by a rather stroke of good luck hospitals get visited occasionally by royalty and by politicians and Sir Keith Joseph was the--, then the minister of health in what presumably was the Thatcher--, I think it was the Thatcher government. Anyway, he was coming round to look at a district general hospital ‘cause this was part of his job. And I had just forced through against the wishes of the matron but the support of my colleagues the idea of having one bay female and the other bays male, and so he was brought to my ward as one of the wards to inspect and I was introduced to him and--, and he said, “Well, you know, what--, what’s new here?” So I said, “Well what’s new is that we have taken this old Victorian [laughs] five bay ward and we’ve created a--, you know, it sounds nonsense today to be talking about this, “We’ve created this female bay with separate toilet arrangements and so on and even though it was rather unpopular at the time.” And he said, “What a splendid idea [laughs].” I always remember, yes, the only good thing I could say for Keith Joseph. I think he was actually quite a decent man but he unwittingly solved the--, or resolved the problem of the [laughs]--, of the ward.

Q: As a consultant could you describe, you know, your working relationship with the matrons a little more?

A: Yes, well ward sisters always have been throughout my career and even with all the reorganisations ward managers or whatever they’re called now, obviously are key people, the key people because they’re there all the time and they not only treat the patients the good ones, which many of them are, are very important in teaching the junior staff. Not formally teaching them but, you know, you learn a lot from your ward sister and of course if you’re a school of nursing as well there are a lot of nurses in training. And usually the ward sister is--, was supported by a staff nurse who would be a qualified SRN and all the rest would be nurses in training and then there used to be a sort of sub grade of nursing assistants who were not doing the SRN. So it was quite a complicated structure and there were pretty large numbers of them around and it was very much politic of course that you should get on with your ward sisters because if you didn’t they could make life hell for you. And most wards had very good relationships between ward sisters and consultants but occasionally the ward sisters would have--, particularly when a new consultant came along would have, you know, rather old fashioned ideas that their dear beloved ‘Dr Foster’ had retired and this young upstart--, but I had none of that. I got on very well with the--, with the ward sisters and worked very much as a team. That again was something which was relatively uncommon in those days. We talk

Dr Eric Beck Page 72 of 123 now about multidisciplinary teams but I remember sort of thinking when we did our big ward round of the week in the sense that consultant, registrar, houseman would go round, that there were many other aspects to the patient’s care which the junior doctor who’s there day to day, you know, might need help and support. Well he did need help and support, he would refer them to the physiotherapists or the occupational therapist and the social worker. And as the consultant although you hoped this would go on smoothly you had relatively little direction, you could say, “Well I think you should refer this patient for physiotherapy.” Anyway, it occurred to me that all the people involved in--, it occurred not just to me to lots of other people, all the people involved in the management of a patient really ought to meet all together so that they could put in their own perspective and learn from the others what the checks and balances or problems were. So on a Friday morning for one ward, and this I think it was a Tuesday afternoon for the other ward, at the end of our formal ward round we would gather in the sister’s office for a cup of tea and a biscuit, so we drew up a biscuit rota, and we would invite along to it not only the sister obviously but perhaps her senior nurse, the physiotherapist, the occupational therapist and so forth [social worker, speech therapist, wart pharmacist]. And although they were busy doing their other things they seemed not only prepared but keen to come along. So this multidisciplinary approach to give it a grand name, we didn’t think of it as such, I think greatly enhanced the care of the patients. And it led to one or two interesting things. Sometimes we would call in one of the other, erm, people dealing with them because there was a special problem, speech therapy for example. I think in fact the speech therapist was welcome to come every week but if there were no relevant patients might not turn up. And one thing that I don’t think people realised at the time, still don’t to this day, is that a speech therapist in a hospital setting has--, may have relatively little to do with speaking and their most important role is assessing patients who have difficulty in swallowing as to the safety of feeding by mouth. And they’ve become very sophisticated in their techniques and they do various tests and so on to establish whether it’s safe for patients to swallow, at the same time if the patient has had a stroke obviously they will be communicating with them. And I still remember talking to one of my colleagues, you know, what we did at our multidisciplinary meetings, he said, “What do you need that for?” And I said, “Well one of the helpful things is when the speech therapist comes along having assessed a patient’s safety in swallowing.” He said, “What do you need that for? I expect my houseman to do that.” And I said, “Well I’m afraid it’s more complicated [laughs] than that.” So I was regarded as a bit eccentric but, you know, they let me have my whim as it were. As they did with--, yes, I remember my new colleagues, all senior colleagues were actually very supportive some of them remembered me from a year or two earlier as a senior registrar, but this first came up in reality when we held an appointments committee for appointing our junior staff. And I may have mentioned the name before but we had to--, we appointed the whole batch for all the physicians so there were, I don’t know, six SHO posts and six preregistration housemen posts and we would interview them. And we interviewed--, amongst the final year medical students applying for the preregistration house jobs was one student came along with a good student record but was awful in interview. He had a terrible stammer, was really very nervous and

Dr Eric Beck Page 73 of 123 very--, called Roland Levinsky. I think I did mention him earlier, and he interviewed terribly badly. Now I knew Roland quite well from my RAP days at UCH when he had been a student on the firms that I was teaching there. And when it came to giving our preferences after the interviews I knew Roland and that he was a good bloke and I put him top of my list and he wasn’t on anybody else’s list because he’d interviewed so badly and they said, you know, “How can you do that?” So I said, “Well it’s because I already know him and I know something about the others because I’d seen them around UCH and, you know, I think he would be a very good--, so they said, “Well all right, you know, you’re a new boy you’ll learn the--, we’ll let you have your head.” And so I appointed Roland Levinsky who was a great success. Did I mention what happened to him after he’d done my job? He had to go and do a surgical job at UCH for a man called HRI Wolfe who used to be--, who I’d come across as a surgeon at St Pancras, at the Tropical Diseases Hospital, who was a violent anti-Semite. And Levinsky, as you can imagine with a name and his appearance, and immediately he made life hell for him so much so that Roland was going to chuck it all in and so he came back and, you know, poured his heart out and I said, “Well look, stick it out,” and he did and became a very successful paediatrician. Yes. So my colleagues, as it were, humoured me in appointing Roland Levinsky. Yeah, so it was a pleasant atmosphere and we--, well I’m going to get back to the teaching very soon but I don’t know if there was anything else about the day to day.

Q: I’m just wondering about the ward structure on your ward or your two wards when you started, did you have people with all sorts of different problems?

A: Diseases you mean?

Q: Yes.

A: Yes, because we were very much an acute medical firm. So on your day those patients who got admitted would finish up on your ward and they would be the mixture I’ve already mentioned before of common diseases with a smattering of gastroenterological ones particularly the bleeders. I mean that was our speciality but there were never too many of those.

Q: Would you swap patients sometimes? So say if you had a patient who had a particular disease that was relevant to one of your colleague’s specialties would you send them to them?

A: Yes, I think that would probably have happened on the day of admission. For example, if a patient came in in a diabetic coma to casualty I’m sure we--, as I say, either I or my junior staff would say, “Well Arnold Bloom is the diabetic specialist, his ward is geared up to dealing with it, the nurses know how to deal with it.” So yes, there would be some movement. Usually in that direction rather than movement in to me as a gastroenterologist because I was already taking all the acute bleeds who were--, if somebody else’s houseman was on at night and somebody came in bleeding he would know to contact our unit. So that was the--, there was a little swapping of ‘specialist emergencies’ I suppose you’d call them.

Q: Sorry, I’m just trying to get my head around how it’s quite different from the system now.

Dr Eric Beck Page 74 of 123 A: Yes. Yes, well the--, one of the things that evolved over the years that I was there was that rather than sending them straight up to our ward we were actually across the road in Highgate Hill which was always a barrier to moving patients, was that we set up an acute admissions ward. There was one dedicated medical ward which a few surgical patients might also finish up where you observed them overnight and then you did what was called a post take round the following morning of your team and that’s when they would go off in different directions from the post take round. So you wouldn’t necessarily admit to your ward all the patients who you’d seen in the acute ward. And I think something similar to that probably still happens. I’m not sure I’m so long out of it that I wouldn’t know.

Q: Thank you.

[END OF PART SIX 01:22:48]

[PART SEVEN]

Q: Okay, so this is our second track on the 22nd of September. Dr Beck, over lunch we were talking a bit about private practice and I was wondering if you could say for the recording any-- , talk about any private patients you’ve seen or your experience in private practice during your career.

A: Well my experience of it is negligible because I never saw private patients with rare exception when somebody from overseas, who was not entitled to NHS treatment anyway, would be referred to me. I did have a clinic on a Thursday afternoon for five new patients which I’d inherited from my predecessor, because Thursday in the past was early closing day in Islington and he especially started this clinic to see people who couldn’t come on any other day. So this was a very handy sort of ‘safety valve’ into which to slip the odd patient. And I remember one of the few private patients I did see then was the wife of the ruler of one of the Malaysian states who obviously had been referred to me because the--, her doctor back in Malaysia was someone who’d worked at the Whittington and knew me and recommended me. They had a custom in Malaysia then, I don’t know if it still exists, where the rulers of the different states take it in turn to be king of Malaysia I think for a year or two at a time and it so happened that she was the Queen of Malaysia. So when she arrived at the Whittington she was first sent to the accounts office to pay her due as an overseas visitor and then she duly came up to my clinic and I saw her and she spent rather a long time so I think she got her money’s worth. And I then got invited back some weeks later to go and see her in the embassy as a follow up because she didn’t want to come to the Whittington again [laughs]. So that was one of the few private patients that I saw. But my exposure to private practice was minimal. I really didn’t--, didn’t like the whole idea of it or the way that it operated alongside the NHS and could create all kinds of conflicts of interests there. When I was the RAP as the senior of the junior doctors, as it were, I was approached by my old boss John Hawksley because the physicians as they were getting older at UCH were increasingly concerned as to who would--, or how to deal with emergencies in private patients who were in

Dr Eric Beck Page 75 of 123 the private wing as patients and would--, as we had now set up this medical rota system with a registrar in the hospital every night, would the registrar in particular be prepared to see patients in the private wing in an emergency for which they would be subsequently remunerated. So I said, “Well I will canvass the opinion of the registrars,” which I did and reported back to him. And every registrar bar one who went on to be a consultant rheumatologist with a large private practice subsequently, all the others said they didn’t wish to be involved in this. And so when I reported this back to Hawksley he was somewhat surprised and taken aback and he said, “Well when I was a young doctor before the war in London I would sit by my telephone hoping that the phone might ring and I’d be asked to see a private patient.” So I said, “Well, you know, things have changed a lot with the NHS.” And he said, “Why do you think it is that they’re so uninterested in this?” and I said, “Well I think a lot of them are rather ignorant of what actually goes on in private practice and sometimes they don’t have a very good image of it.” And he said, “Oh! Like what?” So I said, “Well, sometimes as registrars on their firms they find a patient being admitted for investigation who has jumped the queue of all the other patients on the waiting list by having gone to Harley Street and seen the consultant privately who then agrees to admit them to an NHS bed for what might be rather otherwise expensive investigation and treatment.” And he was somewhat taken aback by my giving this example and concluded by saying, “Well it is quite remarkable, isn’t it, the lengths to which some patients will go?” And I thought well, dear me, we’re on a different wavelength, I’ve got a great respect for you and you helped me in my career [laughs] and was about to do so more, but this was just a time--, partly a time thing and an inability to come to terms with what the NHS was replacing from the previous system.

Q: Thank you. Shall we move on now to the postgraduate courses and teaching that you did at the Whittington?

A: Yes, well that was one of the attractions of going to the Whittington that I would be involved in this and the--, as well as the highly successful evening MRCP course that had been running since the Whittington almost was founded as a hospital, we added on a three month daytime course which was a more leisurely version of what we did in the evenings but seemed to be equally popular. So there were always postgraduate students around. In addition to this we were often asked by various individuals overseas whether we could take as an observer onto our firm an overseas doctor and this was often a very rewarding experience. I remember a cardiologist from Sri Lanka who we’ve remained friends for many years, a lot of doctors from Hong Kong would come along as well. So there was always--, there were always a lot of postgraduates around which is a very stimulating environment in which to work because apart from learning they also ask a lot of questions. So--, and this was as much or even more so than many--, many other hospitals experienced. The other big thing that changed while I was there was in relation to undergraduates. We had--, as medical students I mentioned I’d been out there to do paediatrics with Simon Yudkin and all the UCH students who spent their month at the Whittington way back in my time had a very high regard for it because you went to general hospital meetings as well as doing paediatrics. But then an emergency arose with the closure of something at UCH, I think it was with the closure of the A&E department temporarily

Dr Eric Beck Page 76 of 123 for some months. And the medical school were worried about how students would see acute medical problems and approached the Whittington to see whether we would be prepared to take a certain number of clinical students. And the Whittington physicians asked me because I was the most recent person and from UCH whether I would, as it were, negotiate on their behalf as to what we should do. It wasn’t as straightforward as it might sound because although the physicians by and large were happy and keen to teach because they were doing it at a postgraduate level, the surgeons for example were--, and their relationship with UCH surgeons was not particularly good and they were a bit reluctant and there was a feeling that we might be exploited for their temporary needs and if we were going to do anything like this it should be done on a proper basis. So I was under some pressure, as it were, to do a deal that would satisfy my colleagues and also under pressure to try and help out for the real need of medical students. So anyway, I began talking to the then dean at UCH, Tom Prankerd, haematologist and very nice man who I knew very well, used to play squash with and so, you know, we met fairly regularly. And there was no problem in the idea of getting medical students but I pointed out that we needed resources to teach medical students and these resources might be both human and, as it were, fabric, to which he agreed because he felt and I felt that once they came out for whatever the period was, three months or six months, they would want to keep this relationship going. So he and I worked out what would be acceptable at both ends, as it were, to make this happen. And the first thing we felt would be symbolical would be some kind of bricks and mortar. So we said we would set up an undergraduate--, build a new build undergraduate centre in--, at the Whittington in the Archway wing whose main purpose would in fact be to act as a hostel for students who could stay overnight and observe what was going on in the acute admissions during the night. And this would be quite a novel and advanced idea. Students sometimes did this voluntarily but actually to formalise it and give them a bedroom, as it were--, and we could incorporate into it a teaching room and also we would need secretarial help and we would put a secretary into it. So that would be number one on the list. Number two as far as personnel were concerned the Whittington was already reasonably well staffed at consultant level with twin appointments in most specialties but this was--, there was an uncertain future as to whether new consultant posts would be created. And if there was going to be a significant teaching dimension, which would take up some of their time and so on, that we would want not only their support in making new consultant appointments but ideally we would like some kind of academic department at the Whittington as an extension of the academic departments at UCL. And it so happened that Arnold Bloom, our senior physician and a very much revered expert diabetician, was just about to retire at the same time as UCH diabetes was not very strong specialty there and the lady in charge of it, Peggy Morgan, was also about to retire. And what applied in diabetes also applied largely in endocrinology as well although one of the medical units at UCH, Eric Ross, was an endocrinologist. Anyway, we identified this as an area which needed expanding academically for which there was no strong base at UCH, so why not set up a Whittington academic unit in diabetes and endocrinology? And part of the reason would be to underpin the teaching. And this went through at both ends and an appointment was

Dr Eric Beck Page 77 of 123 made, in fact it was--, the first appointment was the son of Simon Yudkin John Yudkin who had also been my SHO as it was. So the Whittington physicians got quite a good deal out of this. The surgeons were going to be a much crustier bunch to deal with and the obvious person to deal with surgically for me to negotiate with would be the Surgical Unit, the academic unit at UCH. And the professor of surgery at UCH was a Scotsman called Charlie Clarke who didn’t have a terribly high opinion of the Whittington or vice versa but he had a first assistant called John Wyllie who had been his first assistant in every post he’d been on his journey south, first in Glasgow then I think in Leeds and now in London. And John Wyllie was getting a little restless about being permanent first assistant to the professor and would have liked a job of his own as it were. And so we identified John Wyllie as a potential professor of medicine at a surgical unit to be created at the Whittington who would support the Whittington surgeons but wouldn’t be, as it were, a rival to them but would undertake teaching and research. And all this was highly confidential and I still remember meeting John Wyllie down in the basement of the Royal College of Physicians without anyone knowing that either of us was there to negotiate his coming to the Whittington and he was quite keen and willing and then I went back to the Whittington surgeons to say, “You’ve acquired an academic unit of surgery which will share your work and hopefully, you know, enrich the place.” And the surgeons rather somewhat reluctantly, compared with the physicians, accepted this. So anyway, the deal was done and the students started to come and not just for three months but we would set up parallel firms to those at UCH and, to cut a long story short, the Whittington became a very popular posting for undergraduate medical students because they saw a lot of acute medicine which was less likely in a place like Gower Street. So that was the--, and I was made the undergraduate sub dean or something, a title like that, to supervise the whole thing, which I very happily did. So we now had built on top of a strong postgraduate reputation an undergraduate one as well and the Whittington then became designated as a teaching hospital which again helped in matters like recruitment and replacement of consultant posts. The run of the mill Whittington employees, certainly the non medical, the nursing ones, I think were somewhat underwhelmed by this influx of students and didn’t really quite realise the importance of it and I still think rather think that way. When, for example, years later the Whittington was under threat of closure I tried to encourage my colleagues, you know, to play the academic card that UCL would find it very difficult for their students if the Whittington were closed or shrunk down. So there’s never been a great enthusiasm amongst the non clinicians at the Whittington but it’s very much a reality and the students certainly like it and I think it has helped the prestige and standing and survival of the Whittington Hospital having this link. And this model is now being repeated all over the country. The earliest people to do it, I think I may already have said earlier, was the Central Middlesex Hospital who had set up a similar arrangement in the late 1930s because the Middlesex was concerned about the lack of what gets called clinical material [laughs] available down in Bloomsbury. And I’d been at the Central Middlesex and seen it happening when I was an SHO there and I saw how well it worked and how popular it was with the students. And it’s always been sort of at the back of my mind when I was appointed to the Whittington not only the postgraduate teaching side but

Dr Eric Beck Page 78 of 123 the potential to create another Central Middlesex in undergraduate terms and that I think was very much our model.

