umve 1tv of Calg ~ Heal h Science Li ....
Alberta Medical Foundation Medicine in Al be rta: Historical Reflections 75th Anniversary
D.R. Wilson, M.D. W.B. Parsons, M.D. •
Dr. Robert G. Brett
Edited by Carl Betke, PhD 1993 ..______• ------
Alberta Medical Foundation
l\1EDICINE IN ALBERTA: HlSTORICAL REFLECTIONS
with a Foreword by R.S. Fraser
a n~f
Dr. J. Robert I ampar Tel ( 403) 482-2626 Fax (403 ) 482-5 445 E-mail AMA_MA IL@a mda.ab.ca FOREWORD R.S. Fraser In 1980 the College of Physicians and Surgeons of Alberta celebrated the 75th anniversary of its founding . To recognize the occasion, but only shortly before it, the College decided to assemble a number of histories to describe the significant progress in health care in this province. To initiate the endeavour the College established a "History of Medicine Committee" with the intention of supplementing the information recorded in Early Medicine in Alberta by Dr. Heber Jamieson. The original members of the Committee were: Drs. R.J. Johnston (Chairman) , R. Kenneth Thomson, W .B. Parsons, and Donald R. Wilson. In 1980 Dr. Parsons became Chairman and Drs. Alan Hepburn (as representative from the Alberta Medicine Association) and Hugh Arnold were added . At the meeting of October 16, 1979, the Assistant Registrar, Dr. C.R. Giles, expressed doubt that the project could be completed for the 75th anniversary celebrations. His concern was well founded , but, at Dr. Wilson's initiative, editing of the collected contributior:is was resumed a decade later and has now finally been completed ... in 1993. Medicine has moved with increasing speed into the scientific age of cellular anatomy, magnetic resonance imaging, genetic manipulc~tion and informatics. The practising physician strains to remain informed while trying to provide services to an informed and occasionally demanding ll public. But medicine remains a profession, its practitioners determined to serve in the interest of those who seek help ;rnrl relit>:f from worry, pain and illness. In this spirit, it is fitting that we periodically contemplate the experience and wisdom of our predecessors, recognizing their struggles and appreciating their successes. This publication could have been encyclopaedic in scope, but the wisdom of the Committee led to the selection of a limited number of disparate topics that reflect health care in a broad sense. Some 40 subjects that were originally considered were reduced to a more manageable list and submissions were solicited from persons who had contributed in those fields. Not all were completed, and some were not extensive enough to include, so there are obvious gaps that await future treatment. Some of the writers had retired and a number have since died . Regrettably, a few submissions bore no evidence of authors' identities, and for some we have been unable to rectify that. The variety of subject matter and the differing styles and depth of treatment led the College to refer the work to the Archives Committee which, upon dissolution, passed the materials to the Alberta Medical Foundation. Owing largely to the persistence and persuasive enthusiasm of its first president, the late Dr. Donald R. Wilson, the project was revived and received funding from the Foundation. The Foundation engaged the services of historian Carl Betke, Ph.D. to "organize and edit this collection of articles while preserving the original content and improving the clarity and lll continuity". Th is he has accomplished in a most professional manner. Wherever possible the final article has been submitted to the author for comment or correction. We regret that some authors remain unknown to us but hope that both they and those who have not lived to see the publication of their work would have approved of the product. To all contributors we extend our thanks. May this collection serve to remind physicians of the contributions of our predecessors and encourage us to preserve medicine as a serving profession. Robert Fraser, M .D . Past President, Alberta Medical Foundation October 30, 1993 CONTENTS Foreword .... R.S. Fraser Contents ...... iv I. Selected Elements in the Health Care Svstems The Development of Alberta Hospitals Since World War II ...... l R.K.C. Thomson Public Health ...... 22 W.B. Parsons and Charles More The Development of Prepaid Medical Care in Alberta to 1969 ...... 33 W.B. Parsons The Pensioners' Medical Fund, 1947 - 1967 ...... 61 Author Unidentified The Order of St. J oho (St. J oho Ambulance) ...... 64 D.R. Wilson II. Special I'vfedical Concerns Tuberculosis in Alberta: 1905 - 1980 ...... 69 H.H. Stephens Evolution of the Venereal Disease Program in the Province of Alberta ...... 92 D.R. Wilson, with Paul Rentier v IIJ. Medicine in a Crisis Atmosphere Medicine in Alberta: The War Years ...... 97 W.B. Parsons IV. Education and Research The Faculty of Medicine, University of Alberta, 1913 - 1969 ...... 108 D.R. Wilson Memoirs of a Career in Medical Education in Alberta, 1914 - 1959 ...... 120 John W . Scott The University of Alberta Department of Medicine, 1954 - 1969: A Personal Review . .. 136 D.R. Wilson Early Diagnostic Cardiology at the University of Alberta: The Development of Catheterization in the 1950s and 1960s ...... 153 R.S. Fraser The University of Alberta Medical Alumni Association ...... 179 A.G. Markle The Gladys and Merrill Muttart Foundation ...... 185 D.R. Wilson The Origins of the Faculty of Medicine, University of Calgary ...... 190 D.R. Wilson and D.L. McNeil Reflections on the Development of the Faculty of Medicine, University of Calgary . . . . . 196 D .L. McNeil, with A.K. Kirchner The Alberta Heritage Foundation for Medical Research ...... 214 J.E. Bradley The McLaughlin Examination and Research Centre ...... 219 D.R. Wilson V. Professional Oq~anizations The Alberta Medical Association from 1906 to 1980 ...... 228 H.E. Harper The College of Physicians and Surgeons and the Alberta Medical Association, 1948 - 1968: The Separation ...... 236 M. Sereda Formal Initiatives in Public Relations, 1957 - 1979n ...... 242 W.B. Parsons Modern Developments in the Alb-erta Medical Association ...... 248 R.F. Clark The College of Family Practice ...... 287 Author Unidentified The Alberta Thoracic Society ...... 290 Author Unidentified The Alpha Omega Alpha Honour Medical Society ...... 292 D.R. Wilson The Development of Alberta Hospitals Since World War I1 R.K.C. Thomson The North West Mounted Police built and staffed the first hospitals in Alberta, first at the original barracks of Fort Macleod in 1874, and then Fort Walsh in 1875 and in Calgary in 1883 . Construction of the Canadian Pacific Railway through Alberta in 1883 brought new communities, where general hospitals appeared in Medicine Hat in 1889 and Calgary in 1890. At St. Albert, a community that had developed earlier out of the fur trade, the Grey Nuns served a hospital built in 1881 very well, even though they were not trained nurses. The physicians of Edmonton brought their patients to this hospital until the Edmonton General Hospital was built fourteen years later. From these origins, as settlement boomed after the tum of the century, Alberta's hospital tradition developed. Control and Financing In the early days of Alberta's history, the hospital were autonomous institutions operated by charitable organizations, local groups and sometimes by local governments. With increased citizen demand and. increasing costs, government .participation became necessary - first muuicipal, then provincial and eventually federal. The independence of early hospital boards was based on their ability to levy taxes and elect members directly, but the involvement of senior levels of government eroded local autonomy. It is understandable that governments were reluctant to expend public funds without having some control, but as a result governments at 2 vanous levels used spending powers to set hospital policy, reducing hospital boards' independence. The financing of hospital costs in Alberta has varied. Under the Municipal Hospitals Act of 1918, the government had introduced a form of hospital insurance providing basic hospital care for ratepayers at $1 per day user fee. A non-ratepayer could secure coverage by purchasing a $10 "ticket" . Beyond a provincial per diem grant, further revenue came from each hospital board's power to requisition funds from the municipalities within the hospital district. Changes in the Municipal Hospital Act in 1950 permitted municipalities outside a hospital district to contract out their hospital requirements to a hospital in a nearby district. The hospital provided basic care and the municipality assumed all approved basic costs above the $1 per day user fee and the province then reimbursed the municipality for one-half its costs. The Alberta Hospitalization Benefits Plan of 1957 completely covered hospitalization costs and reduced the need for municipal contribution. The requisition was set at a province-wide levy of 4 mills per annum on a uniform assessment. This money went into the provincial general revenue fund to be redistributed among the municipalities according to need. This 4 mill levy was abolished by amendments in the Municipal Taxation Act of 1970. In 1969 the Social Credit Government of the day established two Commissions, one for hospitals, and the other for health care, to place decisions within the authority of a non-political 3 commission operating at arms length from the government. Here was an attempt to cut back hospital costs, since the commission would have no vested interest in avoiding politically distasteful moves such as hospital closure. The hospitals could, of course, always appeal unfavourable decisions to the Minister of Health and Social Development. Hospital costs did nevertheless increase rapidly during the 1970s. In order to increase its control of decisions made and to effect greater economy, the Alberta government in 1978 replaced the Alberta Hospital Services Commission and the Alberta Health Care Insurance Commission with a single department. Removing the political buffer of the Commissions made elected provincial officials directly responsible for decision making. Hospital boards therefore possess only a fraction of the power they held in bygone years. Last dollar financing means that the province has extended its control to an unprecedented level with final authority over hospital budgets. If the department cuts back the budget and if a hospital cannot live within the prescribed amount, then the hospital has Mo choices. It can curtail services and reduce costs, or it can run at a deficit and hope that the province will pick up the debt at the end of the year. The possibility of a return to elected hospital boards with some taxing authority may still develop. Hospitals in 1939 The Department of Public Health reported 94 approved hospitals in Alberta in 1939, including four isolation hospitals (located in Calgary, Edmonton, Lethbridge, and Medicine Hat) that were later deemed units of general hospitals in those cities. The hospital at Fort Smith in the 4 Northwest Territories also counted because it served mainly residents of Alberta, as did the T. lnyrlm in<>tF.r Hmpit;il , located in Saskatchewan, because it was owned partially by the adjoining hospital district in Alberta. Ignoring these institutions, there were still 88 approved general hospitals operating within the provincial boundaries. At that time, each hospital calculated its own bed capacity; the number of rated beds (then referred to as "bed complement") was not governed by provincial standards. The capacities reported in 1939 totalled 4,390 beds for adults and children and 695 bassinets for newborn infants. Based upon an estimated population of 780,000, the ratio of beds in approved general hospitals to population was about 5 . 6 per thousand. Religious groups operated 38 hospitals, ho spital districts (including Lloydminster) owned 24, and community organizations or local municipalities operated 26. The University Hospital was the only general hospital owned and operated by the Province. There were 50 private hospitals licensed under the Private Hospitals Act with something in excess of 200 beds .. Most private hospitals were very. small. Physicians operated some under contracts with mining corporations. Voluntary agencies operated a few larger licensed institutions for the care of the chronically ill. Homes for the aged and the nursing homes of the day were licensed municipally and did not come under the jurisdiction of the Department of Public Health. 5 Through the Department of Public Health, the provincial government directly operated institutions for the mentally ill in Ponoka, Claresholm, Raymond, Edmonton (Oliver) and Red Deer, which provided accommodation for 2, 74 7 patients at the end of 1939. The 290 beds at the Central Alberta Sanatorium at Calgary were insufficient to meet the requirements for patients suffering from tuberculosis. To overcome the short-fall, the province paid for the care of TB patients accommodated in the Edmonton General, Royal Alexandra, University, and a few other hospitals, totalling some 219 beds. Wartime Changes Notwithstanding wartime shortages of materials and personnel, six new rural hospitals opened during World War II at Turner Valley (1940), Magrath (1941), Beaverlodge, Brooks, and Taber (1943) and Raymond (1944), although hospitals closed at Nanton (1940) and Marwayne (1943) during the same period. St. Joseph's Hospital, Edmonton, was reclassified (1944) as a chronic rather than a general hospital. As a result of new construction, closures, reclassification, and changes of ownership, by the end of 1945, of 92 approved general hospitals, religious groups operated 39, hospitai districts (including Lloydminster) 35, community organizations and local municipalities 17, and the province one. Although there was only a net gain of four hospitals, the total number of beds available had been increased by additions to a number of others. The rated capacities reported by the hospitals at the end of 1945 totalled 5, 040 beds for adults and children and 863 bassinets for newborn infants. Based upon an estimated population of 826,000, the ratio of beds to population had 6 increased to approximately 6.1 per thousand. On the other hand, the number of licensed private hospitals had decreased to 35 with ;i.crnmmnrl::ition for 270 he There was no change in the number of provincial institutions during the war but the capacity was increased somewhat. The number of patients accommodated in the five psychiatric institutions at the end of 1945 was 3,059. There were 500 beds available for patients suffering from tuberculosis, including 284 in the Central Alberta (later Baker Memorial) Sanatorium at Calgary. While the government of the province had assumed responsibility for care of the mentally ill and tuberculosis patients as well as a number of programs in the field of public health, provincial funding of general hospitals had been limited to a per diem grant (at that time $.45 per patient day) which totalled in 1945 less then S 1 million. The first direct provincial contribution to financing general hospital services came with the introduction of the Maternity Hospitalization Act on April 1, 1944. Under this legislatio n, women were entitled to up to 12 days standard ward hospitalization for obstetrical sef'lices at public expense. The rates at which the province reimbursed hospitals for obstetrical sef'lices provided under the Act were negotiated between the Minister and a committee of the hospital association . .The stated objective of the program was to improve Alberta's relatively poor maternal mortality rate, which did improve in subsequent years. The hospitals of the province had formed the Alberta Hospital Association in 1919. In that same year, the first three district (then called "municipal") hospitals were built and in 1920 the district 7 hospitals formed an association known as the Alberta Municipal Hospital Association. A few hospitals were members of both organizations. The two associations worked cooperatively, struck joint committees on matters of mutual interest, and for a number of years held conjoint conventions. In 1943, they amalgamated, as the Associated Hospitals of Alberta until 1965 and the Alberta Hospital Association thereafter. The National Health Grants Program Events in the immediate post-war years gave early indications of the social evolution which would affect dramatically the health care scene in Canada in the following two decades. Amidst much talk of health insurance, the introduction of a hospital insurance plan by the government of Canada seemed imminent. Stimulated by the prospect of substantial federal contributions, provincial governments made plans to participate. Action by the federal government was delayed by political opposition in parliament and by the fear that Canada's hospitals, limited in development by five years of wartime restrictions, would be unable to meet the increased demands of health insurance. Moreover, health was a matter of provincial jurisd~ction and the federal government was unable to reach agreement with provinces. Consequently, in the spring of 1947, Prime Minister Mackenzie King announced the National Health Grants Program, a many-pronged array of federal financial aids and incentives to the provinces designed to augment rapidly the country's capacity to provide hospital and other health services. 8 One of the federal grants, known as the Professio nal Training Grant, provi ded funds for training health care personnel. The Hospital Construction Grant provided $1 ,000 per bed, to be matched by an equal provincial contribution, towards the construction of new hospital facilities. Augmenting the Hospital Construction Grant, the federal Department of National Health and Welfare issued a series of construction guidelines recommending minimum building standards for hospital facilities including area requirements for bed accommodation. The final determination of standards was provincial prerogative but Alberta and most other provinces adopted standards patterned close! y upon the federal guidelines. The new "square footage per bed" regulations applied to existing hospitals as well as to new construction. Over a period of two or three years, hospital buildings were inspected, measurements taken, and the area. standards applied. This exercise resulted in the drastic reduction of the number of "rated beds" in many institutions that had previously calculated ratings without the benefit of any uniform guide. Thereafter, the ratings were established through application of the standards approved by the Department of Public Health. Notwithstanding that.there were eight more hospitals and approximately 400 more hospital beds in use in Alberta in 1949 than in 1945, the official reports indicate a total rated capacity of 5, 190 beds and 945 bassinets in 1945, but only 4,684 rate The drop in the ratio of beds (excluding newborn) to population from 6. 1 in 1945 to 5.4 in 1949 is misleading because it reflects the change in the method of counting beds rather than a 9 reduction in the accommodation available. This distortion renders in valid any comparison of bP.cl <;tritistir.' prinr to 1948 with those of subsequent years. Hospital Plans in Alberta Under a statute enacted initially in 1917, the first district hospitals (then known as "municipal hospitals") came into operation in 1919. Subject to the approval of a plebiscite of the ratepayers (those paying taxes on real property), the Act authorized the creation of quasi-municipal jurisdictions known as hospital districts, with boundaries encompassing all or parts of several municipalities, governed by an elected board. A district board was empowered to levy local property taxes in a manner similar to that available to a municipal council. In part at least, the district hospital scheme was a hospital insurance plan . The user paid a relatively small part of the cost of care, usually $41 per day. The bulk of the operating funds and all of the capital costs came from tax requisitions to which all ratepayers contributed whether or not they utilized the services of the hospital. Access to tax funds gave a measure of financial security and stability to a district hospital which was attractive to th~ operators of many voluntary and other types of community hospitals. Primarily for this reason, over the years, many such institutions have been transferred to district status. At the beginning of World War II, there were 24 hospital districts in Alberta. From 1940 to · 1949 the number more than doubled with 14 new institutions and 12 transferred to district ownership from other auspices. 10 As early as 1929, the Government of Alberta authorized an extensive study of "state medicine. " following reports of the studies made, the legislative assembly enacted a "health insurance act" in 1935. In the election later that year, the Social Credit party defeated the United Farmers of Alberta. The new government did not embrace the legislation and the Act was never proclaimed. Anticipating a national program with substantial fe health insurance bandwagon again in 1946 and enacted another statute. The objective of this legislation was frustrated in 194 7 when the government of Canada opte By an amendment to The Public Welfare Act in 1947, the Government of Alberta assumed responsibility for the hospitalization of old age pensioners, blind pensioners, etc. To qualify, an individual had to be 70 years of age and have a very limited income in order to be eligible for an old age pension. The new provincial program benefited the most needy citizens, as pensioners generally. were a disadvantage Administratively, the hospitalization plan for pensioners operated in the same manner as the maternity hospitalization plan which had been initiated three years earlier. Rates were determined by negotiation between the Minister and the hospital association acting on behalf of its members. The billing procedure was simple. Hospitals filed a monthly return with the 11 Department of Public Health covering all patients treated in order to claim the per diem grant. Days of service provided for maternity patients and pensioners were irif'ntifif'Ii nn thi<; rr~ t11m ;inrl hospitals received payment routinely from the government. A group hospitalization plan, operated by the four general hospital in Edmonton, had been initiated in 1934 under the determined leadership of Dr. A.F. Anderson. The plan was deemed successful and benefits to both subscribers and the hospitals were significant, notwithstanding that only city residents were eligible to participate and benefits were limited to services in the four sponsoring hospitals. Similar plans which were area-wide in scope were operating successfully in some other jurisdictions in Canada and in many parts of the United States. On the recommendation of its Economics Committee, the Associated Hospitals of Alberta decided in September 1947 to launch a province-wide Blue Cross plan for the prepayment of hospital care. At a special CDnvention in Red Deer in December 1947, Association members approved the content of a proposed statute to incorporate the organization and authorize the terms and conditions of the first Blue Cross subscriber's contract. The Legislative Assembly passed the Associated Hospitals of Alberta Act in March 1948 and the Alberta Blue Cross Plan was launched shortly thereafter. Initially, the Plan provided a full range of hospital services, upon payment of a monthly subscription of $2 per family, for members of employed groups and their dependents. 12 The Department of Public Health supervised the district hospital plan closely and took rt:spur1silJiliLy fur ils gtuwLl1 and development. During the more than 20 years that he held the portfolio, Dr. W.W. Cross became increasingly enamoured of the plan and used every means of persuasion (and coercion when the opportunity presented itself) in promoting its propagation. His almost total preoccupation with municipal ownership and operation of hospitals so coloured his attitudes that he saw a hospitalization plan for the Province of Alberta in no other terms than the district model. Meanwhile, failure to reach agreement at a federal-provincial conference in April i946 ended, for the time being, aspirations for a national hospital program. Subsequently Alberta's neighbouring provinces of Saskatchewan (1947) and British Columbia (1949) proceeded with provincially operated hospital insurance programs. The Government of Alberta, however, moved in the direction of public funding at the municipal rather than the provincial level of government. The Alberta government's ensuing efforts to force all hospitals into the district mold foundered because many municipalities, including the metropolitan sectors, were unwilling to burden property owners with the level of taxation which would have been required to provide all hospital care in the province on the district plan. The government realized finally that participation by cities and many other municipalities would come only if the province contributed substantial financial support. As it happened, the province's ability to contribute was improving with the upswing in the provincial economy following the discovery of oil at Leduc in 194 7. 13 At the hospital convention in November 1949, Dr. Cross unveiled a new government proposal 1inrlP.r which the province would reimburse municipalities for one-half of their expenditures if they initiated a program to provide hospital services at the direct cost to their results of $1 per day or less. The Hospitalization of City Residents Act, which became operative on June 1, 1950, and amendments to the Alberta Hospitals Act and other statutes in 1950 and subsequent years, created the Provincial-Municipal Hospitalization Plan. The plan did not alter or interfere with existing provincial payments to hospitals. The per diem grant of $.70 per patient day continued, as did provincial grants of hospitalization of maternity cases, pensioners, and victims of poliomyelitis. Because the plan emulated the district hospital scheme, district hospitals automatically met all of the conditions for participation and received provincial grants for eligible patients directly. In the case of an area which was not already part of a hospital district, the municipality could qualify to participate by enacting a bylaw creating a municipal plan under which ratepayers were entitled to hospitalizatj.on at $1 per day with the balance of the cost paid by the municipality, and non-ratepayers could become eligible upon payment of a prescribed premium. The province then reimbursed the municipality for fifty percent (50 percent) of the amount which it had paid to hospitals on behalf of its ratepayers and other participating residents. 14 The enlistment of municipalities grew gradually during the Plan's operation from mid-1950 until March 1957. Most municipalities entered into the program thllt ensured coverage for ratepayers and their dependents. Because the enrolment of non-ratepayers was voluntary, many did not join. At the highest point of participation, something in the order of the 75 percent of the residents of the province became eligible for hospital care under the plan at a direct cost of $1 per day. The government of Canada revived its interest in a national hospital plan in the mid-1950's and renewed its discussion with the provinces concerning the form it which take. In common with other provincial administrations, the government of Alberta commenced active planning, creating a hospital insurance planning committee in July 1956 to draft a hospital insurance plan for Alberta. The planning committee consulted widely and held frequent meetings with municipal bodies, the professions and the hospital association. Under the Hospitalization Benefits Act of April 1957, the government divided the Hospital and Medical Services Division of the Department of Public Health into two separate divisions effective July 1, 1957. The Hospitals Division became responsible for administrative as well as planning functions. The Canadian parliament enacted the Hospital Insurance and Diagnostic Services Act in 1957. When the required majority of the provinces with not less than 50 percent of the population agreed to participate, the federal plan became operative. The Alberta Hospitalization Benefits Act was proclaimed, the government of Alberta entered into a cost-sharing agreement with the 15 government of Canada, and The Alberta Hospitalization Benefits Plan came into operation on April 1, 1958. All residents of the province were entitled to standard ward hospital care under the Plan. Patients paid a statutory daily rate (a portion of the cost not shared by the federal government) and the Province paid the hospital its remaining operating costs. The Province was reimbursed by the federal government for approximately 50 percent of its expenditures under a complicated cost-sharing formula. Municipalities contributed by way of a four-mill property tax levy remitted to the province. Construction of General Hospitals Economic conditions inhibited hospital construction in the depression years and materials as well as manpower were diverted elsewhere during the war. Alberta's capacity increased moderately to keep pace with normal population growth but replacements and updating of facilities lagged. Action on deferred projects caused an upswing in construction in the post-war period, with some stimulation also from the federal/provincial hospital construction grants. The real nee In 1959, the provincial government assumed the bulk (approximately 90 percent) of the capital cusl uf liusµiL.a.ls. Wl1ile Ll1i::, 111uve µ!deed control of liosµit.al construction in the hands of the Province, it also opened the door to hospital boards, chambers of commerce, and politicians at all levels to pressure the government for new or improved facilities. Industrialization was accompanied by urbanization; while the populatior of rural areas tended to decline, the cities, particularly Calgary and Edmonton, grew at phenomenal rates. Although most of the additional hospital bed capacity was built in the major centres, residents of predominantly rural areas were not to be denied their "share of the pie", with the result that construction proceeded apace throughout the length and breadth of the Province. Increases in Total Hospital Capacity The net increase of 30 general hospitals in the period 1946 to 1979 inclusive tells only a small part of the total story. It does not reflect the many institutions which were totally or almost totally rebuilt: at Medicine Hat and Red Deer, the Calgary General, and the General, Royal Alexandra, Misericordia and University Hospitals in Edmonton. Nor does it reflect numerous extensive renovations or massive additions to existing hospitals. Based upon a popuiation of 826,000, the 5,040 rated beds for adults and children (excluding newborns) reported at December 31, 1945 gave a ratio of beds to population of 6.1 per thousand, an inflated figure because of the method of calculation. At March 31, 1979, based upon a population of 1,990,800, the 11,560 rated beds gave a ratio of 5.8 per thousand. 17 Hospitals owned and operated by the government of Canada (Blood Indian, Cardston; Colonel Belcher, Calgary; Charles Camsell, Edmonton; Canadian Forces Base, Cold Lake) are not included in any of the foregoing statistics. Addition of the 804 beds in these institutions would bring the total number of rated beds in general hospitals to 12, 364 and increase the ratio to 6.2 per thousand of population. TABLE: NEW HOSPITALS, CLOSUTc_ AND OWNERSHIP CHANGES, 1945 - 1970 The dramatic swing from voluntary to public auspices during the period is demonstrated with the following ownership alnreviations: D = District; R = Religious; M = Municipality; C = Community, Industrial or Lay; and P = Provincial Government ..... New General Hospitals Built .. • . General Hospitals Closed Ownership Changes of General Hospitals ~I,...... II I . . . ·. FROM TO . • 1946 Cadomin c Berwyn c D Mayerthorpe D Empress c D .... Oyen D Fort Macleod c D Ponoka D Lacombe c D Rocky Mountai n House R D Elnora D To field D l8 Two Hills D ~I Hythe I D IIWayne c I II I I I Blairmore D Coleman c Rimbey D Rimbey (St. Paul 's) R l8Three Hills D 1950 II Glendon I I D I I Fairview I c I D I 1952 Cadomin I I I c IITurner Va lley I I c I D I I 1953 · · IICoaldale I c I . Nor I ·· 1955 / II t..hbddgo Lethbridge (Galt) I D I M I M«i;,; "' H>< I M IT:I 1.. 1956 ·.·•••II Devon IM I I Smoky Lake R D I I I ~I Mercoal I D I II I I I ~I Drayton Valley D I I IICanmore I c I D I I 195911 Bow Island Merco al D lo I II I I I Hinton D I Wet"k;w;, c D Picture Butte D ~ I Wetask iwin c D 1962 ·•. · IILeduc I I D I I Bonnyville (Duclos) R . I I c I 1963 Bashaw D ... Breton D M ilk River D Stony Plain D I· 1964 . II(Edm.) Glenrose P II(Edm.) Beulah Home I I c II I I I 1966 . Boyle D (Calg.) Rockyview D Fort McMurray D Fort Saskatchewan D Valleyview D Whitecourt D ·.. (Calg.) Foothills p 1968 Slave Lake D Sundre D - - Year New GeneralHospit~1lsIluilt Genernl Jlospirals Closed Ownership Changes of General Ilospitals (Edm.) Dr. W.W . Cro ss p FROM TO I(C,lg .) Holy Crn" R D ~I I II I Fort Vermilion R D 1970 Grande Cache D Ft. M c Murray (St. Gabriel' s) R Cold L'lke R D St. Albert D lligh Prairie R D McLennan R D Vi Ina R D Jasper Park R D St. Paul R D ~I II Spirit River R I I D (Calg.) Children's c p ~I I II I Hardisty R D 1973 . High Level D Radway (reclassified as exte nd ed R Lac La Biche R D care) Red Water D ' I I I 1974 II""'h"d R D I I II I Daysland I R I D I 1975 II I I Pincher Creek I R I D I 1979 . 11 I I Galahad R I I D I TABLE: Summary of Hospital Changes; 1945 - 1979 Community Provincial District Religious Municipalitv /Lay Government Totals at December 31, 1945 *35 39 4 13 1 *92 New Hospitals Built 34 _l _l J. 40 *69 39 5 15 4 *132 Closed or Reclassified _lD _{_]} Ul L1Ql *68 36 4 4 *122 Ownership changes - net ill l Totals at December 31 , 1979 *95 17 3 2 5 *122 = = ---- NOTE: Figures do nor include auxiliary hospitals, federal hospitals, or provincial institutions providing psychiatric care. * Includes Lloydminster 22 Public Health W. B. Parsons and Charles More Upon formation of the Province of Alberta in 1905, the administrative department of the Northwest Territories governing the area of the new province was moved from Regina to Edmonton. The Minister of Agriculture became responsible for statistics and public health including hospitals. Thereafter, government responsibilities for health accumulated gradually, reflecting the evolution of health care concerns. In 1909 the first Public Health Act set up a provincial Board of Health with a Provincial Medical Officer of Health who coordinated local Boards. He covered tremendous distances in his visits to the various districts. For many years, the disease that caused the greatest problem was tuberculosis. Ironically, the reputation of Alberta's climate for having a salutary effect on the disease attracted many of its sufferers to the province. In 1918, when responsibility for the public health services, including hospitals, was transferred first to the Provincial Secretary and later to the Minister of Municipal Affairs, the Public Health Nursing Services was set up. Dr. Heber Jamieson, Associate Professor of Medicine at the University of Alberta, who had spent some time in Manitoba investigating the first public health nursing program in Canada, initiated the new programme. These nurses were to inspect school children, interview parents and give health lectures. 23 Alberta's Department of Public Health , created in 1919, was the second in Canada (after New Brunswick' s) and the third in the British Empire. One of its early activities was presentation of the Public Health Nurses Act, which permitted public health nurses with special obstetrical training to act as midwives in isolated areas. At one time, 63 of these nurses served the residents in pioneer communities. But as settlement advanced, doctors and nurses became more readily available and, as Health Units were formed, the district nursing services were gradually discontinued, until only one still functioned in the 1970s, at Worsley, 57 miles from the nearest hospital. Early government responsibility clearly extended first and foremost to areas not effectively served by private or municipal medical facilities. After 1924, for example, travelling clinics toured outlying areas each summer, arriving at each location after a public health nurse had examined the children and identified those requiring further examination. A surgeon, a physician, two dentists and two or three nurses carried out the necessary examinations and performed tonsillectomies and other minor operations. An important function was the education of parents and children in health matters. Doctors practising in the areas the clinics visited complained frequently about the intervention with their patients. In several districts, however, the local doctors responded by making arrangements with their hospitals to hold their own tonsil clinics. On the day set aside, the hospital was emptied as much as possible so that the surgery could proceed. The largest clinic recorded processed 56 children scattered throughout a hospital's wards and corridors. Of each $25 fee, the hospital took $1 and the surgeon and anaesthetist split the remainder. The travelling clinics functioned yearly until the wartime shortage of medical personnel prevented continuation after 1944. 24 Calgary and Edmonton had their own independent health departments after 1905 . Not until 1950 did the provincial government make grants available to these cities for the purpose. To encourage the spread of local facilities, the Minister of Health was given authority in 1929 to establish full-time health districts in municipalities requesting them. The first health units to cover wide regions were established in Red Deer and High River-Okotoks in 1931. During the first three years, the cost of operating each unit was shared by the provincial government (50 percent), the Rockefeller Foundation (25 percent) and the local authority (25 percent). In 1961 the government assumed 60 percent of the total cost and in 1973, by which time 27 health units had been developed, the government undertook to fund all public health programs, including 100 percent of approved health unit budgets. Full responsibility for public health returned to the provincial government everywhere but the two cities, which retained partial burdens. The early function of the Health Unit was carried out by a full-time Medical Officer of Health, a hygienist, a nurse and a secretary. Their activities included examination of school children, education, hygiene inspection, vaccinations and innoculations, and control of contagious diseases. At first, facing limited supplies of vaccine, they conducted smallpox vaccination by transferring the pus from one child's successful vaccination to other children. To control and prevent the goitre that was endemic in many areas, they recommended the use of iodized salt. Municipalities paid for the distribution of cod liver oil to school children. Through the health units, the government went a long way in offering health and security to the citizens of Alberta. Many innovations appeared during the long term of service of Dr. W.W. 25 Cross, Minister of Public Health from 1935 to 1957 and Minister of Public Welfare from 1944 to 1951. Dr. Cross stressed health education and prevention. During his 22 years in office, the infant mortality droppe 8 per thousand to 0.4. Polio presented another widespread problem in prevention and patient care that involved the health units. In 1938, the Alberta government was the first in Canada to offer after-care to polio victims: the necessary hospital and surgical services and rehabilitation. During the great polio epidemic of 1953, health units closed schools, swimming pools and cinemas. Government service increased to cover the acute phase and practically the entire polio treatment. Health units played active parts in the gamma globulin program and subsequently in Salk vaccine innoculations. \Vhen the Salk vaccine was first approved, unfortunately, the medical officer of health in Red Deer considered it useless and refused to use it. The following year he was replaced. As new vaccines appeared, they became part of the health units' armamentarium. When measles vaccine was introduced in 1965 and in 1966, more people were innoculated against the disease in Alberta than in the rest of Canada. Various combinations of the customary vaccines were tried, up to five at a time. In 1973, the Association of Alberta Health Units was formed to discuss mutual problems and to share ideas. Swine 'flu vaccine was used in 1976 but discontinued due to development of some cases of Guillian-Barre syndrome in individuals who had been innoculated. 26 The health units proved to be good pegs on which to hang new government services, often on a tnal basis m selected units. ln one, a dental officer was installed in 1960 and three years later, dental hygienists. The same year an educational psychologist was added. Later this function was taken over by the Department of Education. In 1972 a speech therapy project was undertaken on a trial basis and later adopted. Health units added nutritionists in 1973, though for many years there had been a nutritionist in the Department. An Occupational Health and Safety Program emerged in 1974, the same year in which home care nursing was instituted. In some areas the free health unit nursing services eliminated VON services. In 1979, health units added full-time administrators and established Home Care Management Committees. A Hereditary Disease Identification Program was started in 1980 and genetic counselling became a health unit service. The Alberta Aids to Daily Living program, instituted in 1980 as well, included geriatric surveillance. As the scope of health unit services expanded, the government moved rapidly into other health care areas. The Rowell-Sirois report of 1938, which arose from the Royal Commission on Dominion-Provincial relations, developed the concept of a close relationship between health services and social services addressing other needs. In this, Alberta was already well advanced in a number of categories. Free sanitarium services for tuberculosis had been recommended by the municipalities and Alberta instituted them in 1934, becoming the second province to do so. The Central Alberta (later named the Baker Memorial) Sanitorium served the southern part of the province. In Edmonton, space was at first provided in the general hospitals, and after 1956 in the Aberhart Memorial Sanitorium. 