Q: You’ve talked about some, you know, really big developments that had to happen at the Whittington in order for this to go ahead, so the development of a new study centre and the creation of two posts at very senior level, what sort of managerial systems did you have to process, did you have to go through in order to get that approved?

A: Well obviously I had to get the approval of my fellow clinicians who felt that this was a worthwhile deal. As far as the hospital management was concerned I think because it was going to be largely financed by the UCL they saw it as an addition to the resources. There is a fund which I think still exists called SIFT, which stands for Service Increment For Teaching, so that if hospitals outside of teaching hospitals undertake a certain amount of teaching then money gets diverted from the medical school or--, and inevitably from the teaching hospital they traditionally use to the hospital that does the teaching. So the money follows the students if you like. And so the Whittington I think stood to benefit at all levels and the reluctance I think of the surgeons was largely a personal one that generations of surgeons who’d grown up at the two hospitals were not the greatest of buddies to put it mildly, and there were no joint appointment. That’s the other thing that began to happen after the medical school link was that we started getting specialist--, in fact I met one just last weekend. The oncologist, for example, was very keen--, at UCH was very keen to do a clinic at the Whittington because a lot of his referrals came not only from Whittington but from other places in the region, the Whittington was just up the road. And this was Jeff Tobias and, as I say, I met him last week and he was singing the praises of the Whittington even then though I’d been retired for many years. And this--, and it happened to a lesser extent in other specialties as well as oncology. And of course registrar--, I talked about the senior [UCH] registrar coming out of [rotating through] the Whittington which I had done originally but by now proper registrar rotations were in place. So all the registrar posts in medicine were joint appointments with UCH and Whittington, so all the registrars would rotate through Whittington and again they enjoyed the experience. So although it wasn’t a takeover and we’re in different health--, under different health authorities [in the reorganised NHS], it was a pretty happy symbiosis from which I think both ends benefitted. So I think it just happened at the right time when things were changing in the NHS altogether. The one thing we didn’t manage to achieve, because I remember going off with the interested parties from the Whittington, was radiation medicine not so much radiotherapy but radiation diagnostics, isotopes and so forth. And we were unable to persuade the regional health authority that they needed to set up a similar thing because you need all kinds of precautions with radioactive materials. So that didn’t come about but Whittington subsequently got its CT scanner and MRI scanner and so on. So I think overall the Whittington has benefited but I’m not so sure that everyone there fully appreciates the benefits.

Dr Eric Beck Page 79 of 123 Q: Would you say that the teaching that you’ve done in your career has helped your clinical practice?

A: I think inevitably. Just having people around asking questions whether it’s a first year medical student or a highly experienced overseas graduate. You know, it may slow you down a bit and take more time but I think the--, and so you may see less patients which may not please our managers who want a large throughput of patients to provide statistics for them to--, you know, to make their case, but I think there’s no doubt. And people don’t take on teaching under duress or very rarely would do so and most do it because they want to do it. That doesn’t mean every consultant ever appointed anywhere wants to be a teacher but it was always a thing about the Whittington appointments particularly on the physician side that teaching would become part of their lives and they wanted to do this.

Q: So in your opinion what do you think would be the qualities of a good medical educator?

A: Well, erm, I’ve always--, one of the things that sometimes disappoints me about medical students and junior doctors is lack of curiosity [laughs]. They want the facts because they need the facts to practice their medicine but they want the here and now. And one of the things about academic medicine is that it does sort of ask the question ‘why’ as well as the question’ how’, as it were. And this is something which has bugged me for many years. It still does that in dealing with students today, as I still do sometimes, they want to know the answer to the question which they might be asked in their exam subsequently and if you say, “I don’t know,” which of course I think you have to be prepared to do and we have to drill this into people that saying, “I don’t know,” is not a bad answer provided it’s followed by, “But I know a man who does,” or, “I know how to help you find out.” And so I think teaching has become much more problem solving orientated which I think has happened throughout the educational world in general, but in a fact stuffed subject like medicine it perhaps took a bit longer to get through and, of course, it’s very necessary because the facts change every five minutes anyway. So you have to really know how to find an answer rather than be told by some senior person what the answer is. I mean I’m putting this in extreme terms but this is--, this kind of approach and the attitudes and responses that it produces I think is very healthy. I’ve given the contrast earlier on of our senior physician at UCH as a student who felt he knew everything and it was shameful to ask the opinion of anyone else, as it were. So I think that’s the other end of the spectrum.

Q: Do you have any medical students that you’ve taught that have particularly stayed in your mind?

A: Well, [laughs] as I get older and sometimes read the obituary columns but other columns as well, some have done extremely well. We’ve had amongst current--, taking the College of Physicians the current president Jane Dacre I got to know very well over the years and supported her into her, as it were, entry into the college and up the college ladder. Ian Gilmore, who was one of her predecessors, was an SHO of mine, a very capable young man

Dr Eric Beck Page 80 of 123 who became registrar at the college and then president. So I suppose if you--, if you’re looking for big names, as it were, those are two of them. But no, it is very gratifying when you- -, when you see them doing well particularly if they feel that they’ve benefited from the time they’ve been at the Whittington because many of them have done lots of other things en route. So yes, it’s--, I can’t sort of immediately bring to mind a full roll call of all the others but it is one of the rewards of being a consultant or a senior physician anywhere is to see what happens to your juniors.

Q: And beyond curiosity, which you clearly think is an important quality, what other qualities do you look for when you’re thinking about who is going to make a good doctor?

A: I think the one that the GMC is banging on about increasingly and rightly is communication skills, the handling of patients and, you know, there’s been a sea change in--, right from the clinic level right up to the most complicated medical decisions in the doctor/patient relationship. The doctor is no longer isolated and secure on his pedestal but has to be prepared to not only talk but to be questioned and to positively try and involve patients in their management by informing them about what’s going on. So I think the doctor/patient relationship has changed probably beyond recognition and that is not to say that there haven’t always been doctors who have been good at it, there were a lot of doctors who were not good at it, and we now try and inculcate this in our teaching again under the stimulus of the GMC. And some of our older colleagues just couldn’t get used to the idea that communication skills can be taught and if taught can be examined, ‘you’ve either got it or you haven’t’, which is true to some extent. Some students from day one have it but a lot don’t but can acquire it by practice. So I think, as I say, the changing doctor/patient relationship has been very striking. I can still remember, coming back to irritable bowel which I’ve mentioned earlier on, if you go to see a gastroenterologist with it these days you probably will have it recognised, explained, reassured and you’ll come away satisfied because the gastroenterologists no longer regard it as the--, sort of the millstone round their neck. But I still remember going to surgical outpatients as a student at UCH patients coming up with obvious irritable bowel symptoms, usually abdominal pain and disturbance of bowel habit, and the surgeon being so focused on organic disease doing every test from A to Z, taking time and expense and often unpleasantness from the patient saying to the patient, who would come in finally to get the answer to all this, saying, “There’s nothing wrong with you, you can go away now.” And the patient sort of saying, “Thank you very much sir,” and staggering out with their pain. That--, that epitomises one extreme in the management of irritable bowel that you did everything you did partly of course to try and reach diagnosis and partly because you weren’t confident in making a positive diagnosis for which there were very few markers and also a certain irritability that they’re wasting your time when they could have cancer or something worthwhile. It was that kind of mindset. And I think there are irritable bowel syndromes in other specialties it’s not all people with gastrointestinal problems. And I think that has changed and I think it probably does go down to how medicine is taught these days and some of that one has to, I don’t say it reluctantly but many of my colleagues might, is--, has been due to the intervention

Dr Eric Beck Page 81 of 123 of the General Medical Council in undergraduate education rather than just focusing on what qualified doctors do or don’t do.

Q: Clearly your role in building up the teaching element of the Whittington’s work was very important in your career, what other things would you say that you--, what other sort of major things would you say you’ve brought to the hospital in terms of developments?

A: Well to the hospital I think the things we’ve already said. One of the things we haven’t yet explored further is--, well I’ve talked about the MRCP and doctors preparing for it but inevitably, because of the heavy involvement in the Whittington and the [Medical Tutor’s] correspondence courses I mentioned and the book that I’ve mentioned, I got more and more involved in the MRCP at college level, at intercollegiate level. Which did mean absences from the hospital which were generally tolerated by my colleagues because it was felt that I was doing the reputation of the hospital some good by going out into the big wide world. But I recognise with hindsight that this got up the noses of one or two of my colleagues that I wasn’t there. I wasn’t swanning around but I was doing other things but that it might have put some strain on the system, I’d have to reduce clinics when I was away and this sort of thing. So that’s a negative effect that I had on the hospital. On the more positive side well I think encouraging not only undergraduates but postgraduates and by now when I started going round the world on behalf of the college, I realised that there were a lot of very friendly senior clinicians around the world who had had contact with the Whittington and not that this directly affected the Whittington anymore but their attitude to British medicine. And British medicine was still highly regarded in Hong Kong and Malaya and Singapore and so on and links keenness to establish things and of course a keenness for their junior doctors to come and train in the UK. And that was another thing that became increasingly difficult was to create posts for overseas doctors partly because of immigration rules and so on but it was a constant feature again as I went round the world of, “Why can’t we come to Britain as part of our postgraduate training?” And I think the authorities, not so much the medical authorities but people like the Home Office, didn’t and still don’t appreciate the amount of goodwill there is out there which gets translated from when you’re a junior doctor in Hong Kong to when you become professor and you’re buying, as it were, your next expensive equipment you might turn to the place where you--, your training partly took place. I think it actually is good for Britain not that I’m a great flag waving patriot when I go abroad but I do realise the strength of these links and the benefits from them which I don’t think is generally appreciated. And it’s more so in medicine, it probably applies in other academic fields, but by the very nature of medicine and the length of training and the contact with individuals it’s a--, very much a plus.

Q: You’ve talked about your early involvement in the development of the MRCP exam, I wonder if you could carry on from there. So you were brought in as part of the group that was doing the- -,

A: Question setting.

Q: Question setting.

Dr Eric Beck Page 82 of 123 A: Yes.

Q: What happened next from that point of view?

A: Well again I mean John Stokes, who I’ve referred to already, a complicated man, somewhat misunderstood at times partly through his own fault [laughs], very much pushed me and backed me. He was the--, he was vice president of the college at the time and he was very much involved in promoting the overseas activities of the college with several other colleagues up and down the country, one I particularly remember was John Badenoch in Oxford. Sir John as he became and he was equally enthusiastic about the overseas dimension. But John Stokes got me involved, as I say, in the question group and then because the questions went to the [MRCP] Part Two board to be processed and selected for the exam I was put on the Part Two board at a very early age and remained on it right up to my retirement and becoming chairman of it after, erm, Mike Matthews [an Edinburgh Cardiologist] was the--, my immediate predecessor as a chairman and there weren’t many others, there was Badenoch and then John Stokes originally. So I worked my way up, as it were, through the--, mainly through Part Two of the exam and because the exam was and still is held in many overseas centres inevitably we had to liaise with them. And so not infrequently I would be asked to go on, as it were, college MRCP business to all the places I wouldn’t ever otherwise have got to. Frequent visits to Kuwait, Nigeria, Sudan, erm, where else? Well, in the--, Hong Kong, Singapore, Malaysia. These all became, as it were, part of the MRCP circuit. And although it might be looked upon by some people as neo-colonialism wanting to bring the exam there, we were always scrupulously, erm, conscious of the fact that we had to be invited. We were not imposing ourselves on the former commonwealth this came from a wish for doctors out there, many of whom had British connections, for them to continue a link particularly with the MRCP which was recognised worldwide as a worthwhile exam and sometimes they had to persuade their own countries that this was a good thing to do. And it culminated in some of the countries we went to not only taking the MRCP out there in all its different parts so that the whole exam is--, I’ve forgotten how many centres it’s held in now but it’s held in its entirety in many of these centres, but also at the same time encouraging them to set up their own local postgraduate training system. And having been through it, as it were, in the UK we were able to advise them how best to do it. The other dimension with all these commonwealth countries was of course where they got their manpower from or womanpower and particularly in the Gulf which had very embryo-medical schools of its own much of the medical workforce were expatriates there, many of them from India and some from Africa. And if they wanted to make progress in their careers they needed--, more than just having done their last job in Kuwait they needed some bits of paper of which the MRCP would be one. But the local people also didn’t want to be entirely reliant on the MRCP as a higher qualification they wanted their own. So we helped them, as it were, set up parallel postgraduate exams of their own and in several places actually linked them to the MRCP. And this all again required a certain amount of negotiation and tact. But I remember being involved in Kuwait for example, in getting the Kuwaiti board exam linked with the MRCP. I think at one time you took both exams one immediately after the other while the examiners were still out there but I think in--, I have a

Dr Eric Beck Page 83 of 123 feeling in Hong Kong you took a joint exam and at the end of it if you were a Hong Kong graduate you would finish up with MRCP and the Hong Kong postgraduate thing all for one exam. And we did this I think in Singapore where we had the Australians breathing down our necks ‘cause they were very keen to establish the kind of links with Singapore, which is much nearer, than Singapore had with Britain. And again I remember sort of the politics of this coming up which was something I was not particularly trained nor were my colleagues but I think on merit they probably made the right decisions. So yes, so all this overseas expansion, as it were, came along with the exam itself being reformed. And I mean if one just looks at the--, what has happened to the exam over the years since I did my English--, my French and German papers in the written paper all those years ago, the milestones were first of all the creation of a common Part One exam, multiple choice questions. I’m not quite sure of the exact date of that but this had already happened by the time I got involved in the system, but we still had the anomaly of a common Part One exam but three different Part Two exams in London, Edinburgh and Glasgow, and each one was--, had as part of it a written paper. So the next, as it were, simple or relatively simple thing to do was to create a common Part Two written paper which having passed you could then--, because there was always an interval between the paper and the clinicals you could then choose to change the college through which you wanted to do the clinical exam. So the Part Two written became, as it were, a universal requirement to go on with Part Two clinical. And the Part Two clinicals were different in the three colleges. And bringing them into uniformity was a somewhat bigger task because probably in none of the colleges was it done in an ideal fashion. So all this got hammered out in the--, by then we’d set up a Part Two board to encompass the clinicals as well as the written. The written wasn’t a great problem it was like Part One only again. And so different colleges would have to make different concessions to achieve a common Part Two clinical exam which was largely made up of the components--, existing components. So we gave a sigh of relief when we’d achieved that. We’d at last got a common exam and we sat back self- satisfied, this exam would be the same throughout the UK, you could take the bits in different colleges and you could hold it overseas. And then several things happened and one can best I suppose pick this out if you pick individuals, although I’m not suggesting that individuals were responsible for it. One of the things about the marking system was that in the Part Two exam we had in effect a fixed pass rate. We took the top, I’ve forgotten what it was, 25 or something per cent of people we’d marked to pass the exam and we thought this was a reasonable way of sorting people out as it were. And then along came a character called Chris McManus. Chris McManus was--, I think had had a psychiatric training and he was professor of psychology or medical psychology at St Mary’s Hospital medical school and he was known to be a critic and a rebel and I think he wouldn’t disagree with this. And he wrote a letter to The Lancet criticising initially the way in which the admission ceremony in the London College was conducted for successful candidates, many of whom of course were overseas candidates for whom it was a big day in their lives and families would come from India or wherever. And he particularly targeted David Pyke who was the college registrar who had to read out the names as they came to get their diplomas and would from time to time, not that I went to many of