27 On another front, the Maternity Hospitalization Act of 1939 authorized payment of $15 to all expectant mothers in poor financial circumstances. Five years later free maternity hospitalization was extended to all maternity patients. In 1948 the federal government introduced grants for public health services. This was the year that the federal Department of Pensions and National Health became the Department of Health and Welfare. In line with this philosophy, the Department of Public Welfare was created in Alberta to handle the great expansion in social services. Dr. Cross was appointed Minister, holding the two portfolios and administering all acts governing relief and public welfare until 1959, when the responsibilities were divided. In 1954 the government aided the municipal ities in building senior citizens' homes. Later, in 1959, it developed a five-year plan to build 50 lodges to take the pressure off the hospitals, which were chronically short of beds. In the period before and after World War II , new services proliferated. In 1938 Alberta had its first and only case of bubonic plague. A team which had been organized to investigate this case found that the carriers were gophers in an area south of Hannah. The next year the team followed up cases of Rocky Mountain Spotted Fever. In 1944 the first Division of Entomology to be set up by a Health Department in Canada was established in Edmonton to offer laboratory services in the field of insect-borne disease. 28 The Cancer Treatment and Prevention Act of 1940, which provided for free diagnosis and treatment, went into effect in Calgary and Edmonton the following year. In the post-war years, the Public Health Department developed cerebral palsy clinics and rheumatoid arthritis clinics. It provided space and grants to the Red Cross Transfusion Services, initiated a program with the Alberta medical profession for the investigation of neonatal deaths and provided grants to the University Hospital for experimental work which resulted in open heart surgery. It expedited the training of nurses in 1963 by the introduction of grants to hospitals with training schools of $300 for each nurse who was graduated. Alberta's services in the area of mental health proceeded slowly. Institutional extensions and improvements continued through the years with increased bed capacity, new institutions at Raymond and Camrose and in 1958 the Deerhome facility at Red Deer for mentally handicapped individuals who could not be trained. The Psychiatric Nurses' Training Act of 1955 introduced training for work at these institutions. Gradually refinements were introduced in this difficult field . Alcohol and drug addicts were no longer admitted to mental hospitals. Regulations governing commitment to mental hospitals was changed: a trend to voluntary admission was encouraged. In 1957, when Dr. Ross became Minister of Public Health, changes in government departments preceded new arrangements for health and hospital care. The Division of Local Health Services brought together responsibility for communicable diseases, health units, municipal nursing, health education, nutrition and entomology. The Division of Hospitals and Medical Services was 29 divided into separate sections. The reasons for this became apparent early in 1958 when universal hospital coverage was extended to the citizens of the province by the provincial government, aided by a 35 percent federal subsidy. Henceforth, each patient paid only a $5 admission fee and received complete hospital services. The following year this insurance was extended to Auxiliary Hospitals. In 1960 the Auxiliary Hospitals Act authorized the establishment of chronic treatment hospitals. The government was greatly expanding its responsibility for hospital care. Nor were other areas neglected. On January 1, 1959 the Provincial Air Ambulance Emergency Service went into operation. As well as providing a valuable service, it produced some dramatic episodes. Between 1959 and 1966, the Department created a Division of Industrial Health; transferred the Alcoholism Foundation to the Department of Public Health in a special division; developed new programmes for cystic fibrosis, diabetes and problems relating to thalidomide; and changed the Venereal Disease Act to provide free treatments by a physician. During these years the government was taking an increasingly active part in the provision of prepaid medical care. To conform to the change in the administration of health services, the Department of Public Health was transformed into the Department of Health with two sections: Hospital Services and Health Services, each headed by a Deputy Minister. With the passage of the Health Care Insurance Act of 1969, which introduced federal medicare to the provinces, the Health Services Section became the Alberta Health Care Insurance Commission with Dr. Ben McLeod as Chairman. Further movement in the trend to Boards and Commissions followed 30 with the formation of the Provincial Cancer Hospitals Board and the Alcohol and Drug Abuse Commission. In 1971 the Alberta Hospitals Commission was formed with Dr. J.E. Bradley as Chairman. Concurrent with these changes in the Department of Health, changes were taking place in the Department of Public Welfare, first established in 1952. Its chief responsibility at the outset was to provide income support, institutional services for those requiring them and child welfare. With federal support, the province could give a pension of $40 per month to those physically or mentally disabled. A year later, the Rehabilitation of the Disabled Branch expanded its support with medical services, vocational training and placement. After significant expansion services through the 1960s, the government determined to change the philosophy of social welfare programs from maintenance and custody to "the social development of the individual." Thus, the Department of Public Welfare became the Department of Social Services under the Social Development Act of 1970. The following spring the Health and Social Development Act was passed, bringing the two departments together under one minister. The re-combination of Health and Social Services led to certain new initiatives. While in opposition, Mr. Lougheed, the new premier after 1971, had shown much interest in mental health services. Soon changes were apparent in a new Services for the Handicapped Division, which established community-based services in mental health and for the handicapped. The 31 Center for the Care of the Mentally Handicapped (the Cormack Center) opened in the old Misericordia Hospital. Extended health benefits covered some services not within medical insurance plans. The Social Sterilization Act was repealed and the Eugenics Board dissolved. The administrative categories continued to shift for ever-growing responsibilities. The Industrial Health Services moved to the Department of Labour in 1975. After the re-election of the Progressive Conservative government in 1975 the name of the Department of Health and Social Development was changed to Social Services and Community Health. There was some criticism of the apparent emphasis on social services at the expense of health. The proponents stressed the importance of prevention and argued that integrated programmes featured social services, community health, mental health and rehabilitation services. The close association of this department with that of Hospitals and Medical Care, it was argued, gave blanket care to the citizens of the province. The philosophical assumptions underlying the programmes of the Department provide clues to the tensions between· individual and collective health care responsibilities raised by 75 years of public health development. The D~partment maintained a commitment to personal responsibility and initiative, to the concept of minimal intervention and the promotion of independence, to the pre-eminence of the family unit, the concept of basic rights, and to prevention. 32 The community health and social services system had grown to involve four major divisions (social services, rehabilitation services, mental health, and community health services) at three levels (municipal, preventive social services and health units, some 3,000 voluntary agencies). A massive system had developed in a relatively short period of time. Much of what the government has done is unquestionably good. Some activities have invoked criticism: though preventive social services were introduced in 1966, for example, there were problems with personnel, problems with community acceptance and problems involving funding in a field without experience. However, soon these services were readily available and accepted, like many others. The modern commitment to health care provides a stunning contrast to the nearly blank field of 1905. 33 The Development of Prepaid Medical Care in Alberta to 1969 W.B. Parsons Prepaid medical care was not new in Alberta after World War II, but early versions took other forms. During the early days of non-native exploration, a party of any size was usually accompanied by a physician who also had other duties. The Hudson's Bay Company had resident physicians in certain areas, as did the North West Mounted Police. In 1889 the first publicly supported hospital in what was to become Alberta was erected at Medicine Hat. Its chief function was to care for the great army of railroad workers who were laying the steel westward. The hospital was built through public subscriptions, voluntary fund raising activities and grants from the territorial government. As one of its sources of operating revenue, the Board of Directors agreed to "lodge, board and give nurse and medical attendance" for one year to anyone who purchased a "Five Dollar Ticket." Several hundred people took advantage of this first prepaid medical care scheme in the region. In later years many companies employed doctors to look after their workmen and their families. For the mines and logging operations on the east slope of the Rockies, in many cases the contract was between the union and the doctors. Similarly the employees of railway companies made contracts with doctors to look after them and their families, the company making deductions to pay doctors. 34 Many fraternal organizations provided members with insurance against the cost of medical care and in some cases with cash benefits. These organizations often began as offshoots of "friendly societies" in England, which provided the same benefits to their members. A feature that developed in the isolated regions of the prairies to ensure me the employment of a doctor by the municipality. This scheme of prepayment became very popular in Saskatchewan and spread to Alberta. Its success resulted in an increase prepaid medical services, not necessarily through municipalities. These were practically the only schemes in Alberta for the prepayment of me Great Depression began in 1929. Then the situation became acute, with many doctors collecting less than 20 percent of their fees because many of their patients went for months without seeing any income. The first move in Alberta toward prepayment of me D.O. Wright pointed out that unless the situation changed, state medicine was inevitable. The Mormon Church, through its Mutual Improvement Association, undertook to make an agreement with the local doctors to provide medical care to its subscribers for $25 a year per family. Over 100 families signed up. The doctors agreed to a one-month trial and the scheme went into effect on October 1, 1931. The doctors must have found it satisfactory, for on March 1, 1932 the Cardston Medical Contract was formed. 35 This Contract was run by a committee made up of newspaper editor Wright, N.E. Tanner and W.E. Hinman. In later years the latter two became cabinet ministers in the Social Credit government and had much to do with the advancement of the medical schemes of the government. The doctors in the Contract were Dr. J.K. Mulloy and Dr. M. Brayton. Patients who had not signed up by the operational date of March 1 could subsequently do so in groups of 10 and more. By 1957 the fee had gone up in stages to $50 per family. There were over 1,000 subscribers. A scheme similar to that in Cardston was later set up in Leth bridge. In Calgary and north of Calgary these contracts were regarded with considerable disfavour. Despite this attitude, Drs. Archie Kennedy and F.O. Galbraith introduced a similar scheme in Stettler with a contract between the patients and the Medical Clinic. This carried on until the advent of Medical Services (Alberta) Incorporated, when that corporation took over the contract. In 1935 the provincial government, acutely aware of the need for arrangements to pay for medical care, passed a Health Insurance Act at the spring sitting of the Legislature. However, in August the United Farmers of Alberta government was defeated and nothing further was done. For some time already, groups and individuals in the medical profession had been promoting health insurance. Most knowledgeable among these was Dr. A.E. Archer, who was Superintendent of the hospital that the Home Mission Board of the United Church of Canada had erected in Lamont in 1912. From his earliest days, Dr. Archer had a keen interest in the 36 independence of medical men and their relationships with their clientele. Thus he was very sensitive to rumblings about state medicine and to the various forms of prepaid medical care. His position as a member of the executive of the Canadian Medical Association (AMA) and then as president in 1942 gave him opportunities to study the various schemes coming into effect across the country. At the time of his presidency there were six physician-sponsored prepaid medical plans in Canada, as well as the Maritime Cooperatives which had done much to prove the validity of the cooperative principle. Dr. Archer found that it was not only patients who were in terested in health insurance. Many doctors were sympathetic to the idea, believing that not only would it relieve the patient of anxiety over his bills but it would permit the doctor to pay more attention to his purpose in life , the prevention and treatment of illness. Joining Dr. Archer in his interest in health insurance was Dr. Morley Young, who had become associated with him in practice. Dr. Young made frequent trips to Edmonton to meet with a group dedicated to prepaid medical care. The other members of th is group were Dr. Roy L. Anderson, a surgeon at the University Hospital who ·as a boy had lived in the Lamont area; Clarence David Jacox, President and Managing Director of the Great West Garment Company in Edmonton; W.F. Empey, Edmonton; and Jonathan Wheatley, a farmer, of Chancellor. This group met at irregular intervals to discuss prepaid medical care, to examine the various schemes in operation at that time, and to interest the medical profession in the formation of a society that would offer medical care on a prepaid basis. On one occasion Drs. Anderson and Young met 37 with the Edmonton Academy of Medicine to put forward their proposal. The Academy listened with interest, but many were sceptical on practical grounds, particularly Dr. A.F. Anderson and Dr. Morton Hall, Superintendent and Pathologist respectively of the Royal Alexandra Hospital. Later, Drs. Roy Anderson and Young spoke to the Calgary and District Medical Society. Here, possibly because members of the Calgary group were reacting to the idea of state medicine, the speakers were given a rather bad time. Following the meeting, Dr. Harry Jennings, a Calgary cardiologist, took the two speakers to dinner, saying he wanted to make up for the treatment they had been accorded. The doctors returning to civilian practice after World War II found many things that were new to them. The Cancer Treatment and Prevention Act, passed in 1941 , provided free diagnostic clinics in Calgary and Edmonton, and free radiation and surgical treatment when authorized by the Cancer Clinic. Free maternity hospitalization had been introduced in 1944; compulsory pre marital blood tests in 1945. There was a new Provincial Laboratory of Entomology. For many, the most alarming demand was for health insurance, or some form of prepaid medical care. Most doctors agreed that people should be able to budget for the cost of medical care, but many confused health insurance with state medicine and so opposed it vigorously. It threatened their economic freedom, the doctor-patient relationship, all that the profession considered holy. Meanwhile, interest in prepaid medical care was increasing across Canada. Two broad categories were under consideration: compulsory prepaid medical care, and voluntary prepaid 38 medical care. The compulsory scheme in Swift Current was being watched with considerable interest, as were the many voluntary schemes in operation in various parts of the country. A plebiscite among doctors in Ontario, to which 47.5 percent replied, showed 89 percent in favour of prepaid medical care, but there was a difference of opinion about its administration. The majority felt that it should be administered by the profession, either through the Ontario Medical Association or independently. As this interest in prepaid medical care increased, more pressure was put on the government and the profession to introduce some scheme. From the reactions of the federal government, labour organizations, women's groups and other voluntary organizations, as well as the man on the street, it was becoming more and more apparent that some form of health insurance was inevitable. The Council of the College of Physicians and Surgeons of Alberta became deeply involved in study and discussion of the various forms of prepaid medical care with a strong concern that the doctor not lose his independence as he would in a state-controlled scheme. A keen promoter of the principle of health insurance was Dr. W.A. (Bill) Bramley-Moore who had been appointed Registrar of the College and Secretary of the Alberta Division of the CMA on January 1, 1946 following his release from the army. Dr. Bramley-Moore's thesis was that, if some form of health insurance was bound to come, the profession should try to have a hand in its organization and function. 39 On several occasions Council called in the group with which Dr. Roy Anderson was associated. These men had studied most forms of health insurance and Council found their information valuable. At one of these meetings a citizen from Stettler was there at his own request. Those present developed the feeling that he must be a communist, as he became very agitated, almost violent, in his denunciation of the ideas held by Council and the others present. He felt that their ideas were too democratic. He proposed a more totalitarian approach. Beginning about the middle of World War II, federal political parties had begun to take a keen interest in prepaid medical care or health insurance. This was strengthened by the announcement of the C:l-.l.\ on January 19, 1943 that: 1. the CMA approves the adoption of the principle of health insurance; 2. the CMA favours a plan of health insurance which will procure the development and provision of the highest standards of health services, preventative and curative, if such a plan be fair to the insured and to all those rendering the services. Subsequently the subject of health insurance underwent considerable study by the House of Commons Special Committee on Social Security. Following many public hearings, the Committee reported that it approved the general principles of health insurance put forth in a health insurance bill respecting public health, health insurance, the prevention of disease and other matters related thereto. The proposed bill of the federal government would subsidize provincial health insurance services on a per capita basis with certain stipulations. In August 1945 the federal government called 40 a Dominion-Provincial Conference on Reconstruction which considered health insurance among the subjects discussed. The proposals were much more acceptable to the province than those circulated earlier. In 1946 the Legislature of Alberta passed enabling legislation to take advantage of the federal subsidies, but did not put it into effect because a follow-up Dominion Provincial Conference revealed disagreement over financing, and the federal bill was not put forward. In July of 1946 a resolution at the annual meeting of the Alberta Division of the CMA agreed with the principles of health insurance but did not endorse several features of the Alberta Health Insurance Act. The deep concern of all doctors was that it might put control of the profession in the hands of the government. A December 1946 meeting of the Board of Directors of the Association heard a report on prepaid medical care. The Secretary was instructed to obtain information on any schemes then in operation in the province. On March 20, 1947 the results of a questionnaire on prepaid medical care were released. 46.9 percent of the doctors replied. 79.6 percent reported in favour, 18 percent against; 56.4 percent favoured administration by the Alberta Division of the CMA. On health insurance, the voting proportions of specialists and general practitioners were about equal on each side of the issue. The same applied to age groups, and urban or rural distribution. 41 On April 3, 1947 the Council of the College accepted a report of the Economics Committee approving the principle of prepaid medical services and requesting that the Committee bring in a proposed plan for the provision of prepaid medical care. Interviews with the Registrar of Companies indicated the College should apply for incorporation under the Societies Act. These matters were discussed at district meetings and the cooperation of the doctors was solicited. In July 194 7 the Registrar reported a growing demand for prepaid medical care. One of the biggest department stores had approached an individual doctor. The Civil Service Association was planning to adopt a scheme of its own. Health societies and individuals across the province were endeavouring to set up prepaid schemes. The annual meeting of September 12 adopted a resolution to proceed with the incorporation of a society to provide voluntary prepaid medical care. The College authorities, together with their lawyers, drew up the articles of incorporation and regulations of the proposed corporation and presented them to Government. As a result, on March 1, 1948 the Legislature of Alberta passed an Act setting up Medical Services (Alberta) Incorporated (MSI). The purpose of the corporation was to provide medical, surgical, and obstetrical services to its subscribers in such a manner as would best meet and serve the interests of those receiving and those giving the services. It was expected to amalgamate all pre-existing prepayment plans. The corporation would maintain effective collaboration with the College of Physicians and Surgeons and assist the government, on request, in strengthening health services, and in educating the public in health matters. 42 The Act stated that the Board of Directors should be made up of a member of the College elected by its members, two elected by participating MSI members and two elected by and representing one of the other membership groups to which he belonged. Named in the Act were those who had done much in furthering prepaid medical care. They were Ray Ellis Staples, Branch Manager, North American Insurance Company, Edmonton; Clarence David Jacox, President and Managing Director, The Great West Garment Company, Edmonton; Jonathon Wheatley, Farmer, Chancellor; Albert Ernest Archer, Physician, Lamont. At the first meeting of the corporation held on April 14, 1948, Dr. Morley Young, President of the Council of the College of Physicians and Surgeons, acted as temporary Chairman. Mr. Staples, who had died , was replaced on the Board by W.E. Empey, Edmonton, who later became Secretary of the corporation. Dr. A.E. Archer was elected First Chairman of the Board and Dr. Roy L. Anderson, Vice-Chairman. Carl C. Cook, previously of the Workmen's Compensation Board, was named Managing Director. A medical director was to be appointed as soon as one could be chosen. The first business matter discussed by the Board was. third-party responsibility, particularly in cases of accident. MSI (as it was popularly called) was not to be responsible for third-party medical costs. To obtain the essential cooperation of the doctors throughout the province, the Board circulated a letter to all members of the College, and arranged meetings in all districts to encourage doctors 43 to sign up with the corpQfation. For the most part these visits were well received, but there were areas in which the doctors remained individualists and did not support the principle of prepaid medical care. Dr. MacGregor Parsons, of Red Deer, who became second President of MSI, was invited to address a mixed dinner of the Calgary Medical Society. His choice of subject was MSI. The reception was even cooler than that accorded Dr. Roy Anderson at an earlier date. Many wanted to hear what Dr. Parsons had to say about the new corporation, but could not over the boos and catcalls from its opponents. Later many of these became staunch supporters. The Board of the new corporation decided not to put on a vigorous campaign but to proceed slowly until they had some actuarial experience. Individual contracts were considered too risky. Contracts were therefore confined to groups of at least 25 in which at least 90 percent enrolled. Service was complete except for refractions, treatment of drug addiction and alcoholism, and payment of mileage. Each patient was free to select his own physician for any one illness. The physician was paid on a fee-for-service basis. The first visit fee and the maternity fee were paid in full , other fees on the basis of 75 percent of the 1947 Schedule. There was no specialist fee. Thus all the desiderata of the medical profession had been achieved: freedom of patients to choose their own doctor, freedom of the doctor to accept a patient, payment of doctors on a fee for-service basis, and administration by those receiving and giving the service. A fixed fee deprived doctors of some freedom, but a procedure that would entice patients with lower fees was avoided. 44 The hope for 100 percent enrolment of doctors arose from the reports of all districts that they were in favour of implementing the Medical Services plan. A resolution received from the Calgary Medical Society in June 1948, however, counselled delay. "We feel that there is no urgency in settling the acceptance of the proposed Medical Services (Alberta) Incorporated scheme and that the final decision should be reserved until the annual meeting." Nevertheless, the corporation started to sell contracts, primarily in Edmonton and Lethbridge, and to a lesser extent in Red Deer and Camrose. Some of the Lethbridge group had earlier experience with health societies. At the fall meeting there was a query from the floor: "Under what authority had the College proceeded with the incorporation of a prepaid medical organization?" The Registrar reported that the College's solicitor had indicated that the resolution passed the previous year was valid for the purpose. The monthly cost of the contracts was $1.60 for a single employee, $3.20 for a family of two, $4 for a family of three, and $4.50 for a family of five or more. If the employee was entitled to medical services from the Department of Veterans Affairs (DV A) or the armed forces, monthly payment for a wife or husband amounted to $2. In order to promote MSI, Council made a number of policy decisions in July, 1950. Council disapproved of any agreement between the medical practitioner and any corporation or group that required the payment of the hospital charges by the medical practitioner. It advocated full 45 use of MSI for the provision of adequate medical care and endorsed fees for service in all competitive fields of medical practice. Finally, any agreement for the provision of medical services was to be submitted to Council for its consideration. By December, 441 of the 655 doctors in the province had signed professional contracts with the corporation and 551 were cooperating. Twenty-two of those who did not sign were in isolated districts that were not served by MSI. In the same year, prepaid medical care received a considerable boost when Sir Earl Page of Australia visited the province. As a result of his discussions, a resolution put forward by Dr. Morley Young at the annual meeting was passed. At the fall meeting in that year, however, there was much discussion of the deficit, some speakers thinking it showed the futility of the enterprise. The meeting agreed that both the public and profession must be educated to prevent a misunderstanding of the significance of the early financial position of a new business. The appointment of a new business manager in November led to improvement in the internal management of the corporation. After the peak deficit of 1951, the situation improved. Experience rating was introduced into all contract renewals. One of the chief reasons for the deficits was the enrolment of Health District groups . which previously had health insurance. Some of these had only 40-50 percent enrolment in MSI, while to be economically viable the scheme required a minimum of 75 percent enrolment. An arrangement was made with the doctors serving these groups to accept a pro rara payment until the contracts ran out. The remaining MSI accounts were paid on a basis of a 5 percent hold-back. 46 In 1953 the deficit had diminished to $38,000. As a result, the payment to doctors was increased to 85 percent. At the annual meeting, many doctors still attacked MSI, but a greater concern was the limited contact MSI had with the rural population, chiefly because it was still not offering individual contracts. A further letter went out to the members of the profession to explain the features of MSI. In December the MSI rates were raised and there was an increase in the medical fees. In 1953 MSI had 41 ,000 members and showed a small surplus of $5,000. The group requirement was reduced to ten; moreover, some five percent of the members, who were previously group members, held individual contracts. There were 400 more doctors in the province than when MSI started service so the Albena Medical Bulletin published an article explaining the objects and functions of the corporation. This was also the year in which MSI joined Trans Canada Medical Plans, which aimed to provide maximum health service to the public and to retain the characteristics of the Canadian way of life in the future practice of medicine. This group had more than three million members, and the respect of the federal government. Its philosophy was expressed in a statement to members that: physicians must .not regard medically sponsored plans as third party but an integral part of the practice of medicine. As such the medical profession can keep an intelligent control over their [sic] services and the conditions under which medical care is provided. Medical fees to users must be kept stable, not escalating. It is your scheme, yours to make it work. 47 The then Minister of National Health said, "I would not undertake anything in the realm of medical health insurance without first consulting and having the approval of the medical profession of Canada." At the year's annual meeting a resolution instructed the College to look into a province-wide scheme of prepaid medical care after the plan outlined by Sir Earl Page. The value of this resolution was in its timing. A provincial election was coming up in two years and federal health grants were about to be terminated. The scheme under consideration differed significantly from the Alberta Health Act that would come in 1964. At the annual meeting in 1954, the fact that some groups were supplied with the names of professional members of MSI raised vigorous objections that the public might infer that only they were qualified to provide services to contract holders. The Board of Directors reported having received many criticisms of MSI, some of them anonymous, about extra billing and the acceptance of gratuities. Worse was the excessive billing of MSI. However, the Alberta Medical Bulletin carried a warning that third-party billing and poor book-keeping could extend to straight dishonesty. The names of those involved were published to protect all concerned. By 1955 MSI had 90,000 subscribers, still on a group basis. On April 1, from a large group of applicants, Dr. S.M. Schmaltz was selected as Director of Medical Services for the Corporation. Dr. Schmaltz had been President of the Alberta Medical Association in 1953-1954, a member of the Council of the Canadian Medical Association and Alberta representative on the 48 CMA Special Committee on Fees. He had been secretary of a prepaid medical scheme for southern Alberta, the Lethbridge Northern Health District. The federal government was again discussing Health Insurance. At its 1956 annual meeting, the Alberta Association passed a motion declaring that "this body strongly disagrees with the implication of compulsion by State Control of Hospital Services and Medical Services in Federal proposals." By 1957 MSI had 600,000 subscribers and increased administrative costs at 7.5 percent of income that a new fee schedule could not meet. MSI went into deficit financing, and then agreed with the College Council to a payment to doctors of 80 percent. MSI asked the doctors to use the new schedule with other organizations. Registrar Bramley-Moore stressed that there must be no extra billing with the new schedule; if there were, the Professional Agreement between individual doctors and the Corporation stated that the patient must be advised of it before the service was delivered. The anaesthetists objected that they did not see their patients until a very short time before the procedure and requested a special rate, but it was rejected because they were already receiving specialists' fees. The radiologists argued that the new payments reduced their fees by 13 percent but it was pointed out that the technical component was up 12 percent. There was general dissatisfaction with the diminished payment, particularly since the Workmen's Compensation Board, the Cancer Clinic and the Department of Veterans' Affairs paid at the 90 49 percent level. To do the same, MSI would have to increase its rate, which was considered a very unwise alternative. In a press interview, Dr. Schmaltz combined the low payment percentage with the fact that 80 percent of doctors were working 80 hours a week. He stressed the need for first-class applicants to medical school. MSI offices opened in Calgary and Lethbridge in 1958, the tenth anniversary year of the corporation. Dr. W.G. McPhail was appointed full-time Medical Director on May I. At an anniversary banquet held in Edmonton, MSI's first subscriber received a silver tray. Most important of all , this was the year in which the corporation expanded to take in individual members at slig:htly higher rates. Early in 1959 the College Council made a recommendation to MSI that it not pay non subscribing doctors but pay each patient the amount on the Schedule. The response from Calgary was indignant. A resolution to Council expressed "displeasure and concern that Council has taken on extremely wide powers of negotiation in that it had issued a directive to MSI which created disadvantages for members of the College in good standing." The resolution recommended further that "all prepaid plans offering lo serve the people of Alberta should be investigated by Council and if satisfactory be recommended to the people of Alberta." But Council had nO\ acted beyond its powers: in 1922, Council had been specifically requested by the Medical Association to accept all responsibilities of negotiation with government and other agencies on behalf of the entire profession. The tension over its recommendation to MSI faded out after MSI began to accept assignments of the fee by the patient to the doctor. 50 At the annual meeting the subject of extra billing was again prominent. The doctors were advised to use care in this regard as MSI payments were close to the Fee Schedule and the public was starting to question doctors' incomes. It was stressed that as fees increased the doctors should try to restrain costs, lest others do it for them. When MSI subscription rates were increased the following January, the hope was expressed that it would not occur again. To control rates, professional members of MSI were appointed to serve on the Economics Committee, and the MSI began to pay doctors 100 percent of the Fee Schedule (up from the prevailing 90 percent). The public response was indignant. Dr. Schmaltz, who had been appointed Executive Director of the Corporation on I anuary 1, 1958 explained the principle: "If the supplier of the services makes special demands on the purse of those receiving the service so that he [sic] cannot or will not buy it, a readjustment must be made in the quality of the product, i.e. physician services." The greatest concern was expressed about the proposed increase in first visits. On the basis of 100 percent payment for these, the overall increase in costs would be in the order of 140 percent. Dr. Schmaltz asked the profession to restrain costs or suffer others to decide the cost, the quantity, and the quality of medical services. In February 1960 the College issued standards required for approval of any other prepaid medical plan. Its benefits had to be comprehensive exclusive of pre-existing conditions. It had to ensure free choice of physician. Its administration was to be non-profit, and the payments to attending physician were to be based on the College Schedule and no lower than those of 51 MSI. Woodwards Sick Benefit Plan met the r~uirements and was approved. In the same month a corporation for laboratory and x-ray procedures was set up but since it contravened the Medical Act the owners changed the organization. In June of 1960 W.H. Carruthers, a Director of MSI, presented a brief to the College Council in which he pointed out the need to control costs, which had become more competitive on a world basis. Doctors, he said, should be the ones to control utilization, then increasing by two and one-half percent per year, by education of the physicians and the patients. He indicated that there was some talk of state medicine similar to the new system in Saskatchewan because, for example, MSI did not look after the unemployed and unemployable. He advocated some plan for seasonal workers, who might build up credits while working. Maybe the employer should help and the doctor take only one-third of the fee. The Insurance Companies Major Medical Plan proved that patients wanted to budget. MSI should eliminate the causes for the patient to look at these plans. The heavier utilization of laboratory and x-ray services in rural areas, Carruthers argued, should also be covered by MSI. On the responsibility of the doctors to deal with such issues, Mr. Scott, a group member of the Board, cited the statement of Trans Canada Medical Plans to the effect that either the Profession would lead the way to a sound prepayment system or it would give way to the leadership of others; and that the agency controlling the payment of medical care costs would control medicine, whether it be the state, the commercial insurance companies, the hospitals, labour, industry or the doctors themselves. 52 At the 1960 annual meeting, Dr. M. Sereda represented statistical information regarding usage by patients receiving care from general practitioners in one particular area. He indicated that the first call was normally initiated by the patient, subsequent ones to a large extent by the doctor. Discussion led to a decision that, if any doctor's pattern of practice varied greatly from that in his district, he would be approached in writing and if the unfavourable pattern continued, he could be "pro-rated" or dropped from membership in MSI. This marked the beginning of peer review as a means of regulating doctor participation. Similarly, the Committee on Economics set up a special committee that studied the over-utilization of medical care plans by physicians and recommended revoking the rights of those who were in default of the conditions of the professional agreement. In 1960 the CMA recommended a list of extended health benefits that should appear in all plans. These included nursing, physiotherapy, Rx drugs, appliances, ambulance, oral surgery, blood and plasma, and extra charges by physicians. The Alberta College Council decided that this was not for MSI until it had met its objective of covering all members with no exclusions, limitations, and waiting periods. In 1961 the federal government undertook to subsidize x-ray and laboratory services in hospitals. There was a marked increase in the demands for these services on an out-patient basis in the rural areas. It was decided that payment could best be handled by MSI. A joint committee of the College and the Associated Hospitals of Alberta prepared a Schedule of Fees. MSI paid 90 percent of this Schedule. 