Dr Eric Beck Page 84 of 123 these ceremonies because they’re incredibly boring, he would identify a new, nearly always English, graduate whose father was also a doctor and make some remark, you know, like, “A good chip off the old block,” sort of thing. And if you looked at it dispassionately this, you know, it wasn’t racist but it was something which, you know, the overseas graduates obviously thought was rather quaint. Anyway, he [McManus] wrote a letter to The Lancet complaining about this but more seriously he complained about the conduct of the MRCP exam and its marking system and what an unfair exam it was. So this letter duly got published, David Pyke took off into space but came down again on his feet, and we were asked as the board if we should react to the letter, not to the things about David Pyke but criticising the marking system and the exam in general. And I remember it well the meeting of the Part Two board when the letter came up for discussion and it was heartening to see that the board was made up of London, Edinburgh and Glasgow representatives and almost to a man we said, “Well, you know, there may be something in this we ought to look into it. And the first step we ought to take is it’s McManus who is a sort of educational psychologist should be invited along by the three presidents to come and view every aspect of the MRCP exam on condition that at the end of it he would produce an appraisal of what he had found.” And this was very heartening to see, as it were, a positive response. I don’t think it particularly pleased David Pyke who would have had liked to have seen him drummed out of town. And so over the next year Chris McManus observed the Part One and the Part Two written and, you know, the whole lot and came back and reported to us. And I still remember the meeting it was in the--, the room downstairs here with--, I don’t know whether Ian Gilmore--, I can’t remember who was the president at the time. Anyway, McManus came along and the first thing he said was, “I think it’s a good exam [laughs] and it’s fit for purpose in that it helps you select people who will then go on to higher medical training but,” and then the buts came along, and he said, “But your system of, er--, your pass system is ridiculous and wouldn’t stand up to any scrutiny by modern education blah, blah, blah.” Anyway, the upshot of that meeting was well perhaps we ought to review the exam but the whole exam, every bit of it, it’s never been done before. And so we set up the MRCP review which was not only three colleges but we invited contributions from all around the world from medical educationists, from the Irish college, and this would gather evidence and make recommendations over a year which might lead to changes in the exam. And I remember one of the things that we already had been concerned about in the London college was that in the viva, which was one of the components in the Part Two exam, was the danger that the examiner might dwell upon topics of his own specialty and ask very difficult complicated questions. And I still remember after a candidate had been in and discussing the candidate with my co-examiners saying, you know, “I couldn’t have answered that,” and the co-examiner looking at me in surprise [laughs]. And also how narrow and how variable the viva was, what topics it could discuss, what topics it rarely discussed. Anyway, to cut a long story short, the Royal College of General Practitioners had been going for a few years then and they had devised their own exam which didn’t have a clinical in the sense of examining patients but had a series of structured vivas and I and my colleagues were curious to see how a structured viva, as opposed to a rather random viva, could work. And so I got

Dr Eric Beck Page 85 of 123 myself invited along to the College of General Practitioners and saw what they were doing. And, apart from the content of the viva being structured and covering various domains which were compulsory, every candidate had to be asked something about communication skills, about ethics, what have you, also that the examiners in marking it had to record their marks individually and having written them down had to agree their marks. And also that the examiners in advance of examining on that particular day would agree amongst themselves what the sort of pass/fail criteria were. So it was a much more structured oral exam than the rather haphazard one in the MRCP. And this was all masterminded by a man called Richard Wakeford who was educational--, medical educational expert or something in Cambridge. And he was very much instrumental in setting up the GP exam and also in training the examiners. And that was the other impressive thing was in the morning of the exam before the exam began all the examiners would be assembled with Richard Wakeford and they would go through examples from the previous day of ‘good practice’ or ‘bad practice’. So this was a much more professional thing than we were doing. And so I came back to the Part Two board and said, you know, “We really need to improve our oral exam,” this was before the review had taken place. And so in the London college and I think it was then accepted by the Part Two board for all three colleges there would be--, in any one viva there would be certain compulsory domains which every candidate had to be questioned in along with other subjects that they might like, and management of emergencies was one, ethics and law I think was another, communication skills was another, and if you’re made to do it you jolly well can do it. They’re not unexaminable like some of our colleagues protested. So we had already, as it were, taken a small step in reviewing part of the exam and changing it which was encouraging for the general review that took place. And the general review was masterminded by John Munroe of Glasgow and Alistair Vale [0:52:33] who was the chairman of the Part One board here. And we got input from all sorts of people, Richard Wakeford was obviously one, McManus was asked to contribute to it, erm, various Americans because they were more advanced in assessment techniques than we were. And the Irish college which had a man called Fergus Gleeson who had originally worked with another physician in Dundee called Ronald Harden, and Harden and Gleeson many, many years ago had devised a form of examination called an OSCE, Objective Structured Clinical Examination. And its sort of popular name was a steeplechase in that every candidate had to go round the course, round a series of stations and be examined in an identical manner at each station to every other candidate. And the examiners were given a sort of a tick box checklist to see whether they were doing the things they had to do. And the OSCE had already become quite popular at undergraduate level which is usually much more less sophisticated in assessing students. So there was a--, already experience in the format of OSCEs. In fact the first time I ever saw an OSCE was when I went out to Nigeria to Ibadan for their postgraduate exam but somehow I sat in on their--, on an OSCE that they’d already devised long before we ever had. And they were very pleased and rather proud of it. Anyway, so that was the Irish college had devised--, had changed their MRCP exam, which previously had been very similar to ours, in which I’d been a visiting examiner once or twice, to an OSCE format which they called OSLER and I’ve

Dr Eric Beck Page 86 of 123 forgotten what the acronym of what each letter stands for except that O is obviously objective. So the Irish college were just introducing the OSLER trying to overcome one of the objections that if you formalise it too much you take out the examiner candidate interaction, it just becomes a checklist and it can be very boring. So we had--, all these things got fed in to the potential changes for the MRCP and apart from--, and we said, “Well the papers probably are okay except that we are going to change them into single best answer, best of five,” which wasn’t too difficult but this was much more sort of objective and reproducible. So the papers were not changed much. But then we came to the clinicals and orals and the radical--, what the--, used to happen in the clinical was that a candidate would be given a long case to spend, whatever it was, 45 minutes taking a history, fully examining the patient rather as you would in a clinic and then having a viva on your findings. So that was the long case. But the killer part, and most people could do quite well in the long case, were the short cases where you would be taken round a series of patients often with weird and wonderful physical signs which you had to elicit and explain. So that was the short cases. And then there was the oral examination which we had already criticised and had tried to put right. And we said, “Well, we ought to do two things, we ought to abolish the existing system completely rather than tinker with it further and just so the candidates know what we’re about we will also create a syllabus for the exam.” There was no syllabus you just had to be a good doctor to pass the exam. So we agreed we would do that and what would we replace the clinical and oral exam with? And this is where the OSCE format came up in our minds that we would have a postgraduate OSCE type exam, objective in the sense that every candidate would do the same, the examiners would be programed to mark in a certain way, would agree beforehand what the pass/fail criteria were and this is how PACES was born, the Practical Assessment of Clinical Examination skills. We took various members of the board to look at different parts of the exam and PACES I think one has to give tribute to was Mike Besser and Charles Hind. Mike Besser, retired professor of endocrinology at Barts, and Charles Hind, chest physician in Liverpool, were the two lead figures on PACES and came up with the acronym which was immediately welcomed and has stayed there ever since. So PACES consists, as you probably know, of five stations, some of them are joint stations where you examine particular parts of the body and you are given an introduction as to what the problem is, “This man complains of pain in his big toe which has gone numb please examine his legs neurologically,” something like that. And we did that for every station so every candidate got the same introduction to what--, what they had to do. And there was a very elaborate mark sheet devised and before every exam day the two examiners would agree their pass/fail criteria, you know, if he doesn’t stick a pin in the toe to test sensation he fails whatever else he does, if he doesn’t--, if he does that he can compensate and so on. So it became a much more objective thing and the mark at the end was independently given. People said, “Oh, what if the examiners disagree?” well then they haven’t done their work properly and occasionally you would get disagreements but usually they were within one mark of each other. And furthermore, because all this was written down very carefully on a mark sheet, this was a very good way of giving feedback to the candidate if they should fail. And one person one has to mention here who helped in the

Dr Eric Beck Page 87 of 123 mark sheets side of it was my longstanding friend John Dickinson who is not in very good health now but he was the senior censor ex officio who was on the Part Two Board. And he’s a very keen musician who for years had been struggling in the grades of organ music and failing as often as he passed as he moved up the grades, and en route had been very impressed by the Royal College of Organists having a very objective way of assessing them including this detailed mark sheet. So our mark sheet I think was inspired by the Royal College of Organists. So we had devised a brand new exam, we’d abolished the oral and the part--, and the long and short cases and replaced them with PACES which we felt covered every aspect of what we were trying to test. One of the stations was communication skills in which the candidate would be given a scenario of a situation which he would--, while waiting to go into the room and then be faced by a patient or a surrogate. That was the other big thing, we introduced surrogates, actors, to play the role of patients. And he would--, it would be things like breaking bad news and actors, being the people that they are, were able to do--, reproduce it over and over again whereas if you used a real patient in a perhaps highly emotionally charged situation like explaining the death of someone--, someone had died, you don’t want to do that every five minutes--, or every ten minutes for hours on end. So that was another obstacle we had to overcome was the use of surrogates and again the elder--, old examiners said that this was not proper, it was cheating and it wasn’t real and, “We resign.” So we said, “Thank you very much [laughs], we’re looking for new examiners.” So communication skills and then ethics and law we would again give them a scenario which they would have to interact with the doctor or surrogate or patient or whatever again against a fairly structured mark sheet. So we were examining the unexaminable [laughs] and we were reassured by other exams who had done this. We brought in various experts from other fields who still are around, Amanda Band for example who has a large stable, if you can call it that, of resting actors who, to earn something but also learn something, role played different clinical situations in which she coached them once she knew the scenario so they wouldn’t give totally inappropriate answers. So all kinds of spin offs came from the new exam. And the proof of the pudding was that it--, apart from one or two resistors it was welcomed by examiners and insofar as candidates ever welcome exams was perceived as a much fairer exam. There is an appeals procedure if they feel that they were being mistreated as it were, but I think everyone agreed that the new format was a great improvement and should have built into it the possibility to change with time, that it wouldn’t be laid down in stone forever and I think this has happened several times since I retired from it, which is a good thing. So you don’t come across the sort of fossilised exam of old. And we wondered how it would go down in all the overseas centres. So that was another task going round showing them what we were proposing to do and this was greatly welcomed and all kinds of interesting offshoots. I mean one of them was that their teaching of many of the things that we were going to examine was very archaic and they said, “We must change our teaching practices not only for candidates to pass the MRCP but for our medical students in general.” Again communication skills was one of the things highlighted. And of course the reason why we insisted on this was that if an overseas candidate passed the exam and came over to Britain, having managed to find a post

Dr Eric Beck Page 88 of 123 and tomorrow was starting in Grimsby, he would have to have these qualities and be shown to have them. So it got a very good reception as we went around overseas. Interesting thing like the Gulf when we introduced it in Kuwait one of the things that--, issues that immediately came up was in breaking bad news you don’t break it to the patient you break it to the leader of the family who is the father, or any other news has to go through the--, and that is the culture which is completely at variance with what would go on in the UK. And so we would have briefing meetings with the doctor--, with the examiners, the local examiners in Kuwait or wherever and we’d ask them, “Do you foresee any problems coming up in this particular scenario?” along the lines that we’ve just talked about, and they said, “Well what about our poor confused candidates? What shall we tell them to do?” So I--, we came up with a form of words, I don’t know if it’s still being used, that the candidate if asked a sort of difficult question like this, which we would by and large try and avoid, would say, “The custom where I live or practice is so and so,” and you’d say, “Yes, is there any alternative?” you know, like speaking directly to the patient. And hopefully they would realise there has to be because again if they finish up in Grimsby they’re going to do it rather differently from the way they were going to do it in Kuwait. So it was quite an educational exercise taking the new exam round. We held mock exams. I remember going to one in--, leading one in Cairo the only time I’ve been a professor in my life. To get me to Cairo I--, the British Council paid for me to go as a visiting professor [laughs] so the only time I’ve been a proper professor was for a week in Cairo. And, you know, it was very well received and a lot of people reacted very positively to, you know, the need to advance medical assessment. And the very first exam was held just as I was coming up to retirement. It must have been one of the last things I did was to hold a first ever PACES in the world, before we’d held it in the UK, in Singapore. So they were rather proud to be the first. It just happened to be that way that their exam was in early September and the UK exam was, I don’t know, October or November. So I think that’s right, that the first ever PACES was in Singapore. And so we felt we had made significant advances with the exam but we mustn’t be complacent about it for all time and we must make sure we didn’t get into sort of problems that we might do and medicine changes all the time anyway. So that’s a brief gallop I suppose through my involvement with the, erm--, oh yes, the other thing just to say coming back to Whittington because Jane Dacre, who was then getting more and more involved in Part Two, and I were at the Whittington. One of the things she had set up at the Whittington--, she’d transferred from Barts to the Whittington when the Barts London merger occurred some years ago. And one of the great things she had done at Barts was to set up a clinical skills laboratory which I think was a first certainly in London and I don’t know in worldwide terms, but clinical skills was very much and is one of her fortes and the Clinical Skills Laboratory at the Whittington, which had separate rooms and was very much geared up to the kind of OSCE format we’re talking about, became the test bed for the PACES exam. Because her husband worked at ITN we made a film of PACES before it was actually up and going to send round the world to show people what PACES was about. So that was all filmed at the Whittington mainly with ourselves and colleagues examining and so forth. So somewhere in the college archives will be the PACES video of which we were rather proud

Dr Eric Beck Page 89 of 123 and I did the commentary for it. Yeah, so PACES I think was not quite the crowning glory but was the end of my involvement with the MRCP. One of the last things I did by then on the MRCP Policy Committee, which overarched Part One and Part Two, one of the things we were worried about was elderly examiners getting out of touch when they stopped practicing and I put forward a proposal that no one should examine in the MRCP beyond five years of retiring from the NHS because, you know, things change. And this was reluctantly passed by the Part Two board and I became one of the first people to fall on my sword because my time was coming up [laughs]. So that was an illustration of how it might work. So I’ve not been involved at all since then other than reminiscing about it to various people including yourself [laughs].

Q: Thank you, that’s extremely comprehensive. I’ve just got a few questions. Obviously you took the exam yourself and you passed it at your first attempt.

A: Yes.

Q: Given that I wondered what you think was the motivation for you in wanting to change the exam so fundamentally.

A: I mean the exam had a terrible reputation both in its content and its fairness, its biases against overseas candidates and so forth and there were a lot of things wrong with it and it was perceived more as the college trying to stop people passing rather than it being an educational exercise and that, you know, there were tricks. I don’t know--, did I mention the Roger Gilliatt episode when I was--, about the lady under the sheet?

Q: Yes.

A: You know, that kind of thing is indefensible. It was all right as a party piece in a clinical round but in a serious pass/fail exam. There were all kinds of anomalies and examiners were very much laws unto themselves in their questioning. I mean one example, one good example, was that when I was hosting the--, I was then a consultant at the Whittington, the clinical exam at the Whittington in the old format, one of our visiting examiners was Sheila Sherlock the great liver queen as it were and she was then senior censor. And we still had long cases so in the course of a week there would be, I don’t know, how many candidates a day each one would have a long case for five days a week. And inevitably quite a lot of our long cases were chronic patients with chronic liver disease and I deliberately in planning the exam did not give her any patient with chronic liver disease ‘cause she was the world expert on it and I thought, you know, however hard she tried it would be not fair on the candidates. So on the first morning when she came I said this to her, you know, “We’ve--, you’ve got so many long cases this week and I hope you don’t mind but I have deliberately not given you any liver as a long case, it’s okay as a short case,” and she said, “I entirely agree with you.” You know, that was very heartening and she was, well a remarkable lady in many respects, but she was very sort of direct clear thinking person. She was of course one of the people nailed by Pappworth for doing liver biopsies at Hammersmith in the early days but that’s a different area. But no, Sheila Sherlock was a, erm--, great in many respects and of course one of them being a

Dr Eric Beck Page 90 of 123 woman who rose to the heights which she did and defeating the sexism of the system. There weren’t many senior women in the college or in the examination system in those days, one or two, but yes.

Q: How was she accepted by colleagues?

A: I think by then she was the world expert in the liver and she wasn’t always the easiest person to get on with but no, I think she was greatly respected and basically she was a fair person. I mean if you’d asked--, you know, to warn her off asking questions on liver disease she fully appreciated why I would do this ‘cause if she did it would have--, but yes, we [laughs]--, no, I think she is an important figure in the modern history of the college and of British medicine and of course the figurehead of the Royal Free Hospital when they--, when they moved to Hampstead and I think she was still there when it merged with UCL/UCH. So yeah, she was…

Q: What happened--, before you changed the system and there were so many people failing the old exam, what happened to the people that just never passed the MRCP?