53 In 1961 a survey on prepaid medical care carried out by Western Surveys-Research Limited for the Alberta Di vision's Committee on prepaid medical care, under the chairmanship of Dr. H. V. Morgan of Calgary, found that 67.5 percent of households, involving 800,000 people, enjoyed some degree of prepaid or government-sponsored medical coverage, 54.5 percent adequate and 14. l percent partial. The level of income was directly related to the acquisition of prepaid medical coverage. The public wanted comprehensive coverage, and 76 percent of persons with an annual income of less then $2,000 favoured a means test to determine eligibility for subsidy. On the other hand, the image of MSI was good, lessening the demand for government coverage. The majority of Albertans favoured financing medical coverage through such agencies as MSI with strong secondary preference for payment through taxation. The majority of Albertans did not, however, favour financing medical coverage through government participation. By and large, doctors were highly regarded. The one criticism consistently registered was that "doctors' fees may be fair from their point of view but are too high for the average man to pay." This report was very comprehensive and contained much statistical detail that was assessed by outsiders as reliable. It proved to be of great use later on to those who prepared the brief to the Hall Commission. It was becoming apparent that the principles governing fees required revision. A special committee of MSI suggested paying for periodic health examinations of subscribers who had two years continuous coverage. At the time, an individual who became ill over two months had 54 coverage extended to three months. The Committee felt that this should be increased to six and should also be applied to the unemployed. It suggested that the Unemployment Commission withhold an amount for MSI. The Albena Medical Bulletin ran a series of articles by Dr. G. Grant McPhail, Medical Director of MSI; to educate the profession on what MSI was. He pointed out that the Corporation offered insurance for medical services and that the utilization of these was increasing at four to five percent per annum which appeared to be in the same order of that experienced by similar plans throughout Canada. At the same time, unpleasant reports were coming from Saskatchewan about the view that health services must be regarded as public services that can best be planned, organized, administered and financed by governments. From many sources it was becoming apparent that the changes in medicine most to be expected were changing relationships among doctors, hospitals and governments. On several occasions the government of Alberta had indicated that it was against the compulsory feature of the Federal Health Insurance Plans. Government officials reported that they were pleased with MSI and wished to discuss health insurance with the AMA. In 1963 a special committee of the AMA discussed with the Alberta government a plan to insure all persons against the cost of medical care. The committee outlined suitable principles based on the report to the federal Hall Commission. .55 Later that year, Premier Manning announced the Alberta Medical Plan, under which full medical services would be open to all Albertans. The government would subsidize all except members of sects, defined to include Hutterites and nuns. The subsidy was payment of one-third of the premium to MSI and to any other insuring agency that could match the MSI contract. This did not include the Woodward contract, which Council did not approve. The payment of subsidy was based on income: 90 percent for those below the income tax level; one-third for those paying tax on less than $500 taxable income. The fact that an individual was on subsidy was not to be revealed on the card that indicated his entitlement to medical services. For individuals the rate was now $63 per year. Prior to the introduction of this plan on October 1, 1963, MSI had raised its rates for the first time in three years. Manning had approved of this increase, saying that it would not interfere with the proposed plan. Dr. Schmaltz attributed the need for a raise to greater utilization of the services by subscribers. The medical profession agreed that the new plan must work or else there would be socialization of medicine. A Coordinating Committee was created, made up of four people: one from the provincial government, who was Chairman; one from MSI; one from commercial carriers; and one from the profession. The Alberta Medical Plan proved a success. Much of this was due to the fact that the people of Alberta felt that doctors were trying to cooperate in the provision of good medical care. The good image of MSI was a big factor. The Plan was in accordance with the principles laid down by the CMS and the premiums compared favourably with any in Canada. 56 In July 1965 , Prime Minister Pearson called a meeting of the provincial premiers to discuss the development of a medicare program for Canada. Some of the principles, particularly the compulsory factor, did not coincide with those of the Alberta government. Manning discussed the problem with the AMA, which supported his stand. When the federal Minister of Health, Judy La Marsh, met with the provincial Ministers of Health, Dr. Ross took some members of the AMA along. Some modifications of the federal stand resulted, but the compulsory factor remained. The AMA decided to circulate its statement of policy to the members and to the public. On July 1, 1966 Extended Health Benefits were offered under the Alberta Health Plan. These included physiotherapy , clinical psychology and podiatry, all with some limitations; arnbulii11ce service and a wide range of prescribed drugs and medical supplies. At about the same time the doctors were complaining that the increase in medical fees was not commensurate with the increased cost of practising medicine. In 1966 the federal government announced its plans for Medicare. It offered one-half the per capita cost of the province's medical care plan if the plan covered 90 percent of the population, could be carried by the subscriber to another province, was administered by a non-profit agency, and covered a broad range of medical doctor's services. By some, these federal proposals were described as creeping blackmail. 57 Premier Manning and his government were opposed to the compulsory feature of this plan. In an effort to set up a health system that would qualify under the regulations governing federal health grants, the government passed the Alberta Health Plan Act in April of 1967. This went into effect on July 1. Its purpose was to afford all residents of Alberta, regardless of income level, the opportunity to obtain, for themselves and their dependents, basic health services and optional health services under a voluntary plan; to provide prepaid or insurance coverage for these services, and to provide financial assistance to residents in low income groups from provincial funds. The aim was to have 90 percent of the people under one standard comprehensive plan that would still be voluntary but would qualify for federal Medicare. The Alberta Health Plan included physician's services and certain dental, optometric, podiatric and osteopathic services. No agency other than AHP could sell non-group hospital or medical insurance contracts with premiums subsidized by the provincial government. There were three optional plans that provided hospital and ambulance, limited drugs, and limited naturopathic services. MSI increased its rates to equal those of AHP. Hospital insurance was added, but at rates not comparable to those of the government plan. Despite the increase in premium rates, increased utilization .of services produced the need within a year for a fluctuating reserve to cover unforeseen expenses. A two percent fund was set up to amortize first year losses over two to three years. By the end of the first year the Alberta Health Plan had nearly 925 ,000 subscribers with some 500,000 receiving some subsidy. The doctors recognized that MSI was threatened and many 58 feared that the profession's members would become civil servants as there was only one paying agency. MSI applied to the government for a change in the Act to permit the corporation to sell Extended Health Benefits but without success. The e-0mpJaint circulated that the government rates were unrealistic. The only thing that kept MSI in business was the group contracts that the government did not offer. The corporation could not compete with the government on the individual premiums. Faced with the spectre of the imposition of federal Medicare, the Alberta profession reacted vigorously. Doctors agreed that it would be better to take a lesser rate than let MSI die. At its annual meeting in 1968, the Alberta Medical Association passed a resolution that, if the government became the sole carrying agency, the profession should deal with its patients directly. Then a motion was passed to reaffirm the profession's support of MSI and to convey strongly this sentiment to the government. A committee was set up to study direct billing with special reference to public relations. A further resolution urged that fees be related to economic conditions in the province, as professional income was not keeping pace with the increasing costs of medical practice. The administration of the Alberta Health Plan produced so much unhappiness among the doctors that the directors of the AMA asked the government to let MSI, with its experience and expertise, take over the administration. This did not occur. They then urged the government, equally unsuccessfully, to confine the Alberta Health Plan to subsidized persons only. Finally, still in 1968, the AMA made a presentation to Prime Minister Pearson's Task Force on Labour 59 Relations. It stressed the following points. First, physicians should not be subject to civil conscription in any form, director or indirect. Second, neither governments nor other agencies should undertake to provide physicians' services without the physicians' consent. Third, the government should preserve the physicians' rights to license, practise, contract for services, control education, and organize in any way that would further the rights of physicians and the public interest. In the two years following the introduction of the Alberta Health Plan , MSI lost $1. 7 million in the face of more expensive claims, additional benefits offered, higher physicians' fees and 100 percent fee payment. Yet the Alberta government's scheme to enter into federal Medicare with the Alberta Health Plan was unsuccessful. To qualify for the federal grants, provincial plans had to cover 90 percent of the population at the plan's inception, and 95 percent at the end of three years. Although this requirement could be met, a second requirement that the plan be administered by a public authority could not be met by MSI involvement. To qualify for federal Medicare grants, Alberta was forced to create a government administrative body. MSI was doomed. The efforts of dedicated men from as early as the late thirties had resulted in the formation of a successful prepaid medical care scheme acceptable to the people, the doctors, and the provincial government. Although the federal regulations governing grants ended the scheme, it had not been a failure. Its successful operations had helped to stimulate prepaid plans and principles throughout North America. 60 Medical Services (Alberta) Incorporated ceased operations on June 30, 1969 and spent the next few months winding up its affairs. Most of the 190 employees were absorbed by the Alberta Health Insurance Commission, the body which had been set up to administer the new Medicare. There remained the problem of what to do with the surplus and reserve fund, which amounted to $4,000, 000. The cost of distributing these funds to individual members of the Corporation would have absorbed much of the money and reduced individual payments to very small sums. A statement of the Board of Directors in the Edmonton Journal on June 27, 1969 described the solution: with the aid of provincial legislation, to establish and fund the Medical Services Research Foundation of Alberta to foster and support "research into any aspect of the provision of medical and allied health services and the promoting of matters of health in the interest of the . l people of Alberta." As Medical Services (Alberta) Incorporated disappeared from the scene, extensive tributes were made to some physicians who had contributed much to its success: Dr. Roy Anderson, Dr. MacGregor Parsons, Dr. Steve Schmaltz and Dr. Grant McPhail. Its legacy was rapid advance in the matter of health ca.re distribution and the enduring Foundation for research into continuing improvements. 61 The Pensioners' Medical Fund, 1947 - 1967 Author Unidentified Before 1947 the care of indigents in Alberta was the responsibility of each municipality. The attending doctor's authority was a written order, except in case of emergency, when an order to continue treatment was required after the emergency was treated. A new clause added to the Public Welfare Act in 1947 empowered the Minister to provide medical services for any resident in receipt of the Old Age or Blind Pension, any woman in receipt of the Mother's Allowance, and for their dependents. This included complete dental care for those under 18 years of age, and emergency dental care for adults. Dentures were not supplied. The Department paid for optical refractions by ophthalmologists automatically and for glasses on approval. Drugs and appliances were not provided. Hospitalization was provided, with some stipulations regarding length of stay. For full medical, surgical and obstetrical coverage, the government paid $10 per family to the College of Physicians and Surgeons, which agreed to administer the scheme and to provide certain statistics. This was the minimum fee of th~ College. The initial payment to the doctors was 50 percent, with the possibility of more later depending on funds available. X-rays by other than radiologists were limited, and the fee to radiologists was considerably diminished. 62 After the first year the scheme was judged a success , though some adjustments were W:{uired. Some doctors did not realize that the 50 percent payment was the initial payment, so they charged the patient or relatives. They were required to reimburse. Because some elective surgery that would not prolong life was carried out under the scheme, it became necessary to develop a procedure to authorize elective surgery. An Assessment Committee was appointed to monitor accounts, to decide whether to demand consultations, and to review x-rays and electrocardiograms. During the first year of the scheme, the College required that accounts be submitted within 30 days. For the second year this was extended to 30 and later to 90 days. At the end of the year the books were closed and any money left was distributed on a pro rat.a basis . The first year payments amounted to 52 percent but this was for the care of patients who would have paid little or nothing. Each year the government grant was increased so that in 1959, the twelfth year of the scheme, the annual grant was $24 per patient, with the percentage remaining more or less the same due to higher fees and increased utilization. One year, however, it did drop to 42 percent, but by 1960 it had risen to 60 percent. After 1952 the Old Age Pension was automatically paid to all citizens over 70, so to obtain an Alberta Department of Public Health and Welfare card which authorized medical care, it became necessary to pass a means test. Blind Pensioners and recipients of Mothers' Allowance received them automatically. 63 There was some abuse of the scheme on both sides. In some cases of third party involvement, some doctors charged both. In one kind of special circumstance in 19 51, cases treated through the Cancer Clinic were paid for by that body as well. On the other side, patients could be seen to have taken advantage of the scheme by the size of the estates they left, while others were known to have given their possessions to their families and taken payment under the table. In 1954 the College's Council recommended to the Assessment Committee of the Pensioners' Medical Fund that it check the patterns of practice in the province for possible abuse. In February of 1962 wards of the government became eligible for treatment under the Pensioners' Medical Fund . People became wards by court order, and babies over three months did automatically if they had not been placed for adoption. In 1963 the rate of payment for these was dropped to 70 percent of costs because they proved to require more than average care. In 1966 the initial payment reached a high of 60 percent, but the following year the Alberta Health Plan took over the responsibilities of the Pensioners' Medical Services. As a Canada centennial project, the residue of the fund, amounting to $195,000, was transferred to the building fund for Alberta House, the College's new fa.cilities at 9901 - 108 Street, Edmonton. 64 The Order of St. John (St. John Ambulance) D.R. Wilson The origins of the Order of St. John date back to the year 1099, when the English army of the First Crusade discovered in Jerusalem an ancient hospice for Christian pilgrims that had been founded in the year 600 under the instructions of Pope Gregory the Great. This hospice opened its doors to the crusaders and from that time on the quality of the care in this hospice was such that its fame spread throughout all Christendom and as a result attracted increasing funds, enabling it to prosper throughout the years. Over 100 years later, the Order of Hospi ta.llers acquired the ancient monastery of St. John the Baptist, who subsequently became the patron saint of the Order. After moving subsequently to Cyprus, Rhodes and Malta (from whence came the eight-pointed cross of Malta and a reputation for superb hospitals and strong military force), the Order surfaced during the nineteenth century in France and Great Britain, largely because the Knights of St. John continued to be active in France. In 1888, the Order received a Royal Charter during the reign of Queen Victoria and ever since that time, the reigning British monarch has always been the sovereign head of the Order. Not until 1934 did His Excellency, the Earl of Bessborough, become the first Canadian Commander. Succeeding heads of the Order in Canada have been Governors-General. It is not quite certain just when St. John's Ambulance (one of three main branches of the Order) became 65 active in the province of Alberta, but it is known that Dr. E.A. Braithwaite was active before World War I at teaching first aid to the employees of the Canadian Northern (later National) Railway. The CNR always staunchly supported the activities of the Order of St. John. Alberta's prominence in the affairs of the Order was due almost entirely to the contributions of many dedicated physicians and surgeons, not only in the field of first aid but later in the fields of industrial safety and accident prevention. In Edmonton, in addition to Dr. Braithwaite, a little-known physician, Dr. V.S. Kaufmann, in a very quiet and modest way took an active interest in the work of the Order over a period of years. Dr. Mark Marshall emphasized the importance of eye injuries and their treatment by first aid personnel. Edmonton physicians who have served as Provincial Surgeons contributed a great deal to the high standards maintained throughout the province: Dr. Mel Little, for many years the city Health Officer, followed by Dr. Harvey Hebb, Dr. Tony Peers, Dr. Alistair MacKay, Dr. E.W. Bissell and Dr. Harold Schwartz. In Calgary, the activity in the work of the Order of St. John has always been greater than in Edmonton, apparently because Calgary had a much higher percentage of Anglo-Saxon citizens than Edmonton, in which a large middle-European population knew little or nothing about the tradition and work of the Order of St. John. There is a verbal evidence at least that a Mr. Rutherford conducted a "first aid class" in Calgary in 1908, but the first enduring records for Calgary point to formation of a Calgary centre for first aid in December 1929 and a subsequent reorganization in 1931. In 1932, Dr. Frances Douglas Wilson of Calgary was made a life 66 member of the Grand Priory in the British Realm of St. John Ambulance Association in London, England, the first Calgary resident to be awarded this honour. Prior to this, the only other person honoured in Calgary was Dr. Stewart McKidd, who was made a Knight of the Order. The Right Honourable R.B. Bennett was made a Life Member of the Association in 1933. In May of 1936, Colonel J.M. Gunn was made an Officer of the Order of St. John and during the immediate pre-war years and during the war, Colonel J.S. McCannell was of great assistance in furthering efforts in first aid . Dr. W.A.J. Donald exerted considerable influence throughout the whole province for many years, particularly with reference to his organization of the ambulance service in Calgary. Dr. H. 0. Wagg, also a prominent Calgarian, had over 20 years of service with the Order. Dr. Lola McLatchie, a pathologist, also became interested in the work, of the Order and contributed during her period in the city. In Medicine Hat, the mainstay in the work of St. John was for a long time Senator Gershaw, who later was able to interest Dr. Cranston in carrying on. In more recent times, these and other physicians were responsible for a major upgrading in the standards of teaching first aid, not only in its conventional setting, but also in industry. Because of the high standards and the influence of Dr. Frank Hall, first aid became a very major activity of the Workers' Compensation Board, particularly with respect to occupational health and worker safety. Throughout Canada, all Workers' Compensation Boards came to rely entirely on the assistance of St. John's Ambulance in the industrial field. By contrast, during World War II, the old , original first aid book in its 39th edition was so antiquated that the Royal Canadian 67 Air Force refused to use it, ultimately publishing its own manual of first aid for service personnel. After the war, Dr. Harvey Hebb did a great deal to upgrade the 40th edition of the first aid manual and the modern manual became second to none in the world. During the time that Dr. Hebb was the provincial surgeon, he received great assistance from Dr. Ted Emmett and Colonel Darling of the RCMP, who as a trio were known as the "western rebels" in agitating for updating of the antiquated 30th edition. During the late 1950s and early 1960s, Dr. Hebb and Dr. Jim Pearce, Professor of Physiology at the University of Alberta, were able to bring enough pressure to bear through the Canadian Medical Association to have mouth-to-mouth resuscitation incorporated into the training program of the Order. By 1980, the activities of the three branches of the Order of St. John were responsible for training some 300,000 Canadians a year in various courses in first aid. An industrial project carried out in the Peace River country showed that industrial accidents decreased by about 30 percent where the workers had taken first aid. St. John's Ambulance has been particularly active with Bell Canada. In many industries, the successful completion of a standard first-aid program became a mandatory pre-requisite to employment. Indeed, the incidence of accidents in the homes decreased 30 percent in those families where one member at least had taken training in St. John's preventative programs. In Alberta alone, by 1980 some 25,000 to 30,000 citizens were taking standard first aid training every year, and 3, 000 to 5, 000 Albertans were taking the advanced course, all of them examined by physicians and surgeons throughout the province. 68 In later years, Dr. Bob Henderson, Tom Speakman, Les Willox, Nelson Nix and Frank Hall all made major contributions to the work of St. John's. In the 1970s, the Order embarked on a completely new program to evaluate the performance of candidates in all its teaching programs. Previously, evaluation for first aid certificates was carried out in a very patch-work manner through local written and practical examinations carried out by the instructors who taught the course. In an effort to standardize the evaluation of first aid competence in Canada, a very generous grant to the Order of $200,000 from the Gladys and Merrill Muttart Foundation launched a nation-wide objective examination system, the first in the world. Ensuring a nation-wide minimum standard for competence, this became a pre-requisite to obtaining a certificate of the Order, and a major advance in developing the quality of Canadian first aid teachers. The Order developed the system in close cooperation with the R.S. McLaughlin Examination Research Centre (Western Division) and its former Director, Dr. D.R. Wilson. Bringing a great international tradition of health care to Alberta, the St. John Ambulance has in its turn made an Alberta contribution to the world. 69 Tuberculosis in Alberta: 1905 - 1980 H.H. Stephens Between Canadian Confederation in 1867 and the addition of Alberta as a province in 1905, the chief cause of death was tuberculosis, which was reported to have reached epidemic proportions I I by 1880, with a morbidity rate near 200 per 100,000 population. The rate in the West was I probably about half that, and its chief victims were Indians and Metis. I I During the fust decade after Alberta became a province, the influx of settlers from eastern I Canada, the United States and other countries, chiefly of Europe, produced such a rapid increase in population that existing medical and hospital facilities were ab le to cope only with acute illnesses and emergencies. Most infections, including tuberculosis, were treated at home. Those tuberculous patients who had homes, friends and relatives at hand were fortunate. Because word had spread that the climate in western Canada and the United States was beneficial in curing chest disease, many tuberculosis sufferers sought a cure in the Calgary area, where however they encountered a lack of facilities. Many searched out homes, rooming houses, hotels, or lived in shacks or tents. These conditions spurred a group of Calgary women led by Mrs. William Carson and Mrs. Harold Riley to form the Calgary Tuberculosis Society. They accepted the offer of an older home on 6th Street East, not far from the General Hospital. Assisted by the city, business men, physicians and volunteer help, they raised money to support their project by tag days and other functions . In November 1911 they had 12 beds in the house, two on the verandah; and six wooden walled tents in the yar~ for 12 beds - in all about 25 beds. The 70 poorly cared for patients were among the first admitted. After 13 deaths in the first three months of operation, the picture brightened. The city took over o_peration of this make-shift hospital in 1912 and in 1914 moved all patients indoors to what had been the Smallpox Hospital in the same area from 1904 until it was no longer needed. This had better accommodation, was equipped for easier care, and served as the city's hospital for tuberculosis until November 1920. In 1913 an attempt was made to form an Alberta Society for the Prevention of Tuberculosis, such as existed in Ontario. Mr. Price of the Canadian Pacific Railway, Calgary was Chairman, and the committee had representatives from Edmonton, Lethbridge, Macleod and Medicine Hat. The objective was the erection of a sanatorium, and they began to raise funds to support the project. Although some money was collected, the outbreak of war in 1914 terminated the effort, and the group apparently disbanded. The seriousness of tuberculosis was fully recognized during the war. Canada lost almost as many people from tuberculosis (40,000) during this period, as were lost to the war overseas. In 1916 almost 400 soldiers were under treatment for tuberculosis in various sanataria across Canada, and half of ·these had never been overseas. ·The Department of Soldiers' Civil Re establishment (DSCR), set up about 1917, needed accommodation in Alberta and obtained the temporary use of the former CPR Hotel at Frank, Alberta. It opened in November 1917, with Dr. J.B. Ritchie in charge. Captain A.H. Baker of the Reserve Force joined him there. Additional accommodation was found in Wetaskiwin, with Dr. A.D. McPherson in charge. 71 Years later (April 11, 1958) Dr. Ritchie described the Frank situation for the Calgarv Herald: It was quite a place for a San! There was that awful wind coming out of that tunnel they call the Crowsnest Pass , and the nice clean air the patients were supposed to enjoy was full of coal dust. Funhermore, the patients were supposed to have plenty of rest, [but] even that was difficult, for at any time rocks kept tumbling from Turtle Mountain scaring the daylights out of us. Trains went by day and night that could be heard for miles, but one thing for the railway, the patients could sit on the lawn and wave to the train crews who always waved back. [Of the] pedestrians passing along the road, only a few waved back, [because] many thought the San. a dangerous place, and even wore hankies over their faces when passing. Representation had been made to the Federal authorities by several groups in the province concerning the need for a sanatorium. Before 1905, the Calgary General Hospital Board rep.orted haJt-ing to restrict-the admission of tuberculosis patients, with grave consequences for many patients. The federal government did allocate land west of Calgary, but no funds. All provinces had erected sanatoria by 1917 except Alberta. Finally in 1919 the federal and provincial governments drew up plans for one to be built on the original assigned land. Each agreed to pay $200,000 for a 180-bed complex: two infirmaries for 52 beds, and four pavilions for 128 beds. The agreement was signed by Sir James Lougheed for the DSCR and A.G. McKay for the provincial Department of Health. The facility opened on October 20, 1920, to 72 be supervised by Dr. A.H. Baker, Medical Superintendent, and Dr. G.M. Reid, Assistant Medical Superintendent. The first patients were from Frank, followed by the veterans from Wetaskiwin, and then the civilians from the Smallpox Hospital, Calgary, and other areas throughout the province as they could be accepted. The Central Alberta sanatorium (CAS) was the CPR flag station at Robertson. The first winter was disastrous, because the dedication to a treatment of rest, fresh air and good food meant that only the bathrooms were heated in the four pavilions. The relatively harsh climate required the installation of additional heating the next year, when two of the pavilions were changed to infirmaries, adding 30 beds for a total of 210. Without protective trees or grass on the grounds, it was in a dust bowl in summer. In a year or two, however, gardeners had the basis for a very beautiful setting, with a variety of trees and flower beds, and well-kept lawns facing the Bow River. The DSCR had stipulated a five-year limit on its operation of the CAS. In 1925, it came under the operation of the province. During the greater part of the first decade of operation, the medical staff was not a stable one. Physicians discharged from the service found employment there for a few months or up to a year or two. Dr. Baker and Dr. Reid were the only original staff (except the matron, Miss E. McPhedran, who had also arrived in October 1920) when Dr. L.M. Mullen joined them in September 1929. Dr. G.R. Davison was appointed in June 1930, as travelling diagnostician to do clinic work throughout the province, to examine former 73 sanatarium patients, contacts, and suspect cases referred by physicians. Such clinics discovered many new active cases of tuberculosis, and developed a waiting list for admission. In 1927 Dr. Baker held the first outside clinic in the mining town of Drumheller. In 1928, weekly Wednesday afternoon clinics were instituted at the Calgary Health Department, City Hall, and in Edmonton on the first and third Thursday of each month, at the University Hospital Out-Door Clinic in downtown Edmonton. During the 1930s additional stationary clinics appeared twice yearly in Lethbridge, Medicine Hat and Red Deer; and once yearly at Drumheller, Vegreville, the Residential Schools-Blood Indian Reserve , Cardston, and Blackfoot Schools, Gleichen. On February 1, 1934 Dr. H.H. Stephens was appointed to the CAS medical staff, and assigned two infirmaries, for admissions and the more seri ously ill patients. In 1925, when the province assumed the operation of CAS , civilians were expected to pay the per diem cost, then about $2.25. For those not able to do so , their municipality of residence would be sent the account. The DSCR paid veterans' costs from federal funds. In 1924-25 there had also been concern regarding bovine tuberculosis, and Dr. Baker reported to Dr. A.C. Rankin, Dean of Medicine and Head of the Bacteriology Department at the University of Alberta, on the use of BCG vaccine in dairy herds . Bovine Tuberculosis was the cause of much of the disease in children and young adults, such as scrofula, and crippling bone and joint tuberculosis. Pasteurization of milk helped greatly to control this problem. In 1910 a federal Commission report stated that "when a cow's udder is infected , her milk contains vast 74 numbers of tubercle bacilli, in tum they are transmitted to calves, and the milk is very dangerous to children." Following this report, the program of tuberculin testing of cattle across Canada began in earnest. Reactors (cattle with the disease) were destroyed and the owners compensated for the loss. In 1925, the 223,974 tuberculin tests done across Canada discovered 10,566 reactors, leading to compensation payments totalling $537, 688. 1,989 herds were accredited. In 1920 the mortality rate for tuberculosis was about 60 per 100,000, and it remained on a plateau until after 1927 when 394 deaths were reported, at a rate of 63 .8 per 100,000. In 1930 there were 406 deaths (57.3 per 100,000) and in 1937 there were 340 deaths (43.6 per 100,000). During the 1930s, a large percentage of the active pulmonary tuberculosis patients had advanced extensive disease, also presenting one or more concurrent non-pulmonary tuberculous infections, such as laryngitis, corneal ulcer, pleurisy , peritonitis, enterocolitis, salpingitis, renal epididymitis, orchitis, tenosynovitis, bone or joint disease. The number who had haemoptysis, in small or large amounts, was unbelievable. Some repeated over several days, while others had a sudden large amount and died. Blood replacement was possible by direct donor-to-patient transfusion. Usually. this was obtained from a relative or friend; occasionally it came from a professional donor for $20 - $25 after matching blood types. Much time could elapse and this was not an easy or an emergency procedure. Sixteen patients had solar laryngoscopy therapy for laryngitis in 1934. Heliotherapy with ultra violet quartz lamps was given to 26 men and 31 women to assist some of the non-pulmonary 75 infections. About 300 beds were being used in the province for the treatment of tuberculosis in patients other than Indians: 210 at CAS Calgary; 30 in the Royal Alexandra Hospital, Edmonton; 21 in the University of Alberta Hospital, Edmonton; and about 40 in general hospitals scattered throughout the province. There were also about 151 non-pulmona..ry tuberculosis active patients, most of them in general hospitals. Of the active pulmonary fuberculosis patients treated in the CAS Calgary, 85 percent were reported having a positive sputum. In January and February 1935, Dr. H.H. Stephens was granted leave to go to the St. Boniface Sanatarium, Winnipeg, Manitoba to learn the techniques of performing internal pneumonoalysis and to observe pulmonary collapse procedures as carried out in that instirution . Later that year, Dr. L.M. Mullen resigned from CAS medical staff, and Miss Eleanor McPhedran, matron at CAS since it opened in October 1920, retired, to be succeeded by Miss E.K. Connor on January 1, 1936. On June 1, 1936 the Provincial Government proclaimed the Tuberculosis Act, assuming the financial responsibility under the Department of Health for the treatment in sanatoria of all infectious tuberculosis afflicting residents of the province. Alberta was the second province in Canada to legislate "free treatment", as it was known, after Saskatchewan did in 1934 or 1935. In 1936 there was an immediate urgent demand for additional beds, and the Department of Health was able to arrange for 37 beds in the Royal Alexandra Hospital, 21 beds in the 76 University of Alberta Hospital, and 143 beds in the old General Hospital in Edmonton. Dr. G.R. Davison, attached to CAS Calgary, was transferred to Edmonton, as Medical Superintendent of treatment and clinic director for Northern Alberta. His office and medical records rooms were established in the Tuberculosis Section, Edmonton General Hospital. The Edmonton tuberculosis clinic, held twice monthly in the University Out-Door Clinic downtown, was also transferred, to where x-ray and medical offices were available for weekly clinics. Dr. A.H. Baker, Medical Superintendent, CAS Calgary was also named Director, Division of Tuberculosis Control, within the Department of Health. Dr. W.H. Scott at the University of Alberta Hospital, Dr. Irving Bell and Dr. J.B. McKay of the Royal Alexandra Hospital received part-time Tuberculosis Control appointments. Dr. J.C. McPherson was appointed to the medical staff at CAS Calgary in 1936, but transferred to the Tuberculosis Section of the Edmonton · General Hospital the next year. His replacement in Calgary was Dr. J. W. Downs. In 1936, in an Alberta population of 772,(JJQ, deaths from tuberculosis numbered 382 for a rate of 49.4 per 100,000. But of those who died, 161 were Indians and 27 were Metis. In 1930 the tuberculin testing was conducted at the residential schools of the Blood/Peigan at Cardston. In 1934 students at the Blackfoot schools in Gleichen were tested. All reactors were x-rayed and the results were interpreted by CAS medical staff. In 1937 and additional IO residential schools were tuberculin tested and reactors x-rayed locally. Testers diagnosed 49 new active cases, and all who were considered infectious were either admitted to hospital on the Reserve or to a provincial sanatorium. 77 When Dr. G.M. Reid, Assistant Medical Superintendent, CAS Calgary since 1920, retired in 1937, he was succeeded by Dr. L.M. Mullen, who rejoined the CAS medical staff. Dr. Baker recommended the same year that a surgical unit be established at CAS Calgary. Dr. H.H. Stephens was granted leave of absence from January to July 1938 to spend three months at Glen Lake Sanatorium, Minneapolis, and the remaining time at the Mountain Sanatorium, Hamilton, Ontario and the Weston Sanatorium, Toronto, to study Collapse Surgery in pulmonary tuberculosis. In June 1939, representatives of service clubs and organizations that had undertaken during the previous few years to raise money for tuberculosis treatment through the sale of Christmas Seals met at the Central Alberta Sanatorium to consider plans for greater anti-tuberculosis work in the province. They represented the Kinsmen Clubs of Edmonton, Calgary and Drumheller, the Rotary Clubs of High River and Red Deer, the Lethbridge Nursing Mission, and the Seal Sale Committee of Medicine Hat. In September 1939 they reconvened to form the Alberta Tuberculosis Association with E.C. Shaughnessy of Edmonton as President and D.A. Chertkow of Drumheller as Secretary. Following a survey of Residential Indian Schools m 1939 to keep them free from gross tuberculosis, 32 Indians were admitted to provincial sanatoria. They responded to treatment very satisfactorily, but no great reduction could be expected in the provincial death rate for tuberculosis until competent therapeutic and preventive measures were made available to the Indian population. 78 In 1940 the Central Alberta Sanatorium acquired the surgical equipment to carry out all forms of collapse procedures for pulmonary tuberculosis. In August 1943 the Alberta Tuberculosis Association presented a mobile x-ray unit to the Division of Tuberculosis Control. The x-ray 70 mm photofluorographic unit was purchased with the proceeds of the sale of Christmas Seals. The Division provided staff and maintenance for its operation, and the Association provided an organizer to arrange operating locations and to publicize the itinerary and schedules of clinics. Between 1940 and 1945 the annual numbers of new and reactivated tuberculosis patients fluctuated, but never below 181. Much larger numbers were receiving treatment, and testing continued. In 1943 the routine x-raying of recruits proved most valuable. New treatment facilities were important. In 1942 the provincial Department of Health announced plans to erect a 300-bed sanatorium in Edmonton. In 1943 the CAS opened a 22-bed surgical unit. New procedures also helped. Whereas the average stay in a sanatarium in 1939 was 440 days, it dropped to 340 days in 1944, a reduction attributed to the application of pulmonary collapse therapy to some 40 percent of pulmonary tuberculosis patients. With a full-time executive-secretary, C.R. Dickey, after October 1943, the Alberta Tuberculosis Association continued to make valuable contributions. Following mobile x-ray unit survey of more than 60,000 people in 1944, the Association presented the Tuberculosis Division with mobile x-ray unit #2 in 1945. The units x-rayed 84,822 of the general population that year, finding 114 cases of pulmonary active tuberculosis, five cases of pleurisy active tuberculosis, 79 and 684 cases of pulmonary inactive tuberculosis. Among 3,076 Indians tested, 95 showed active tuberculosis, seven showed pleurisy and 147 showed inactive tuberculosis. At 11 Indian Residential Schools, 29 active and 46 inactive cases were discovered. In 1946 the Charles Camsell Indian Hospital (CCIH) opened in Edmonton in what had previously been the US Base Hospital when the Alaska Highway was built. Dr. H. Meltzer, who was previously with the Manitoba Sanatorium at Ninette, Manitoba and was also the chest surgeon there, became Medical Superintendent at the Charles Camsell Hospital. All Indian patients in the provincial sanatoria were transferred to the CCIH, and the survey work previously carried out by Division Staff was assumed by Department of Indian Affairs staff. Education and research remained important. In 1946 Dr. G.R. Davison established tuberculosis clinics on a regular basis for 4th-year medical students of the University of Alberta Medical School at the Edmonton General Hospital Tuberculosis Clinic. In 1947 a new antimicrobial specific for tubercle bacilli, discovered by Waksman in 1944, was first used at CAS for one patient. During the same year, Dr. H.H. Stephens was granted three months leave to visit sanatoria in eastern Canada and the United States to assess surgical procedures being used for pulmonary tuberculosis. Vaccination was being offered to nurses in training, medical students, non-infected members of families in which active tuberculosis was found, and persons expecting to work in high-risk areas or countries where tuberculosis was prevalent. 