A: It was a bit like the senior registrars who never got a consultant job, they would go round the other colleges when there were separate exams but of course the MRCP UK took that away. I think you were allowed and you probably still are six attempts at the exam. If you didn’t get it after six attempts hopefully you would have some deep reflections as to why--, you know, what was wrong, what was going wrong. And I think they went off into other--, other fields. I certainly saw people give up careers in medicine because they couldn’t pass the MRCP exam. Some finished up as general practitioners which was always rather derided as a lowly form of medicine, quite wrongly because GPs have changed enormously much more than physicians over the years. Some would finish up in accident and emergency departments which again was always a Cinderella area where you didn’t have to have an MRCP to be an A&E consultant it helped if you had some surgical experience. Yeah, so they went off and did other things. I don’t know how many people’s lives were, as it were, permanently blighted or changed by failure to pass the exam. I’ve cited the example of Philip Marsden who was an outstanding tropical diseases doctor who couldn’t pass the exam. He was perhaps the best example because he reacted very positively in setting up informal ward rounds and so on. And of course Pappworth had passed the MRCP exam but fought this personal crusade against the college to get as many people through it as he could. Yeah, I think the hardship or career change certainly did happen and I suspect general practice was where the majority would have finished up.

Q: You’ve mentioned one or two ways in which people criticised the new exam particularly the older--,

A: Yes.

Q: The older physicians in terms of using actors, were there any other worries or criticisms at all?

Dr Eric Beck Page 91 of 123 A: Well certainly surrogates was one of them, the other was the nature--, the content of some of the stations and whether you really could examine in it. And until you’d actually seen it in operation if you--, the idea of examining somebody’s communication skills, which now seems a fairly obvious thing, but how do you actually examine and, you know, different people communicate in different ways and what’s your criteria and your pass/fail criteria and can it be done, largely because it hadn’t been done at least not in medicine. I think in other walks of life communication skills have been tested. And we got various experts to come along and help us. I’ve forgotten her name--, her name escapes me at the moment [Anne Cusing] but she was very helpful in, as it were, drawing up the communication skills station and in the training of surrogate actors, also the training of patients because you can use patients for this the problem is consistency from one candidate to another so you actually have to train the patient in giving their own history. And the trouble with actors is in their acting roles if they forget their lines they’re told to improvise and if you do that in a medical history you may say something that’s completely--, you know, destroys the credibility of what you said. So this is why you had people like I mentioned Amanda Band who coaches her actors into what to say and what not to say. So yes, I think it was entering areas like this which traditionally you didn’t go to. The undercurrent of criticism, if that’s what you’re asking, had begun to some extent when we introduced the structured oral examination, examiners didn’t like being told what they should and shouldn’t ask questions about. I mean some of the questions that they used to ask were incredibly complex and highly related to their own interests and hence I used to say, and I used to encourage other examiners to say, “If you’re with a co-examiner who is asking what you consider difficult or unfair questions you must say so to your co-examiner,” you know, like “I couldn’t have answered that question.” “Oh, couldn’t you?” That--, so that--, that was a shift. Yes, I think communication skills and ethics to a lesser extent because the kind of ethical questions that you get posed in the exam are not usually all that complex. Yeah, that’s where the resistance came from. I think examiners also missed the whole case, the long case, which was much more like real life, if somebody examining a--, taking a history, examining a patient, presenting the findings that’s what we do every day and here you are chopping it up into little bits and we don’t think that’s for real, which is to some extent true. But yeah, so it wasn’t the way they had always done it either in clinical practice or in examination practice.

Q: How long did the whole process take?

A: Of PACES? Well from McManus’ letter which--, and response--, our response which I think took a year while he looked at the exam and then we set up the review which took at least another year, possibly two years and then we had to test the exams. It must have been about four years. As I say, the first ever real one which I did after I’d retired, so it must have been after 1994, I should think it must has been about four years from the initial grit in the oyster that produced the pearl.

Q: How much did the pass rate go up by?

Dr Eric Beck Page 92 of 123 A: Well now that’s another interesting, er, thing which I don’t know whether it’s been resolved yet, but when I was involved in setting up PACES we had a fairly rigid marking scheme in that the candidate went through five stations but in fact met seven examiners because some stations were double stations or at least not seven examiners they were assessed under seven different topics. And the examiners in the end, after they’d filled in their mark sheet, had to give a mark from one clear fail to four clear pass and two was borderline fail and three was borderline pass So the maximum mark that a candidate could get was, erm--, for some reason it was 42. I don’t quite know how that works out. Anyway, it was--, why is it 42 the maximum mark they could achieve? If they got fours at every station they would get from two examiners--, oh perhaps it was the maximum mark, yes, that would be seven eights, that would be 56 would be the maximum marks that they could get and three quarters of 56 is 42? Well I know the number 42 came up. And we suggested that there should be a fixed pass mark if the candidate achieved it and for some reason it was suggested it was 42 but nobody wished to do that and they wished--, what they--, because it--, the easiness or difficulty of the exam could vary from one exam to another. So a special panel I think was set up after every exam to judge what the mark would be and it would be somewhere in that area. And it was only when the secretary--, our secretary to the Part Two board Patricia White, who long since left and went to Scotland, said, “Of course it has to be 42 because that’s the meaning of life in The Hitchhiker’s’ Guide to the Galaxy [laughs],” but we weren’t quite prepared to do it because Richard Adams said so. So that’s how the mark used to be arrived and I imagine it still is the same that there is some kind of panel which after exam, because in every centre they’re all doing the same exam, could adjudicate on the ease or difficulty of it. But it’s no longer the fixed percentage which it was in the old exam which Chris McManus objected to, probably correctly.

Q: How often does it run each year?

A: The exam, well again I’m not entirely up to date but originally it was three times a year.

Q: And the same time? In every centre at the same time?

A: Yes, yes. Yes, well it had to be because the content in each centre is the same that’s all part of its objectivity. So if we were taking it in--, yes, when you’re taking it in Cairo or Kuwait the timing of the exam has to coincide with the UK so some of the poor candidates may have to do it at midnight or whatever. And I think that still holds. It may have changed but I know it was one of the initial problems that if it was going to be a truly uniform worldwide exam happening simultaneously the time zones would [laughs] have an effect on the candidates.

Q: And what about the content? Who’s responsible for setting the content?

A: The PACES examining board. This has replaced the Part Two board and again, as with all the previous exams, you have a bank of things that you use and re-use so, erm, particularly in the things like communication skills and ethics and law it’s easy to pull them out of the bag. When it comes to clinical exams where you want patients with, I don’t know, a withered left leg you would hope to have in every centre the same kind of patient but you might have some

Dr Eric Beck Page 93 of 123 adaptability, you might say, “Well we want every patient to have a leg problem. And each problem that the candidate is asked to unravel does have a lead in so, you know, “This patient complains of pins and needles in his left big toe please examine his legs neurologically”. This is instead of examining the whole of the nervous system, which you couldn’t possibly do in ten minutes, but focusing on part of a neurological examination is the compromise for examining the whole of the CNS. And the only way you’d ever in the past have examined the whole of the CNS was perhaps in a long case, if you were given a patient with pins and needles in their left big toe you would examine every system in the body and every part of the neurological system with largely negative findings some of which could be important negative findings. So it’s become much more focused and, to some extent, less real in that way but it’s the objectivity and the reproducibility of it. And I imagine, again I’ve been out of touch for so long, that after each exam they probably review the performance of each station to see, you know, whether the marking patterns were very different for the gastrointestinal station from the respiratory station and you would look then at what the problems were and was there something about the way the patient was selected or the introduction to the patient. So there’s a continual feedback mechanism going on which existed in the previous exam. We used to spend a lot of time not only setting the next paper but reviewing the one that had just gone before it and modifying the questions before they go back in the question bank. And one of the early leaders of the Part One exam was Peter Sanderson and he used to produce very detailed statistics on the performance of every part of every question and some of the questions were remarkably consistent in their performance over a number of years and these became sort of the ‘marker’ questions. So when we set a paper we would always want out of whatever, I’ve forgotten how many questions there were in a paper, but a certain number would be ‘marker’ questions because we knew how they would perform and if the new questions didn’t perform so well we could relate a candidate’s performance in the new questions to how they did on the old questions. So a lot of thought over the years has gone into it, a lot of change and the potential I think to change it further if necessary which is the important bit that we didn’t have in the old exam. I mean all the old exam did was to abolish Latin and Greek and then German and French [laughs] and a few--, well it’s a bit more than that.

Q: Did you have any criticisms about the pass rate going up about reducing standards?

A: No, I think if you--, if you have a syllabus as you have now and you expect every candidate to be competent in A, B, C, D to Z and it happens that every candidate is more competent by your criteria in this exam then the pass rate will be higher, the next time round it may be lower and whether there are demographic reasons for why you get a higher pass rate, I don’t know, in June than you do in October there may be all kinds of subtle reasons which we don’t know. And--, but no, I think this is one of the things McManus had to convince us of that the fixed pass rate although it fitted our procrustean approach of we want so many MRCP graduates to fill our registrar posts and blah, blah, blah to one where everybody potentially could pass or everybody potentially could fail but the argument is actually quite a strong one. One of the other things that I don’t think it has or ever will happen is that if the whole thing can be done on

Dr Eric Beck Page 94 of 123 paper, and obviously PACES can’t but all the written papers, why couldn’t you if you’re in Hong Kong go along to a college terminal under supervision on a Monday morning, key in Part One written paper, at this end a random Part One paper made up of this, this and this would be given? The candidate would tick the boxes, get to the end of the exam and walk out of the hall knowing whether he’d passed or failed Part One. I mean that’s the kind of thing which could happen but it obviously can’t happen where there’s a confrontation with an examiner and the confrontation with an examiner remains an important part. And this is one of the major criticisms I think of the exam that you have lost or may have lost the interpersonal relationship and this is a criticism when you use OSCEs as an undergraduate as well and it’s actually very boring to examine in an OSCE because you’re asking the same, expecting the same and there’s very little flexibility but it makes it much fairer.

Q: In terms of it being an international exam--,

A: Yes.

Q: Is there anything that you’ve had to take into account relating to that? For example if there’s an incidence, an illness that’s much more common in the UK than it is--,

A: Yeah.

Q: In another country do you have to balance out?

A: Well I think the first thing to say is it’s an international British exam. Nonetheless, it is an exam whose purpose is to select candidates to go onto specialist training in the UK who would finish up as consultants in this or that. And if this happens to coincide with our international audience well and good and there’s always, as I’ve said, the caveat that having passed the exam it may give them access to come and practice in the UK so we want their standards to be comparable to ours. So I think it’s a matter of standard setting which we--, which was a relatively novel idea and of course standard setting depends on a syllabus. And so one of the things that we did, I don’t know if they still do in setting the exam, we used to abbreviate the syllabus into A to Z to see how many of the objectives of the syllabus were covered by the exam that we were setting and I think that’s important. It may be a rather blunt way of doing it but the exam would be comprehensive and--, and people would reach a standard which we consider meaningful or important. One of the dangers in the past, and this exists in all exams where you have--, which rely on confrontation, is that you may be over impressed by a candidate who gives a very good answer to one thing and then is awful or vice versa by a candidate who gives an awful answer to one thing and then is very good and the objectivity of the present exam does get round that. And there’s no doubt that, you know, the interaction with examiners particularly with such a wide range of candidates could sometimes act to the disadvantage of candidates other times it could act to the advantage of them. And I think I told you my own experience being asked at the end of my short cases which hospital was I working at, no relevance to the exam. And I was working at the Brompton Hospital and one of the examiners was the senior physician at the Brompton who I hardly knew ‘cause I didn’t work for him and I‘d obviously done all right and sort of broad smile on this face and didn’t

Dr Eric Beck Page 95 of 123 quite nudge his co-examiner, you know, “That’s one of our boys.” And that kind of thing has fortunately all gone and I don’t think I passed the exam because of that [laughs] but I was aware of it but…

Q: Is there anything else you’d like to say about the MRCP and PACES before we move on?

A: No, I mean long may it live [laughs] and I think its international reputation hasn’t been criticised too much, you know, is this neo-imperialism that we’re imposing our exam? And we did go--, and I imagine still is the case, we’re keen that it should be recognised as such but I don’t think there was any way in which we forced it down people’s throats. And I think the advantage of having a universal exam, and it doesn’t have to be the MRCP, but it happens to be in English which is spoken widely in the world is it’s a benchmark for doctors who may never even practice in the UK. If you’re an expatriate doctor in the Sudan working in Oman or Indian doctor working in Kuwait and you get the MRCP it still has and I hope will continue to have--, you know, it will tell people that you’ve achieved a certain standard and I think that’s the great strength of it and why I would always defend its use overseas. And I think it’s particularly interesting, as I alluded to, that in some places it’s actually merged with the local postgraduate exam in the sense that if you--, if you’re looking for a job in a totally different country and your only qualification was the postgraduate degree of Kuwait it wouldn’t carry as much weight as if you’d passed the MRCP and now you’ve passed both. So yeah, I think it’s something, you know, flying the flag we have some skill and experience in doing and enough adaptability to make it universally applicable. I mentioned how we sit down with local examiners on contentious issues and how will you deal with this or with that and, having said that, I’m sure it still can be a problem and may be perceived as unfair by local candidates who feel they’re being marked by British examiners, but they’re never on their own we always pair a local examiner with a visiting examiner. So, unless there have been major changes of which I’m unaware, it’s something which I think works well, has had a lot of thought put into it over the years, a lot of experience, has made mistakes, has learnt from them, can evolve and, you know, it’s a thing to be proud of.

[END OF PART SEVEN 01:39:57]

[PART EIGHT]

Q: Today is the 13th of October 2015. My name is Sarah Lowry and I’m interviewing Dr Eric Beck and this is our fourth meeting.

A: God!

Q: Dr Beck, we talked a lot last time very interestingly about your involvement in medical education and the MRCP. We’ve also been talking off the records about some of the--, the times that you’ve taken on the medical authorities and I wondered if you might want to start this recording session talking about some of those events.

A: Well, as I was saying, I’m a rather lazy letter writer and I’ve only written three or four letters in my life on medical issues but each time, sometimes they’ve been joint letters as well,

Dr Eric Beck Page 96 of 123 something has happened as a result of the letter. And perhaps the first one that I wrote as a junior doctor, along with I’ve forgotten how many other junior doctors signed it, was a protest about the--, and this must has been in the mid 1960s when there was the problem of a lot of junior doctors having reached the rank of senior registrar and the lack of consultant posts and the time expired senior registrar waiting and waiting and applying and applying was quite a big issue. And the BMA came along promoting an idea that there should be a permanent sub consultant grade, something like a Senior Hospital Medical Officer, (SHMOs), I think they were called, and that this would be an important step to solving this bottleneck. And we junior doctors, who were the ones looking for the consultant jobs, felt outraged that after many years of training we were going to be fobbed off with a lesser permanent post. And our own trade union, the BMA, was in cahoots with the Department of Health in suggesting this alternative. So as a protest we--, I think it was 32 of us mainly from UCH and the Middlesex wrote this letter to the BMJ saying that we were all resigning from it, we were members of the BMA, as from now and giving the reasons that I’ve just stated. And it happened that the issue of the BMJ was on the same day as the BMA’s annual clinical meeting so it got maximum publicity and I still remember switching on the eight o’clock news in the morning and hearing amongst the news items ‘32 doctors resign from BMA’. So it got a lot of publicity and the, er, upshot of it was that people came round to interview us from the various other papers and I was interviewed on television as well which was very helpful in putting our case. And I still remember one, again one’s mistrust of the press, a very nice man from The Sunday Times whose name escapes me came to see me at UCH where I was senior registrar, RAP. And I explained to him the background of it all and he said, “Yes, when you become a consultant of course you can do private practice, can’t you?” and I said, “Yes, but that was not really, you know, the burden of our case.” He said, “How much do people earn in private practice?” It sounded an innocent enough question and I said, “Well it depends very much on how much you do and what speciality you’re in and probably the top speciality is plastic surgery.” And he said, “Oh yes, how much do plastic surgeons make?” and I think I plucked a figure from the air, something like 40,000 pounds which at that time probably was a lot of money. And so in the following Sunday Times this article appeared but the subeditor had picked out from our conversation 40,000 [pounds] a year doctors resign from BMA, a complete distortion of what I’d said. That really made me very wary [laughs] of what one reads in the newspapers if you know anything about it. So that was the first letter and in fact the SHMO grade faded away though there were already some people in it from the early days of the NHS, the grading system, and the proposal was to expand it to deal with all these would be frustrated consultants. So it did have some effect and years later I re-joined the BMA and am a supporter of the BMA because it is our trade union and I think their practices have altered and they’re much more in touch. So that was--, that was letter number one.