80 In 1948 the federal government approved a Tuberculosis Control Grant to all provinces. The projects suggested and accepted in Alberta were: free treatment for non-pulmonary tuberculosis, provision for two diagnostic clinic physicians, free streptomycin and other antimicrobials, sanatorium affiliation with training schools for nurses, clinic x-ray equipment, improvement in sanataria libraries, travelling clinic instructor, and technical equipment for both CAS and the new sanatorium coming in Edmonton. Two major facilities opened in 1949. In Calgary, the CAS opened a new recreation building in September. The auditorium accommodated 300 people. The Alberta Tuberculosis Association donated 250 folding chairs and the stage and window drapes. The building had occupational therapy rooms to which the Association also donated some equipment. Then, in October, the comer stone for the new sanatorium in Edmonton was laid by Mrs. William Aberhart. Premier E.C. Manning paid tribute to the anti-tuberculosis program in the province. Finally, late in October the chapel built at CAS was opened. The A TA provided furniture for the sanctuary as a memorial to Mr. E.C. Shaughnessy of Edmonton and Mr. W. Way of High River, two of the founding members of the Alberta Tuberculosis Association. The CAS staff home for 55 women .was also completed. The use of streptomycin and para-amino-salicylic acid (PAS) brought about a dramatic reduction in the tuberculosis mortality rate. In 1948 there were 259 deaths, a rate of 31.6 per 100,000, but two years later the number of deaths had dropped to 171 for a rate of 19.3 per 100,000. 81 In February 1952, the new Aberhart Memorial Sanatorium was officially opened by Mrs. William Aberhart, who presented a ceremonial key to Dr. H.H. Stephens, the Medical Superintendent. With a bed capacity of 295, it was very well furnished and equipped. Adjacent to it was a three-storey nurses' residence, a spacious laundry and a maintenance building. Dr. J.C. McPherson was appointed the Assistant Medical Superintendent, and Miss E.K. Conner the Superintendent of Nurses. Dr. G.R. Davison moved the office of the Director, Division of Tuberculosis Control and the Division Central Registry from the Central Alberta Sanatorium to the Aberhart Memorial Sanatorium, Edmonton. Active cases in both sanatoria in 195 2 totalled 552, and non-pulmonary cases, 94. The larger number were now at the Aberhart Sanatorium. In 1952 Dr. Colin Ross joined the medical staff of the Aberhart Memorial Sanatorium for one year. He had recently returned from Britain and Sweden, having completed his specialty training in thoracic surgery. It was an opportune time to change the treatment program for pulmonary tuberculosis patients gradually from collapse procedures to pulmonary resectional ones, which were favoured in many sanatoria in Canada and elsewhere. Pulmonary resection in positive sputum patients prior to the use of drugs was considered high risk by most, in that bronchial stumps became infected frequently and failed to heal, resulting in branch-pleural fistulas and empyema, while a spread of disease not infrequently occurred: hence the preference for collapse procedures. Drug usage changed pulmonary resection in tuberculosis to a comparatively safe procedure which, with destroyed tissue removed, lessened the chance of a recurrence of active disease. 82 The number of collapse procedures used in pulmonary tuberculosis gradually declined during the 1950s. Isonicotinic acid hydrazine became available for general use in 1952 and combined with streptomycin and PAS proved to be effective therapy in all forms of tuberculosis. Rarely was surgery considered until four to six months of medical treatment was completed. The number of patients for whom surgery was indicated decreased appreciably. Where there had been considerable destroyed tissue, removal often seemed best. Indian Health Services expanded the use of BCG vaccinations among Indians because it was reported to decrease the incidence of meningitis. The Division also increased the use of vaccine among the Metis. In 1953 Dr. Ross established his own office, but continued the work at AMS on a consultation basis. Later he was joined in partnership by Dr. Colin Dafoe, also a specialist in thoracic surgery, and both contributed much to the treatment of pulmonary tuberculosis at the Aberhart Memorial Sanatorium. On April 1, 1954, the name of the Central Alberta Sanatorium in Calgary was changed to Baker Memorial Sanatorium in tribute to Dr. A.H. Baker, Medical Superintendent from the time it opened in October 20, 1920 until he retired September 30, 1950. He had proven himself an excellent administrator, esteemed among his fellow workers across Canada. In 1936 when the provincial Government proclaimed the Tuberculosis Act for free treatment of infectious tuberculosis, Dr. Baker was named Director, Division of Tuberculosis Control, Department of Health in the Province of Alberta. 83 Year Number of Deaths from Tuberculosis Rate p~r 100.000 1945: 259 31.6 1950: 171 19.3 1952: 125 12.9 1954: 63 6.0 1956: 43 3.8 Year Total New Active Cases of Tuberculosis in Alberta 1954 494 1955 482 1956 500 1957 565 (includes 46 Hungarian refugees) While the number of new active cases of tuberculosis regularly hovered around 500 per year in the mid-1950s, the number of deaths from tuberculosis dropped dramatically, averaging 12.9 per 100,000 population in 1952 and 3. 8 in 1956. The Alberta Tuberculosis Association replaced mobile chest x-ray units #1 and #2 in 1957 with units #3 and #4, both of which were purchased with funds raised by the sale of Christmas Seals. X-rays of 106,509 individuals in 1957 showed 44 new active pulmonary cases and 299 inactive ones. This, too, was a sharp decline compared with results in 1944, the fust year of mobile x-ray surveys, when 159 new active cases of tuberculosis, and 768 new inactive ones, had been found in 60, 186 persons. Furthermore, the use of drugs helped to reduce the average stay in Alberta sanatoria in 1957 to 251 days from 382 84 rn 194 7. There was no longer a waiting list of patients for admission to sanatoria in Alberta. By the end of 1960, there were 381 patients in the two Alberta sanatoria: 175 in Calgary and 206 in Edmonton. There was, however, an increasing problem with patients who left a sa'1atorium against advice, or walked out, while still infectious. Public Health personnel assisted greatly to have such patients readmitted. The Amended Tuberculosis Act permitted the apprehension and return to the sanatorium of patients considered a danger to family or associates. The majority had a history of alcohol, drugs, or trouble with the law. In 1960, 21 of 381 admissions were readmissions. Another clear pattern also received special attention: approximately 40-50 percent of the new active 1961 cases were from two high-risk groups: the Registered Indians and the Metis. Following Dr. Davison's retirement as Director of the Division of Tuberculosis Control, the Department of Health offered the position to Dr. H.H. Stephens, Medical Superintendent of the Aberhart Memorial Sanatorium. He was asked to carry both positions as Dr. Baker had much earlier. He accepted. only reluctantly for a trial period, but a decline in the use of beds led to a delay in any change. The incidence of tuberculosis continued to drop throughout the 1960s. In 1962 one infirmary at the Baker Memorial Sanatorium was empty, and the Department of Health allocated it to the Department of Mental Health. In the same year, 377 cases of new active tuberculosis were 85 discovered (28.3 per 100,000), most of them by mobile x-ray surveys conducted in 210 locations throughout the province covering 160,930 persons. The proportion fell to 24.6 per 100,000 population in 1964 and again in 1965; but for Treaty Indians in 1965 the proportion was 287 per 100,000 and for Metis, 224 per 100,000, dropping the rate for all others to 16.6 per 100,000. Deaths from tuberculosis in Alberta fell to 24 (1.9 per 100,000) in 1968 and 20 (1.3 per 100,000) in 1969. The main reason for these reductions seemed to be the increasin g effectiveness of certain drug treatments. Antimicrobials came into use: streptomycin in 1947, P ..\S in 1949 and INH in 1952. Because the use of any of these in isolation could not prevent the development of resistant strains of tubercle bacilli in a few months, they were usually combined to delay the emergence of resistant strains. During the 1970s, six to eight more toxic drugs appeared, but even they needed to be used in combination, with greater discretion and additional supervision, against strains resistant to the three earlier drugs. Some of these newer drugs were pyrizinamide, viomycin, cycloserine, seromycin and capreomycin. In 1970 a new antimicrobial drug, Rifampin, discovered a few years previously in Milan, Italy, made its appearance in Alberta. Trials in Europe, the USA and Canada showed great promise. Bacillicidal against tubercle bacilli, it is of low toxicity to humans, not unlike I~n, is well tolerated and seemed ready to replace the older first-line drugs. As a result of the effective use of drugs, and a marked reduction in new cases in southern Alberta, the bed occupancy of the Baker Memorial Sanatorium declined rapid I y. Reflecting a 86 bed usage rate between 90 to 100 patients, the remaining infirmary and pavilion were emptied and all tuberculosis patients accommodated in the front buildings facing the Bow River. In 1964 the bed complement was set at 105, and in 1967, at 84. The number of in-patients dropped to 40 at the end of 1969 and 31 in 1970. A similar pattern occurred in Edmonton. As gradually vacated rooms were used for occupational and physical therapy, the number of beds kept available declined from 295 in 1966 to 267 in 1967 and 200 in 1970. The number of in-patients dropped from 200 at the end of 1965 to 132 in 1969 and 105 in 1970. By 1970, dwindling numbers of in-patients had ended use of the Charles Camsell Hospital in Edmonton for treatment. Long-time staff members moved on to other things. On August 31, 1963 Dr. L.M. Mullen resigned as Medical Superintendent of the Baker Memorial Sanatorium, Calgary, after 30 years service treating tuberculosis, to enter general practice in Calgary. In 1963, Mr. Alex Reid, DPW maintenance supervision at AMS since it opened in February 1952, retired. He had given excellent service with a multiplicity of adjustments necessary when that sanatorium opened. Other initiatives were taken. The provincial government's Division of Tuberculosis Control conducted an Outpatient Clinic that offered chemoprophylaxis INH to all children who were recent tuberculin reactors with no demonstrable disease. A follow-up program for Registered Indians in Alberta was placed on the Division of Tuberculosis Control Central Registry. Ongoing work on surveys and clinics was to continue on a combined basis with the Division of Indian Health Services. To cope with the steadily increasing work and time required in the 87 Division of Tuberculosis Control with respect to out-patient therapy and supervision, Dr. H.H. Stephens arranged for the separate appointment of AMS medical staff member Dr. Gordon Duncan as Medical Superintendent of the AMS in September 1969. Extra clinics, Central Registry work, and follow-up programs required special attention from Dr. Stephens and the Director of Tuberculosis Control. In September 1969 the Albena Tuberculosis Association also presented the Division with unit #5 completely set up in a van, which could move to special areas where infections had recently occurred, or to special areas for survey purposes. It was obvious to Dr. H .H. Stephens in 1969 that some use of empty beds in AMS must be considered. Discussions were held with Dr. Brian Sproule and Dr. Walter MacKenzie with the idea of establis hing a chronic respiratory centre, and another idea to move in former polio patients with respiratory problems. The medical staff of AMS was somewhat apprehensive about the latter proposition in an area close to tuberculosis patients. Further discussions followed between the Alberta Department of Health and the University of Alberta Hospital to plan a transfer of the AMS to the Hospital. December 31, 1970 was the last day of operation of the Aberhart Memorial Sanatarium under the Division of Tuberculosis Control. The next day it was transferred to the University of Alberta Hospital, which would provide a tuberculosis section for treatment of all active cases of tuberculosis that required admission from northern Alberta. The Division of Tuberculosis, Department of Health was to remain operational, and plans were completed for appropriate renovations of the previous AMS Nurses' Residence: all the first floor, and the west half of the lower floor to accommodate the Division staff, out-patient clinic 88 and nurses' offices, medical offices, stenographic office and medical records, x-ray facilities. a small business office; and the Central Tuberculosis Registry Records, its staff and staff rooms. The Division moved to the new quarters on July 1, 1972 to operate the Tuberculosis Out-Patient Services for northern Alberta, and the Central Tuberculosis Registry for the province. On March 22, 1971 Dr. H.H. Stephens, Director of the Division of Tuberculosis Control since October 1961 (and Medical Superintendent of the Aberhart Memorial Sanatarium from February 20, 1952 to September 1, 1969), retired. Dr. J. Ryder, formerly the Medical Superintendent of BMS from September 1, 1963 to March 1971, was appointed Dr. Stephens' successor. Dr. Ryder was replaced in Calgary by Dr. R. Boyd, staff chest surgeon at BMS. Dr. Ryder retired June 30, 1975, and was succeeded by Dr. D. Todosijczuk, who had come to the Division of Tuberculosis Control in Edmonton in 1972 from St. Agathe Sanatarium in Quebec. During the 1970s, the impact of tuberculosis continued to be checked. The Registered Indian population continued to be most at risk, suffering even higher active rates in 1972 than in the 1960s, averaging 340 per 100,000 population, ranging from 134.5 in Lesser Slave Lake to 612.1 at the Stony/Sarcee reserves. The average declined to 206 per 100,000 population the following year, but it was reductions in new active cases throughout the rest of the population that brought the overall Alberta rate ever lower, despite the influence attributed to the arrival of refugees. The overall Alberta rate of new active cases declined from 16.6 per 100,000 in 1973 to 11.2 per 100,000 in 1976, fluctuating thereafter no higher than 1980's 12.7 rate. Of the record low 207 new active tuberculosis patients in Alberta in 1979, 114 were classified as pulmonary (minimal, 89 moderately or far adv;:ince miliary. Changing conditions resulted in changing practices. Throughout the province in 1975, 23 stationary clinics held 388 sessions and assessed 7, 845 individuals. Of these assessments, 1, 638 were new and 6,212 review. Miscellaneous clinics, chiefly by x-rays, submitted 2,836 new assessments and 9,324 reviews for a total of 12, 160. That year, routine surveys by the mobile x-ray unit were discontinued, henceforth to be used only in selected locations. The policy of tuberculin testing in schools was reduced to testing students only upon school entry and leaving, and x-raying the reactors. In 1974, an overall assessment of the Division of Tuberculosis Services gave consideration to providing initial therapy at some general hospitals. Between 1975 and 1980, some general hospitals and attending physicians gradually admitted new active cases of tuberculosis, especially in northern Alberta, at locations like High Level, Grande Prairie, St. Paul, Elk Point, Edmonton (the General and Misericordia Hospitals) and in Calgary 's General Hospital. In 1978, patients on out-patient therapy totalled 327 and patients given BCG vaccination, 1,260. 1,272 tuberculin reactors received chemoprophylaxis. In the southern part of the province the Baker Memorial Sanatorium reduced its bed complement to 28, occupying the previous Surgical Unit, and in 1978 all major surgical procedures were carried out in the Foothills Hospitals, Calgary. Arrangements were also completed to have all 90 active cases of tuberculosis in the Foothills Hospital, and in April 1979 all the out-patient clinic services were moved to the Foothills Hospital. The last few patients were either discharged or transferred, and after 59 years of service to the people of Alberta, the Baker Memorial Sanatorium closed in October 1979. By the late 1970s , the Health Centres in northern Alberta at Chard, Anzac, Wabasca and Loon Lake had acquired x-ray equipment and received regular visits by Division personnel. Follow up x-rays were submitted to the Tuberculosis Services for interp retation and reporting. In 1979 the Correctional Institutes in the province discontinued routine chest x-ray on admissions and began to use a tuberculin test and x-ray reactors at the nearest hospitals. The majority of new active cases of tub erculosis were being admitted to the Ab erhart Hospital, Edmonton from northern Alberta, and to the Foothills Hospital, Calgary from southern Alberta.. The modem initial therapy was to use, where possible, a combination of four antimicrobials (rifampin, INH, pyrizinamide and streptomycin) for two months, and change to INH and rifampin for nine to 12 months, usually on an out-patient basis. The average stay in hospital dropped to about 60 days. Death rates from tuberculosis in Alberta underwent the most dramatic and welcome change. Where once only three members of an entire family of seven patients in CAS Calgary survived, by 1980 the fear of tuberculosis had been much reduced. 383 deaths from tuberculosis in the Alberta of 1936 represented a rate of 49.4 per 100,000 population; by 1970, just 13 deaths from tuberculosis represented a rate of 0.8 per 100,000 population, a level maintained in 1980. Much of the drop occurred between 1946 and 1960. 91 The World Health Organization set the following standard for control of tuberculosis: recording "less than 1 percent tuberculin reactors of 14-year-olds in schools, one may assume the disease controlled." Many Health Unit areas had reached this level by the 1970s, especially in southern Alberta and more rural areas. In larger cities and several areas in northern Alberta, especially Residential Indian Schools, close attention was still important. There was no room for complacency, despite all that had been accomplished in 75 years. Credit is due to those dedicated to work towards control of tuberculosis -- family physicians, medical officers of health and their nursing staff, district health nurses, and hundreds of volunteer workers, service clubs , women's groups, church groups, the Alberta Tuberculosis Association; and indirectly the Canadian Tuberculosis Association, which kept all tuberculosis workers in all provinces in touch with each other -- in a wonderful cooperative effort. The personnel in the Tuberculosis Division tried to direct that effort for the benefit of all. 92 Evolution of the Venereal Disease Program in the Province of Alberta D.R. Wilson, with Paul Rentier The first step in the government effort to control venereal disease in Alberta emanated from the 1918 Act for the Prevention of Venereal Diseases. Under this Act, the government created a division for venereal disease control and shortly afterward changed its title to the more positive Division of Social Hygiene. Dr. Harold Orr issued its first report in 1920. He noted that every person suffering from a venereal disease was required by regulation to seek treatment by a regularly qualified practitioner. Those who were riot able to pay for treatment services could avail themselves of free treatment at clinics set up in Calgary and Edmonton. In the first year of operation, some 456 patients were treated and plans were underway to establish similar clinics in Medicine Hat and Lethbridge. During that ye.ar, the immediate value of the clinics became evident: in a great many of the cases, the diagnosis of active venereal disease had been known for years, but no treatment had been carried out. In the same year, routine tests were carried out on some 477 prisoners admitted to provincial jails and it was found that 79 of these were active syphilitics and that 49 had active gonorrhea. One of the early regulations required prisoners who still had active disease at the tennination of their sentence to remain in detention until treatment was considered effective and the patient cured. 93 A decade later, in 1930, Dr. Orr reported that 68 Alberta practitioners reported some 624 cases in the province. In view of the fact that some 500 doctors were registered that same year to practice in the province, it became obvious that many physicians were not reporting venereal disease cases at all. During the decade from 1920 to 1930, many attempts had been made in the United States to estimate the prevalence of venereal disease in the general population, concluding that about 10 percent of the population and 25 percent of the inmates in mental institutions were suffering from venereal disease. Subsequent work done in the province of Alberta suggested that only 7 percent of patients in mental institutions were suffering from syphilis and that the incidence in the general population was about 3 percent. In 1950, the wisdom of establishing social hygiene clinics was demonstrated by the fact that the instance of syphilis in jail populations had fallen to 2.98 percent, compared to a 16 percent figure in 1940. The highest incidence of syphilis in Alberta at mid-century was reporte General's Department promptly took action to close these "houses of ill repute," but could not prevent their re-opening. The Chief of Police reported great difficulty under the rules available to him in bringing these cases to court. Apparently, the problem of dealing with venereal diseases in the rural areas was not so difficult, largely because the Royal Canadian Mounted Police had a mandate to round up alleged sources of infection. 94 As further evidence of the valuable identification work being done by the provincial clinics, in 1940 roughly 25 percent of 1,662 Wassermann tests showed positive results. Furthermore, some 25 percent of cerebrospinal fluid tests also showed positive. By 1950-51 , the Director of the Division of Social Hygiene was happy to report that organized prostitution had been reduced to an absolute minimum and that formal houses of prostitution were virtually unknown in Alberta, due to the excellent cooperation between the Division and police departments throughout the province. Many of the girls who had been treated up north subsequently reported to the clinic in Edmonton still wearing their badges. But other concerns continued. During the latter part of his office as Director of the Division, Paul Rentier became increasingly convinced of the importance and efficacy of educational programs, which in the beginning he could devise and distribute as he saw fit, based on the statistics of the year's operation. However, with the passage of time and the increasing growth of government, the reports had to go through non-medical governmental channels where a fair amount of unnecessary censorship took place. This unfortunate state of affairs was somewhat circumvented by the appointment of a full-time educator to work directly with people at the local level through health units and the school system. The work of the Edmonton clinic was further enhanced by the movement of treatment centres to the edge of skid row of downtown Edmonton. The clinic was moved to the Alberta Provincial Building, where it worked in conjunction with the Department of Vital 95 Statistics, the Out-Patient Department of the University of Alberta Hospital, and some of its associated clinics. Paul Rentier has related an interesting story about Dr. Harold Orr's early war on houses of prostitution that illustrates an aspect of the social context. When he had narrowed the number of known "houses of ill repute" in Can more down to one, he encountered considerable resistance to having it closed down. The townspeople opposed its closing because they thought their daughters would be in danger. Even the local police resisted closing the house. Later Paul Rentier observed that, with the passage of time and the growing affluence of the population, formal bordellos declined in number but the call-girl phenomenon grew. The call-girl network was virtually impossible to control because it could be run from so many different places without official awareness and because of their sophisticated operations. On the other hand, the call-girl system proved not to be a real venereal disease problem because the call-girls were sufficiently well off that they could take care of their health. A problem in venereal disease control did appear to be arising in the ranks of amateurs who, in return for favours, would accept a few drinks and a warm bed for the night. From Paul Rentier's experience as director, he drew the conclusion that the only real way to deal effectively with the venereal disease problem was through the development of specific vaccines. By the 1970s, nevertheless, control and treatment programs had reduced the incidence of disease to a minimum except on Indian reservations , in the Metis population, and in out-of the-way logging and mining camps. The Division of Social Hygiene always received the greatest 96 cooperation from local health units, Indian health officials, provincial laboratories and the federal and provincial departments of health. In later years, Social Service agencies and youth development programs provided more help. Those long connected with this work in the province have observed that increasing cooperation with the medical profession itself made the work of the Division much easier to carry out. 97 Medicine in Alberta: The War_Y_ear:s W.B. Parsons World War II created military demands for doctors at home and abroad that severely strained the capacities of those available for both civilian and military duties. When Canada declared war on Germany on September 6, 1939, some Alberta doctors took the colours that very day. By October, 19 were in uniform. Others were prepared to join up but waited until the state of mobilization would absorb them into the stream of enlistments. In 1941, the Department of National Defence surveyed the number of doctors who were willing to go into His Majesty's Services, emphasizing the continuing need . As mobilization speeded up, more and more doctors enlisted, but never enough. The Department of National Defence set up Medical Procurement and Assignment Boards in each province, both to stimulate recruitment among doctors and to determine civilian needs for doctors essential to certain communities or, as in the case of the University, to the war effort. The Chairman of the Alberta Board was Dr. H .H. Hepburn, an Edmonton neurosurgeon. By late 1942, 154 Alberta doctors had enlisted in the three services, reducing the number of civilian doctors to 410 compared with 567 in 1940, but the Department of National Defence ·still estimated its additional req_uirements at 300 doctors. As a result of its continual surveys, the Procurement and Assignment Board indicated to some physicians that their services would be of greater use to their country in the armed forces than in civilian communities. The Board had no coercive power but most doctors responded to their suggestions. The few who did not provoked friction. They included some who took the 98 opportunity to move into Calgary or Edmonton from smaller communities without the excuse of doctors who had been declared medically unfit for active service. This tendency to migration raised several public proposals that doctors be frozen in their current locations. The number of doctors who could not be used in the Services was small. Those who were unfit, or too old for overseas service, could readily be used in the Home War Establishment, particularly on Standing Medical Boards in any of the three services, and in Department of Veterans' Affairs (DVA) boards and hospitals. Some doctors performed military duties under the Canadian government's General Order 139 of 1939, which permitted them to serve the military while preserving their civilian status. Some who 'had served in the First \Yorld War and were too old to go overseas, or who did not wam to serve full-time in the Home War Establishment, possibly because their services were required in the community in which they practised, did work under G.O. 139. In the early days of the war, more doctors could have been used in the Home War Establishment, but the system to handle the enlistments had not yet been set up. The members of the militia units that were quickly activated received their examinations chiefly in Calgary where there was a medical board at Sarcee camp. In the small centres about the province, civilian doctors carried out the examinations as provided for in the National War Measures Act. Local doctors conducted the required x-ray examination of the chest for each recruit and sent the film in for examination by a radiologist and filing in the recruit's record. Medical Boards 99 wen~ J;:iter est;:ihli .c;h13. Special Reception Centres with Standing Medical Boards in Calgary and Edmonton. Earlier, in 1941-42, a medical officer accompanied an Air Force Recruiting Team which toured Alberta and eastern British Columbia in an effort to recruit badly needed flying personnel. By 1942, it became apparent that the military requirements for medical officers could not be met from the civilian population. In April the Minister of National Defence announced that 800 medical officers would be required that year. He asked the universities to accelerate their medical courses. After the first year, the government would compensate those who needed help and planned to go into the armed forces. Later the government allowed a medical student who had completed two years to enlist and receive pay and allowances. The universities decided that diluting the course content was not the proper way to achieve speed, so the traditional long summer holiday was abandoned and instruction was carried out the year round. At the University of Alberta, one medical class was registered June 1, 1942; the next on February 1, 1943. This naturally increased the burden on the teaching staff, which had been greatly diminished by enlistments. Those remaining, most of whom combined teaching with their practices, were already loaded with work due to the marked decrease in the general medical population. Civilian hardship is a part of war. In the medical world, this was experienced by both patients and doctors. The Alberta Medical Bulletin of January 1942 indicated that 31 communities needed doctors. Many of these had had a doctor until he enlisted. Patients had then to travel 100 to a community where there was a doctor, only to find that a considerable wait mieht he involved. In an emergency, this was a particularly trying situation. To the doctor, the shortage of confreres meant an increasing amount of work. For those on the university staff, the numbers of patients who came to their offices and the referrals of problem cases from out of town increased even as they stepped up the pace of medical courses. One week after one class graduated, a new class was ready for instruction. This left no time for holidays; indeed, even though they gave additional time to the Department of Veterans' Affairs in the Mewbum Pavilion at the University Hospital. Its 225 beds were usually fully occupied by problem cases sent in from the military hospitals and by those returned from overseas. The University doctors were also responsible for the medical care of the RCMP and the prisoners of war at Westaskiwin. Dr. Roy Anderson, one of very few general surgeons at the University Hospital after Dr. Fife died, spent many whole days in the operating room on DVA cases in addition to his regular practice and his university duties. Anything to do with the war effort had priority; this included looking after the wives and families of doctors who were in the services. In Calgary, the situation was similar, though there was not the problem of the University. But all doctors were over-worked. Dr. Gordon Townsend, an orthopedic surgeon, reported that for a period it was almost impossible to get a surgical assistant, particularly for work done on Red Cross children at the General Hospital. He said that on several occasions Dr. Sidney Gelfand 101 drove in from Canmore to assist him at 8:00 o'clock morning operations and then rushed back to his practice. This he did without compensation . Those in general practice were as busy as the rest, though Dr. Scott McLeod reported in his memoirs that each year during the war he took two or three weeks holiday in the summer. At Medicine Hat, the establishment of an RCAF Service Training School and a POW camp, as well as a Defence Research Board station at nearby Suffield, all increased the medical load. Medicine Hat had been chosen for a training school because it had the most sunshine and the least rain in Canada, pennitting more flying hours. Many of the permanent staff brought their wives and families from Great Britain, Australia and other areas of Canada, as did some of the staff in the other military establishments. All these newcomers placed a load on the local doctors. Though there had once been four independent doctor..s in Medicine Hat, by 1939 they had passed on, so that the Medical Arts Clinic alone offered medical service to the community. Two of the group had gone into the service, leaving five to carry on: Dr. D.N. McCharles and Dr. W.C. Campbell, surgeons; Dr. S.F. McEwen, radiologist; Dr. B.C. Armstrong, internist; and Dr. F.W. Gershaw, MP. As Dr. Campbell reported, Some of us doing surgery worked six mornings a week and held office hours every afternoon and again in the evening from 7:30 to 9:00 p .m. House calls were very frequent and done in late afternoons and evenings. Sundays were not days of rest but were busy in the office in afternoons. During summer months, July and August, we alternated on Sundays, allowing us to take our families to Elkwater Lake or somewhere. 102 In the small towns the situation was the same as in the r.itiP.';, po.ssihly worse sinr.P. thf': :::irf'-'1 involved was greater. A specific case, possibly the worst in the province, illustrates the tremendous burden that some civilian physicians carried during the war. Early in 1939 there were seven doctors in Red Deer. Two of them did the referred surgery for a large area; others acted as medical consultants. By mid-1942, four Red Deer doctors had enlisted, together with 11 from the referral area. Of the three remaining in Red Deer, Dr. Richard Parsons' working capacity was considerably diminished by a severe ar1gina which terminated with a fatal coronary occlusion in 1944. Dr. C.R. Bunn, who served as a medical officer in World War I, was again in uniform, attending to his civilian practice while performing medical duties at the Army Service Corps Training Centre that had been established in Red Deer. This Centre, along with the Commonwealth Flying Training Centre at Penhold, greatly increased the civilian population of the city. There was only one full-time physician to serve them, Dr. R. MacGregor Parsons, a surgeon. He was swamped in the flood of general practice and the tide of surgery. Many nights he had no sleep. For surgical cases, it was the rule rather than the exception to be without an anesthetist or an assistant. The Medical Act, which required three physicians in attendance at all major surgery, ·demanded the impossible. The Deputy Minister of Health, Dr. Somerville, gave him special dispensation to administer the anesthetic, if possible spinal, turn it over to a nurse, and proceed with the operation, assisted by a nurse. This applied not only to relatively minor surgery but also in major cases involving gall bladder, stomach and bowel. The results compared favourably with those achieved under much better circumstances , but at the expense of the surgeon's health. 103 For a short time Dr. Parsons had an assistant with limitei:l experience in surgery. One morning Dr. Parsons operated on a case of hyperthyroidism. The next morning when he arrived at the hospital, he was alarmed to find that the patient had gone into a thyroid storm, a very serious, often fatal complication of thyroid surgery. He was more distressed when he heard that the night nurse had reported to the new assistant that this patient had a temperature of 104 degrees, almost certain evidence of a storm. The doctor told the nurse to give 30 grains of sulfanilamide, helpful in infection but useless here. Fortunately, the patient recovered, but Dr. Parsons decided that it would be easier to carry on alone rather than worry about inadequate help. There does not appear to have been any analysis of the effect of these war years on the lifespan of the doctors who served on the home front. In Red Deer, the citizens became alarmed. Aware of the pressure under which their doctor was living they did not want to bother him except in really necessary circumstances. More than that, they did not see how a man could carry on at the pace he did over so many hours. They did not want to lose what they had. So the City of Red Deer, the Chamber of Commerce, the Canadian Legion and many other public bodies petitioned the federal Minister of Health, pointing out the gravity of the medical situation in the community and asking for the release of a· medical officer from the Home War Establishment. The Minister replied, after consultation with the authorities involved, that none could be spared. In the fall of 1943, the Board of Directors cancelled the traditional tour of the President-elect of the Alberta Division of the CMA because the few doctors in practice were too busy to attend 104 the district meetings. For the first time since its inception in 1924, the Travelling Medical Clinic did not function due to lack of medical personnel. This Clinic had been organized by the provincial government to carry out health education, examine children, give vaccines, attend to teeth and carry out minor operations, particularly tonsillectomies. In 1944, the attendance at the annual refresher course held in Edmonton was good, but most participants were service personnel. The release of doctors from the services was not a rapid process. Prior to the end of the European War a few doctors were demobilized for medical reasons. After the cessation of those hostilities the rate increased considerably. When the bombs were dropped on Japan the need for medical officers dropped sharply. Some stayed on with the occupation troops, and others were busy on the medical boards examining the troops being discharged. With the hope of distributing returning doctors about the province in a manner to provide doctors to all communities requiring one, a Medical Placement Board was appointed. Having no power, it could merely recommend. Dr. H.H. Hepburn, the chairman of the Board, found it a very frustrating job. Some of the doctors returned to their pre-war practices, but a great many wanted to set up in Edmonton; failing that, in Calgary. Those going to the smaller towns wanted hospital facilities, preferably in their own towns or else in adjacent ones. Some communities used to having doctors before the war ended up without a resident physician. Dr. Hepburn's disgusted comment was that "after a third war, for all of me, doctors can go to Mars or Venus." 105 Early in 1945, doctors invalided out of the service and newcomers to thf': provinr.f': hrrnreht some relief of the doctor shortage. In September there were 4 77 doctors registered in the province, of whom 397 were active in private practice. The Medical Association, foreseeing that problems would arise in the post-war period, had formed a special committee under the Committee on Economics to study the situation of those rendering medical services in the province. With Dr. A.E. Archer as Chairmen, the Committee members, Dr. H .H. Hepburn, Dr. A.C. McGugan, Dr. Morley Young, Dr. Roy Anderson, Dr. Mark Levey and Dr. H. Siemans, held four meetings during the winter of 1945 and subsequently met the representatives of at least nine important lay organizations. They were involved in the plans being made for veterans who had not completed their internships, and they had a good fund of information produced by the Procurement and Assignment Board on medical services, disposition of doctors, number of people they served, age of practitioners, the number of hospital beds and the number of doctors in full- or part-time work. The Committee found large areas in the province in which medical and hospitals services were almost non-existent. · While over 60 locations that had·previously had medical services now had none, the greatest concentration of doctors was in Calgary and Edmonton. Overcrowding and long waiting lists characterized many hospitals. The Committee presented a set of general conclusions about key trends in Alberta medical care at the 1945 annual meeting of the Alberta Division of the CMA. 106 1. Alberta had gone farther than most provinces in establishing certain medical services as a state responsibility, including the care of mental cases; the care of those suffering from pulmonary tuberculosis , venereal diseases , and infantile paralysis; the diagnosis and radiological and surgical treatment of those suffering from cancer; and free hospitalization for maternity cases. 2. Alberta had established 17 full-time health districts, though some are short of pro fessional staff. 3. The Alberta Municipal Hospital Plan had been success fu l with 43 hospital districts and had applications for 25 more. 4. Free hospitalization for maternity cases had created the problem for doctors practising in areas without hospitals th at they lost the maternity work. 5. Efforts should be made to obtain the use of an y military hospitals which might be of use to the civilian population. 6. The services built up in Alberta were most worthy but if maintained and developed along the same lines, would constitute a system of State Medicine rather than State Assisted Health Insurance. 7. Conferences with lay organizations are of-great value. While the Committee clearly exhibited concern about the wartime tendency to organize state supported and controlled medical services, it also went on to express marked interest in preventive medical services. From the wartime legacy of crisis medicine under exhausting 107 conditions, Alberta doctors looked forward to rebuilding a medical system that combined traditional practices with innovative approaches to health care. 108 The Faculty of Medi_ci~,JJ_niyersity Qf Alberia, 1913 - 1969 D.R. Wilson The teaching of medicine in Edmonton began before the first World War. The University of Alberta first organized a Faculty of Medicine in 1913. During the next 10 years, the medical school functioned as a three-year program of pre-medical subjects taught in the Arts Building. It is almost unbelievable to note that the pre-clinical subjects throughout this period were taught by only two full-time professors, Dr. J.B. Collip in the biological disciplines and Dr. D.G. Revell in anatomy. The first medical building (which much later housed the Faculties of Dentistry and Pharmacy) was completed in 1922. Before its completion, 150 students participated in this program and went on to complete their clinical training and to graduate at McGill University, the University of Toronto and the University of Manitoba. The new medical building that opened in 1923 made it possible to develop and expand the clinical teaching program. Three new clinical professors conducted the new classes: Dr. Edgerton Pope in Medicine, Dr. Hastings Mewburn in Surgery, and Dr. Leighton C. Conn in Obstetrics. Dr. John· Scott, who had been associated for many years with Dr. J.B. Collip in his remarkable pioneering efforts in the field of biochemical and endocrinological research, was appointed to assist Dr. Pope in Medicine and to become the resident physician in the student health service. For these services, he was paid the handsome salary of $500 per year. 109 During the period 1923 28, Dr. Scott and Dr. Collip did all of the undergraduate teaching in the medical area, but left virtually all of the clinical teaching to Dr. Scott, as Dr. Collip preferred to concentrate all of his efforts in the field of medical research. In assisting Dr. Pope to teach clinical medicine, Dr. Scott learned a great deal about this newly emerging specialty. The 1930s can at best be described as a dismal period in University affairs generally, and there was no exception for the medical faculty. A financial crisis came in 1933 when the provincial government defaulted on its bonds, the only Canadian province to do so. The Faculty made use of existing facilities. Clinical teaching on the outpatient level was carried on almost exclusively in the McLeod House, which was located downtown near the site of the 1960s City Hall. Inpatient teaching was carried on at the University of Albena Hospital, which at that time had 80 beds, plus some other clinical facilities in the Wells Pavilion, a World War I Soldier Civil Re-establishment hospital wing. Some clinical teaching also took place at the Royal Alexandra Hospital. Up to the mid-1950s, for all practical purposes, there were only three ma1or clinical departments: Medicine (which included Psychiatry, Pediatrics, Preventive Medicine, Rehabilitation and Anesthesia), Surgery and Obstetrics, and Gynecology. Prior to the outbreak of World War II, the average number of students in each year was roughly 15, gradually rising in the late 1930s to a level fluctuating around 35. 110 With the outbreak of war in 1919, most of the ahle-hn armed forces. The clinical teaching load fell largely upon the older members of staff, the majority of whom had served in some capacity in World War I, aided and assisted by those unfit for military service and a small group considered as essential who were not permitted to join the armed services. Upon the retirement of Dr. Pope in 1942, part-time volunteers conducted all of the clinical teaching, a few of them at the rate of up to 20 hours per week. The Royal Canadian Air Force, which had established a research and medical selection unit in the Normal School (later Corbett Hall), provided valuable assistance to those carrying a staggering teaching load by seconding medical officers for specific purposes to assume some of the clinical teaching duties. As the war progressed, the medical school term was extended to 11 months per year, and the internship shortened to nine months. Students enrolled in the army as privates, becoming sergeants on graduation and second lieutenants on completion of internship. It is interesting to note that as late as 1944, which falls within the memory of many of us, the total Faculty of Medicine budget was $60,000 and many members of the clinical staff received part of their stipends in Social Credit scrip! As trained medical officers and those completing training under various graduate training programs across the country returned to the University of Alberta after the war to assume teaching and research responsibilities, many of the older physicians retired as soon as it was possible to a well-deserved rest from the staggering load of teaching they had carried throughout the whole of the Second World War. 111 With the end of World War II, large numbers of young medical officers who had served in all three branches of the Armed Forces returned to the city. Because of meagre clinical training and less than one year's internship, they sought post-graduate training. This necessitated the development of formalized graduate training so that many of those who were incompletely trained could fulfill the requirements of the Royal College for specialist training and subsequent examination for certification or fellowship. Following the initiative of Dr. J.J. Orr as Dean, Dr. J.W. Scott as Professor of Medicine and Dr. Marshall, Professor of Ophthalmology, a formal graduate training program known henceforth as "the Marshall Program" flourished for a number of years until all the physicians and surgeons who had done their time in the Armed Forces had satisfactorily completed specialty training. At the end of the Second World War, on the eve of a period of unprecedented expansion in medical education and research, research funds available for medicine for the whole of Canada as allocated by the Medical Division of the National Research Council (NRC) totalled $500,000. As late as 1954, the total research budget of the University of Alberta's Faculty of Medicine from the NRC was about $10,000 a year. Nevertheless, the rebuilding program had begun. After a lapse of some 12 years, the first geographic full-time appointment within the clinical disciplines -- the Professor of Medicine -- was made in 1954. He had at his disposal a princely budget of $10,000, which was available to him to pay all staff members in internal medicine, psychiatry, pediatrics, public health, preventive medicine and rehabilitation. Of this same budget, $4,000 was earmarked for the Dean's salary, who had previously been the Professor of Medicine - Dr. J.W. Scott. The accreditation team that visited the University in 1956 was so 112 :::tpp:::tllt>.rl by the lack of budgetary support from the University, and the inadequate or virtually non-existent facilities for research, that the school was put on a two-year probationary period to meet specified requirements in order to recover full accreditation. At the time, staff members of the Faculty of Medicine were the poorest paid medical faculty throughout the whole of Canada. Department heads in the three basic medical sciences were paid the handsome salary of $4,500 a year with no increments to meet rising costs of living and no prospect for any further advances in their basic salaries. The President of the University, Dr. Andrew Stewart, was outraged upon learning of the recommendation of this report, but the strong criticisms embodied in the report provided the stimulus for increased financial support and facilities for the whole faculty. From that time on, the Faculty of Medicine was on the road up. The increasing financial support from the University steadily improved teaching and research facilities until the late 1960s, when the government again applied the squeeze to all University funding and continued to do so through the 1970s. Faculty administrators turned elsewhere for research support, following the 1946 example of a $5,000-a-year income made available from the original 1922 Rockefeller Foundation Grant. Dr. Angus McGuggan very shrewdly set aside $15,000 that had accumulated as surplus revenue during his tenure as Medical Superintendent of the University Hospital. He also set aside $50,000 to create a special services research fund. Along with the money from the Rockefeller Grant, this played a major role in the development of research, which had previously been virtually non-existent. 113 At the same time, the Surgical Medical Research Institute was created under the energetic leadership of Dr. Walter MacKenzie, who had succeeded Dr. H.H. Hepburn as Professor of Surgery in 1950. From that time on, Dr. MacKenzie provided outstanding leadership and drive until his untimely demise in 1978. During his term as Dean of Faculty from 1959 to 1974, with the assistance of very capable department heads, the Faculty rapidly achieved a reputation as a first-class medical school. The virtual absence of research funds had been a long-standing state of affairs within the Faculty. Despite the efforts of the Collip Club, a group of pre-clinical and clinical instructors interested in pursuing research, the lack of a funding was one of the principal factors leading to the school being put on probation in 1956, when only $10,000 was available to all faculty members. It took some time for outside research fund sources to develop. Following the establishment of a Medical Division of the NRC during World War II under the direction of Sir Frederick Banting and then Dr. Collip, the research budget for the Medical Division grew from a small sum of $350,000 for the whole of Canada to $50 million in the late 1970s. In the early 1950s the NRC Medical Division set aside a sum of $4,000 per year for the four western medical schools to conduct an annual meeting for the-purpose of reporting research canied on throughout the year. This was done to help overcome the relative isolation of western schools from the large metropolitan centres during that time. However unwelcome they were to the University administration, the strong criticisms in the 1956 accreditation report were the best thing that ever happened to the Faculty. By 1960, there 114 was more money available for research in the Faculty of Medicine than the original budget of the Medical Division of the NRC for the whole of Canada. $400,000 was made available that year. Research grants to the Faculty of Medicine rose to $1 million in 1965, to $1,500,000 in 1970, to more than $2 million in 1975 and to $5,700,000 in 1980-81. The long, lean years of hard work by dedicated faculty members eve.ntually resulted in the proper prominence for research within the Faculty of Medicine. During the latter half of the 1970s, the provincial government, recognizing the importance and the rapidly rising quality and quantity of medical research emanating from the University of Alberta, set up a Heritage Medical Research Fund of some $300 million to support medical research at both Alberta medical schools from its interest. In 1981 , Dr. Lionel McLeod, an Alberta graduate who had been Dean of Medicine at the University of Calgary, was appointed the first President. It would take some time for space and facilities to expand adequately to make use of the full range of available research funding. During the latter half of the 1970s, major Medical Research Council of Canada grants were made available to the Faculty. An Immunology Transplant project received grant support in the amount of $1, 125, 000 spread over a five-year period. A $2 million grant to the Department of Biochemistry supported the study of the structure and function of protein. A $1 million grant to Dr. Vern Petkau (Biochemistry) from the National Cancer Institute funded his studies in cancer. From another source, an endowment grant from the Gladys and Merrill Muttart Foundation established a new and innovative centre for research training in the field of diabetes. 115 The firi~t one of itc; kinci in \.anada, it was somewhat comparable to the 10 or 12 centres that had been set up in the United States under congressional law. These highlights constitute but a fraction of the many fine teaching and research endeavours in the modem Faculty. Research advances paralleled developments in medical education. From the inception of the full four-year course in medicine, the objective of the medical school was -- as indeed it was in many Canadian and American schools -- to prepare good medical graduates primarily for general practice after a year of internship, but also for entry into special ty training , which only began to emerge as a serious emphasis just about the time that World War II broke out. At the end of the war, the demand for specialists in Canada was so great that the Royal College of Physicians and Surgeons developed two types of recognition for specialty training. Certification was a lesser qualification than the fellowship status following graduate training programs in existence since the beginning of the College in 1929. Although this was a temporary expedient to meet the urgent demands of the time, it survived 25 years of reports, committees and innumerable studies before the College returned to its 194 7 tradition of the single fellowship qualification awarded after examination in the various specialties. In keeping with the new demands, teaching in the medical schools began to respond to the need for specialists as well as candidates for general practice. Until the end of the war, certainly at the clinical levels, voluntary medical staff taught all undergraduate and graduate medical students for only modest honoraria. In the post-war years, reorganization of the curriculum required a marked increase in staffing. In the early 1950s the prime mover in overhauling undergraduate 116 and graduate medical education was Dr. Ward Darley of the University of Colorado. Through a very close liaison with the University of Colorado in those years, the Faculty of Medicine at the University of Alberta received extremely helpful advice in implementing major curriculum changes. After only a few years, completely new concepts in medical undergraduate education emerged at Case Western Reserve Medical School in Cleveland and Duke University in North Carolina. These changes, which involved the blurring and indeed the blotting out of departmental lines and the advocacy of case-oriented small group teaching, almost totally eliminated mass conveyance of information through the lecture system for schools that could afford it from a staffing point of view. Again Alberta was caught up in the continent-wide changes, but they required a massive increase in staffing, particularly of geographic full-time teachers. The new curriculum went into effect in the late 1960s with the promise of a marked increase in full-time staff to come. But the Faculty was caught short in the general shrinkage of funding for the University as a whole, leaving too few instructors with a huge burden of teaching. With the passage of time, a gradual but not adequate increase in staffing and a modification of the curriculum effected a practical solution. Despite staffing inadequacies and a rapidly escalating number of medical students in each succeeding year, the University of Alberta's clinical teaching achieved improving results in the Medical Council of Canada examinations until the mid-1970s and top level ratings thereafter. 117 With the increasing demand for more specialists, the graduate training program also changed, much to the credit of Dr. Mark Marshall's so-called "Marshall" program of multi-specialty training. It improved in quality with each passing year, despite the large increases in the numbers of people entering into specialty training programs. In 1956 the Department of Medicine had considered itself fortunate to have the appointment of its sixth resident, making the full quota for that particular year. Within 25 years the number of residents in training increased from six to 72 and the number of research fellows and formal research programs leading to advanced degrees increased from one to ten. Almost all clinical departments experienced comparable increases. With increasing emphasis on selection , both at the undergraduate and graduate levels, the increasing quality of training programs at both levels shows up in the results of national examinations of the Royal College of Physicians and Surgeons of Canada. In the mid-1950s, as a generalization, somewhat more than half of the graduates were successful in the examinations on the first try, but by the 1970s it was rare to see a failure. With increases in production of undergraduates and graduates in graduate training programs all across the country, Canada rapidly reached a saturation point in the number of physicians. The remaining problem of maldistribution had yet to be solved satisfactorily, but self-sufficiency in the production of undergraduates and graduates became a matter of pride to the institutions concerned. Perhaps as a result, the number of candidates entering training declined markedly in some specialties with each passing year. 118 The Faculty came a long way from the war years and the arduous struggles of the early post-war period. An incident from the early period illustrates the contrast. In 1946 the Committee on the Allocation of Research Funds, in forwarding its Minutes to the President of the University at that time, Dr. Robert Newton, requested payment to cover a small expense of some $8. 92. The President, in acknowledging receipt of the Minutes (which he always read meticulously), noted that this small item would be paid, despite the absence of supporting documentation. He actually took the time to suggest, however, that the Committee use more suitable English in its future presentation of the Minutes to the President's Office! The new medicine also required new technical specialists. At the end of the Second World War, there were no formal training programs for laboratory technicians of any kind. The training of such laboratory technicians as were required largely followed the apprenticeship approach. The tremendous expansion during the post-war era and the rapidly developing and expanding technology soon made it obvious that large numbers of laboratory technicians would be required to bring the recent advances to the bedside. Training of laboratory technicians first received serious consideration in 195 8, in the form of a proposal to develop a formal course for medical technologists. It envisioned a two-year university course accompanied by two summers of practical training at an approved hospital laboratory. After due consideration, the University's Faculty Council rejected it on the grounds that a diploma course was not properly within the compass of university work. This reversal paved the way for development of a more sophisticated medical laboratory science degree program, while the Northern Alberta Institute 119 of Technology developed a Medical Laboratory Science program that produced its first technologist graduates in 1963. Dr. R.E. Bell, the prime moving force in the early days of the University program, initiated a further recommendation to the Faculty Council in May 1958. After going through a series of modifications, the final result was a medical laboratory science program leading to the degree of B.Sc. after a full four years of training. This revised program did not come into effect until 1964, when a Division of Medical Laboratory Science was created to operate within the Department of Pathology. After expanding over a period of five years into various temporary quarters -- the old medical building, the Wells Pavilion, the basement of the Clinical Sciences Building and the University Hospital -- the Division obtained space in the newly opened Clinical Sciences Building in 1969. Finally, the rapid pace of change demanded constant upgrading. To supplement the major education programs, courses in continuing education varying all the way from night courses to two- to three-day programs were designed for technologists and even graduates from the nurse practitioner program, Thus, it may be seen that the requirements of modern medical education generated a sophisticated research program, which in turn transformed the nature of medical education, all in the space of a quarter century. 120 Memoirs of a Career in Medical Education in Alberta, 1914 - 1959 John W. Scott My earliest recollection of the University of Alberta dates back to 1914. The School of Medicine under the Faculty of Arts and Science had been organized in 1913, as a three-year school. At the end of a three-year course in Medicine, students were accepted for the final two years at McGill University and the University of Toronto. Alberta continued for ten years as a three-year school. I recall that the only bridge between North and South Edmonton in 1914 was the Low Level Bridge. To reach the University from the north side one either walked across the river ice in winter or took a trolley car over the Low Level Bridge, which travelled up 99th Street and along 82nd Avenue to a turn-around at about the junction of 82nd Avenue and 109th Street. From there one walked along a trail in dense bush to Assiniboia Hall or Athabasca Hall, which were the only University buildings. The Registrar's Office was located in Assiniboia Hall. Mr. Cecil Race, the Registrar, was a very kindly gentleman who, after examining my credentials indicating that I had passed the English Matriculation Examination in Belfast where I had been a student, allowed me to register in the Faculty of Arts and Science. In the following year I registered in the School of Medicine. By 1915, most of the first year of Medicine was taught in the newly constructed Arts Building. I recall studying Physics, Inorganic and Organic Chemistry, Botany and Zoology, French and German. The teachers of 121 those pioneer days were a dedicated group who carried a heavy load with few assistants. Graduate students did not exist. Among the group who taught in first-year Medicine were R. W. Boyle in Physics, who later distinguished himself in the field of ultrasonics in submarine detection, A.F.L. Lehman, a gifted teacher in Chemistry and J.B. Collip, a youthful and enthusiastic teacher in Zoology. The second year of Medicine was devoted to the basic sciences: Anatomy, Physiology, Biochemistry and Bacteriology. As would be expected of a new medical school in a pioneer province, the classes were small, with about 20 students. One wonders, looking back, how so few teachers could carry out the program. Only two actually instructed full-time: J.B. Collip, who taught Physiology, Biochemistry and Pharmacology, and D.G. Revell, who taught Gross and Microscopic Anatomy. It was indeed a privilege to have known both these dedicated teachers. Following the completion of third-year medicine, I lost touch, for several years, with medical education in Alberta, although I know that the Medical Building completed in 1922 gave added teaching space for the basic sciences. In the early 1920s, the Rockefeller Foundation gave a .grant of a half million dollars to help the University of Alberta establish clinical teaching and a complete program in undergraduate medical education. This program got underway in 1923, ten years after the Medical School opened as a three-year school. From 1913 to 1923 about 150 students had participated in the Alberta program and been admitted to McGill, Toronto and Manitoba to complete their courses. Dr. Egerton L. Pope in Medicine, Dr. Frank H. Mewburn in Surgery and Dr. Leighton C. 122 Conn in Obstetrics and Gynecology occupied the three clinical professorships established in 1923 . A McGill graduate, Dr. Pope received his graduate training in Medicine in London. He was a meticulous clinician and excellent teacher who followed the Oslerian tradition in teaching and practice. I had the privilege of being associated with Dr. Pope in the Student Health Services and the Department of Medicine from 1923 until his retirement in 1944, when I succeeded him as Professor of Medicine. My own association with the Faculty of Medicine as a teacher began in 1923 with a post as lecturer in the Department of Biochemistry. In the summer of that year the Department of Medicine, which was headed by Dr. Heber C. Jamieson, put on a three-day course on the clinical use of insulin, discovered just two years earlier. Associated with Dr. Jamieson in giving this course was Dr. J.B. Collip, the professor of Biochemistry who had recently returned from Toronto after making a major contribution in purifying Banting's crude pancreatic extract to make insulin available for clinical use. I had the opportunity of meeting Dr. Collip during this course and told him of my plan to go to England for a two-year program of graduate training in Internal Medicine. Dr. Collip suggested that a year with him in the Department of Biochemistry would be a good basis for Internal Medicine. I agreed to accept this opportunity. Dr. Collip suggested that we should go and see President Tory. In those early days in Alberta, decisions were made with directness. Hearing of my plans, Dr. Tory agreed and offered me an appointment as lecturer in Biochemistry. He indicated that the University would soon establish a Department of Medicine with a full -time professor, and that 123 following my year with Dr. Collip and two years of graduate training in Medicine, I might be considered for a part-time appointment with Dr. Pope. Dr. Tory stated that the new Professor of Medicine would be appointed as Director of the Student Health Service, where I might act as resident physician to the University. For examining all incoming students, holding a daily student sick parade and visiting sick students in their lodgings, an honorarium of $500 per year might supplement my modest salary as a lecturer in Biochemistry. Although these appointments and the salary seem trivial 56 years later, at the time they played a very significant role in shaping my destiny and academic career. The one year I had planned on staying with Dr. Collip stretched out to five years at Alberta and a year at McGill. Dr. Collip was a keen investigator with a brilliant mind and a friendly interest in those who worked with him. His primary interest was research and I quickly found that I was expected to do most of the undergraduate teaching, poorly fitted as I was. I managed to spend some of the summer months at the University of Chicago in the Department of Biochemistry as a graduate student. My association with Dr. Pope did indeed give me a valuable training in Internal Medicine. When Dr. Collip left Alberta in 1926 to take the Chair in Biochemistry at McGill, he invited me to go with him as Assistant Professor. I declined and made plans to go to London. As I was about to leave, President Tory asked me to his office, where he told me that the University was unable to find a suitable successor to Dr. Collip and asked me to carry on as acting head of the Department for a year. This is did, with one graduate student. When I finally did get 124 settled down to a graduate program in Umdon, a wire arrived from Dr. Collip, who was then in Montreal, asking me whether, since the Associate Professor of Biochemistry at McGill had been appointed to the Chair of Tulane, I would come to McGill for one session and take over some of the teaching in Biochemistry. I was reluctant to interrupt my program in London and declined Dr. Collip 's offer. However, in response to a second telegram, in deference to my teacher and former chief whom I held in high regard, I "pulled up stakes" in London and moved with my family to McGill. I found this to be a valuable year in an active research department in which, despite a heavy load of teaching, I was able to carry out some research under Professor Babkin. At the end of the academic year, Dean Martin and Professor Collip offered me an associate professorship in the Department. Feeling that my field of interest was Internal Medicine, however, I sent my family back to Edmonton and went off to complete my program in London. On my return to Edmonton I was appointed lecturer in Internal Medicine on a half time basis under Professor Pope. I saw considerable development of laboratory services in the Department of Medicine. During my undergraduate student days at the University of Alberta, at Glasgow University, where I spent six months in . 1919 awaiting demobilization from the Canadian Army, and at McGill, laboratory tests were few. As I recall, apart from bacteriological tests, a routine urinalysis and blood count were the only ones done. Microscopic methods in blood analysis conducted in the early twenties by Folin and Benedict, among others, introduced biochemical procedures that developed rapidly. For many years the Department of Biochemistry carried out the clinical biochemistry for the University Hospital. My first appointment on the University Hospital staff 125 was as "Honorary Assistant Biochemist" in 1924. All specimens from the Hospital were sent for laboratory procedures to the Department of Biochemistry. In the late 1920s, when 1 was acting head of the Department, I protested this separation to President Wallace. Things moved slowly in those days. Not until many years later was a clinical services wing built and Dr. R.E. Bell appcinted Director of Laboratory Services. The thirties were a dismal period in Alberta with the Provincial Government defaulting on its bonds, cutting back the Faculty of Medicine's operating budget to $60,000 in 1934, and later ruthlessly reducing staff salaries and honoraria by the device of partial payment in "Social Credit Scrip". Research funds dried up. The student registration in all faculties diminished, and the graduating class in Medicine numbered a mere 15 students in 1933. However, youth is a great asset and in looking back on those experiences, 50 years later, I can recall some compensations. Professor Pope as head of Internal Medicine constantly stimulated interest with his teaching. Despite the lack of money, there were still sick people to treat and medical students to teach. I recall carrying on out-patient clinics attended by students for two full days a week in .the McLeod House on the present site of the Canadian national railway station in downtown Edmonton. The Department of Internal Medicine included an enthusiastic group of part-time teachers. Dr. Heber Jamieson took a keen interest in diabetes and metabolism. Dr. Charles Hurlburt was the fust cardiologist in Alberta. Dr. Walter Scott was interested in chest disease. Dr. Irving Bell taught therapeutics. The clinical teaching in medicine was done for the most part at the University Hospital, which had only 80 beds; the 126 Department of Veterans Affairs (DVA) and the Royal Alexandra Hospital provided further clinical material. In the early days of clinical teaching, the Department of Medicine administered Pediatrics, Psychiatry and Preventive Medicine, disciplines organized as separate departments only in the early 1950s. The program of graduate training as now set out by the Royal College was still many years away. Residents and interns were few. Dr. R.K. Thomson and Dr. Keith Maclean were residents in Medicine when I joined the Department in the 1930s. The first program of undergraduate teaching in medicine occupied six years, with the final year in an undergraduate internship. In the late thirties, the economic clouds in Alberta began to lift. Student enrolment in Medicine had increased and the graduating class numbered 35 in 1940. The Second World War, however, attracted a number of the teaching staff to military service. The urgent need for medical officers in the Navy, Army and Air Force led to enlisting all physically fit students in the Anny, lengthening the teaching year to 11 months and shortening the junior intern year to nine months. After this period of. training for three years for an .MD degree, all medical students were required to serve in the Armed Forces with the rank of Lieutenant. This program increased the teaching load of all teachers in the Faculty of Medicine, some teaching up to 20 hours a week for the 11-month session. We were fortunate in having Canadian and US service units stationed in Edmonton whose medical officers kindly volunteered their services as clinical teachers. Dr. 127 Donald R. Wilson, who was a medical officer with the RCAF, gave valuable service in the Depanment of Medicine. In 1943, the Canadian Department of Defense recognized the possibility that the Canadian Armed Forces might have to serve in tropical areas such as the South Pacific, where they would be exposed to such tropical diseases as malaria and dysentery. As Canadian Medical Officers had little knowledge or experience with tropical diseases, the Faculty decided to offer training in tropical medicine as a part of he undergraduate course. Dr. R.M. Shaw and I were selected to attend the Army Medical School in Washington or the Tulane School of Tropical Medicine in New Orleans for a two-month intensive period of training in tropical medicine to be followed by two months of hospital experience in central America. On completion of this program, for several years Dr. Shaw and I put on a lecture and laboratory course on the subject in third-year medicine. The end of World War II was followed by the discharge of many medical officers who had entered the Armed Services following a year of internship. Many Alberta graduates wished to pursue a program of graduate training leading to a specialty but the press of similar requests from graduates of eastern Canadian and American medical centers left no places available for Alberta medical graduates. One evening Dr. M.R. Marshall and I met with the Dean, Dr. J.J. Ower at his home to discuss the siruation. As a result, we set up our own program of clinical graduate training under the direction of Dr. Marshall. The Royal College had by then outlined programs of training to qualify for the Certification and Fellowship examinations in the 128 vanous specialities. Over the next few years Dr. Marshall directed this graduate training program with vigor, offering various clinical spec1al1ties in hospitals approved by the Royal College. Research in the Department of Medicine and other clinical departments was slow to develop in a pioneer school. In the early 1940s, the National Research Council budgeted less than a half million dollars a year for medical research. Later, an expanding budget and the establishment of a Western Regional Division of the National Research Council stimulated interest in medical research among our Faculty's basic science and clinical departments. In subsequent years of affluence in Alberta, it would be di ffic ult to realize that Alberta was for a long time a "have not" province. This lack in the provincial economy extended to the University and its Faculty of Medicine, which had the unenviable reputation of paying the lowest salaries in Canada. I recall becoming Dean of the Faculty in 1948 and finding, to my chagrin, that the maximum salary of heads and chairmen of basic science departments was $4,500 per year, half what it should have been, with no provision for increments, even for such superior administrators as Ralph Shaner in Anatomy, Ardrey Downs in Physiology and Robert Shaw in Bacteriology. Dr. Bert Rawlinson and I interviewed President Newton and told him we thought this was disgraceful. Dr. Newton was sympathetic and suggested stating our case to the Board of Governors. Dr. Earle Scarlett, an internist from Calgary who was Chancellor of the University, supported our viewpoint. We indicated that these salaries should be doubled. To 129 the credit of the Board, it put the recommendation into effect over two years. Of course, within that period the Leduc oilfield provided a number of producing wells. Still, the provincial government was not interested in providing money for medical research. Dr. Angus McGugan, superintendent of the University Hospital in the 1950s, was instrumental in having the hospital board set aside a small "Special Services Fund" of $50,000 to be used for getting research projects "off the ground" in hopes that he NRC would support them. The fund was later increased and provided some stimulus to research. These paltry figures explain why, when we hear of a Heritage Medicine Research Fund of $300 million for the Medical Faculty, we stand in awe and expect great things. I enjoyed all of my 36 years on the staff of the University of Alberta. Several colleagues stand out in my memory: Dr. H. C. Jamieson, the first internist in Edmonton who befriended me immeasurably in my early days of practice; Dr. J.F. Elliott, a true Oslerian physician and teacher with whom I had the privilege of being associated in practice from 1945 to 1979; J.B. Collip as a personal friend and advisor and a great scientist to whom I owe a great deal; E.L. Pope, a master clinician who taught me many basics in Internal Medicine; H.E. Rawlinson, a gifted and articulate scholar who as Assistant Dean gave me the benefit of his wisdom and guidance; A.C. Rankin, the first dean of the Faculty, who always showed wisdom and restrain and the hallmarks of a gentleman. He will always stand out in my memory as "The Dean". J.J. Ower, who preceded me as Dean, had a buoyancy of spirit and humor that helped him to bear "the slings and arrows of outrageous fortune" of which he had more than his share. 