Q: Can I--, can I ask you a few questions before you move on to letter number two?

A: Yes.

Dr Eric Beck Page 97 of 123 Q: Quite a few people have mentioned to me that there was a kind of dearth of consultants posts at this particular point, do you know why that had come about?

A: I think it was just the way that the NHS was structured from the outset, the different grades and the training grades feeding into the consultant grade. The traditional consultant post before the NHS was a mixture really of two things, that if you worked for a local authority hospital like the LCC or the county then there were consultant posts created in those jobs usually with very little opportunity for private practice. But the traditional teaching hospital consultants were called visiting consultants and their careers were mainly in private medicine but being attached to a teaching hospital added to their CV, as it were, and most of them were unpaid consultants in teaching hospitals. So this--, this had been the original model which of course was inappropriate for the new NHS, but I think it was because of that or partly because of that that not enough consultant posts had been created. So eventually following--, not as a result of our letter but in the years that followed more and more new consultant posts were created and this is no longer the problem that it was. I think the other problem was there was no control or not much control exerted over which junior doctors would be recruited and would finish up wanting consultant posts. There were no proper postgraduate training schemes for junior doctors and so a lot of them probably never would have been very appropriate consultants and this of course has changed now because postgraduate training, specialist training is now quite rightly an important part in a doctor’s career. So I think it was a lack of posts on the one hand and the excess of not always fully trained doctors, but you did see some very sad--, sad stories of people who went on and on and on and eventually dropped out and did other things, went into general practice or some went into accident and emergency medicine, casualty consultants and so forth.

Q: You mentioned your colleague Tony Strange who I think was employed at the Senior Hospital Medical Officer level.

A: Yes, well he was an interesting man. A very nice man, very gentle man for a surgeon which is almost an oxymoron [laughs] particularly when his colleague was Mr Savage. And Tony Strange because of his personality never really wanted to be a consultant because it would--, when you become a consultant you take on all sorts of extra managerial roles which he felt he wouldn’t have been up to, he wanted to deal with patients which he did. I think I mentioned he’d been a missionary doctor in China and he was a man of high principles but there was a certain timidity about him and so he was one of this rare breed of SHMOs. The Whittington actually had another one, a chest physician, who again had sort of fallen foul of the system and had finished up as an SHMO and there was a move--, part of the expansion of the consultant grade became the abolishment of the SHMO grade so all people who were SHMOs had the opportunity to present their case to become a consultant. I remember this move with a particular feeling ‘cause there was one rather remarkable day in my life when everything seemed to happen in that the Whittington grand round which physicians took in turn it was my turn to do it so I’d spent the morning with my team presenting our cases. And I was then

Dr Eric Beck Page 98 of 123 asked to do a domiciliary visit on a very eminent microbiologist living in the Holly Lodge Estate in his 90s and I’ve forgotten the details of what was wrong with him but, you know, he was a much revered man with textbooks and so on after his name [Wilson of Topley and Wilson fame]. So that was the next thing. And then I had to come to the College of Physicians to support the case of this SHMO who wanted to be a consultant and they’d asked for various--, he’d nominated me as a colleague at the Whittington and he hadn’t nominated his other chest consultant because he didn’t think he would be sympathetic to his cause but the other consultant was nonetheless invited along because it was that specialty. And what I thought was going to be a mere formality unearthed all kinds of tensions between the two of them [laughs] and it didn’t exactly result in a falling out but the--, he got--, there was no reason why he shouldn’t be made an SHMO--, a consultant so he got that. Interestingly he also became the medical officer for Holloway Prison down the road from the Whittington. The Whittington has the proud of boast of being in Islington which has got two prisons in the borough, Holloway and Pentonville [laughs] which did have knock on effects for the hospital when prisoners became ill they tended to finish up in the Whittington Hospital right down to pregnant women being shackled to their beds while in labour and so on. There were one or two minor scandals associated but that’s I think going off the question.

Q: Did you have any particular stories around that, of people you treated?

A: Prisoners? Well I remember being called to do a domiciliary visit on both, in Holloway on one occasion and in Pentonville on another, and being rather shocked by what I--, what I saw, the way they were being treated medically. And what was particularly worrying was that the--, each prison has a medical officer who is supposed to be there to look after the health of the prisoners but is also there as an aid to the prison governor to maintain law and order. And I became aware of the ‘chemical cosh’, that’s to say giving sedation to troublesome prisoners. And I’d already had an experience, I don’t know if I’ve already mentioned this, Angela Lambert, did a World in Action program about the death of a young offender in Ashford prison. That was a very interesting episode. He was found dead in his cell, he’d been remanded on some fairly minor charge of burglary or whatever and this--, the reason World In Action took it up was, you know, 16 year olds shouldn’t be dying in prison and also looking, as it were, at the prison service and she for a doctor to comment on what was going on. And so I [laughs] was interested to take part in this production of this program. And it--, this is how I first became aware of the role of the prison medical officer, I’m not saying all prison medical officers were the lapdogs of the governor but there was this strong tendency that this could happen. And I still remember being interviewed in my office for the program with a lawyer from Grenada Television sitting next--, or sitting out of sight and they were very worried about the possibility of slander, me making slanderous comments, and periodically butting in and saying, “You can’t say that, you can’t say that [laughs].” And anyway, the program got made and it went out and it was an interesting experience of both how television works but also how the prison medical service works. So when I was asked, as you asked me a moment ago, about prisoners who are patients I’d already had this experience of this television program.

Dr Eric Beck Page 99 of 123 Q: Did they find out how the boy had died?

A: Yes. Now what was the actual cause of his death at the post-mortem? I don’t think he’d killed himself. Perhaps he had. Perhaps he had and the wardens who were supposed to look in regularly through the peepholes had obviously failed to do so and hadn’t seen what was going on. I can’t remember the exact circumstances of his death but, you know, the mere thing of a 16 year old boy dying in a remand centre was enough to alert public attention.

Q: And you mentioned the chemical cosh.

A: The chemical cosh, yes.

Q: Could you--, were you able to bring that up or address that in any way?

A: I can’t remember whether it was relevant to this lad. It might have been that he had--, you know, that he was making a row in his cell and might have been given something but I don’t know. My--, I haven’t got a transcript of the original program. I doubt if Granada--, well they might have. World in Action, I’ve forgotten what it--, what the program was actually called but Angela Lambert, who sadly died some years later, was the television reporter whose task it was to put this program together. And I met some interesting people as a result of it. His local MP, the MP for Battersea who I think, yes, had raised this in the House of Commons, you know, as a potential scandal. He was, again his name escapes me, [Alf Dubs, who had come to Britain in 1939 as a refugee on a ‘Kindertransport’] a nice sincere man who restored your belief in politicians a little [laughs]. Yeah, there were--, it was an interesting experience.

Q: Just coming back to your protest against the BMA, what were the career implications of resigning from the BMA?

A: Well not--, it wouldn’t have a direct effect on your career but if you got branded as a rebel, as it were, it might not do you any good. And one of the co-signatories of the letter was the late John Francis, a friend of mine from medical school days, a very bright doctor who was then senior registrar I think to the Medical Unit. And this was one of the acts of kindness resulted from that of Max Rosenheim, who I think I’ve mentioned before who was our professor of medicine. And he called John over--, when we got to work that morning of course because it had been on the news and people at work knew what was going on and there was a certain feeling amongst some of the consultants, you know, that we shouldn’t really be rocking the boat and not very supportive, and Max Rosenheim called in John Francis and said, “Although I may not agree with what you’re doing I want you to know that I will continue to support you.” And I thought that was a very typical Max Rosenheim thing to do. He was a--, you know, he was a very kind man. Yes, so it created a bit of a stir and possibly had some effect on the debate going on at the time.

Q: Is there anything else you want to say about that particular episode before we move on?

A: No, I think, you know, the dust settled and things improved and there was still a lot of time expired senior registrars. I mean I--, as a junior doctor I’d worked with some of these senior registrars and it’s funny I was recalling this yesterday with, er, Mike Besser at John

Dr Eric Beck Page 100 of 123 Dickinson’s funeral. One of the people I had worked for at the Brompton was called Neville Oswald who was very much a sort of Harley Street chest physician who also was a physician at Barts and also at the Brompton where he I think came once a week and did a ward round and then we would sit down and have the usual coffee in the sister’s office afterwards. And without denigrating Neville Oswald, he was always full of sort of aphorisms [0:20:10] which were not very original and not particularly amusing, but we had this senior registrar who was getting pretty desperate for consultant jobs and he fawned to him quite sort of [laughs] unashamedly. And when he came out with one of his trite aphorisms [0:20:26], while we were sitting round serving coffee, he came out with the memorable phrase is, “What I always say sir, is that never a Friday morning goes by without me learning something,” you know, the ultimate cringe [laughs]. And this became a catchphrase in our own family, you know, never a Friday morning goes by--, but that was the kind of thing that people were reduced to. He got his consultant job ultimately and, you know, he was a perfectly nice chap but he was getting--, getting quite desperate and obviously the support of people like Neville Oswald was important to him.

Q: So what about your next--, your next--, the next stand you made?

A: Well I think that was probably the doctors going on strike over the renegotiation of the consultant’s contract. And this was the year I think it was 19--, it’s in the preface of the book there. Anyway, the doctors were very dissatisfied with what was--, what was going on and I think almost for the first time in the history of the profession there was a strong movement for doctors to go on strike because they felt they had a just cause. And several of us--, and I think the two people who sort of were the instigators of this alongside myself were David Patterson my consultant cardiology colleague at the Whittington and Tom Prankerd the--, who was then I think dean of UC--, University College Medical School, a consultant haematologist, who I regularly played squash with and I think it must have been discussions in the post squash thing about what was going on in our profession. And we felt that however, er--, however just our cause was that going on strike was not the way to do it. And so we wrote a letter to The Times about the dispute over the consultant’s contract and the--, one of the upshots of it had been in what was going on was that this was in the spring of the year of the general election and to try and take the heat out of the debate the government, almost for the first time, had decided to implement the annual review body’s pay award to doctors. Usually--, this reported every year and we got an increase in our salaries which was usually far below what was recommended and the panel were supposed to take into consideration what other professions earned and so on and it still exists. And they decided to fully give the pay award which was amazing, just a coincidence that there happened to be a general election round the corner. And again this, we felt, really stirred it up because a few months earlier before Christmas the government had been particularly harsh in dealing with the pay demands of other health care workers like the nurses and the auxiliaries and, erm, other staff at the NHS saying that the country couldn’t afford it and, you know, that they were being very unpatriotic in not accepting the lesser pay award. And in percentage terms I think they had been given a 4.6 pay award--, per cent pay award and the doctors were being offered I think the full amount 8.4 per cent

Dr Eric Beck Page 101 of 123 which was, as I say, unprecedented. And so we felt particularly bad that--, about this divisive pay award and that was the gist really of our letter. And in it we had by then recruited other likeminded doctors to sign the letter and we said that we proposed when we received our generous pay award to deduct from it the difference in percentage between the 4.6 and the 8.4 and to use this money for some NHS purpose as the NHS was so hard up obviously, you know, they needed help as it were. And so we wrote this letter to The Times. And on the same day that we wrote it or they published it the professor of medicine in Cambridge, a rather eccentric man called Ivor Mills, had written a purely personal letter again bemoaning what was going on in the medical profession and threats of strikes and so on likening doctors to lemmings jumping over the cliff into the sea. So these two letters appeared on the same day. And again it created a certain amount of stir. I got rung up by the BBC to appear on Newsnight and to be interviewed along with Dr Bolt of the BMA who was then president of the BMA who was, as it were, following the orthodox government line. So there were the two of us and this interviewer who was very--, hadn’t said very much beforehand as to how the interview was going to go, started off with a picture of the Central Middlesex A&E department saying, “On a day when a patient is taken to Edgware General Hospital with a suspected heart attack where the doctors are on strike and will not see him gets taken to the Central Middlesex and dies in their A&E department we ask, ‘should doctors go on strike Dr Bolt?’” So he was put in the hot seat immediately and he sort of blustered away and then Ivor Mills had also been asked to come along to the interview and then they asked me and I put our case as it had been in the letter. And then Ivor Mills was--, again before we went on screen had been expounding some rather eccentric views following on from lemmings and the producer, what was her name, Barbara Maxwell I think, came and whispered in my ear before we went on she said, “You won’t let him say those things on television will you [laughs]?” So he made a fairly bland statement. And then Dr Bolt came back again saying, er, I’ve forgotten exactly what he said, but it--, it wasn’t very supportive. And I still remember watching it because it was filmed earlier in the evening so I got home and actually saw it on television and, as Dr Bolt was blustering away making the official BMA case, the camera focused on my face where I had a look of utter disbelief which sort of completely undermined what Dr Bolt was saying [laughs]. So that was the power of television. Yes, so that was a--, as a result of this letter many other doctors wrote in and said well they wanted to do likewise and what were we going to do about it as it were. And so David Patterson and I and Tom Prankerd as the main instigators decided that this--, if other doctors were going to do it it might be quite a tidy sum of money that would be coming but we didn’t know how much for how long and so forth. So we thought we would set up an organisation which we would call Doctors Award Redistribution Enterprise, or DARE, that was the acronym. And we would write to every health authority in the country saying who we were and why we were and that we were inviting bids for projects which they had been unable to undertake because of shortage of money in the NHS, making it clear that we hoped that these would be one off projects because we--, or one off payments because we couldn’t guarantee it. So hopefully it would be a kind of pump priming exercise. And, as I say, we invited them to write to us to make bids for this. And David Patterson there as the main

Dr Eric Beck Page 102 of 123 instigator of it put a tremendous amount of work in it and we got--, I can’t remember how many of the health authorities actually responded and some of the things they wanted were totally unrealistic but there was some very worthwhile projects. And so we selected some from this and we made it a condition that in handing over the money, as it were, one of our supporters should be involved in the handover to create some publicity for what we were doing. So I’ve forgotten exactly how many DARE things we funded. It’s listed in a book that subsequently emerged. And this was a very heartening experience going up and down the country and all kinds of odd things like one of them I remember was creating low level flowerbeds in Bradford for patients with disabilities in wheelchairs who could then, as it were, create a garden. There was the--, one of the ones was the ‘screaming babies of Salford’ that Salford Health Authority wanted to set up a telephone helpline for mothers who--, of relatively new born children who were getting beyond their depth when their babies were screaming and needed help and support. And so we agreed to fund that with the proviso that they would take it on after a year of funding. And there were several others sort of rather innovative things that came about. Anyway, at the end of, er, a year or so--, well we asked people to enter into four year covenants to donate their salary difference and we made it clear that this would be for four years only and that we would then stop and at the end of four years despite the schemes that we had supported there was still money left in the kitty for distribution one way or the other. And we thought well perhaps to sort of bring it to an end we will commission a book on the future needs of the Health Service called In the Best of Health, and we got experts in different fields of the NHS to state the current position in their particular field and what needed to be doing and we thought a book like this is bound to lose money but it didn’t [laughs]. So we finished up with an interesting book which in its preface outlined what DARE was and how it had been created but with money left in the bank. And so we thought well, you know, again we wanted to draw a line under this, we felt our protest had, four years ago or whatever it was, you know, made its mark and that we would use the residue of the money to try and fund something that might carry on the idea of DARE. And the Faculty of Public Health Medicine was a relatively new faculty at that time, obviously unlike the various colleges of physicians it didn’t have great reserves or resources and its president, June Crown, was somebody I’d known over the years, in fact she’d been a medical student on the firm when I was on the Central Middlesex. So I approached June Crown to see whether the Faculty of Public Health Medicine would be interested in promoting an annual lecture exemplifying some of the principles of DARE that we had set down and that this would fund the lecture. And they very keenly accepted the idea of an annual DARE lecture at their Annual Clinical Meeting. And they had full control over it but I as one of the trustees of DARE was always consulted about who to choose and would go their annual general meeting and would usually make a brief statement before the lecture began about what DARE had been about and so on. So this--, this went on for several years and we had some interesting people speaking and I don’t quite know what has happened to it and I must check with the faculty, maybe they’ve run out of money, but the idea was that the money would be used to pay the expenses of a guest

Dr Eric Beck Page 103 of 123 lecturer and would enable them to cast their net wider and get people who otherwise might not be able to afford to get along as it were. Yes, so the DARE lecture was founded.

Q: It’s a remarkable story. I just have a couple of follow up questions. You said that there was--, that the whole thing was sort of generated in the first instance by the wish of some physicians to strike against the new consultant’s contract.

A: Yes.

Q: Can you remember what it was precisely in the contract that people were protesting against?

A: I can’t, er--, I--, I ought to be able to remember but I can’t remember. I mean one of the things that the new contract when it came along (the whole thing was rather suspect, as I say it was in the run up to a general election) was it gave the right to every full time consultant--, consultants as you may or may not know were appointed either as full time ten sessions a week as it were or part time and you could be maximum part time where you would surrender I think a couple of sessions to enable you to do private practice in those other two sessions or you could have a much lesser contract. And what was proposed in the new contract was that every consultant would have the right to do a limited amount of private practice without having to give up a session. And it was sort of ‘scout’s honour’ that they would tell the department of health how much private practice they in fact were doing and if it exceeded or the time exceeded a certain amount they would have the right to reduce your contract from full time to whatever. I mean the whole thing, you know, was a--, we felt was a bit of a stitch up to mollify a group of people who might have or were already creating trouble and difficulty. So yes, that was one of the issues which hadn’t been raised in our letter, we were not worried about private practice because although some of the signatories did do private practice this was not an issue for us, this was a gratuitous thing that was thrown in by the department of health into the new contract to mollify consultants.

Q: And you mentioned that this was in the run up to the ’83 election so obviously Margaret Thatcher would have been, you know, prime minister at that time--,

A: Oh yes.

Q: Somebody who divides opinion [laughs]--,

A: Even after her death, yes.

Q: Can you remember what the feeling of your colleagues and health professionals at that time was towards the Conservative government [0:39:05]?

A: Well I think we all resented as we still do the political football that it [the NHS] has been from its inception and a sort of great wish that, you know, could this be taken out of politics? Of course the answer is you can’t there’s always going to be a political dimension to it. But I think this certainly was a concern that politicians interfering with the running of the NHS. And that there was--, certainly in the Conservative government and Mrs Thatcher, that the enterprise of the NHS as a public service institution hugely popular with the public so they couldn’t, as it were, take it on headlong and dismantle it even though this argument continues to this day.

Dr Eric Beck Page 104 of 123 There was a certain underlying hostility to the whole idea of the NHS amongst the--, in the Conservative government but they were restrained in doing too much about it by the overall popularity of it and the relative dearth of private medicine, you know, private medicine continued in pockets in the--, and of course it was an important source of overseas earnings, foreign patients coming to Britain for medical care. So I think private medicine probably was one of the issues but it’s become a much bigger issue since then and of course by unleashing all consultants to be able to do private medicine this seemed, I think to those who didn’t do it, like myself, a retrograde step. I mean I’ve probably seen about one private patient in the whole of my career and that was a rather amusing afternoon. Have I mentioned it already? Yes, about the queen of Malaysia [laughs] and Alan Bennett who was not a private patient he came as an NHS patient but was delayed because of the queen of Malaysia.

Q: But was very charming about it I seem to remember.

A: Oh yes. Oh yes, yes.

Q: This is obviously many years ago now and it will be stretching your memory, but I don’t suppose you can remember approximately how many doctors would be subscribing at the height of DARE? Would have been contributing the difference in their—[pay award and that given to ancillary staff]?

A: The DARE thing--,

Q: Pay reward.

A: It is actually listed in--,

Q: Okay.

A: The book In the Best of Health where we have an explanatory introduction about DARE and we listed all the people who had contributed to it, yeah. It was also closely linked with but separate from another organisation which had grown up as a result of protest which is the NHS Consultants’ Association, and again this was set up during the troubles by a microbiologist at the Royal Free Hospital called Paul Noone who was known as a rather rebellious character amongst his colleagues but had a strong social conscience. And, erm, there was--, amongst the founding members, of which I was one, there were some very impressive people, Sam Galbraith, a neurosurgeon in Scotland, who subsequently when the Scottish government was set up became Scottish health minister for a while and sadly died very young. So he was one of the supporters from the early days. And another person who is still around although well retired now Peter Fisher, physician in Banbury. And the NHS Consultants’ Association became a sort of ginger group to protect the NHS and to have dialogue with whoever was running with it--, running it. And so it wasn’t specifically allied to any political party and we would have conversations whoever the Minister of Health was, whichever party he came from and it was a way of presenting the views of consultants to the Department of Health if they wanted to know as it were. It’s now morphed into a larger organisation in that originally you had to be an NHS consultant to join it we then encouraged

Dr Eric Beck Page 105 of 123 doctors in training to join it, so senior registrars and so on could join, but as its main purpose was defending the NHS it’s now as of this year I think become Doctors for the NHS [campaigning against the privatisation of the NHS]. So the nucleus was there but quite a few general practitioners have now joined it and they’ve just had their first annual general meeting which unfortunately I couldn’t attend. And I hope that they will, you know, continue to be a force for the good because there’s plenty of current problems that need to be aired and debated. But Peter Fisher has been from the outset a leading figure in it. I was originally I think [NHSCA] treasurer when they first set it up not that we had much money to play with [laughs]. Yes, so that was another spin off of protest as it were.

Q: Are there any other changes that happened, major changes that happened with the NHS during your time as a consultant that you’d like to talk about?

A: Well I think the original vision of the NHS has been attacked but not eroded. I mean one of the big arguments was do we really need to have a service paid for out of taxation or wouldn’t we be better off having some form of health insurance, which of course is how many people fund private health care and very much the American model. But I think we’ve always--, or I certainly and people like me always wished to retain the underlying principles of the NHS. I think the biggest recent change which really came after my retirement was the involvement of the private sector and this was the Kinnock government [changed to ‘promoted by the Blair government], Labour government, so one can’t pin this, as it were, on one particular party. And this of course is gathering apace now and particularly with the new system of paying the so called Clinical Commissioning Groups who have to set up contracts for the provision of health services in the particular area they represent, are encouraged to look at the private sector as well as the public sector [providers]. And one of the worrying things is that, you know, when profit becomes a motive in doctoring then some of the corners get cut, as it were, to please the shareholders and there’ve already been quite a few instances where private companies have not been up to--, up to the mark in fulfilling their contracts. So I think this is ongoing now and of course I think this is where one has to pin it on the Conservative government that many of them would wish to see the NHS as such changed into a purely insurance system without--, with choices of where you can go. I think what people often forget--, the general public often forget is that the so called private sector in many instances is heavily subsidised by the NHS. When they employ nurses in private hospitals these nurses will have been trained--, if they’re British nurses, and they’re becoming fewer and fewer, will have been trained under the NHS and the doctors who work there if they’re British doctors will have been trained by the NHS and many of them--, of the consultants are working [part time] in the NHS and then part time in private practice. So it’s not as if it’s a completely separate issue. There's a lot of blurring of--, at the margins of which I don’t think people are fully aware. And people like myself and the NHS Consultants’ Association and so forth have often felt that there should be a complete separation between the private sector and the NHS and where the two overlap there is potential abuse. I think did I mention in an earlier discussion about the wish at UCH of the consultants in the Private Wing to have help from--, and the reaction of the junior doctors and the reaction of the consultants who made this request? And I think that

Dr Eric Beck Page 106 of 123 exemplifies, you know, that where the two overlap it’s not in everyone’s best interest, but I think it’s--, the momentum at the moment is for this to increase and sadly it was the Labour government of Kinnock [Blair] that first introduced the idea. So I would say that probably is the biggest change. I mean the constant reorganisations and the battle between central control and local control, which isn’t unique to the health service but happens in all our public services, has been going on for years as well. And probably one of the things that has slowed down what a lot of people would like to see is a fuller integration of health services and social services, this is becoming more and more relevant with elderly patients admitted to hospital with an acute medical condition which is rapidly and successfully treated whose home conditions are so poor that it is dangerous, as it were, to discharge them home without making social provisions. And this is one of the reasons we have what are very unfairly called the ‘bed blockers’, patients waiting for social support in the home. And one of the ideas I think which both the main political parties subscribe to is a greater integration between the local social services and the NHS. And I don’t think it--, despite the aspiration I don’t think it’s really got very far, but would lead to a much better service and also make considerable economies along the way. Yeah, so that’s I suppose in a nutshell my current concerns about the NHS and this interface with private practice throughout I think has been one of the--, well it’s too dramatic a word to say one of the cancers of the NHS but it has not helped the NHS even though it is always lauded as a way of, you know, shortening waiting lists for example. Well who’s doing the operations on a Saturday in the private sector? The same people who are doing it in the NHS on a Friday in the local hospitals. I don’t think the general public really realise this, they think there’s a separate cadre of people running private health who because profit is the motive they’re bound to be running it more efficiently than you can run a public service. But the NHS has got built within it enough mechanisms to change and improve itself and has been doing so over the years. Although the profit motive may be important in many other aspects of life I don’t think it’s the key to a successful health service.

Q: So given I think everyone accepts that costs of running the health service have risen enormously--,

A: Yes, and will continue to do so.

Q: And the limits on the amount of public funds that are available, what would you say the solution would be?

A: Well I don’t think there is any easy solution. I think, as you say, the demography is against it but it’s still a very efficient way of treating people and their needs. And the thing that is always raised was should people pay for health care? And prescription charges is a small drop in the bucket which was sufficient of course when they were first introduced to lead to resignations of, erm, Labour MPs who felt the Bevan principles were being eroded. It is more money and I suppose taxation is the answer and I think most people, myself included, would be against a so called hypothecated tax where you say, “X per cent of the taxes I pay should go to the NHS,” this is and always will be a political decision. But there are many ways in which taxpayers’ money gets spent over which we don’t have direct control, you know, one can list

Dr Eric Beck Page 107 of 123 them depending on one’s political view, the cost of Trident for example, the untaxed offshore incomes of international companies, you know, there are many other ways in which money could be raised but in the end it probably is taxation. And the wealthy having to shell out a bit more, but of course this is a political dynamite if anyone wants to raise taxes. And this is why some people said, “Well it should be a hypothecated tax, you should--, if we’re going to increase income tax by x per cent, that x per cent will be set aside for the NHS,” but I’m not sufficiently aware of the workings of government to see the arguments for and against it. But I have an instinctive feel that if you identify all the things you’re paying your taxes for you lay yourself open to people saying, “Well I don’t believe in Trident anyway please knock five per cent off my income tax.” You know, that kind of response which makes me feel that this is not the way to do it, but increased taxation probably is.

Q: As somebody who trained at a time when junior doctors were supposed to work extremely hard for very little pay, what are your current feelings towards the current issues around junior doctors’ contracts?

A: Well, that’s certainly true. I mean when you were appointed as a houseman you were in effect expected to do 24 hours seven days a week and there was no specific mention in the junior doctors’ contracts in those days about hours of work or even about holidays and I think this has--, quite rightly over the years has been tightened up considerably. And one thing that was a big step forward was the European Working Time Directive which limited the hours of work not only of doctors but many other professions to I’ve forgotten what the figure is. Is it 35 hours a week or something like that? And to implement that of course was going to be very difficult in a health service where people had been working 24/7. I don’t think too many did but you were--, if you were a houseman you were usually living in and if you left the premises you always felt a sort of slight pang of what’s going to happen and you would get one of your colleagues to cover for you. So a lot of informal arrangements meant that you weren’t actually doing 24/7 but it was--, that was the official position. So the European Working Time directive, as it were, concentrated the mind as to how to continue to staff hospitals. One of the answers of course was to invite people to do overtime and pay them accordingly if they did more than their contracted hours and this for some junior doctors was obviously a very important boost to their pay if they were working long unsocial hours, but of course the idea behind it is that doctors working those sort of hours are perhaps not best for the patients. So the current controversies that are going on about seven day a week acute medicine and surgery for that matter all, as it were, stem from this--, from this background. And I think the solution will have to be, as the bottom line always is, money, but money to buy doctors and nurses and you can’t--, although we have a huge support from around the world from the Philippines to Europe and so forth, in the end it’s having enough of our own trained staff. So in the end I think it does come down to medical education. We should be producing more doctors and more nurses, which is expensive but it’s perhaps not as expensive as the stopgap measures of employing agency staff. And I think that is--, and people are just waking up to the--, the enormity of agency staff costs and it’s the--, you know, it’s the ‘quick fix’. It’s--, and it’s becoming now such that nurses who--, even nurses who have trained in this country rather

Dr Eric Beck Page 108 of 123 than nurses from overseas will not sign contracts with a specific hospital to be a nurse there but will sign with an agency who will second them to hospitals where they will actually get higher wages than if they were employed by the hospital and the agency gets its fee as well. And I think the whole agency thing from doctors, nurses and others really needs to be tackled and I don’t--, I haven’t seen any of the major political parties take this on although they are beginning to identify this as a problem. And I think the other trouble with agency staff is that they come and go and they don’t develop a great loyalty to where they are working because they may be somewhere else the next day and this in turn has an effect on morale. And I think that again one of the big worries about the health service today whenever you talk to anyone in any part of it you do realise how poor the morale is. And that the--, and you also realise that for many years the goodwill of its employees from the tea ladies upwards, as it were, was that they felt that they were doing a worthwhile job, not always fully financially rewarded but there was a sort of esprit de corps, to use an old fashioned term, which is less and less now and I think the sort of agency problem, which is getting bigger and bigger, is partly to blame. And where we would be without the Philippines I don’t know. Whenever you set foot in any department of any hospital now the chances are you are going to have a Filipino nurse, who are perfectly good, you know, nothing against them except I do wonder about the Philippines training all these nurses and not getting much in return, but they do send remissions back home to support their families and so on. So it’s part of a worldwide problem as well, but the NHS I think could and should have a greater influence on who we are training, how we are training them and of course one of the problems is that if you start interfering with medical training and insisting that people should work for the NHS well you can’t really do that. Although interestingly some countries--, I remember going to Nigeria years ago and their medical system was that when you had done your year as house jobs and were getting on the medical register you had to do a year in the community, that’s to say you were sent to unfavourable parts of Nigeria which were very short of doctors and so on. It was a nice idea, in fact [laughs] there were so many loopholes that people got round it rather like the odd and even days on number plates in Lagos to try and deal with the traffic congestion which is another example of a nice idea that led to all kinds of corrupt practices. But, you know, this is a problem as if you’re training people for professions you can’t really put conditions on how they are going to use their qualifications even if they’ve been highly subsidised in obtaining those and there’s a limit to, as it were, insisting that the state gets a return on its investment. And I don’t think people have really explored this avenue and I would imagine there would be a lot of protests if you did, but I think the onus is on making the work offers to doctors and nurses and other medical staff sufficiently attractive for them to want to do it rather than having to be directed to do it. And certainly one of the encouraging things in my retirement involved in teaching first year medical students is that, you know, many of them are idealistic and, er, would subscribe to this kind of approach, whether they will by the time they qualify [laughs] and have a shell of cynicism to protect themselves I don’t know, but I think we do need to look more deeply at the whole system of training, recruitment, morale and so forth. It’s a very woolly answer to [laughs] an important question.

Dr Eric Beck Page 109 of 123 Q: Not at all, thank you. It was very interesting. We were talking a bit earlier about the accelerating costs of the NHS and all the different treatments and diagnostic tools that are now available, I wonder if you could say something about the major changes that you saw--, sorry this is a very big question so do break it down, the major changes that you saw in medicine both in general medicine and in gastroenterology during the time you were practicing.

A: Yes, well one of the things which sadly because of my age I never really got fully to grips with was the computer but, you know, if you ask anybody anything about modern life the appearance of the computer and the way it’s taken over, in most cases very helpfully but occasionally in a counterproductive way, the--, every facet of life. As I say, I’m somewhat computer dyslexic or illiterate and although I can stand by and admire I didn’t in my latter years up to retirement really have first-hand experience of using it, but I do acknowledge how important it is. In--, the other advances of course have been pharmaceutical and although I have many reservations about big pharma and how they promote and sell their drugs inevitably there have been major changes in drugs available. And antibiotics, which of course are coming back to bite us now, nonetheless has had a transformative effect and in most specialities cardiac drugs, blood pressure so forth. In gastroenterology I think one of the breakthroughs in drugs was the control of acid secretion. In other words people were getting indigestion symptoms due to ulcers and peptic ulceration was a major occupation of gastroenterologists which has been radically changed by two things, one was more and more drugs were developed to suppress gastric secretion which allowed ulcers to heal and the ultimate, which I don’t think has yet been supplanted, are the so called proton pump inhibitors, Omeprazole and the various derivatives of Omeprazole. And this made a huge difference in not only relieving symptoms but also in healing ulcers. But the other--, dealing with peptic ulceration, which was a major concern for gastroenterologists, the other major discovery that came along was helicobacter. And it is a remarkable story the helicobacter story because people had suspected for over a century that bacteria might be the cause of peptic ulceration but they were never able to identify them and then the--, people said, “Well there’s so much acid in the stomach that bacteria couldn’t live there anyway.” Anyway, to cut a long story short, as everyone now knows helicobacter pylori is strongly associated with duodenal ulcer, also with gastric ulcer, to some extent gastric cancer, and the more this has been studied the more one realises that there are defensive mechanisms that the bacterium has to prevent it being destroyed by acid in the stomach. So now instead of suppressing acid with Omeprazole, which is still a short term way of fixing symptoms, you can try and eradicate this bug helicobacter. And this has been a major advance and it’s continuing because drug resistance, as we’ve already alluded to, with antibiotics can be a problem in treating in helicobacter. So that’s one end.