130 I enjoyed the 1930s most, as a junior member of the staff of the Department of Medicine. Classes were small. One knew all the students on a first-name basis. The reaching of medicine was done for the most part in small bedside groups. The so-called combined clinics of third and founh-year students held for two hours on alternate Thursday mornings in the Mewburn Auditorium, presented unique teaching opportunities. Over two years, students who attended these combined clinics saw patients presented by their feliow students covering a fair spectrum of medicine. Members of the teaching staff in Medicine, Anatomy, Physiology, Biochemistry and Pathology discussed the cases and attempted to correlate the basic sciences with clinical medicine. Over nearly 50 years, significant changes occurred in the pattern of diseases presented for teaching. In the twenties and thirties, typhoid fever and tertiary syphilis were common. Indeed, Dr. Pope devoted ten lectures of his introductory course in clinical medicine to these two diseases and used to quote Osler's axiom: "If you know typhoid and syphilis in all their manifestations, all things clinical will be added unto you." Patients with tabes, general paresis, meningo-vascular syphilis, aortic aneurysm, syphilitic aortitis and aortic incompetence were common. Before th~ days of compulsory pasteuriza~on of milk, brucelloses was always with us. Tularemia occurred in the days of skinning and feeding of rabbits to domestically raised for bearing animals. Robert Macbeth and I published a paper on ten such cases of patients in the University Hospital, three of whom died of the disease. Before the days of Salk and Sabin vaccine, poliomyelitis was a common and dreaded disease in the hospital wards. The last major epidemic of this disease occurred in Edmonton in 1953 and attacked many adults, including the 131 late Dr. R. E. Bell, one-time Director of Clinical Laboratory Services in the University Hospital. The Royal Alexandra Hospital set up a special unit for the respiratory cases. The members of our Department of Medicine among others gave generously of their time on a round-the-clock voluntary basis in providing medical services to these patients. Over the years the natural history of some diseases had changed. Scarlet fever was at one time a common and occasionally fatal disease. A severe epidemic of scarlet fever in the thirties affected a great number of University students in the residences. The outbreak was severe enough that, in my capacity as Director of Student Health Service, and in consultation with the provincial and city departments of health, I advised President Kerr to close down the University. It remained closed for a three-week period. The major milestones in the investigation and treatment of sick people that have occurred in my medical lifetime include the introduction and use of insulin in the early twenties, the use of liver in the treatment of pernicious anemia in 1925, the use of sulphonamides in the early thirties and antibiotics soon afterward. The isolation of adrenal cortical hormones and radioactive isotopes and the concept of immunity in disease have revolutionized our concepts of internal medicine. Some strong memories involved administrative and professional rather than technical matters. Dean Rankin asked me to his office in 1944 and told me I had been appointed Professor of Medicine. Dr. J.J. Ower, who occupied an adjoining office, congratulated me and in his whimsical way told me my first task should be to help select my successor. I took Dr. Ower 132 very seriously and a year or two later made a trip to Boston to talk to Dr. Donald Wilson, who had attained senior rank as a medical officer in the RCAF. I was able to interest him and him wife, Ruth, in coming to live in Alberta after completing his graduate training at the Massachusetts General Hospital. He soon won a Markle Fellowship and began a distinguished career in the Department of Medicine, succeeding me in 1954. It is gratifying that Dr. Wilson, Dr. Fraser, Dr. Sproule and Dr. Molnar, who have so efficiently acted as professors of Medicine, were at one time Alberta students. As often happens with a closed teaching hospital in a community, a "town and gown" relationship divided medical practitioners in a way that has, I hope, disappeared. Two agencies helped to dispel it. Most Edmonton doctors belonged to the Edmonton Academy of Medicine, which existed long before the establishment of the medical school. I was privileged to be a member of the council for several years and its president. The Academy did a good deal to create understanding and good fellowship between the University and non-University practitioners. So also, though perhaps more fleetingly, did the "Journal Clubs" organized by Dr. J.J. Ower. Dr. Ower astutely selected groups of University and non-University Hospital doctors to meet monthly for dinner and discussion of members ' reports of medical journal articles. A number of such groups created a mix of doctors that served a useful purpose. A medical school should exist not only to further undergraduate and graduate teaching and medical research but also to lend support to organized medicine at the municipal, provincial, national and international levels. The Department of Medicine and other Departments strove 133 to do this, and the Edmonton Academy of Medicine worked at the municipal level. The Alberta Medical Association has had a close liaison with the medical school and one of its officers has for many years been a member of the Medical Faculty Council. Two of the members of the Department of Medicine, Dr. Harold Orr and Dr. R.K. Thomson, have been presidents of the Canadian Medical Association. The Association of Canadian Medical Colleges was established in the 1940s as a forum at which the Deans and other officers of Canadian Medical Schools could discuss matters of common interest. Originally the American Association provided the meeting places. The Canadian group met annually with a part-time secretary and no permanent office. During my tenure as President, I made an unsuccessful attempt through the Commonwealth Fund and the Rockefeller Foundation to obtain funds to upgrade the Association, expand its activities and employ a permanent secretary. A few years later Dr. Joe McFarlane, Dean of the Medicine of the University of Toronto, called representatives of the Association, the Royal College and the Division of Medical Education of the CMA to a meeting to hammer out the terms of agreement and financial support that would greatly expand CMA activities. Dr. H.M. Tory, first President of the University of Alberta, was instrumental in the mid twenties in founding another national organization in which I was interested, the National Research Council. Initially it had no interest in medical research, but in the 1930s, the Council formed advisory committees in various fields of research. Sir Frederick Banting first chaired the one on Medicine with Dr. Chester Stewart, Dean of Medicine at Dalhousie as secretary. 134 Sir Frederick and Dr. Stewart visited our Faculty of Medicine in the mid-thirties in an effort to stimulate medical research in Alberta. Following Banting's untimely death, Dr. Collip was appointed Chairman of the Medical Advisory Committee with Dr. Ettinger, Dean of medicine at Queens University, as secretary. I served on this Committee for a number of post-war years when the amount allocated annually for medical research in Canada through this Committee was $350,000. Fortunately, it was increased dramatically following "Sputnik", when the Canadian government became more research-conscious. The Medical Research Council then became a separate entity under the presidency of Dr. Collip. The budget now is over $50 million. Dr. Thorlakson of Winnipeg and I played a part in the project that encouraged medical research in Alberta, British Columbia, Saskatchewan and Manitoba by making small grants to establish western regional meetings at the four western medical schools. The Royal College of Physicians and surgeons of Canada was founded in 1929 by a small group that shortly afterward asked me to join as a charter fellow. It was a fascinating experience to see the development of this organization over the past 50 years from a small group of a few hundred to over 26,000 fellows. Our Faculty of Medicine has contributed greatly over the years to the development and functions of the royal College. ·Dr. E.L. Pope was one of the first Vice Presidents. Dr. W.F. Gillespie and Dr. W.C. MacKenzie were presidents. Dr. Donald R. Wilson of the Department of Medicine made a monumental contribution as Chairman of the R.S. McLaughlin Research Centre in studying and advising the College on methods of examinations. Initially, the annual meetings in Ottawa attracted only a few of the fellows . We had dinner together and discussed College business. At one of these meetings in the early thirties, 135 Dr. Ray Farquharson and Dr. Fulton Gillespie suggested a short scientific program following dinner. The program has expanded to three or four days and provides a forum for discussing the best of Canadian medicine. I had the privilege of being associated with the College from its beginning, serving on many of its committees and acting as College Examiner at both the Certification and Fellowship levels. I served on Council for eight or ten interesting years and as President of the College for 1959 to 1961. Finally, I enjoyed serving on the American College of Physicians' Board of Governors for nine years and having the privilege of being a Fellow and Master of the College, which made a fine contribution to Canadian medicine. The two outstanding contributions I recall apart from the annual meetings were the regional meetings of the College and the graduate courses. Dr. Allan Edwards, a member of the Department of Medicine who served for many years as a College Governor, was instrumental in arranging many of the regional meetings in Western Canada. Some of these meetings held jointly with the Royal College included members of our Department of Medicine as speakers. Thus was isolation bridged and thus were University of Alberta Faculty of Medicine staff members made part of national and international support networks. The medical school brought international medical learning to the new province in the first place, and in due course began to make contributions to it. 136 The University of Alberta Department of Medicine, 1954-1969: A Personal Review D.R. Wilson My stewardship as Chairman of the Department of Medicine probably had its beginnings as far back as 1933, when Dr. ("Daddy") Revell, then Chairman of the Department of Anatomy, called me as a student into his office and put it to me directly that I should apply for a Rhodes scholarship. After I had been awarded the scholarship and arrived in Oxford, I found that the Medical School would not recognize any of the four years of Medicine that I had taken at the University of Alberta. After an impossible attempt to cover the whole programme in three months, I then chose the only remaining option: an honors degree in the Department of Physiology. On completing my training in Physiology and receiving my degree in 1937, I returned to Canada and completed my medical training in 1939, at McGill University. This background of two years training in Clinical Physiology, Dr. Scott intimated several years later, should give me very good prospects of becoming the Chairman of the Department of Medicine on his retirement, should I return to the University of Alberta after my years in the Air Force. That combination of events brought me back part-time in 1947; and in 1949 I undertook as a Markle scholar to develop an Endocrine Laboratory in a little room behind the elevator shaft in the old 1912 wing of the Medical Building, launching my career in the Faculty of Medicine. I will never forget the first day in office as Chairman of the Department when Dr. Scott, Dean of the Faculty of Medicine at the University of Alberta, showed me the budget for the Department of Medicine. At that time the Department of Medicine also included what ultimately 137 became the Departments of Psychiatry, Pediatrics, Preventive Medicine and Public Health, and Physical Medicine and Rehabilitation; yet the total budget for all of those areas at that time was $10,000 a year, which had included Dr. John Scott's salary as Head of the Department and Dean of the Faculty at $4,000. Indeed, the total Faculty research budget was less then $10,000 a year. Such as the clinical and research picture in the year 1954 when all clinical teaching was done by part-time staff. When I took office as Chairman of the Department, I became the first geographic full-time· member of the staff, along with Dr. Bob Fraser, who was then on a medical scholarship program. We were very lonesome people, for whom the part-time staff had no particular love or affection . One very powerful member of the pan-time staff told me quite frankly that he would make it his own personal business to see that the concept of geographic full-time positions in the Faculty was destroyed. Fortunately, this never came to pass. In 1954, the full teaching staff in Medicine, Pediatrics, Psychiatry, Preventive Medicine and Public Health, and Rehabilitation totalled 19 staff members at the University Hospital. The Department of Psychiatry comprised one person, Dr. ·Sid Spanner. The total teaching staff in those clinical departments for all of the hospitals involved in the teaching program was 32 members, all part-time. In that same year, however, the first two sub-specialty units, which ultimately became Divisions of the Department of Medicine, came into being: the • "Geographic full-time": full time at the University, but with the opportunity to offer consulting services to private patients. 138 Cardiovascular Unit under the direction of Dr. R.S. Fraser, and the Endocrinology Laboratory. Dr. Brian Sproule, then a member of the resident staff, was awarded a special scholarship to enable him to assist Dr. Fraser in the development of the Cardiovascular Unit. Dr. Sproule developed a special interest in the pulmonary aspects of cardiovascular disease, and subsequently went on to graduate training in the United States, before returning to the staff. 1954 wa.s also the year after the last serious polio epidemic, and the space turned over to the continuing care of the respiratory polio patients greatly reduced the number of teaching beds in the Department of Medicine. Respirator cases from the old Infectious Disease Hospital on the grounds of the Royal Alexandra Hospital had just been moved to the University Hospital. From the early 1930s, when I was a medical student, to about 1954, the Department and its facilities had remained relatively static, reflecting the lack of money during the depression and the wartime dedication to turning out as many physicians as possible with the existing facilities. From 1954 on, after the return of physicians from the War and from postwar training programs, and with prosperity just beginning to make a local impression after the discovery of oil at Leduc, rapid expansion prevailed until 1968 or 1969. A chronological review will illustrate the process. In 1955, the Cardiovascular Unit expanded. The University Hospital used radioisotopes for the first time, introducing radioactive iodine a.s a diagnostic and therapeutic tool. During the year Dr. Adam Little became the last appointed resident in the Department of Medicine, arriving from New York in January. This brought the total to six, a number thought at the time to represent a stunning level of achievement. 139 In 1956, with return of Dr. Brian Sproule from the United States, the recruitment of Dr. George Mond.1on in the field of Neurology, and the addition of Dr. R.E. Rossall to the Cardiovascular Unit, the diagnostic and research facilities in these three areas became well established and added greatly to the clinical and research activities within the Department. The new established Special Services Committee used revenue derived from funds that had been accumulated under the shrewd management of Dr. A.C. McGugan to stimulate a great increase in activity in the field of clinical investigation. The University Hospital received accreditation from the Royal College of Physicians and Surgeons for the teaching of postgraduate students in 1956, the last year in which individual hospitals rather than whole university programs were approved for postgraduate training. By this time, many of the clinical areas which were divisions of the Department of Medicine had begun to split off and become separate departments in their own right. The first was Pediatrics, followed the same year by Psychiatry. The new Department of Psychiatry had the magnificent total of two psychiatrists on staff to service the needs of a 1,200-bed University Hospital, grown mightily that year with completion of the last of the clinical service wings. Designed primarily to provide space for Rehabilitation Medicine and Pediatrics, it was immediately adapted to accommodate Orthopedics, Cardiovascular Surgery, and Eye, Ear, Nose and Throat patients as well. By 1957, the Cardiovascular Unit had become sufficiently well developed to permit the opening of the first Open Heart Unit in Canada, after Dr. John Callaghan had become the first surgery 140 appointee the year before. During the year, the geographic full-time concept had spread to Pediatrics, Psychiatry, Clinical Laboratories, and Rehabilitation Medicine. In several of these Departments, in addition to the Chairmen holding geographic full-time positions, so also did several Divisional Heads. The Outpatient Department organized many new clinics. Double the number of patients from the previous year provided a much greater variety of clinical teaching material. By this time, postgraduate clinical investigation had become well developed. Every year after 1954, the Department of Medicine had at least one postgraduate student pursuing clinical research towards an M.Sc. degree. In 1956, there were two. Three new geographic full-time appointments followed in 1958, accompanying a more comprehensive continuing medical education program. Again, two fellows completed the requirements for M.Sc. degrees in fields of clinical research, and research funds of $67,000 for the Department of Medicine alone were almost seven times that of the total Medical School research budget when I had first returned from the war in 1947. The Pulmonary Medicine, Cardiovascular and Endocrinology Divisions continued to expand in 1959. The addition of Dr. Gordon Brown permitted the first full-fledged teaching program for diabetic patients with the full-time services of a teaching nurse, Miss Ruth Shaw. Mr. and Mrs. Muttart established a diabetic reference library, the first of many large Mutt.art family and Foundation gifts to the Department, the Faculty and the University Hospital. In 1959 the Outpatient Department returned to the University Hospital itself from the Alberta Building in downtown Edmonton, where it had functioned during and after the war years. The concern that 141 the movement of the Clinic to the Hospital would result in a decline in numbers subsequently proved unfounded. This was also the second year of the full five-year graduate training program leading to fellowship in the Royal College of Physicians and Surgeons of Canada, and formalized programs were developed. Dr. A.C. McGugan, who had served 18 years as Superintendent of the Hospital, and the first non-medical Administrator of the Hospital, Mr. Reg Adshead, both retired in quick succession in 1960 and 1961. Adshead, previously the Hospital's Business Administrator, had been associated with the Hospital from his teens. His successor, the new Executive Director of the Hospital, Dr. J .D. Wallace, expressed his concern over the rising cost of operating clinical facilities in the Hospital that necessitated an increase in the day rate from $18 .97 to $20. 64. Little did he realize that he was identifying a massive long-term trend in hospital cost escalation. The Department of Medicine introduced an artificial kidney as the result of Dr. Lionel McLeod's increasing interest in this new lifesaving device in the field of renal disease. At the undergraduate level, medical student were introduced for the first time to the concept of "living in" as clinical clerks or, for all practical purposes, junior interns. The same problems of increasing demands for services at both outpatient and inpatient levels continued to beset the Department. Renovations to the old 1912 portion of the Hospital, and construction of new facilities in the South wing of the Hospital, were completed in 1962. The Department was reorganized into a series of divisions, each operating within the geographic confines of its own respective ward. 142 Increased collaboration between the Cardiology and Pulmonary Divisions improved the quality of care and research in the field of cardiopulmonary disease and also in the pre- and post operative care of patients coming to the hospital for open heart surgery. In the field of Endocrinology, Dr. David Fawcett' s work considerably enhanced the quality of commercially available radioactive iodine, making a real contribution to the utilization of radioactive iodine right across Canada. A new Division of Clinical Pharmacology worked closely with the Department of Pharmacology to test the clinical effects of new drugs as they appeared on the market. The development of the new ward system concentrating patients with similar diseases in geographic areas of the hospital markedly improved the quality of patient care, but it did pose problems requiring solution for undergraduate teaching. One of the unforeseen benefits of the ward system, however, was a significant shortening in the length of stay of patients in hospital. The ward system also allowed the creation of comparable outpatient clinics so that patients seen in any particular division returned to a divisional outpatient clinic, which made possible long term care of patients under the same clinical staff. In 1963 cardiac pacemakers appeared, and the Metabolic Unit operated for the first full year, facilitating intensive study of patients with metabolic disease in a separate unit of the hospital. The activities of the unit, which had been initiated in 1949, were at this point closely integrated with the artificial kidney program to accumulate much valuable research data. Completion of another renovation program in 1964 made it possible to add one new clinic in General Medicine to the Outpatient Department, a valuable addition not only for treatment of 143 patients but also for teaching at all levels of undergraduate and postgraduate medical training. The Department introduced a Division of Gastroenterology during the year and completed plans for computer recording of data on some 2,600 cardiac patients who had been treated in the Cardiovascular Division. In the Division of Pulmonary Disease, the Inhalation Therapy Unit showed a marked increase in utilization. Both the Divisions of Cardiology and Pulmonary Disease established very profitable working relationships with the Faculty of Physical Education. Two graduate students in the Division of Pulmonary Disease enrolled in the postgraduate educational program proceeding to Master of Science degrees. Dr. Patricia Lynne-Davies subsequently joined the staff, and Dr. Philipson joined the staff of the Toronto General Hospital, where he has subsequently made important contributions in the field of pulmonary disease and in the understanding of sleep disorders. Dr. David Fawcett received a Medical Research Council Scholarship which permitted him to continue his studies in the field of thyroid disease and to refine simpler, more reliable techniques for the measurement of various steroid hormones that greatly facilitated the clinical work in this particular di vision. The Division of Clinical Pharmacology expanded its activities into collaborative studies with the Cardiac Division and the embryo Division of Gastroenterology. The Division also developed collaborative worA: with the Department of Obstetrics and Gynecology, studying the effects of various adrenergic drugs on normal and premature labor situations. During the year, Dr. Russell Taylor developed and directed a special cardiac resuscitation team. With the completion of the renovation program, the Department responded to constantly increasing demands of the public for highly specialized diagnostic and treatment programs by 144 continuing to add new members to the staff. By this time, however, staffing could not be expanded further without the addition of further clinical beds in which to house the patients requiring inpatient diagnostic and treatment facilities. In 1965, the Division of Neurology was fortunate to obtain the services of a well-trained neurological biochemist, Dr. Taiichi Nihei. Dr. Nihei devoted his full time to studying protein chemistry in relation to muscle disease. Increasing collaborative studies between the Divisions of Cardiology and Pulmonary Disease with the Faculty of Physical Education resulted in the bilateral appointment of Dr. Paez as an assistant professor in Physical Education and Medicine. Dr. Joseph Martin, who subsequently became a Centennial Fellow of the MRC in 1967, left our program to complete his training in Neurology in Cleveland. Through a succession of distinguished appointments in the United States and McGill, he subsequently returned to Boston to become Professor of Neurology at the Massachusetts General Hospital of the Harvard Medical School. Feverish planning for the future occupied 1966, with attention to detailed planning for the Clinical Sciences Building and to preliminary planning for the Centennial Hospital addition. The Division of Cardiology introduced even more complex methods for assessing cardiac function and further refined geographic techniques for coronary artery visualization, which have been of great assistance in selecting appropriate patients for coronary artery surgery. Dr. Fraser introduced programs for the computerization of electrocardiogram interpretation following his sabbatical year. In the field of endocrinology and metabolism, Dr. Crock.ford was able to 145 introduce new methods for radioassay measurement of Insulin and new laboratory techniques for the measurement of glucagon and growth hormone. With the increasing demands for artificial kidney therapy during the year, it was possible to increase the establishment for professional and technical personnel to deal with these renal problems on a long-range basis. During the year, the Department formally established the Division of Gastroenterology. The Royal College of Physicians and Surgeons of Canada made one of its periodic five-year reviews, and the Department was gratified to receive a report indicating that the postgraduate training program was among the best in Canada. This reflected a growing number of superior applicants applying for training in the program produced by a staff of growing national and international status. In 1967, the Department further refined the clinical clerkship program, introducing new methods to evaluate student progress and to provide effective individual personal counselling. The fourth year clinical clerkship program was decentralized to a considerable extent to the affiliated teaching hospitals. In the field of graduate medical education, all former residents who took the examinations of the Royal College were successful and three students enrolled in the Faculty of Graduate Studies for their Master of Science degrees. During the year, an international three day symposium in the field of renal disease, developed largely as a result of the enthusiasm of Dr. L.E. McLeod, took place on the campus, attended by a distinguished group of research scientists from all parts of the world. The medical research budget for the whole Faculty had grown to a research grants program of some $250,000. 146 Because of the increased awareness of a need for more reliable evaluation of graduate students, the Royal College of Physicians and Surgeons of Canada established the R.S. McLaughlin Research and Examination Centre within the University of Alberta. As the first Director of the Centre, over and above my workload of running the Department, I undertook to develop this new venture in the evaluation of postgraduate medical education. This would not have been possible without the able work of Mr. J. G. Kerr, a former Air Vice Marshall and Deputy Chief of the Air Staff, as Administrative Officer of the Department, assuming control and direction of all non-medical administrative activities in the Department. During the year, a Rheumatic Diseases Unit was established at the University Hospital, funded by the Canadian Arthritis and Rheumatism Society, under the direction of Dr. J.S. Percy. Through the generosity of the Gladys and Merrill Muttart Foundation, it became possible to establish a visiting professorship to recognize the scientific contributions of Dr. J.B. Collip, most specifically with respect to the role which he played in the discovery of Insulin. Dr. Brian Hudson, the Professor of Medicine from Monash University and a distinguished scientist in his own right, was the first J.B. Collip visiting professor. His year of tenure proved most stimulating to all members of the staff, and specifically to the Division of Endocrinology. He was further responsible for the development of computerized techniques for evaluation which subsequently resulted in the introduction of computer-based examinations in the field of pediatrics, the fust such venture anywhere in the world. In addition to participating in departmental affairs, at both the undergraduate and graduate levels, he also was able to develop new methods to measure androgens in biological fluids . The Mutt.art Foundation again was 147 instrumental in providing funds for the purchase of an electron microscope which made it possible to develop the J.B. Collip Research Laboratory in Neurological Diseases. During the year, three members of the Department held important positions as presidents of Canadian Societies and Associations. Dr. Ken Thompson completed his term as President of the Canadian Medical Association, Dr. L.E. McLeod was President of the Canadian Society of Nephrology, and Dr. R.S. Fraser was President of the Canadian Cardiovascular Society. Dr. Allan Gilbert was Vice-President of the Canadian Association of Gastroenterology and Dr. D.R. Wilson was Vice-President of the Division of Medicine of the Royal College of Physicians and Surgeons of Canada. A new Student Evaluation Board responding directly to the Faculty for all undergraduate evaluations was the first of its kind in Canada, producing fully objective examinations with complete computer storage and retrieval capability, along with complete computer marking of all written examinations. Collaboration with the R.S. McLaughlin Centre permitted complete psychometric analysis of all examinations. In 1969, the last year of my tenure as Chairman of the Department, one of the major episodes involved the very significant physical move from the University of Alberta Hospital to the new Clinical Sciences Building. The requisitioning of new scientific equipment, the detailed planning and installation of the equipment and the phasing of the move of existing laboratories all posed major problems, all very smoothly and expertly handled by Mr. Kerr, the Department's Administrative Officer, working in collaboration with various divisional heads. The clinical clerkship program continued to improve. During the year, postgraduate students enrolled in the 148 Faculty of Graduate Studies were successful in obtaining their Master of Science degrees. Ten members of the postgraduate group were successful in their fellowship examinations of the Royal College, and one further member of the postgraduate training plan was successful in his certification. The first international conference on evaluation of medical education was conducted during the year under the chairmanship of Dr. J.A.L. Gilbert. This conference attracted 150 participants, including authorities from many parts of the world. In the field of medical research, staff members obtained grants totalling in excess of $280,000. In the Division of Cardiology, staff members carried out major studies with respect to the hemodynarnic response to exercise before and after open heart surgery. The Pulmonary Division developed major studies in chronic obstructive lung disease, bronchitis and emphysema. In the Division of Endocrinology, new investigations commenced the replication of an fu"l"A virus and the effect of the virus on host metabolism. New research areas of activity began to appear with the development of plasma Insulin responses to oral and intravenous glucose loads. In the Division of Infectious Disease (which was created with the return of Dr. George Goldsand to the staff), three new studies got under way during the year: on Colicin activity in human serum; on the role of bacterial cell wall variance in human disease; and on the role of anerobic bacteria in infections of the middle and paranasal sinuses. Dr. John Dossetor, a new staff member, launched studies in the field of tissue rejection. After several of the Department of Medicine personnel moved into the Clinical Sciences Building, a Transplant Immunology Laboratory was developed in the University Hospital. Dr. Dossetor brought with him several of his staff from McGill University and began to establish a new Division of Immunology. This new venture, 149 in collaboration with Dr. Diener and his group, attracted an MRC grant of $1,250,000 over a five-year period. By contrast, the departmental budget in 1954 was $10,000 ($4,000 of which went to the Dean' s office) and this money had to cover everything in the Department of Medicine and its branches - - Pediatrics, Psychiatry, Public Health & Preventative Medicine and Rehabilitation and Physical Medicine. In 1969, the Department of Medicine operational budget alone was $330,940. The research budget was $437 ,284 plus the transplant group budget of $1,250,000 spread over a five year period and $80,000 for the operation of the Edmonton Unit of the McLaughlin Centre. The research budget for the whole Faculty was $2,045,000 as compared to $10,000 in 1954. With the gradually increasing activity of the R.S. McLaughlin Foundation Research Centre, it became necessary to make a choice between directing the newly developed Centre, or continuing on as Chairman of the Department. After 15 years as Chairman, I decided that it was time to move on into the development of the new Centre, ending a 15-year period at the head of ceaseless expansion at the end of July 1969. Of course, there are unique moments that stand out in my memory of that period. In the year preceding my appointment as Chairman of the Department, for instance, Dr. John Scott asked me to deputize for him on the Medical Advisory Board, feeling that a year's experience on the Board would be helpful when I had to take over the reins of office. During this 12-month period, Dr. McGugan, who was then the Medical Superintendent and a rather testy old Scotsman 150 at the time, twice threatened to throw me off the staff of the Hospital. The first clash I had with him was over the application form for appointment to the University Hospital, which required that the applicant declare his religious denomination. I felt that this had nothing to do with staff appointments to the Hospital; I insisted that this be removed. He became so incensed at the insistence of this young upstart that, although he did not physically throw me out of his office, he asked me to leave while he considered whether I should remain on the staff of the Hospital. The next morning, he called me into his office and said that he had thought it over and he felt that perhaps this was a good idea after all, and that he now had no objection to this change. It was subsequent to this change in the staff application forms that Dr. Joe Dvorkin was appointed to the staff of the Department. The second clash I had with Dr. McGugan was over the building of a private office on University Hospital premises by one of the members of staff (not in the Department of Medicine). The whole Medical Advisory Board was so incensed at this development that the members recorded their feelings in the minutes. I personally went to see Dr. McGugan about it and again, although not physically tossed out, was asked to leave forthwith. With the passage of time, however, Dr. McGugan and I gradually became the best of friends, and, in subsequent years, when his physical vigor began to decline somewhat, Swede Gourlay, who was then in the Department of Surgery, and Morris Adamson, Head of the Rehabilitation Unit, and I, used to take Dr. McGugan out prairie chicken shooting. He always insisted on wearing his double breasted, navy blue winter overcoat -- hence, he stuck out like a sore thumb against the golden autumn background. Swede, Morris and I did most of the walking whilst he reclined at his 151 leisure against a large tree. Although, I do recall, he shot most of the grouse, because almost every bird we flushed seemed to be drawn (as if on a string) toward the double-breasted, blue overcoat. One other memory I have of my years in the Department is that, during the 15-year period, my office was moved no fewer than seven times, which indicates in some degree the physical activity that went on in the renovation of the old areas of the Hospital, and the development of new facilities. My first office in the Hospital, which Dr. McGugan felt very proud of, had formerly been the University Hospital coal bin when the Hospital was heated separately from the rest of the campus. The two rooms which I was allocated with the new central heating pipes running through them were hot almost beyond human endurance, and when I moved. to somewhat cooler quarters, I noted that my original office was converted into a quick-drying room for rubber gloves from the operating room. The time I held this position was a most interesting and happy period of University and University Hospital life. There were no "factions", and there was little if any in-fighting and relatively little political maneuvring. It was a period of rapid expansion when obtaining funds for new staff members and research equipment constituted no problem. The main problem, really, was to find the best personnel available to staff the Department. It became obvious in the latter part of 1968 that the screws were gradually being turned on the University budget, so that, in many ways, I considered myself fortunate to have escaped just at the time that increasing restraints were being placed on all faculties. If there were any difficulties, they were minor 152 ones, usually associated with the fact that we lived, for a number of years, in a state of physical chaos with jackhammers working overhead or underneath, construction workers knocking down walls outside our doors or walking through our offices or laboratories to rip out old installations and install new equipment. We lived this way so long that, after a while, we scarcely noticed it. I was also fortunate in having as my predecessor, Dr. John Scott, who was a constant source of help and encouragement to me. I think it is quite remarkable that the four Chairmen who succeeded one another after his retirement in 1954 were all former students of his. After his retirement from the Department, Dr. Scott continued for a period of five years as Dean, and this was of great help to me , as I gradually began to feel my way along in the Department. Fifteen years later, I left with the great satisfaction of having had the good fortune to work with a happy and active group, not only within the Department, but among Chairmen of the other clinical departments as well. 153 Earlv Diagnostic Cardiologv at the University of Alberta: The Development of Catheterization in the 1950s and 1960s. ·• Robert S. Fraser The only person of record performing cardiac surgery at the University of Alberta Hospital before 1953 was Dr. W. Carleton Whiteside. Whiteside had graduated with 17 classmates in the fourth graduating class of the Faculty of Medicine at the University of Alberta in 1928. His formal post-graduate training was scanty. In his autobiographical sketch published in 1950 ("The Nomadic Life of a Surgeon"), he recorded an internship at the Moses Taylor Hospital in Scranton, Pennsylvania for 18 months and a total of 12 months of "externship" at the University of Alberta Hospital and the Royal Alexandra Hospital in Edmonton. He then spent a year visiting and observing surgeons in London, Edinburgh, Paris and Vienna before returning to Edmonton in December 1931 to begin five years of general practice. After obtaining his Fellowship in Surgery from the Canadian Royal College (he also passed his American Boards) he restricted himself to general surgery, including thoracic operations, from 1936 until 1946, including five years with the Royal Canadian Army Medical Corps. He wrote that he "commenced specializing in thoracic surgery only on January 1, 1946". •• Adapted from R.S . Fraser, Cardiology ar the University of Albena 1922 - 1969 (Edmonton: Department of Medicine, University of Alberta, 1992). 154 Dr. Whiteside was attracted to the new challenge of cardiac surgery and in the spring of 1946 visited Ann Arbor, Michigan and Detroit after which he reported to a meeting of the Academy of Medicine in Edmonton on the status of the developing field of cardiovascular surgery with particular comments on pericardectomy, ligation of patent ductus, repair of coarctation of the aorta and the Blalock-Taussig operation. In May and June of 1947 he travelled again, this time to England and Sweden and recorded his admiration for the medical facilities in the latter country and his respect for Crafoord' s skill as a cardiovascular surgeon. A search of the medical records of the University Hospital for all patients seen by Dr. Whiteside between January 1, 1946 and August 1, 1953 revealed the type of surgical practice he had at this hospital. As surgeon to the Cancer Clinic and thoracic surgeon to the Department of Veterans Affairs (which was responsible for the care of Veterans in the Mewbum Pavilion of the University Hospital), Dr. Whiteside did a large number of endoscopies, mainly bronchoscopies. The greater proportion of this major surgery consisted of resection of bronchogenic carcinoma and bronchiectatic lung, although he did some esophageal and breast surgery. Between 1946 and 1954, however, he also performed a variety of heart operations at the University Hospital and elsewhere, many of them successful despite less than adequate diagnostic techniques, resources or facilities. Surgeons of \Vhiteside's era attempting to do cardiac surgery at the University Hospital could expect little diagnostic help from pediatricians or internists and only rather limited information from the radiologists working with venous angiograms and chest films . There were no cardiac 155 catheterization facilities in the province. By 1953, however, two internists had returned to Edmonton with a special interest and added training in cardiology. Dr. Gordon I. Bell, son of the pioneer Edmonton internist and teacher, Dr. Irving Bell, MB (Toronto), FRCP (C), received his degree in Medicine from the University of Alberta in 1940. After spending two years on the housestaff of the University Hospital, he joined the RCAF as a medical officer. Upon Dr. Bell's return to Edmonton, the University of Alberta's Dean of Medicine, Dr. J.J. Ower, approved a recommendation that Dr. Bell be appointed an Instructor in Medicine. His colleague, Dr. John Scott, encouraged and helped many graduates of this faculty to seek further training in well-known medical centres. A letter dated May 10, 1946 from Dr. William Evans, a senior British cardiologist, was evidently in reply to one from Dr. Scott. With the customary brevity of a British correspondent it read in total, "Both Dr. Parkinson and myself would welcome Dr. Bell at the Cardiac Department of the London Hospital." Supported by a Nuffield Travelling Fellowship, Dr. Bell spent a year in London (1947-1948) at the London Hospital and at the National Heart Hospital where pioneers of the invasive cardiology of the fifties and sixties were beginning their work. On returning to Edmonton he agreed to Dr. Scott's suggestion that he write the certification examinations of the Royal College in Internal Medicine which took place within the month. He successfully completed these despite the short notice and once more took up practice with his father, with major clinical 156 appointments at the Royal Alexandra and University Hospitals and re-appointment to the University staff as a Lecturer in Medicine. Gordon Bell played an active role in the Division for a number of years, taking part in the weekly rounds and in the early years contributing in an essential manner to the flow of patients for investigation when others still harboured some doubts about both the safety and the necessity of invasive investigation. Later on, in keeping with the requirements of most of the metropolitan hospitals that a practitioner have active privileges in one hospital only, he chose to confine his practice to the Royal Alexandra Hospital, although he remained a teaching member of the University's Division of Cardiology. Dr. Joseph Dvorkin was a Calgarian who obtained his M.D. degree in September 1943 in one of the accelerated University of Alberta classes of wartime. He interned at the Royal Alexandra Hospital until April 1944 when he was commissioned in the RCAMC and was posted first to Camp Borden (Ontario) and then to London, England. After marrying and returning to Canada as a Major he was discharged and began postgraduate training at the Royal Alexandra Hospital, first in Medicine and then for a year in Pathology under Dr. Morton Hall. After a final year (July 1948 - June 1949) as resident in Medicine at the University Hospital, Joe left for the United States. He was one of the first group of trainees to enroll in the newly established faculty program of graduate training directed by Dr. Mark Marshall (Levy). Dean Scott and Dr. Marshall expected each person to spend at least one year at a centre with an 157 established reputation in medical education. Joe Dvorkin was fortunate to be able to spend his year at the Mount Sinai Hospital, New York City, with Dr. Arthur Master, the originator of the Master Two-step Stress Test, the first test designed to confirm the presence of myocardial ischemia with the electrocardiogram. Joe was lastingly influenced by Dr. Charles Friedberg, an accomplished clinician and one of the last clinical cardiologists to produce a comprehensive textbook on cardiology written by a single author, and Dr. Isador Snapper, who had come to the United States after teaching medicine for a number of years in China. Joe returned to Edmonton in 1950. After successfully passing the examinations of The Royal College for Certification in Internal Medicine he was appointed to the staff of the University Hospital and given the rank of Sessional Instructor in the Faculty of Medicine in December that year. As was customary at that time, he also obtained staff privileges at the Royal Alexandra Hospital and consulted at both the Misericordia and General Hospitals. As time passed, he spoke of restricting his practice to referred cases and to cardiology. He managed to do neither completely. He could not refuse to see an old patient or an old friend and it did not matter that they had non-cardiac problems. His enthusiasm for teaching and his loyalty to the University never flagged, and no replacement for him was found after his sudden death from a myocardial infarction on December 9, 1976 while in Calgary to attend a meeting. 