Q: Do you remember--, do you remember what the feeling was in your particular part of the profession when this breakthrough was made?

Dr Eric Beck Page 110 of 123 A: When helicobacter--, erm, I think it was probably--, it wasn’t one of ‘told you so’ because people had actually postulated this and they’d been laughed out of court. I think it was one of great interest, some disbelief initially because of the previous history of bacteria in the stomach and an enthusiasm to embrace it. I mean, just as one aside, there are ways of testing for helico--, different ways of testing for helicobacter, one is to do an endoscopy and take samples from the stomach and duodenum and actually see the bacterium there, but various [non invasive] tests have been derived. One of them is a breath test where the presence of the bacteria will break down a substrate with a radioactive label which will appear in the breath and this is an--, quite an important way of screening populations, looking for helicobacter and also confirming that it’s been eradicated. And it led me to a very small change in practice which my colleagues also adopted was that when general practitioners referred patients as outpatients to hospital, gastroenterologists, often their referral was a request for them to undergo endoscopy. And endoscopy is--, which I’ll come to in a moment, has been another major advance and in some hospitals GPs may have direct access to endoscopy units but in--, at the Whittington when I was working there you had to, as it were, go through a referral to a consultant and this would mean seeing the patient in the outpatient clinic saying, “Yes, I think you need an endoscopy,” arranging the endoscopy and so forth. And it occurred to me that if I--, if I screened all the GP referral letters I could, erm, pick out first of all those which said ‘please endoscope my patient who has got tummy pains’ and I could--, or ‘please see this patient with stomach pain and act appropriately’ and sometimes it was very obvious that they did need an endoscopy if there were alarm symptoms which might suggest cancer like weight loss or whatever. So this was one way of expediting endoscopy, putting them straight on the endoscopy list rather than having to wait to see someone in outpatients before being put on the endoscopy list. But the other thing which I introduced because I don’t think GPs were as aware of the breath test as the gastroenterologists were, was writing to the GP and saying ‘well this patient with dyspepsia may or may not have an ulcer but it would be useful to screen them with a breath test to see if they’ve got helicobacter and then act on the results of the test’. And in this way again you could reduce the number of patients coming up to the clinic or reduce the number of requests for endoscopy. And so I started doing this and my colleagues thought I was rather eccentric looking at the referral letters which were of varying helpfulness and the patients, you know, when they were told by the GP they were going to have an endoscopy jolly well wanted to have one, although I don’t think it’s the greatest experience [laughs] in the world. So anyway, I started doing this in the latter years of my time at the Whittington and I was pleased to see that my colleagues continued it after I retired and actually wrote it up as a piece of research in the Journal of the Royal College of Physicians. So helicobacter certainly has been a big change. Endoscopy, fibre optic endoscopy has been--, has had a revolutionary effect on gastroenterology because what existed before optic fibres in a bundle which is flexible which you can pass instruments through, were so called rigid gastroscopies or rigid sigmoidoscopies where you would get a stainless steel tube and get the patient to swallow it which was quite an unpleasant procedure and you could then look inside the stomach and it wasn’t done lightly. And doing it at the other

Dr Eric Beck Page 111 of 123 end with a rigid sigmoidoscope wasn’t quite as unpleasant as having to swallow the thing, but having a flexible fibre optic endoscope has opened up the gastrointestinal tract almost completely. You can get down beyond the duodenum and you can get up to the beginning of the colon. There is a slightly grey area in between of the small intestine but this now can be covered by so called capsule endoscopy where you swallow a pill that sends back images and information from the rest of the gastrointestinal tract. And not only has it become a very important diagnostic tool but also a therapeutic tool, you can do things down an endoscope looking at an ulcer, particularly if it’s bleeding you can zap it with a laser beam and as well, you know, thermocoagulate the vessels in it. One of the most remarkable advances which is now an everyday procedure was to pass an endoscope into the duodenum to what is called the ampulla of Vater which is where the pancreatic duct empties its digestive enzymes into the intestine. And the pancreatic duct is a very narrow thin structure but with an endoscope and considerable skill you can pass through the endoscope a very fine fibre into the pancreatic duct and again do various diagnostic procedures or even therapeutic procedures. And this is called ERCP, endoscopic retrograde cholangiopancreatography because you can also show up the biliary tract which comes in at the same point as the pancreatic duct. And this was like landing a man on the moon to be able to do ERCP. Now it’s done every day by everyone and has completely changed our practice and also had an effect on surgical practice on--, if gallstones get stuck in the bile duct after being expelled from the gallbladder you can go in and widen the duct and grab the stones and pull them out. And so interventional endoscopy is important. And alongside it radiology has improved as well and radiologists now undertake interventional radiology. So if you want to do, say, a liver biopsy although you can do it as a blind procedure through the skin into the underlying liver with a suitable needle, you can also do it through a so called laparoscope where you can see the liver and take a sample from it. And laparoscopy, the idea of passing a tube into the abdominal cavity and visualising the various organs there and doing procedures on them, again has been a major advance in gastroenterology. So the gastric surgeons, those who specialised in ulcer operations, have been almost done out of business now because you can do it either by curing helicobacter or endoscoping and thermocoagulating bleeding ulcers or under running them with stitches. I mean, you know, the innovations in--, continue day after day after day. So that has transformed the practice of part of gastroenterology. The other main part of gastroenterology is--, in terms of patient numbers is probably the irritable bowel syndrome which still remains a mystery, very common problem, creating anxiety, caused by anxiety which then reinforces it. And the main burden is to be able to exclude more serious conditions which might be provoking these symptoms and then to try and help the patient by looking at their lifestyle and their background to modify the symptoms of irritable bowel. It’s a fascinating area of interaction between the very ‘organic’ diseases which might or might not be present, with the patient’s psychological state, with their habits, their eating habits, many patients think their irritable bowel is all due to eating the wrong things if only they knew what it was. And it takes up a large part of not only general practitioners’ time but gastroenterologists’ times. And I was perhaps considered a little eccentric in that I actually got interested in irritable bowel. This was

Dr Eric Beck Page 112 of 123 often thought of as the sort of--, the ‘rubbish basket’, don’t waste my time thing. But I soon became aware that a lot of patients had miserable times because of this even though they had nothing seriously wrong with them that you could operate on or where there was any major therapeutic intervention. And I found that someone as a physician talking to patients a fascinating area. As I say, people used to think I was mad for being interested in irritable bowel syndrome and I think it probably goes back to something I mentioned early on in my training that I’d never been trained as a proper gastroenterologist but I had met gastroenterologists and one of them was David Edwards who I think I‘ve already referred to. And he was a great listener and he listened to people with irritable bowel and I used to sit in with him and listen with him and he didn’t have any cure but you did realise that just listening and talking to patients often was highly therapeutic itself, which is--, as an aside any drug that comes along and claims to cure irritable bowel syndrome which is subjected to a trial you really have to eliminate the doctor from the trial because going to see a doctor is a--, can be a highly therapeutic thing and the drug may be nothing more than a placebo. And if any drug company could find a pill for irritable bowel syndrome they would be the richest company in the world. They’ve tried over the years but nothing has really come up to solve the problem. Yes, so although it’s a mundane condition it’s a very common gastroenterological condition. Cancers of the GI tract I think our management has improved considerably there and one of the issues that has come up in recent years is screening for colon cancer, that’s to say to take a population without symptoms but who are coming to an age in their life when colon cancer may begin to develop and looking for the pre-symptomatic condition and dealing with it. And this is mainly done by initially looking at the stool to see if there's occult bleeding rather than overt bleeding and then undertaking colonoscopy where you can visualise the whole of the colon and you can take biopsies from suspicious areas, or the things always looked for are polyps which may be benign but may be a precursor of cancer. So this initially was a controversial issue as a lot of screening procedures have been because the worry always is that you create abnormal fears in people who haven’t got the condition or investigating people who might have the condition is not without hazard as well. Doing colonoscopies, you know, causes not only discomfort but a certain amount of trouble [carries a small risk of complications]. So the whole thing about gastrointestinal screening as with other cancers has developed over the years and I think most people now are convinced that it has a role. I mean a field completely outside of my own is mammography and breast screening where the same arguments have been put forward that there is a cost not just a financial cost but a cost to the patient by what you, as it were, let loose by doing it. So yes, I suppose those are the--, have been the main changes. The other big area which has to be distinguished from irritable bowel is inflammatory bowel disease, ulcerative colitis and Crohn’s disease. And although advances have been made there it still remains a--, with many unanswered questions, potentially serious and dangerous diseases which to some extent you can solve surgically, if you take the whole colon out you can’t get ulcerative colitis but then you’re left with a life without a colon which is not impossible and Crohn’s disease because it can affect any part of the gut is much harder to treat surgically. So these remain problems. The other big area of gastrointestinal symptoms

Dr Eric Beck Page 113 of 123 doesn’t affect the--, our western population so much but in world terms of course gut infections and particularly in children in the third world remain an enormous problem, but you don’t tend to see this in N19. Yeah, so I suppose those are the main things in gastroenterology [during my working life].

Q: Thank you. I don’t know whether you might have any stories you’re willing to share about particular patients that really benefited from some of the advances you’ve been outlining particularly around, say, helicobacter pylori or…

A: I can’t think of individual patients. I mean it has changed our whole approach to patients. Er, certainly I think bleeding ulcers or bleeding from the upper gastrointestinal tract, which is still a relatively common medical emergency, has greatly benefited from endoscopy and what you can do down an endoscope so that emergency gastrectomies or partial gastrectomies are very, very rare nowadays. One bleeding from the gastrointestinal tract which is a life- threatening situation which I haven’t mentioned because we haven’t really talked about the liver disease (hepatology), which is really part of gastroenterology but some--, the way we subdivide professions now you have some people who only deal with diseases of the liver, the hepatologist like Sheila Sherlock was a great pioneer on and some only deal with the GI tract but most people like myself would deal with both. Now liver--, chronic liver disease leads to cirrhosis of the liver of which the public is well aware of the effects of alcohol causing alcoholic cirrhosis which is a problem and also post viral now we’ve identified the viral causes of hepatitis we realise that hepatitis B and hepatitis C can go on to cause chronic liver disease which can result in liver failure of which the only cure would be a liver transplant. But more acutely and dangerously is that a cirrhotic liver will cause what are called gastroesophageal varices. This is varicose veins, if you like, on the inside of the lower end of the gullet and the upper part of the stomach and if these bleed, bleeding varices is a really alarming problem. And although endoscopy has helped a bit in that in you can try and obliterate the veins by injecting down an endoscope you may nonetheless still have to undertake emergency surgery or other emergency procedures such as passing a balloon and inflating it to compress the varices and hopefully stop them bleeding. So bleeding varices is--, remains a problem but has--, in some cases through the techniques that I’ve mentioned, the outcome has improved. One of the big scourges of talking--, coming back to cancer I think cancer of the colon we’ve alluded to and its possible screening, cancer of the stomach is declining probably because we are treating helicobacter ulcers although helicobacter doesn’t cause a cancer direct it may cause an ulcer which becomes cancerous, but the other big area of cancer which we haven’t really as far as I’m aware got--, made much progress with is cancer of the pancreas. Pancreatic cancer. And that is still a fairly sort of killer disease and despite ERCP, which I mentioned earlier, and various scanning techniques the answer usually is by the time you make the diagnosis it’s too late and we really need some way of screening for pancreatic cancer and there are tests in the pipeline but I don’t think any of them have yet had universal approval.

Dr Eric Beck Page 114 of 123 Q: Thank you. Erm, I had one other question about the college. So you’ve obviously talked a lot about PACES and the MRCP, erm, do you feel like you’ve had any other kind of--, whether other--, any other relationships that you developed with the college beyond the medical education element that you’d like to talk about?

A: No, one of the interesting things by having been a pro-censor and a censor you inevitably become a minor part of the college establishment which means you get invited to take on various other roles. And I’ve had interesting well secondments might be the word to other developing institutions through the college where the president has asked me to take--, or she to take on a task. One of them was accident and emergency medicine, have I already mentioned this? The Accident and Emergency Medicine, casualty medicine has always--, had always been the rather sort of ‘poor relation’ of specialities that people became A&E consultants sometimes because they couldn’t get other consultant posts as I mentioned earlier. And because casualty is such a mixture of medical, surgical and psychiatric and social for that matter problems presenting acutely for one of the other specialties, like an orthopaedic surgeon, to take on all these roles was becoming increasingly difficult. So quite rightly a faculty of accident and emergency medicine was set up to deal with the training of people who wished to specialise in this field rather than to fall into it by default as many did. I mean I can’t think of--, I can only think of one person amongst my contemporaries who started out with a wish to do A&E medicine, that was Howard Baderman, who I may or may not have already mentioned, who was the--, one of the first casualty consultants at UCH. So anyway, the embryo-faculty was beginning to spread its wings and it was going to be a multi college thing. It seemed to start I think in the Edinburgh college of--, or was it the Glasgow college of surgeons? Anyway, I was asked to go along to advise on how you would assess the training of A&E consultants because there was no specific training program or qualification to become an A&E consultant and if you could set up a qualification and standards and a proper training program not only would you find more people hopefully to do it but better trained people to do it. So it was an idea which certainly appealed to me and I had some very interesting times helping them devise a training program and exit exam and took part in the first few exit exams and of course in parallel we were developing things like PACES so we--, I could tell them our experiences there. So yes, that--, that was an interesting secondment. The other one I had and I think it was--, yes, it must have been through the college was the Faculty of Occupational Health who again in their assessment, which they sought advice and help on, always wanted to ensure that in the examinations that there would be a physician representative. And although it overlapped with many other specialties I was asked to take on this role and became an examiner in the occupational health qualifying exams which again were taken by a wide variety of people. And who was interested in occupational health? Well some people were occupational health 100 per cent from the word go but many other people, particularly general practitioners, might be called in by a local business or factory to act as their part time occupational health doctor. So there was a broad area of, as it were, part time. And again it was a wish to set proper standards and test them with an exam and using the oral examination as the major way of doing it. And I’d already been sold on the idea of structured

Dr Eric Beck Page 115 of 123 orals by I think my experience of going to the College of General Practitioners voluntarily, I wasn’t seconded there but I asked to go and see it and, as a result of what we saw there, we modified the MRCP exam. So this sort of cross fertilisation. And I had many interesting sessions examining in occupational health, in fact met one of them on our oral history panel. And one of the things that immediately came home to me, which was so obvious, was that occupational health doctors, a bit like prison doctors, have a conflict of interests. They have a patient or potential patient in front of them but they also have the people who employ them and the people who employ them may wish to undertake things which are not in the patient’s best interests. So for a subject to go and see the occupational health doctor thinking this was a nice kindly general practitioner, which often he is and will be, nonetheless there is a potential sting in the tail that what you are revealing to an occupational health doctor could be used to influence your future career and probably quite rightly. I mean you want to identify people who could be a health hazard to themselves or to the organisation. And one of the things that always came--, that always struck me in a good occupational health candidate, who was put in a position of how would you explain to Joe Blogs this, that or the other, was the need to first of all explain who you were and what your role was. You know, “I am the doctor employed by the company to look after your interests but also to feed back.” And the whole issue of confidentiality is particularly great in occupational health and of course the power of occupational health to alter working practices by inspections of premises and so on I began to realise how important that is. And of course this has become a political issue in that occupational health is, to some extent, undermined by the needs of businesses to make profits and so forth. So again I found that a very interesting side-line that I was--, got into through the college. And perhaps the most interesting one of all was the General Medical Council Performance Procedures. Have I mentioned this before? The General Medical Council, again I haven’t got the exact dates in front of me, was becoming increasingly concerned about poorly performing doctors in general who were not necessarily causing particular individual acts of medical negligence but they were the sort of people everyone, both patients and colleagues, were aware of that you wouldn’t want to send your cat to as it were. And so under the leadership of Donald Irvine, who I was very impressed by, who was chairman of the GMC, general practitioner from the north east, decided to set up Performance Procedures. Now what this meant was that in any specialty if there were--, a concern had been expressed about a doctor’s practice, even though one couldn’t identify specific instances, that the GMC would have the right to make further enquiries before renewing this doctor’s registration ‘cause that’s the great power of the GMC you have to be registered with them to practice medicine. And so they set up a multi-specialty body on performance procedures and I was asked to--, to lead the Performance Procedures in Medicine. The--, as I mentioned, Donald Irvine was the president of the GMC but the person who was empowered to enact it was another very impressive person, Lesley Southgate. She was a general practitioner, a thoughtful general practitioner [laughs], who had become an academic general practitioner and had a chair--, an undergraduate chair in general practice at Barts which again was a rather novel thing to have general practice academic departments in medical schools. So she was very much given the