158 Neither Joe Dvorkin nor Gordon Bell had personal experience or skill in invasive procedures but together they urged Dr. Scott, who was both Dean and Professor and Head of Medicine, to establish a cardiac catheterization laboratory. In 1952 I returned for a visit to Edmonton from Minneapolis, where I was a fellow in Medicine in the graduate training program, preparing to spend my final year working as a research fellow for Dr. Carleton B. Chapman in a project o evaluate the exercise tolerance of patients who had recovered from myocardial infarction. A change encounter with Dr. John Scott, Dean of Medicine, outside the old "Med. Building", led to his proposal that the faculty nominate me for a Markle Scholarship. In 194 7 the Markle Foundation of New York had established a funding program to support some 16 potential academic physicians or scientists selected from nominarions invited from the medical schools in the United States and Canada. When my nomination proved successful, I returned to Edmonton in July 1953 to initiate plans for a cardiac catheterization laboratory. The nearest similar facility at that time was in Winnipeg. There was little formality to appointments in those days -- no contract, no job description, just a chat and a handshake followed by a congratulatory welcome note from the President. Dr. Scott referred to his "chagrin in 1948 when he found on assuming duties as Dean, that heads of basic science departments were paid a maximim salary of $4 ,500 with no provision for increments." The Markel of $6,000 annually for five years must have seemed to him, as it did to me, to be most generous. Mindful of worse tlmes, Dr. Scott exhibited his inherent caution, saying that he though I should draw $4,800 but leave $1,200 of the annual award to take care 159 of other things. This was done, stretching the funds well beyond the five years and providing travel funds for Dr. Dvorlcin and an initial salary for Dr. Rossall when he joined Cardiology as its second geographic full-time person in 1957. Joe Dvorkin was always willing to take part in the introduction of new methods of diagnosis and treatment. This made him an ideal companion with whom to work when I returned, with limited experience, to introduce new and recognizably dangerous methods of diagnosis to a conservative medical community. Gordon Bell generally acted as a moderating influence, waiting to be convinced that procedures were truly useful, but once converted he became an enthusiastic user. Invasive studies using cardiac catheterization were less than ten years old in 1953. To the original objectives, which were to measure intracardiac pressures and cardiac output, had been added the need to identify left-to-right shunts by measuring oxygen saturation and right-to-left shunts by intracardiac injection of radio-opaque contrast material. Intracardiac dye curves, using Evan's blue, and later Fox green, were developed in the early fifties by Dr. Earl Wood, clinical physiologist at the Mayo Clinic. In his expert hands, and in association with Dr. Howard Burchell, dye curves were used to measure cardiac output and to identify and quantitate both kinds of shunt. Essential to this technique were the Waters cuvette oximeter and the ear oximeter which were designed and developed in Rochester. The skillful use of dye curves at the Mayo Clinic appeared to delay the use of intracardiac angiocardiography at that centre. The widespread adoption of angiocardiography in most institutions awaited the 160 later introduction of appropriate catheters, pressure injectors, and probably most important of all , rapid changing devices for the radiographs. In 1952-53 at the Heart Hospital, University of Minnesota Hospitals in Minneapolis, pressures were measured using the Hamilton manometer, a photographic recording system which was frustratingly difficult to balance and use. This was being replaced about that time by the strain gauge (Statham) and direct recorders (Sanborn) which permitted operators to monitor pressure tracings for catheter positions through an auxiliary oscilloscope. Radiologic equipment consisted of a fluoroscopic screen and standard table which together resulted in reduced mobility of the catheterizer, his assistant and the patient, particularly in the completely darkened room required for fluoroscopy. There were no defibrillators generally available to lessen the anxiety which the catheterizer experienced when he heard his assistant announce premature ventricular beats. Cardiac resuscitation, which demanded a thoracotomy, was infrequently attempted except in the operating room where direct cardiac massage was occasionally successful. In preparing for catheterization in Edmoncon, equipment was purchased and assembled between July and November 1953. Dr. H.E. Duggan, Head of the Department of Radiology, agreed to let us use one of the radiologic rooms which was equipped with a table-mounted fluoroscopic screen. Part of the 1913 Wing of the University Hospital, this room faced west; with no air 161 conditioning and a late afternoon sun it became unbearably hot to work in an operating room gown (under which one wore the old and much heavier lead apron) , mask, cap and red glasses. Work began at about 4:00 p. m. when all the "regular" radiologic work for the day was finished. The small team included Dr. Gerry Copesta.ke (an English trained radiologist) , Joe Dvorkin, me, Brian Sproule (first as a resident and then as a Fellow for the year 1954-55) and Ann Shaw (seconded to us once a week by Dr. Ted Bell, Director of Clinical Laboratories, to help me with the blood gas estimations). Equipment was meagre. A tray of instruments was prepared by Central Supply and a thoracotomy set was on stand-by. Catheters were mounted on pl ywood boards to maintain the curve at the tip although steam sterilization generally defeated this purpose. Gas sterilization was introduced later. The remaining equipment consisted of a Statham strain gauge, a cuvette oximeter and the associated Waters control unit and galvanometers, and a Sanborn Twin-Viso, which recorded one pressure tracing and an electrocardiogram. Joe Dvorkin sat before the recorder with a towel over his head to prevent the light of the machine from interfering with fluoroscopy, watching the tracings. It was his responsibility to identify changes in the pressure tracing as the catheter passed into the various chambers and to warn me of extrasystoles, harbingers of disaster when the only electrical defibrillation I was aware of had been accomplished by Dr. Richard Ebert in Minneapolis in the course of one of their catheterization studies. (He had attached two wires to the ECG electrodes and had 162 attempted defibrillation by having an assistant thrust the other ends into the electrical wall outlet.) Joe's warning consisted of the word "extra", repeated with increasing urgency for each consecutive premature beat, and alarming to both me and the patient. Cardiac output and shunts were calculated by the Fick principle, which necessitated collecting expired air in a Douglas bag, taking blood from the femoral artery and obtaining a mixed venous sample from a central site, preferably the pulmonary artery. Ann Shaw and I together did the measurement of oxygen content and saturation on duplicate samples of blood with the requirement that we differ by no more than 0.2 ml/100 ml. This usually meant working in the laboratory until 10 or 11 p.m. - or until we ran out of blood. Before attempting the first catheterization of a patient it had seemed wise to check our equipment out on a dog. We proposed to Dr. Angus McGugan, the Hospital Superintendent, that we bring a dog to the hospital to spend an hour or so in the ECG laboratory. Dr. McGugan was an old fashioned Superintendent, occupying the position which became President in later years. He had never been faced with such an outrageous request but, after giving us a heartfelt lecture on the potential hazards of introducing germ-laden animals into his hospital, he reluctantly agreed to a brief experiment to test our procedures and equipment. There was little formal training in new techniques forty years ago and certainly no authoritative body established standards or issued certificates of competence. Both Joe Dvorkin and I, and later Dr. Neil Duncan, "learned on the job" . My earlier experience had consisted of several 163 sessions m the catheterization laboratory in the spring of 1953 in the Heart Hospital at the University of Minnesota Hospitals, under the direction of Dr. Craig Borden and Dr. Paul Winchell. At that time I was spending a year as a research fellow with Dr. Carleton Chapman, investigating the response to exercise of patients who had recovered from myocardial infarction. Because I had accepted Dr. John Scott's invitation to return to Edmonton to start a catheterization unit, it seemed necessary to gain some experience, albeit slight. Joe Dvorkin had less, or - perhaps more accurately - no personal experience. Nevertheless, supported by Gerry Copestake, whose help, ingenuity, skill and knowledge were invaluable, we saw the unit grow to a busy diagnostic service, responsible for both pediatric and adult investigation. In the third year (1956), with one full-time and one part-time physician and a Fellow, and referrals from a supportive group of internists and pediatricians, we did 89 catheterizations and had by that time introduced selective angiocardiograms. Joe Dvorkin would have been the first to admit that his skills did not lie in activities involving manual dexterity. .Sometimes, when the lights were turned on after several minutes of manipulating a catheter, there was a tangled mass of limp catheter lying between the cut-down in the patient's arm and the stop--<::ocks to which the catheter was attached, the result of the one way twisting to which Joe had submitted the catheter while trying to coax it into the pulmonary artery within the ten minutes which we were allotted in total radiation time. Nevertheless, Joe thoroughly enjoyed the challenge and the drama of the cath lab and continued working there until 164 the responsibilities were re-assigned in 1967-68 and the original catheter pushers were spared further radiation. Between 1953 and 1969 significant changes took place in technique, personnel and in the volume of work. A 28 year-old man with pulmonic valvular stenosis, a patient referred to Dr. Dvorkin, was the first person to be catheterized, on November 18, 1953. We were unable to pass a catheter into the pulmonary artery but on the strength of a right ventricular pressure of 141/20 we thought we had reasonable confirmation of the clinical diagnosis of pulmonic stenosis. This man first had a transventricular valvotomy and later the incompletely relieved obstruction was further reduced under direct vision when extracorporeal circulation became available. He was well and active 33 years after his first, and our first, catheterization. A nine-month-old baby was catheterized in January 1954 to prove the presence of a patent ductus. She was given rectal pentothal, nitrous oxide and oxygen by Dr. Ted Gain, then Chief of Anesthesia. This form of "sedation" was used on babies and small children until we adopted the intra-muscular injection of the Toronto Sick Children's Hospital -- a very effective mixture consisting of chlorpromazine, promethazine and meperidine. There was a steady referral of pediatric patients with congenital heart problems and of the 12 patients catheterized in the first part of 1954, six were children between four and 13 years of age. The adult patients proved to have congenital, rheumatic valvular disease or what was considered to be chronic severe pulmonary disease. 165 Although only one study a week was booked in 1954, it proved difficult to correlate all the associated functions if the patient was not admitted on the planned day. Finally, one bed a week was set aside after February 1954 for admission of patients who were booked for catheteriz.ation. Although this may seem to have been a minor accomplishment it made a major improvement in the functioning of the unit and established an arrangement which continued and was modified for the increasing numbers as our work expanded. In September 1955 the Minister of Health set aside $50,000 per year to support the development of special diagnostic services in the University Hospital. For some unexplained reason the minutes of the Hospital Board also record the statement, "The fund will not be publicized". It may be that those involved considered that it was wise to keep the knowledge of this windfall from the other city hospitals. The fund led to the establishment in 1956 of the Special Services Committee with Dr. Ted Bell as secretary. This source of money proved invaluable in subsequent years for both the purchase of equipment and the support of personnel in the Division of Cardiology as well as for the development of other special diagnostic areas. Dr. Ted Aaron had been heavily involved in the care of patients with respiratory failure during the poliomyelitis epidemic of 1952-53. He accepted responsibility for the care of some of those with chronic respiratory paralysis and arising out of this he was asked to develop a respiratory laboratory in conjunction with the cardiac unit, as it was then called. The years 1955-56 saw the purchase of a Liston-Becker gas analyzer and the first pulmonary function tests were carried out in May 1955 by one of the cardiovascular technicians who had this added responsibility until 166 April 1956, when a second technician was employed to work primarily rn the pulmonary laboratory. As a response to the need for accommodation of patients with chronic poliomyelitis, the Albeii.a Government authorized the University Hospital to build a western addition to the south wing. This was opened in 1957 and provided much needed space for Pediatrics, Cardiovascular Surgery, Orthopedics, Ophthalmology, Ear, Nose and Throat, Rehabilitation Medicine, Administration and a new cafeteria in addition to the space for the polio patients. The presence of the patients with chronic respiratory polio led to one of the early projects of what was then called the Cardiopulmonary Unit, namely a study of the nature of heart failure which was being recognized as one of the complications of this di sease. By 1956 the catheterization laboratory boasted an Electronics for Medicine multichannel recorder, a polaroid camera and several strain gauges, but no adequate equipment for angiocardiography. Dr. Aaron continued to add to the pulmonary equipment and both diffusion studies and the measurement of pC02 became available in 1957. In 1956 the Hospital calculated that a cardiac catheteri zation study cost $285 . The patient was charged $50. Sometime late in 1954 a professional fee of $35 for the procedure was accepted by the physician-sponsored medical insurance plan, M.S.I. 167 Some aspects of invasive investigation were cheap but nevertheless useful. Early in our cath lab experience we introduced the "ether" test about which I had learned from Dr. Dick Rowe at the Toronto Children's Hospital. It had been brought there from France by Dr. Peter Vlad, one of the authors of a paper describing it in 1949. This proved to be an accurate and simple way of identifying the site of a right-left shunt. Amounts of 0.05 to 0 .2 ml of anesthetic ether, the dose varying with the size of the patient, were ejected rapidly into the central circulation through the catheter. The injection ordinarily produced a cough but when introduced proximal to a right-left shunt it resulted in a prickling and burning sensation around the mouth, nose and forehead. Shunts through a ductus in the presence of pulmonary hypertension, or simply an injection into the descending aorta, resulted in similar sensations in the perineum and the feet. By repetitive injections at appropriate levels the source of the right-left shunt could be identified even in sedated infants whose grimace or squirming provided evidence of a "positive" test. Even after the introduction of intracardiac rapid sequence angiocardiograms this test was used to identify the site at which the injection could best be made. It was finally discarded completely when the hospital would no longer tolerate cans of ether in either the OR or the Department of Radiology. Catheterizations increased to four a week and, after the first open heart operation was carried out in September, 1956, included patients who were brought back for post-operative studies. Universal hospital insurance had not yet been introduced and many of these patients could not afford to bear the cost of th is added expense . We remain greatly indebted to the Kinsmen Club, 168 whose generous support of a Kinsmen Research Bed over a number of years permitted, until the introduction of Provincial Hospital Insurance, the uninterrupted post-operative studies of all patients who underwent open heart surgery in those early days. What we learned contributed to better care as our experience grew. The equipment which appeared on our 1957-68 budget was basic and not a bit sophisticated by the standards of 1986. It consisted of a bicycle ergometer, a pneumotachograph , a spirometer, a gas analyzer, a second ear oximeter, and an intermittent positive pressure breathing machine. The computer had not yet figured in our plans and the "chip", so essential to all modern equipment, had not been developed. The next year, we gained access to the Radiology Department's new 5-inch image amplifier, and a larger one was promised for 1959. That 1957-58 budget also provided for a new colleague, Dr. Dick Rossall, who arrived in November 1954. Dick Rossall graduated M.B ., Ch .B. with Honours from the University of Leeds in 1950. After two years in which he served as House Physician in Leeds and then in London at the Brampton Hospital, and at the post-graduate school at Hammersmith, he served in the Royal Army Medical Corps for two years. He returned to Leeds in 1954 to continue training, first in Radiology and then with emphasis on radio-isotopes and cardiology. In 1957 he was Senior Registrar in the Professorial Unit at the General Infirmary in Leeds. The number of consultant positions was small in England and there appeared to be no early opportunity to obtain an appointment in his field of interest. The replies he received to an 169 advertisement he placed in the Canadian Medical Association Journal were "not exciting". He had been following the positions advertised in the British Medical Journal and the Lancet and responded to one from the University Hospital. Within eight months he and his family were acclimatizing themselves to a new culture and the stimulating weather of Alberta in November. It was exciting for both Joe Dvorkin and me to be joined by a well-trained clinician and we lost no time in introducing him to our catheterization laboratory and the Canadian type of referred clinical practice. 1957 had been a busy year. We did 100 catheterizations, 36 transbronchial pressures and a similar number of pressures at operation. John Callaghan was well launched into the "open-heart" program. I was personally busy in planning for the construction of the proposed Clinical Services Wing where we were to have our first designated quarters. I had also been occupied in founding the Alberta Heart Foundation and serving for two years as its first President. In June 1957 I succeeded Dr. fohn Keith as Secretary-Treasurer of the Canadian Heart Association, as it was then known. Dick Rossall came on faith with no firm promises, like most other new staff in those early days. His basic salary was .supplied by the Special Services .Committee, which struck its first budget in 1957, as the Assistant to the Director of the Catheterization Laboratory (RSF). His other income was earned through consultant practice. By 1963 it was possible to arrange a shared responsibility between the Hospital and the University and Dick was appointed Assistant Professor and awarded tenure. 170 For seven years, from 1957 to 1964, Joe Dvorkin, Dick Rossall and I carried out all the cardiac catheterizations, phonocardiograms, pulse tracings and the medical care of patients having "open heart" surgery. During these busy years Dick joined Joe and me in writing a number of clinical papers and case reports. He had stated, when he first joined us, that he had no experience or interest in animal experimentation and during the years devoted his energy and unusual ability to teaching and to administration at all three levels - divisional, departmental and faculty. To his wide range of activities and to a busy consulting practice the Directorship of the Division was added in July 1969. In the 12 months reporting period 1958 to 1959, 237 cardiac catheterizations on children and adults were completed. During the early years of catheterizations, pediatricians had referred infants and children to us adult cardiolo gists, inexperienced though we were. It was only appropriate that a pediatrician take over thi s responsibility and we were fortunate that Dr. Neil Duncan had been interested in this aspect of pediatrics since his graduate experience in Chicago, where Dr. Potts had established an international reputation as a cardiac surgeon of skill and ingenuity in the treatment of congenital heart disease. Dr. Ken Martin, Professor and Head of Pediatrics, arranged .for Dr. Duncan to visit three pediatric cardiac centres - Chicago, Detroit and Toronto. For three months early in 1956 Neil was seconded full-time by his partners at the Baker Clinic to work in the catheterization laboratory and the Division of Cardiology. By 195 8 he had established a monthly pediatric Cardiac Clinic and in 1959 Dr. Ken Martin arranged for him to spend the equivalent of half-time at the hospital. Tuesday was set aside as the morning in which children would be catheterized and we adult catheterizers gradually did less of this 171 work. We were pleased in particular to be able to turn over the newborn to someone with requisite knowledge of this age group. The new Clinical Services Wing was opened in the summer of 1960 and provided Cardiology with office space next to the catheterization laboratories, which were equipped with exciting new radiologic equipment. The additional space freed up in the Well' s Pavilion was quickly claimed for research. In 1961 we had, for the first time, a defibrillator in the catheterization laboratory. This Electrodyne External defibrillator, costing about $1,600, served not only the lab but the whole Department of Radiology. Fortunately it was not often required. In our budget submission that year we asked for a second defibrillator - a Corbin-Farnsworth direct current model costing S2,500 - to be used in the cath room to supplement the AC machine which kept blowing fuses. We also planned for a new Electronics for Medicine multichannel recorder. There were no formal training programs for cardiopulmonary technicians in Alberta, nor were we aware of any in Canada. We had been fortunate in employing several Dutch immigrants with various backgrounds. Tony Van Kessel had worked in the Dutch Naval Recruiting Services administration before immigrating to Canada, where he found a job as orderly in the University Hospital. After moving to Nuclear Medicine to work under G<~orge Tosh he came to the cardiopulmonary laboratory, where he played a major part in developing the technical support staff. Across the street from his previous home in Holland lived Peter Van Moll, a machinist who worked for Phillips. When Tony persuaded Peter to come to Canada, it was the beginning 172 of a Dutch connection which resulted in a highly visible Dutch component m the cardiopulmonary laboratory for a good many years. Two of our staff, Tony Van Kessel and Hank Albregt, later took leaves of absence to go to University, but continued to work in the cardiopulmonary laboratory during vacations. They each obtained degrees in science and Tony returned as Laboratory Supervisor in 1960 while Hank took over the responsibility for the pulmonary function laboratory in 1961. During those early years, our complement of Dutch workers increased despite the observation of one of them that a Dutchman could never work with another Dutchman. Those who joined us in the late fifties and sixties included Peter Van Moll, who would later take charge of the pulmonary laboratory; Cun Voss, who became a practising physician; Case Ceeskuperschoek; and Adrian Van Son, who later worked in one of the other research laboratories. Tony had become a valuable member of our technical staff and we established with him what proved to be a useful policy of funding trips for our senior technicians and laboratory scientists to visit other centres and to attend appropriate meetings. Unfortunately the contacts which were made on such trips sometimes tempted our best workers to leave for more exciting employment. Such, at any rate, was the result when we sent Tony to a series of places in 1962: to a biomedical symposium in San Diego; to Beckman in Palo Alto to learn about polarography and gas chromatography; and to Seattle to learn about exercise testing from Dr. Rushmer. The diet was too rich. That same year, both Hank and Tony left for more lucrative jobs in the United 173 States, Hank going to Toledo and Tony to the Exercise Research Laboratory at Stanford University in California. Before this occurred we had established an on-job training program ( 1961) to provide new staff with fundamental knowledge in cardiopulmonary physiology and the associated instrumentation. All technicians were encouraged to enroll in evening courses at NAIT and in addition a series of 50 lectures was given by Hank, Tony, Dr. Brian Sproule, Dr. Dick Rossall and me. This led in time to the recognitio n that these technicians constituted a special group and they established a provincial organization, the Physiologic Laboratory Technologist Association (incorporated in 1968). They were instrumental in the organization of a national group, the Canadian Physiologic Laboratory Technologist Association , in 1969. Alberta led the way through the provincial association in taking responsibility for setting up training programs, examining applicants for competence in th is new technological field and for the exchange of scientific information. In October, 1963 Martha Gossman, R.N. , started work in the catheterization laboratory as a technician, having worked as such in London, Ontario after transferring from the nursing service. We were soon to appreciate our need for nursing skills after Martha exhibited her ability in both nursing and technology. She was joined later by Mrs. Margo McCarthy, R.N. When we began to employ nurses who did not have experience as cardiopulmonary technicians, the Nursing Office of the hospital made it clear that our nurses should report directly to their 174 office. It took some time to establish our authority to run the laboratory as a unit which included our nurses, but eventually a satisfactory arrangement was reached. Another important interdisciplinary link with the Depanment of Radiology continued to be strengthened. Radiology had from the start been both panner and landlord, but the relationship became even more closely integrated when Dr. Don Hendin joined Radiology in March 1960. Don obtained his M.D. from the University of Manitoba and after taking graduate training in Radiology he developed a special interest in cardiovascular radiology. We were fortunate in having a long and unique association with such a competent radiologist and fine colleague. He attended and contributed to all meetings of what we called the Division of Cardiology - as did Dr. Neil Duncan - although the divisional status was unofficial even within the Department of Medicine as far as the specific members were concerned. Perhaps it was because there was a lack of structural formality that the informal but close working relationships were possible. Dr. Hendin spent much time planning and arguing for the new radiologic equipment from which we benefitted. In a less traditional way he made a more significant contribution because there were few medical centres which were able to boast that· the cardiologists and radiologists worked together so congenially and productively, both in the cardiac catheterization laboratory and in the interpretation of the results. In 1963, for example, after a visit to the Department of Radiology at the Hotel Dieu in Montreal, my report to our own Directory of Radiology hastened our eventual acquisition of much more useful equipment than what was on hand. 175 New equipment was matche introduction of trans-septa! catheterizations. Prior to 1963, left heart studies were accomplished through retrograde introduction of the catheter through an arteriotomy. Information concerning the left atrial pressure and left atrial pulse waves was gathered in the early days by transbronchial puncture of the left atrium. The bronchoscope was a rigid metal instrument and the patient was very much aware of its passage over the often inadequately anesthetized upper airway. By the time the carina was reached the patient lay rigidly on the table, with a hyperextended neck and an expression of apprehension and distress, looking less like a patient undergoing an investigation than an unwilling medical shishkabob. A good number of patients investigated between 1953 and 1956 suffered from rheumatic valvular heart disease and assessment of the mitral valve both before and after operation often included measurement of the left atrial pressure: we had used this procedure 30 times by March 1956. Gradients across the aortic valve were measured by recording a femoral or brachia! tracing and comparing it to the tracing obtained through a needle introduced through the left precordium into the left ventricle. An alternative method of obtaining left atrial pressures, occasionally used by Dr. John Callaghan; involved the introduction of a needle through the left paraspinous area of the back. The first trans-septa! study was done on a patient of Dr. Rossall's in March 1963, by Dr. Tal Talibi, then resident in cardiology. Dr. Talibi came to us in 1962 from a residency in cardiology in Pittsburg. His English was coloured by his Turkish origin and his medical 176 education in the French language in Switzerland. His unqualified opinions were delivered in rapid bursts and with great certainty. When he came to Edmonton, Tal found we were not yet doing trans-septa! studies and in his decisive way he immediately went about remedying this deficiency. During his time with us during 1963 and 1964, he continued to make contributions to our work, particularly in invasive studies, in which he was enthusiastic and skilled. Joe Dvorkin, Dick Rossall and I (two geographic full-time appointees and one private practitioner) agreed that we needed a third person with experience which none of us had in the current methods of research. An enthusiastic mood of expansion had gripped the faculty members, who were then planning new buildings - a Clinical Teaching and Research Building, a Centennial Hospital and at one point a Health Sciences Centre. Renovation of the catheterization room was completed in February 1965 and we were equipped with a bi-plane angiographic unit, with a C-arrn being promised for the future. In 1965-66 I suspended my clinical activities for 12 months in order to start a computerized record system in the Division of Cardiology. We saw an opportunity to attract a third person to our staff by using my clinical practice as a temporary source of funds. Through Dr. Steward Reid, Chief of Cardiology at the Montreal General Hospital, I learned of Dr. Simon Lee, who was spending a year in Stockholm. Simon John Koo Lee, the son of a South Korean physician, gained his M.D. from. Seoul National University in 1957. He came to Canada to intern at the Victoria Hospital, London. Following a year in Pathology at Toronto's Mount Sinai, two more years in London, and a residency in Medicine at the Montreal 177 General Hospital, he turned to cardiology. He spent two years as a Fellow in Dr. Stewart Reid's Division of Cardiology before leaving for the Karolinska Institute in Stockholm on a Merck, Sharp and Dohme Travelling Fellowship in 1964-65. He had already obtained his Fellowship in Medicine from the Royal College of Physicians and Surgeons of Canada in 1963. We were pleased to have Simon agree to join us under the rather bootstrapping arrangement by which he would produce his own salary for 12 months by taking care of my consulting practice. Our long-term goal was to see him restrict his activities largely to teaching and research. We hoped that he would support other members of the Division in mutual efforts in clinical research. His own interests were in the circulatory adaptation to exercise, on which he had worked in Sweden, and hi s stated ambition was to become a leader in his field . Through a Fellowship obtained from the Heart Foundation beginning in July 1966, he established the basis on which the Department was able to arrange a progressive increase in the University funding which by 1969 was contributing one-half of his salary, making it easier to assume the full amount at the end of his term as a Senior Research Fellow of the Foundation. Simon was appointed Assistant Professor in 1967 and full Professor ten years later. In March 1969 we concluded negotia.tions with Dr. Glen Friesen, a graduate of UBC who had trained in invasive cardiology in Portland, Oregon. He joined us in August 1969 as the second adult "catheterizer". Expansion in the late 1960s produced its share of organizational and work load frictions, but it also led to new research catheterization facilities separate from the Department of Radiology, eventually opened in 1971. Clearly, with new techniques, new staff 178 and new facilities in place, this diagnostic procedure had become firmly established. In the 1980s, the next steps would involve ·non-invasive methods: radionuclides, positive emission tomography and magnetic resonance imaging. 179 The University of Alberta's Medical Alumni Association Alex G. Markle A musty 1941 edition of the student newspaper, The Gareway , featured a medical class banquet at the Corona Hotel. The late Dr. D.B. Leitch, honorary Class President, was guest speaker on the subject, "The Young Medical Graduate's Position in Relation to the War". During the course of the evening there was discussion regarding the establishment of a University of Alberta Medical Alumni Association. A committee (Drs. E.A. Watts, J.J. Ower, J. W. Macgregor, G.R. Blott and one student from the final year class in Medicine) was appointed to complete the arrangements. The fledgling body, burgeoning with enthusiasm, expanded quickly as graduate doctors combined with the general alumni director, doubling as MAA Secretary-Treasurer, promoted membership. Almost at once, annual membership fees were introduced to support the ambitious plans of the new organization. One of its members was designated to serve as resident contact on the Executive Committee of the General Alumni Association. After this flying start, in the mid-fifties it was decided that hundreds of graduate doctors ' names and addresses should be added to addressograph plates. A suggestion that a reserve Loan Fund be established to assist needy interns was warmly received. To start the ball rolling, $1,200 from MAA general revenue was assigned for Fund purposes. Eventually, and for want of takers, the project was discontinued in 1959. 180 Another MAA first was initiated in the summer of 1954. Permission was received from the Alberta Medical Association for the MAA to sponsor an annual dinner at Fall Conference time. All doctors and their spouses were to be guests. As the Conference meetings alternated between Edmonton and Calgary, the respective professional Medical Associations in each of the cities kindly agreed to underwrite the cost of the receptions prior to the dinners. Early minutes carry instructions that "the dinner speaker should elucidate in light vein - it doesn't matter if he represents football, oil interests, or happens to be a successful rancher. In a pinch a wildlife movie might be shown". Something zestful was added to MAA undertakings in 1959. At an annual dinner meeting at the Palliser Hotel in Calgary, mem bers established the John W. Scott Honor Award Fund. The prestigious annual accolade was designated to perpetuate the name of the University of Alberta's retiring Dean of Medicine. The substance of the Award was a medal and cash prize of $500 offered yearly to a medical student completing the final year of the MD program who, over the four years of the program, had shown himself or herself to possess to an outstanding degree those qualities of scholarship, leadership, and character that might be expected to lead to a distinguished position in the medical profession. The recipient was selected by a committee on which faculty, students, and alumni were represented. Dr. Lawrence Harker was the first recipient of the "John Scott" in 1960. Other awards sponsored by the MAA were those commemorating the name of the late Dr. R.F. Shaner (awarded annually to a student completing Phase I of the MD program for outstanding merit in Histology and Gross Snatomy) and the 181 memory of the late John James Ower (a gold medal and scholarship in Pathology placed annually by the MAA with a graduating student for outstanding merit in Pathology). With the advent of the sixties the MAA was challenged to examine new dimensions by the then Dean of Medicine, Dr. Walter MacKenzie. Ideas were triggered in 1961 with the Dean's "State of the Faculty" message to medical graduates gathered at the Palliser Hotel in Calgary. A post conference . meeting with the Dean followed. Consideration was given to the support of continuing medical education in the province. It was suggested that possibly the MAA should support an overseas medical alumni scholar, perhaps bringing such a person to Canada and the University of Alberta from one of the underdeveloped nations at a cost of about $1,200 per annum. The executive of the day agreed on behalf of the MAA About this time some renewed attention was given to a little known fact that the medical class of 1941 had an Emergency Fund. Dean MacKenzie was of a mind that the MAA should give it succor. A most pleasurable and popular innovation was introduced by the MAA in 1961. It decided to sponsor an early morning breakfast for medical graduands at Spring Convocation, to take place on the morning of Convocation. The occasion regularly provided an excellent opportunity for the Dean of Medicine to place academic honors and awards. As a highlight, a member of the silver (25th anniversary) class in medicine was always invited to speak briefly on the subject "What Medicine Has Meant to Me". The early instant success of the breakfasts assured their permanency. In 1962 Dr. Malcolm Taylor, Principal of the University of Calgary, joined the MAA Fall Dinner assembly at the Palliser Hotel as guest speaker on the topic, "Higher Learning 182 and Society". A plaque of the late Dr. J.J. Ower was purchased by the MAA to hang in a place of prominence in the Medical Building on campus. In 1963, the Medical School geared up to celebrate its Golden Anniversary. An MAA gift of $1,000 seemed suitable to commemorate the School's semi-centennial, the money to be used by the faculty members for research in medical education. The School, later the Faculty of Medicine at the University, came to enjoy world-wide acclaim and attention. Distinguished medical practitioners added lustre to the reputation of the institution. Early on it seemed appropriate that their contributions should be tangibly recognized. In 1963 the first MAA Outstanding Achievement Award was placed. Recipients annually were outstanding University of Alberta medical graduates who made a contribution to the welfare of medicine, directly or indirectly. Fittingly the time and place for the presentation of the Annual Awards was the MAA Fall Dinner held in conjunction with the Alberta Medical Association Conference. A ward recipients were invited to serve as principal guests and speakers. The eminent MAA Outstanding Achievement Award list encompasses the names of such notable personages as Drs. T.B. McLean, G:M. Lewis, E.F. Donald, E. Corday, L.D. MacLean, G.B. Pierce, J.D. Wallace, D. Lander, H.L. Dobson, J.F. Elliott, J.W. Macgregor, H. Arnold, M. Matas, R.K.C. Thomson, J.S. Gardner, H.M. Freeman, W.S. Simpson, L. MacLeod, H.E. Reid, H. Huston, J.E. Bradley, A.E. Walker, and F.M. Christie. 