Dr Eric Beck Page 116 of 123 task of developing and masterminding it. And so in medicine I was asked to recruit a panel of people to help. And Sheila Reith, who I knew from old days up in--, physician in Stirling, I enrolled Jane Dacre who we all know [laughs] because of her experience in assessments and I can’t remember all the other members of the group initially but we had the power to co-opt and call in. So what we had to devise was a detailed questionnaire come interview to try and detect if there were--, if there were problems and if necessary some kind of investigation or examination into the areas under question and to come up with recommendations to the GMC as to whether this person’s registration should be modified in any way. Like, for example, being told that they should stop doing a particular activity until they knew more about it, recommending retraining, rarely recommending that they be actually struck off because it was not of that sort of severity. And so we devised procedures in medicine which were--, and through Lesley Southgate other--, the other groups surgery, ophthalmology, psychiatry devised very similar procedures and started testing them. One of our worries, and it still is a worry with me, was the potentially mischievous use of Performance Procedures to deal with, for want of a better word, awkward ‘cusses’ [01:40:21]. And as anyone could alert the GMC not just other doctors but patients or managers that--, particularly managers we were highly suspicious of this new breed of people who were ruling our lives, who might find an awkward doctor who they wanted to get rid of to put it bluntly. So as with all disciplinary procedures you do worry about not only the good that you’re doing in protecting patients, which is what the GMC is all about, but the harm that you might do to individuals. I mean we’re seeing this in the press at the moment in other contexts. So yes, the GMC procedure--, performance procedures was very interesting and took up a fair bit of my time. It came roundabout the time I was retiring and quite rightly when you retire you withdraw from all these things so I was sad to have to, as it were, give it up having been there at the beginning of it. But I came away more impressed by the General Medical Council as a force for good. I mean most--, if you talk to most doctors about the GMC they’ve got fairly negative impressions of it, “They’re the people who strike you off and they’re the people who charge you an annual retention fee [laughs],” and so on, but I think the GMC did undergo and has undergone considerable changes in recent years. And Donald Irvine, the president at the time, had a lot to do with this. In fact he--, I think he became the second DARE lecturer, I suggested him to come and give the DARE lecture. Yes, so that was again a spin off from college activity. And I mean the best spin off was the various overseas assignments I was sent on usually to do with the exam but not entirely some were primarily teaching exercises. And, you know, finishing up going to examine in the MD in Khartoum, I may have mentioned this already, and being asked by the local examiners, “By the way, a new medical school is holding its first ever exams in Kurdufan,” a remote province of Sudan, “And while you’re here would you mind going and being external examiner?” So I got on the plane to Kurdufan and examined in their first MB exam there which was an interesting experience as well. I mean also the whole structure of Sudanese medical training, as one could say about places like the Philippines and so on, is producing a surplus--, or is producing doctors whose futures are mainly outside the Sudan which has medical needs of its own but are not particularly richly rewarded. But as you have

Dr Eric Beck Page 117 of 123 freedom of movement once you’ve got a medical qualification--, and every new state in the Sudan as a status thing has to set up a university and to be a proper university you have to have a medical school. So they’re churning out doctors in a relatively, or what was a relatively poor country until the oil revenues began to flow, who would go off to rich Gulf states to be doctors there. You know, it’s a crazy world in that third world doctors and nurses then get employed in the first world having been trained at the expense of these poor countries, but--, well that’s another [laughs]--, another issue.

Q: You mentioned that the young man that you were investigating as part of your GMC work was a promising doctor, I wonder if you could say what you thought the qualities of a good doctor are.

A: Oh, how long is a piece of string [laughs]? Well, intelligence obviously is important but it’s not the be all and end all. So, you know, you’re going to have to have a body of knowledge or know how to access a body of knowledge and to do this I’m not suggesting that you carry it all around in your head, that’s very much not the way to do it these days, but you have to know how to solve problems. So I think problem solving at all levels is what medicine is about. But you also have to have an interest, a curiosity and empathy with people and not just to categorise them in a very superficial way. I’m not saying good and bad but, you know, irritable bowel I cited as an example, who might be regarded as patients you don’t wish to be involved with although there was a lot of them about. So empathy I think is an important quality. And ability to change I think is also very important as you’ve seen from the developments in all the specialities including my own. So not getting too fixed in your ways, even if they have served you well over the years you have to be prepared to change and even I learned to do upper GI endoscopy [laughs] as a token of this. And I think there has to be a certain sort of honesty and probity which applies to any profession but temptations may come your way as a doctor and not just where the patient’s interests may be potentially harmed but I’m thinking of interactions with a field we haven’t really talked about, but I have views on like many doctors have, of the pharmaceutical industry. And there’s a sort of love/hate relationship with the pharmaceutical industry which is important in providing new drugs and so forth but it--, I think the relationship with it--, of doctors with it is open to abuse and can be unhealthy and can lead to conflicts of interests and even corrupt practices. I’m not suggesting that many doctors, you know, crossed the line but to be aware of this and because of your position as a doctor you’re going to be subjected to influences and of course you’re also going to be still I think a respected member of the community which carries certain responsibilities with it as well. I think another thing which you have to be prepared to do is that as in most professions you have an inbred loyalty to colleagues but you have to be prepared if you see things going wrong to stick your neck out and I suppose the short hand term for it is to be a whistle blower. I’m not suggesting everybody should be a whistle blower but not to ignore things going wrong in the management of patients hopefully not by yourself but people around you. Yeah, so I think that’s--, that’s a start [laughs].

Dr Eric Beck Page 118 of 123 Q: And you mentioned that now you’re involved in working with first year medical students, I wondered if you had any observations on some of the values and the skills they’re bringing to the profession as a…

A: Well most of them have come straight from school and find the transition to university life difficult in some cases and others they take to it very readily. Erm, trying to instil in them the importance of communication skills and ethics and law and so forth is--, particularly the latter is probably relatively novel concept although they will have, I hope, strong moral and ethical feelings. The communication skills I think is—[paramount], some obviously have it by nature or by upbringing but in others you do realise that they are somewhat deficient and can you train people in this? The conventional wisdom was you couldn’t but you certainly can and this is I think where the GMC has been quite influential in that medical school curricula has emphasised the importance of this because many of the problems they have to deal with are due to poor communication skills by doctors, not them doing awful things but not handling patient problems properly. So, as I say, it’s interesting to see from day one, as it were, some have got it, some haven’t but are prepared to go through the kind of exercises we give them, although in the end a lot of it also depends on learning from peers and also from people who you come to work with as role models these particular skills. But I think the other refreshing thing is that most of them do come--, they are fairly idealistic and come to medicine in a way that is different perhaps from other professions. They don’t just come because it’s a nice secure profession with a good pension at the end of it and the possibility to do some private practice as well to further enrich yourself. Private practice never gets mentioned in the medical school [laughs] I think it perhaps should be. But yeah, so I think their motivation is usually quite strong except for a few who you can identify fairly early on who have been pushed into medicine for all the wrong reasons by ambitious parents or for want--, or having a misjudgement of what medicine is going to be about. And this is where I think the current medical education system at UCL and I think it’s being copied up and down the country and partly at the instigation of the GMC who in the past had very little influence on undergraduate education, I think the, erm--, I’ve lost my train of thought.

Q: You were talking about pushing people into…

A: Yes, pushing people in--, yes, one of the things that we have retained is a first year examination. Of course examinations are considered by some in education now as not the proper way to proceed, that you learn apprenticeships and so forth and you don’t have high stakes exams pass or fail determining the future of your career. And obviously in course assessment and so forth and continuing assessment is important but I think you still need to have particularly in a training program like medicine, which is going to take five and a half or more years, an opportunity to cull those who shouldn’t be there in the first place. Not usually through ignorance I mean they’ve all got brilliant A levels and so on, but that they really shouldn’t be doing medicine. So we have a first year examination covering all the aspects that they’ve learnt so far and a certain number fail and then have a resit a month later and a certain number of those fail altogether and have to leave the medical course. You say, “Well that’s

Dr Eric Beck Page 119 of 123 cruel having been accepted,” but I think it’s an essential thing that it should be because they probably shouldn’t be there in the first place. And the interesting thing is when we have our annual cull, it isn’t enormous, but it’s still a significant number, we--, one of the strengths of the current system at UCL and I think probably elsewhere is having--, splitting them up into relatively small tutorial groups during the first year where they will have a teacher who acts as a facilitator. Not necessarily filling them in with facts which is what they often want, but, you know, showing them how to acquire knowledge, how to solve problems and so forth and they meet them every week. So by the end of the first year the tutors have a pretty good idea of their students and when you go back to the tutors and you say, “Sorry that so and so and so and so didn’t make it,” they say, “Well we could have told you that in the first week.” And it’s not, as I say, necessarily their intelligence, there’s something about them that made them realise they were not doing the right thing. And probably, you know, it’s right and proper that we should do this. They will have acquired some skills in the first year which are generic skills, some of them will go off to the City and become hedge fund managers and by the time their colleagues qualify they’ll be rolling in money [laughs]. And others go off--, we try and help them find something or somewhere to go. Others may go into other science subjects with the hope that they may be able to come back and have another go at medicine later on and a few do that. So--, so yes, that’s the way that it seems to work.

Q: I have just one last question.

A: Ah!

Q: I promise, just one more. I was wondering looking back on your career what would you say you were the most proud of?

A: Oh! Having survived the course [laughs]. No, I think it certainly wouldn’t be my--, any great professional advances in my specialties. I think I left behind a body of patients who I still occasionally bump into in my teaching who I got to like and hopefully this was mutual. So I think the relationship with patients was something, but also I have to say because it did take up a lot of my spare time and very enjoyably so, was the medical education aspect, the both undergraduate and postgraduate and the opportunities to go to parts of the world with a purpose rather than as a tourist. I think that’s an enormous difference when you visit somewhere, not that I’m denigrating tourism, I think it’s a great thing but if you go to a place and you have a reason for going there that makes--, that’s an enormous bonus as it were. Yes, and I suppose some of it is--, was displacement activity to get away from the harsh realities of everyday life but--, which is what some of my colleagues might have said. And I do have some regrets as well that I never really got--, got very far in research. When I first qualified I think I was full of hopes that I would if not become a medical academic nonetheless, you know, undertake some meaningful research and I had various stabs at it which didn’t come to anything much but made me aware of the problems that research does create. And one of the regrets was I suppose at how little guidance as a young doctor I was given in how to go about research. And yes, so I didn’t really achieve much, I’ve written papers and reports

Dr Eric Beck Page 120 of 123 and so on but I’ve never done any real bit of research that I can--, could turn back and be proud of and say, “I did this or discovered that.”

Q: Is there anything else you’d like to say before we finish?

A: Erm, no I don’t--, I don’t think so. Oh, I mentioned--, I made several allusions to--, oh, to the pharmaceutical industry not particularly favourable ones, and I think like many doctors I share this love/hate relationship with them but basically I suppose I do have a rather low opinion of big pharma which many others have. And I’ve had one or two experiences and I think I, when we were talking beforehand, mentioned a particular drug that I--, where I came to clash with big pharma. I don’t know whether you’d like me to--, this was being a gastroenterologist and dealing with, erm, bleeding stomachs, as it were, emergencies. A major cause of upper--, of stomach bleeding was initially Aspirin which has been superseded by other drugs within the category called Nonsteroidal Anti-Inflammatory Drugs [NSAIDs] most of which still have some of the same properties as Aspirin because it’s tied in with therapeutic effect that by inhibiting what are called prostaglandins you also inhibit the defence mechanisms of the stomach. So what is doing you good in one aspect may be doing you harm in another. I’ve already mentioned that if someone can find a pill for irritable bowel syndrome, you know, any drug company they would be in clover. The same applies with nonsteroidal anti-inflammatory drugs which are important drugs in the management of [acute] pain and chronic pain, arthritis, rheumatoid arthritis and so forth. So the ‘holy grail’, which I think is probably unattainable because of the inherent nature of the drug, is to find a nonsteroidal anti-inflammatory drug that doesn’t cause gastrointestinal bleeding. And along came a company who thought they had found it with a drug called Naprosyn. And unlike most new drugs of which the public become aware it’s when they’ve been tried and tested in clinical trials against placebos and so forth, but the manufacturers of Naprosyn were so impressed by what they thought they had got they, erm--, they jumped over these steps and went straight to the media to announce this great discovery of a nonsteroidal anti-inflammatory drug that particularly wouldn’t upset the stomach while still having the painkilling properties. And most doctors, for the reasons that I’ve said, were pretty cynical and said, “Well let’s wait and see.” They got on to radio programs the morning--, one of the morning breakfast ones and the message that came out was if you have chronic pain which is not being adequately controlled rush round to your doctor and ask for Naprosyn. And of course the general public quite understandably did this. So suddenly this new drug, which normally with a new drug it would take quite a long time for sufficient body of evidence to grow, got a huge exposure to a lot of patients early on. And perhaps not surprisingly within a month or two of this I had two patients admitted with bleeding from the stomach both of whom had taken Naprosyn and this was when we endoscoped them we could find no other cause for the bleeding. And so with a feeling of sort of ‘told you so’, as it were, I felt this was sufficient to warrant a letter to the BMJ describing these two cases and warning about the--, this being no different from other nonsteroidals as it had been claimed. And in the same issue of the BMJ where they published this letter was another letter from a rheumatologist at the Westminster Hospital saying exactly the same. The response to this was well people say, “Well you’d expect it, wouldn’t you?” but the response from the company

Dr Eric Beck Page 121 of 123 was to say, “We want to come round and discuss the patients that you have reported and we will send our medical advisor round as soon as possible, please fix a date.” And of course this is one of the criticisms of big pharma that it’s a highly profitable, lucrative business, adds enormously to our--, the British economy with exports and so on and so forth but their methods are very much directed to the bottom line. And I’m not alone in this and many doctors have similar feelings. And of course one of the ways in which they try and influence doctors is perfectly respectable funding clinical meetings, trips to meetings and I’ve been the beneficiary of this as well, but I think one must always make it quite clear what one’s doing and why one is doing it. And of course the scourge of them is, I don’t know if you’ve come across Ben Goldacre, who used to have a regular column in the Saturday Guardian called Bad Science and he wrote a book Bad Science which is very interesting reading but he also wrote another one called Bad Pharma strongly recommended, and he was another DARE lecturer we got. So had the opportunity to talk to him face to face. So yes, I think the relationship between the medical profession and the pharmaceutical profession [industry] is an essential one and it has been a source of conflict of interests even corruption in the past and still goes on and the college here is well aware of it and is trying to draw up guidelines. I remember coming back from an international congress of gastroenterology in Portugal and the British delegation or many of the British doctors going there were being sponsored by Glaxo which I was. And I still remember on the plane going to Lisbon I think they chartered--, yes, they chartered a special plane for us so we were all doctors given, as it were, first class treatment and a very nice meal on the way and halfway through serving the meal to the people in the cabin they ran out of the fillet steak which was on the menu and people were given something else instead. And I still remember the pilot coming on the intercom grovelling and making profuse apologies that not everybody had got their fillet steak. And I thought here we are, you know, a bunch of freeloaders [laughs] being apologised to by--, and I remember when I came back, I’ve forgotten who the president was I think it might have been Les Turnberg [corrected to Bill Hoffenberg], having been--, and the college was beginning to get interested in the interface with pharmacy, sending him a detailed account of what had--, what had gone on on the--, this Glaxo sponsored trip to Lisbon, which I thorough enjoyed. Only time I’ve ever been to Lisbon. Yes, so I mean big pharma is a problem.

Q: You strike me throughout the interview as somebody who is extremely fair, you know, in terms of wanting to change the MRCP exam to make it a fairer exam and the work that you did with DARE which was about the differences between the doctors’ pay award and other health professionals pay award. Where do you think your fairness and your moral codes have come from?

A: Well I suppose it has--, with most people, it probably does come from my parents. I mean I don’t remember them--, my father didn’t express many of the views that I’ve expressed but I think, you know, there was a basic decency and I think also his life experiences which were quite harrowing, I think I’ve mentioned early on, and my mother who was his strong supporter. I think it must be mainly parental influences but I think many of the doctors who I--, senior doctors who I worked for probably influenced me for the good and one or two had the reverse

Dr Eric Beck Page 122 of 123 effect of waking me up to things that could go wrong. Yeah, so it’s--, erm, and fairness in society--, yeah, it’s interesting it was an issue that came up in one of the interviews I did earlier on that people just don’t like to tolerate unfairness. And you see a lot of it going on around you in groups of people who have a--, a much less prospect in life who are being exploited or treated unfairly and so injustice, unfairness I suppose are the other side of the coin that make me want to see fairness and justice and I suppose if I’m honest gives me a certain amount of schadenfreude when I see people coming unstuck in their unfairness, you know, when politicians are exposed for their venality.

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