183 In 1968 the MAA executive decided that pictures of eac h of the Past-Presidents of the Association should be hung handsomely on the foyer walls, second floor of the Clinical Sciences Building on campus. The presidential rosters included Drs. P.H. Sprague, W.W. Eadie, J.S. Gardner, H.E. Rawlinson, E. Hitchin, 0 . Rostrup, R.E. Jespersen, S. Hanson, H.A. Arnold, A. V. FoUett, J.A. O'Brien, J.L. Edwards, N. W. Nix, A.L. Hepburn, J .E. Bradley, L.W. Johnston, N.R. Bertrand, D.C. Ritchie, W.T. Boyar, B. Michalyshyn, G.S. Balfour, R.E. Hatfield, E.G. Kidd, J. Dvorkin, C.J. Fairbanks, N.F. Duncan, J .M . Cowan, J.R. Settle, J.D.M. Alton, F. Gore-Hickman, J.H. Hook, and D.S. Wallace. As an added flourish , in 1969 the MAA Executive saw fit to recognize its retiring "presidential" members in a tangible \l.ay, presenting each a handsome engraved set of University bookends at the close of each ann ual business meeting. The framing of medical class pictures became an annual undertaking of the Association. In the late 1970s, when it had been decided by the MAA to discontinue support of the earlier "quality of practice" project, an exciting new topic took its place. It was brought to the Executive's attention that the highly secret and miraculously preserved Word War II prisoner-of war diaries of the late Captain Ben Wheeler reposed with the doctor's family, and that daughter Anne and son Alan were bent on producing a documentary film and book about the heroic work and travail of their father. Seed money was required. In 1978 the MAA executive quickly and enthusiastically approved an initial grant of $5,000 to get the projects underway. 184 In later years, the MAA volunteered its years of know-how to assist the Faculty of Medicine at the University of Calgary to formulate its own fledgling Alumni Association. In a way, the wheel of the MAA had thus completed a circle. 185 The Gladvs and Merrill Muttart Foundation D.R. Wilson Even before 1952, Gladys and Merrill Muttart had developed a growing interest in philanthropy for many needy areas of society. Just prior to the outbreak of the Second World War, they were making a living in the scrap lumber business; but from that time until the time of their deaths (within a year of one another) in the late 1960s, they developed a very large industrial empire that was spread all the way from Newfoundland to Hawaii, including some 120 companies at the peak of their development. In the period before 1952, they subscribed substantial sums of money to medicine and the arts. After the Gladys and Merrill Muttart Foundation was finally established with a federal charter in 1952, its policy and areas of interest gradually evolved during the ensuing ten years into about ten categories, many of which were interrelated. Some of the more important of these were medicine (specifically, research and medical education), university activities in general, and the fine arts and music. The Muttarts also had interests in the problems of native people, the problems of the young, the old, the disadvantaged and disabled, and in a variety of activities that could best be placed under the umbrella of colleges and universities. The Foundation always laid an emphasis on supporting worthwhile projects in areas where there was little evidence of support from governmental, civic or other fund-granting bodies. Their fund granting was primarily directed towards the provision of start-up funds with the thought in 186 mind that if projects were worthwhile and received anywhere from one to five years of financial pump priming, they should receive further ongoing supp-Ort from civic, provincial or federal agencies. The Foundation benefitted from the experience of many large foundations in the United States that had become so committed to continuing support that funds for initiating new projects gradually disappeared. The Foundation also learned that, when philanthropic organizations became totally involved in long-term support programs, any significant decline in Foundation revenues resulted in disastrous curtailment of ongoing service programs. The Muttart Foundation did not confine itself to local projects alone; in fact, it gave preference and priority to projects of global significance, followed by national programs in Canada designed to improve the quality of life for all Canadians, and only then by local projects within western Canada and Alberta in particular. Aside from major capital projects for the creation of the Mutt.art Conservatory in Edmonton and the Art Gallery in the old Carnegie Library in Calgary, generally speaking, funds were not available for capital projects; nor did they assist national or international organizations to pick up operational deficits. Prior to the establishment of the Foundation, the Muttarts' most noteworthy contribution to medicine in Canada was to provide funds to start the first cardiovascular unit in Canada to perform open heart surgery at the University of Alberta. Their second major contribution to Canadian medicine was through the development of the Canadian Diabetic Association through Mrs. Muttart's energetic personal and financial effort over a period of three or four years, with advice from local resource people knowledgeable in the field of diabetes. Following the creation 187 of the Foundation itself, there was continuing support to the Canadian Diabetic Association and provision of the services of a western Diabetic Counsellor, a diabetic nutritional counsellor who made her headquarters in the Foundation office in Edmonton. Contributions to the Canadian Diabetic Association over the years and through the 1970s exceeded $375,000. Prior to the establishment of the Foundation, Mrs. Muttart provided funds for the creation of a medical centre for the Alberta Diabetic Camp located just outside the city of Edmonton. In another direction, Muttart grants over the same period to the University of Alberta Faculty of Medicine and through it, to the Royal College of Physicians and Surgeons of Canada, amounted to more than $2 million. One specific major contribution of $300,000 over a five-year period to the Royal College of Physicians and Surgeons of Canada made possible the development of the first computerized system to evaluate medical competence anywhere in the world. For a period of three years, nation-wide examinations were conducted on a computer network and proven to be feasible, not only from an operational point of view, but in terms of cost effectiveness. After a three-year period, the study was discontinued because the sophistication of the techniques involved had advanced beyond the capabilities of the hardware. During this three-year period, it was possible for candidates sitting Royal College examinations to take the examinations either in French or English. The techniques that were developed during this program are now utilized in Australia and New Zealand, and provide a capability for computerized self-assessment of competence in the field of continuing medical education on a global basis via satellite. 188 The Foundation also provided substantial funding in the new field of virology, specifically with reference to the slow virus. A grant of $169,000 to the University of Alberta made possible a tri-partite research program of world class excellence at the Universities of Alberta, Pennsylvania and Glasgow. Substantial sums of money were devoted to projects in the field of research in medical education itself, exceeding $100,000 through the 1970s. Similar grants were also made to international organizations to study the feasibility of assessing competence of physicians on a world-wide basis in the English language. Somewhat later, Muttart funding provided for the very interes ting and promising work of growing insulin-producing cells on artificial culture media. One major grant request to the Foundation Board sought to expand the activities greatly in the diabetic research field and put Alberta in the forefront of diabetic research in Canada. Capital equipment grants for electron microscopes, again exceeding $100,000, were made to the Division of Neurology for the study of diabetic neuropathy and allied disorders. In the paramedical field, over the years, grants in excess of a quarter of a million dollars were provided to many organizations, including the Canadian Paraplegic Association, the Multiple Sclerosis Society of Canada, and the Edmonton Epilepsy Association . The Foundation directed grants to Alberta colleges and universities of about half a million dollars for many and diversified activities through to the 1970s. To about ten universities and colleges outside 189 Alberta, grants in the order of a quarter of a million dollars supported a variety of medical and non-medical fields. It is somewhat difficult to estimate the total funding from the Foundation from its inception in 1952 through the 1970s, but the fund granting, including private donations of Mr. and Mrs. Muttart themselves, probably amounted to more than 4 million dollars to the end of the 1970s. 190 The Origins of the Faculty of Medicine, Universitv of Cal2arv D.R. Wilson and D.L. McNeil In the early 1950s, it became apparent that Canada needed more medical practitioners. The Second World War had created vacancies; and although the population of Canada was increasing rapidly, existing Canadian medical schools were not expanding their output. Many other factors contributed to the problem. It was quite obvious that any increase in the number of physicians in Canada meant expanding the existing medical schools, opening Canada to suitable graduates of foreign medical schools, or creating new medical schools to make Canada self-sufficient. The last alternative, although the most desirable, would at the same time be the most expensive in terms of funding new buildings and assembling a highly competent staff. Medical specialists at the University of Alberta and in various medical groups throughout the province, especially the College of Physicians and Surgeons of Alberta and the Alberta Medical Association , conducted many informal discussions of this subject. A unanimous feeling emerged that a new medical school must be developed and that Calgary was the only remaining metropolitan centre in Canada with sufficiently large population base (including the southern half of the province) to support a new school. The only other alternatives were to create second medical schools in bigger metropolitan centres like Toronto and Vancouver. Before 1960, however, Calgary institutions had been given a relatively minor role in the field of post-secondary education. The origins of what was ultimately to become the University of 191 Calgary lay in a teacher training program. Continued expansion at Calgary, combined with limitations to expansion at the University of Alberta, did eventually result in the creation of a branch of the University of Alberta in Calgary that evolved into the University of Calgary, and these developments coincided in the 1960s with formal discussions within the Faculty of Medicine of the University of Alberta, the Alberta Medical Association and the College of Physicians and Surgeons of Alberta about various expansion options. One possibility was to enlarge the University of Alberta Faculty of Medicine to cope with the whole problem; another was to develop the basic sciences section of the Faculty of Medicine so that it could produce a sufficient number of students to support clinical schools at both Edmonton and Calgary; a third was to establish two completely independent and separate medical faculties, one in Calgary and one in Edmonton. While these discussions were taking place, the Royal Commission on Health Services made one of its 1964 recommendations the development of a school of medicine in Calgary with funding from the provincial and federal governments. The Hall Commission recommendation, base The Minutes of the Board of Directors of the Alberta Medical Association in 1964-65, the Minutes of the Education Committee and the Minutes of the Council of the College of Physicians and Surgeons all contain numerous references to the wisdom of this course of action: to establish a medical school as a full-fledged faculty of the University of Calgary. In 1964-65, with the full endorsation of the Alberta Medical Association, the College of Physicians and 192 Surgeons, and the Dean of Medicine at the University of Alberta, Dr. W.C. MacKenzie, a joint Committee consisting of Dr. D .L. McNeil (President of the Association) as Chairman, Dr. Hugh Arnold, Dr. E.J. Moriarty (President of the College), Dr. J. Morgan, Dr. J. Dawson and Dr. Sig Balfour from Lethbridge met with Dr. H.S. Armstrong, then President of the University of Calgary. The Committee submitted a recommendation that was given careful consideration by the President and his advisors. On completion of their study, Dr. Armstrong declared "that before he could make such a recommendation to the Chancellor, the Senate and the Board of Governors of the University , he would seek consultation from medical educators of world renown." He further urged the representative institutions of the profession to make data available for further examination by the University and its consultants. Later, Dr. Armstrong advised the Committee that a Commission or "Troika" of experts had been established with Dr. J.A. Macfarlane, Dean Emeritis of the Faculty of Medicine of the University of Toronto (Chairman), Sir Charles Illingworth, Professor Emeritis of Surgery, University of Glasgow, and Dr. George Wolfe, Junior, President for Medical and Dental Affairs, Tufts University, Boston, Massachusetts as members. Early in June 1965, the "Troika" met with the President of the University of Alberta in Calgary to survey the whole scene with respect to facilities and other potential assets essential to the establishment of the Faculty of Medicine. Arrangements were completed for interviews with representatives of the medical profession and visits to local hospitals and other University of Calgary facilities that would become intimately involved with the Faculty of Medicine, once established. The "Troika" also arranged to meet in Edmonton with members of government, a committee of the University of 193 Alberta Faculty of Medicine and appropriate members of other faculties of the University of Alberta. The Mcfarlane Committee soon discovered unanimous support for a University of Calgary medical school at all levels throughout the province. The essential conclusions of its 25-page report read as follows: We believe that there is a need to begin planning now for a new medical school in the province of Alberta. The most suitable site for such a school is the city of Calgary. The province has just been able to keep up with its supply of doctors by virtue of immigration from other countries. The flow of immigration can easily change. Moreover, it is highly desirable that as many young Canadians as are qualified to enter medicine, have the desire to devote their lives to some of the branches of modern medicine, should be enabled to pursue the necessary studies against the very urgent needs for more doctors, both in our own country and in other rapidly developing areas of the world. The Commission further recommended a timetable for the development of the school. The first task for the University was to "seek within the next 12 months a suitable and qualified Dean who would be entrusted with the further planning for development of a medical school in Calgary." With the support of the government of Alberta, the Board of Governors of the University of Calgary commenced to follow the prescribed schedule. In 1967, they appointed Dr.. William Cochrane, Professor of Paediatrics at Dalhousie University, as the first Dean of the 194 new Faculty of Medicine. They established a schedule in which the first class of the University of Calgary would graduate in 1975. Shortly after appointing Dr. Cochrane, they made key appointments in the clinical departments: Dr.' John Dawson of Calgary as Associate Dean of the Faculty; Dr. Lionel McLeod of the University of Alberta as Chairman of the Division of Medicine; Dr. Tait McPhedran from the University of Toronto as Professor of Surgery; Dr. Holman in Paediatrics; Dr. Farney of Edmonton as Head of Anaesthesiology; and Dr. Pearce as Chairman of the Division of Psychiatry. The usual difficulties encountered in the establishment of any new medical school in a city where none had existed before were ultimately resolved in favour of a program committed to graduating a ma.,ximum of 64 students, at least in the initial phases of the school's development. The Minister of Health at that time, Dr. J. Donovan Ross, had a very strong interest in developing a major famil y practice component. In keeping with new developments in medical education, the planners designed a more integrated curriculum, following the lead of other new medical schools in North America, including two in Canada: at McMaster University and ultimately Memorial University in Newfoundland. The newly developing medical school was fortunate to avoid the usual "town and gown" friction at this stage in its development, receiving real and sincere support from other prospective teaching . hospitals in Calgary and from the medical community in the city. Very encouraging support came not only from within Calgary but also surrounding municipalities, even extending into south-eastern British Columbia. From the outset, the undergraduate curriculum appeared to work well, although the Faculty appointees from traditionally developed medical schools initially had some difficulty in fitting 195 into the new format. An immediate heavy emphasis on maintaining very open relationships among the various clinical and basic science departments proved, in the opinion of Dr. McLeod, to be a major factor in the success of the school in its early years. The total faculty was committed to the multidisciplinary approach that incorporated an internal audit of the program as a whole. The province of Alberta soon turned out more medical graduates on a per capita basis than any other province in the country. At the beginning of the 1980s, the Faculty still had a long way to go in developing specialities training. Only about 16 of the 36 specialities recognized by the Royal College could be said to exist with any degree of effectiveness. Dr. McLeod, the man later to be Dean, recognized that this situation must lead to some deficiencies in undergraduate preparedness for graduate work. Continued development would be required over many years. On the other hand, with Canada rapidly reaching a saturation point in the production of physicians, it seemed that representatives of both Alberta schools might soon need to sit down and determine whether or not to cut back in the output of medical graduates, looking at the experiences with such actions that took place in Australia and New Zealand. 196 Reflections on the Development of the Faculty of Medicine, Universitv of Calgary .. D .L. McNeil, with A.K. Kirchner Kirchner: What is your recollection of the development of the Medical School in Calgary? McNeil: I have perused the minutes of the "Board of Directors" of the Alberta Medical Association, searching for references pertaining to the medical school at the University of Calgary. I find that my predecessor, as President of the Alberta Medical Association, Dr. Hugh Arnold, at a meeting with the Board of Directors in 1963, raised the subject first. The Board was asked, "Should we be making some effort to consider the development of a medical school at Calgary?" In 1964 , while I was President. .. , the minutes indicate that following my raising the subject again, the Board struck a committee to deal with this subject. The committee were directed to arrange an appointment with Dr. H. Armstrong of the University of Calgary to discuss the subject. The committee members were, as I recall, Dr. H.E. Duggan, Dr. G.S. Balfour of the University of Lethbridge (which at the time was still affiliated with the University at Edmonton), Dr. John Morgan, Dr. John Dawson (the Chairman of the Education Committee of the Alberta Medical Association) and myself as the Chairman. Before arranging the meeting with the University President, we made, I think, a wise decision, and this was to visit Dr. Scarlett. He was, by this time, the Chancellor Emeritus of •• Excerpt from D.L. McNeil, with A.K. Kirchner, "Medicine of My Time" (Manuscript, University of Calgary Archives) 197 the University of Alberta, and we were certain that he could give us sound advice with regard to our actions. The committee presented our plans sitting down with Dr. Scarlett in his library at home. His advice was clear and, as we expected, very worthwhile. "Before and indeed after you meet with the President do not do anything in a coercive manner, do not make any announcement to the media in this regard -- leave such to the President". I do not know the exact date that we saw Dr. Armstrong, but it was the fall of 1964 when he received us in the Arts Building. It seemed to me that he was expecting our request and his response was positive from the outset. We learned that he did have some very definite opinions about such a Faculty, and these had been developed in part through associations and discourse with the University administrators, one of whom was notably Dr. Walter McKenzie (the Dean of Medicine at the University of Alberta). Some of Dr. Armstrong's tenets were not upheld later, such as the geographic location and the University control of the Hospital. Kirchner: There is one thing which is surprising. The population of Alberta was less than two million people, yet much larger cities, for instance Vancouver, may have needed another medical school. Why is it then that it was Alberta who [sic] decided to have another medical school? McNeil: I think that your question is most reasonable. The Province of British Columbia had been very slow (one might say derelict in their responsibility) in the development of their [sic] present Faculty. On the other hand, Saskatchewan had for years, before BC, provided the two. pre-medical years, and the first two years of the medical course. The Faculty at Manitoba 198 had been in operation for more than a half century and the University of Alberta somewhat less in time. The Social Credit government in the now prosperous Alberta may well have thought that acting upon this socially responsible recommendation of The Royal Commission ... would not only be feasible financially but politically wise. Dr. Armstrong promised us that our proposition would receive his careful thought and attention. He told us then that before he would make any recommendation to the Senate and the Board of Governors of the University, he would seek and be guided by counsel of medical educators both in Canada and beyond. He advised us that he would, if at all possible, insist upon certain other conditions. He believed that the teaching hospital, while not in itself needing to be large, must be geographically situated on the main campus and be under the administrative control of the University. He quoted another president: "If you develop a medical school, never make the mistake of not having your hospital right on campus; it must be an integral part of the University." As you know, this didn't happen. The Foothills Hospital was already in place as a Provincial Government Hospital. Dr. Armstrong didn't believe that the University Hospital should be a great ten-storey edifice. His thinking was that it consist of a small hospital providing the basic training in Medicine, General Surgery, Obstetrics, and Pediatrics. The President advised us shortly of his "modus operandi" for the study. He had made arrangements to bring to Calgary a panel of three outstanding medical educators and this "triumvirate" would agree to meet interested parties here. These groups who would meet the triumvirate would consist of representatives from government, the present faculty of the University of Calgary, the Faculty of Medicine at Edmonton, the 199 medical profession of the city, and of Alberta. He would make his recommendations to the Senate and the Board of Governors based upon their report. He provided us with the names of the triumvirate. These were to be Sir Charles Illingsworth Kerr, the emeritus Professor of Surgery at the University of Glasgow; Dr. J.J. Mcfarlane, the former Dean of Medicine of the University of Toronto; and Dr. George Wolff Junior, the President for Medical and Dental Affairs at Tuft's University, Boston, Massachusetts. Dr. Armstrong asked me to arrange for the part of the hearing which would involve the medical profession. I believe that my choices were comprehensive, and on the day that we met with these three noted men, we had a representation of some fifty people. I may well have fo rgotten some but I will try to list the doc tors and indicate my reasons for their choice. From Edmonton and the Faculty of Medicine were Dr. H.E. Duggan (radiology), Dr. 0. Rostrop (orthopedics), Dr. Yoneda, Dr. E. Haines, Dr. Sam Kling (surgeon), Dr. Lloyd Grisdale (the President of the College of Physicians and Surgeons), Dr. Robert Woolstencroft (Secretary of the Alberta Medical Association). From Lethbridge Dr. Hugh Arnold, Dr. Sig. Balfour, and from Drumheller Dr. Roy le Riche. I cannot recollect that anyone was present from Medicine Hat, but I must have invited some representative such as Dr. Don Lewis, an internist, and I think a member of the Board then. From Calgary were present Dr. John Duffin (pathology), Drs. !rial Gogan and Cob Johnson (hospital administrators), Dr. Smith Gardiner (Veterans Affairs and the Belcher Hospital), Dr. Bob Pow (surgeon), Dr. John Crichton (pediatrician), Dr. Hugh Gallie (surgeon), Dr. John Morgan (cardiologist), Dr. Morris Camat (psychiatrist) , Dr. Morris Vernon (President of the Calgary Medical Society), Dr. Harry Brodie (gynecology - 200 - and later to become the first professor), Dr. Bob Wintemute (gynecologist), Dr. Hemstock (anesthesia) , Dr. John McAllister (obstetrics), Dr. Howard McEwen (internist), Dr. Steve Thorson (internist and a member of the Board of Governors of the University), Dr. Joe Moriarity (general practice). I believe that I had consulted the various societies (eg. the Psychiatric Society, etc.) to name their selection[s]. Representatives of the nursing profession were present and I know that in the earliest plans the school was to be integrated with that profession. We met this "august" group in a large room of the Arts Building and spent several hours with them. The three men sat at a large table in front of us and proceeded to field questions to all of us. Tne more vocal of the three doctors was Dr. Mcfarlane, and I recall some of his questions in particular: "Do you really want this? Do you realize the work involved? Would you be ready to give your time? Would you teach? If you truly want this, it is not enough to say that you'll support it. You'll have to give all you have to make this thing go". Later in the day he confessed that he was tremendously impressed by the degree of support that we had shown. He told us, too, of the similar impressions that the triumvirate was receiving from other than the profession . . The triumvirate, of course, met with other Faculty "heads" and members to learn for themselves the attitude these people would have to the presence of this new Faculty. I understand that the other departments were supportive, but with the caveat that the school would not be isolated, but rather become closely associated with the rest of the institution. I think they envisioned exchanges of teaching resources and facilities. I do not think that this ever eventuated and it was a source of disappointment to them . The medical faculty at Edmonton 201 [were] supportive as they did not believe that they should attempt to enlarge their enrolment. The triumvirate moved on to Edmonton where they met with Premier Manning and the cabinet and with the Chief Justice of Alberta, Mr. Justice Cairns. I might say that Mr. Cairns was very favourably inclined towards the University of Calgary. Dr. Thorson played a rather key role in this story and this properly should be told by himself. Steve Thorson had been named to the Senate of the U of C and the Senate named him as their representative to the Board of Governors of U of C. The Chairman of the Board, Mr. Thorseen, was opposed to the development of the medical school at Calgary. This might have quashed the whole project if Dr. Thorson had not acted as he did. I cannot remember the details of the process but Dr. Thorson made a motion upon some subject .. . which it was impossible for Mr. Thorseen to oppose. In some manner this resulted in the resignation of the Chairman, and later full support for the medical school [from] the Board of Governors. The visit of the three distinguished doctors was concluded by a reception for them, their wives and members of the University. I am reminded of the charming Mrs. Wolff, who was a writer of some note, and my companion at dinner. One of her many books was entitled, Anything Can Happen in Vennont. The report of the triumvirate will be familiar to you and should remain as an essential part of the history of the Faculty at Calgary. The conclusions of the report are as follows: 1. Within the next 12 months, the University should seek a suitably qualified Dean who would be entrusted with further planning for a medical school in Calgary. 202 2. The school should be an active and integral Faculty of the University of Calgary. 3. In planning for future needs, provision should be made for setting up in due time of a school of dentistry and a school of nursing as well as for the provision for training of the ever increasing number of paramedical and allied professions. 4. The planning should include a University owned and operated hospital of not less than 150 beds with provision for 50 to 100 beds if this is justified by the total need for hospital beds in the City of Calgary at the time that it is being built. 5. The plans included used closed teaching units in all the active general hospitals in Calgary, notably the Calgary General Hospital, the Holy Cross Hospital and the Foothills General Hospital. It is noted that even if the initial plans are undertaken within the next 12 months, we do not see the possibility of a first class graduating before 1975. I would like to quote further from the Commission's report, so that I may make a certain emphasis. President Armstrong, a scholar in his own right, has had wide experience in scholarly activity and academic administration--he is cognizant of the problems which confront university presidents when a medical school is on campus. He seems eager to face the challenges if a substantial case for a medical school on the campus can be made. Inasmuch as the success of a university medical school is dependent upon the support of the President of the University, President Annstrong's attitude and ability is considered an important asset by the Commission. 203 In their survey of Calgary hospitals, the Commission noted in reference to the Foothills General Hospitals that the hospital, while being built by the Provincial Government has an appointed Board of Governors and a locally appointed Medical Advisory Board. There is a Nursing School adjacent to the hospital and the Director of the School has been appointed and the School is in operation. A Superintendent of the hospital has been appointed who is a layman, and he will appoint a Medical Superintendent who will be his assistant. Although it is situated on a magnificent site, the hospital is across the Trans-Canada Highway about a mile from the University. It is establis hed that a medical school, th at is to say the Faculty of Medicine of a university, can gain a great deal by close proximity to the university departments. This need for close working relationships applies not only to the basic medical departments, such as Anatomy and Physiology, but also to departments such as Medicine, Surgery, Obstetrics, Psychiatry, which are necessarily located within the teaching hospital. It follows that the ideal relationship is one in which the main university scientific departments, the pre-clinical medical departments and the hospital are located on adjoining areas of the same site. In Calgary we are assured that there would be no problem in providing a site for the pre-clinical medical departments, immediately alongside the common science building. 204 The relationship between the University and the governing body of its principal hospital is of great importance. It is our considered opinion that to insure recruitment of staff of suitable quality at all levels, the University must have full control of all appointments. It is our considered opinion that in order to make it possible for teaching to be conducted in a satisfactory way, the University must have full control over the conditions governing admission of patients. We are of the opinion that the most satisfactory solution would be to build a University Hospital, of say 350-400 beds, on the ideal site envisioned above. This plan of a combined medical school and teaching hospital related to the General Science Building on the University campus would give Calgary an opportunity to establish a centre for medical teaching and progressive developments which would be second to none in the western world. The report recorded the Commission 's interaction with other faculty members: They did not view the medical school as a status symbol, nor did they fear the presence of basic medical sciences as a threat to their own programs. They obviously had been giving serious considerations to the question of a new medical school, and it was gratifying to note that they were prepared not only to cooperate but also to experiment in the areas of pre-medical and pre-clinical education. In western society, it is becoming increasing! y evident that medicine, while in its practice retaining some of the characteristics of an art, is rapidly more and more dependent upon the scientific method. At Calgary, those interviewed seemed to accept this fact and seemed willing 205 to bend their efforts to make the physician not only well educated in the classical sense but knowledgeable in the basic physical, chemical and behavioural sciences related to medicine. The Commission envisioned this Health Sciences Centre as one which would immediately plan to include a Faculty of Dentistry (an anticipated early need in the province, in their opinion), a Faculty of Nursing (in an active planning stage at the present), and to provide within the Health Science Centre arrangements for the training of various paramedical personnel such as radiology technicians, laboratory medical workers, etc. Kirchner: Now I would like you to proceed with your perception as to how these aims and recommendations were carried out and fulfilled. l\1cNeil: The committee was struck for the purpose of selecting the Dean of Medicine. It consisted of Dr. W. Trost (Vice President - Academic) as Chairman, and the members Dr. Baker (Education), Dr. T. Penelhum (Arts), Dr. Neville (Engineering), Dr. Hyne (Chemistry and later Graduate Studies), Dr. Hartland Rowe (Science) and myself. The members of the committee, other than myself, were the most senior faculty at Calgary. It was unfortunate for the institution that the wise Dr. Trost did not remain at Calgary. The committee sought applications widely and the "short list" finally included three men. Kirchner: Dr. W. Cochrane, of course, would be one, but who were the others? 206 McNeil: I am afraid that I now cannot remember their names .... They were all excellent men. Only one of the interviews is at all fresh in my mind other than Dr. Cochrane. This was the then Dean of Medicine at the University of Vermont, I think. We were most impressed with this man (Dr. Armstrong reminded me recently that this applicant was a Canadian), and he might well have been offered the position. We would have been bringing him from an established school of medicine, and his qualifications were completely satisfactory. He gave us the distinct impression that his interest in coming to Calgary was not great. A salary of some $45,000 a year would be an initial demand before he would consider making this great change in his life. This income now seems paltry, I'm sure, for such a position , you will agree. However, this one stipulation was a major influence upon us and our decision not to invite him. I cannot remember that anyone took the time to show him any of the man y attractions which Calgary and environs could offer. I do know that something so important as this should have had a major priority. Dr. Cochrane was, at the time, the head or in the Department of Pediatrics at Dalhousie in Halifax. He was obviously very keen from the outset to receive the invitation for the position. I remember one of my questions to him was, "should the provincial government fail to carry out the recommendation of the Commission as to building a University Hospital on campus, what would be your reaction?" His response, as I recall, was that this would not deter him in proceeding with the plans for the faculty, and he would use the Foothills Hospital as the University facility, notwithstanding its drawbacks as indicated in the Commission report. I cannot remember the other questions, but I do believe that the committee failed to uphold Dr. 207 Armstrong's admonitions, which the Commission had so strongly supported. Had we done so, we might have avoided some of the unhappy events which occurred later. Kirchner: Who made the decision that the school would produce family physicians? I I McNeil: The Commission made recommendations with regard to general practitioners. These recommendations pertained to the availability of continuing education for practitioners in the southern half of the province. They acknowledged the work of Dr. Kling 's department in Edmonton and stated that similar arrangements should be made within the Health Science Centre in Calgary. The Minister of Health, Dr. Donovan Ross (a general practitioner) , did have the opinion that the school at Calgary should have as a primary responsibility the training of general practitioners. "Family Medicine" was not a specific designation then, as I recall. I have always thought that such a recommendation was rather naive in that it would be difficult to restrain a physician in his desire to become further trained and become competent in a particular area of medicine. Kirchner: Exactly when was it that Dr. Cochrane was appointed Dean of Medicine? McNeil: I would think it was within the year 1967. 208 Kirchner: You mentioned that even the Alberta Dental Association was asked and provided a very positive, encouraging answer to have a medical school in Calgary. At the time, was it considered that a Dental Faculty would be added? McNeil: The Commission spent some time with the Dental Faculty in Edmonton. They were well aware of the situation of dentistry in the province. As I have said, they predicted the early need for a second dental school in Alberta, and recommended that the Health Science Centre should plan to incorporate this Faculty. The dentists of Calgary, observing the development of the medical school, naturally made representation, so that they might see the recommendation for a dental school fulfilled. Dr. Armstrong appointed a committee, and again I was placed on this committee. No positive recommendation was forthcoming from this committee. It was held that the government had committed itself to health education about as much as it would do so for the present. Perhaps I could mention that at about this time, Dr. Gordon Swan, the orthodontist, was made Chairman of the Board of Governors of the University. He distinguished himself in this position and the "Dr. Gordon Swan Mall" on the campus is a recognition of his great contribution. It might be of interest to note that Dr. Cochrane and he became close friends and a son of the Cochrane's married one of Gordon and Margaret Swan's beautiful daughters. Kirchner: Will you please proceed with the development of the Medical School as perceived from your vantage point? 209 .McNeil: Dr. Cochrane produced a "Philosophy of the Calgary Health Science Centre". I cannot lay my hands on this at this time, but I recall being impressed with it. It was not pan of the decision-making process with regard to the further developments of the medical school. Key appointments were made to the major clinical departments. Dr. John Dawson was appointed Associate Dean of the Faculty , Dr. Lionel McLeod of Edmonton was appointment Chairman of the Department of Medicine, Dr. T. McPhedrin of Toronto as Chairman of the Department of Surgery, Dr. Harry Brodie of Calgary as Head of the Department of Gynecology and Obstetrics, Dr. Farney of Edmonton in Anesthesia, and Dr. Pierce of Saskatoon as Head of the Department of Psychiatry. I was requested to provide references for two candidates for these senior positions and was pleased that one of the references, namely Dr. Harry Brodie, was successful. Dr. Brodie was one of my fo rmer senior interns at the Calgary General. The pre-medical academic requirements of the Faculty were a new departure. There were almost none of the old calendar prerequisites, other than evidence of superior academic performance. I am speaking of that time only: no sciences, languages, or humanities were catalogued as necessary. I understood that a Physical Education degree could be taken as constituting a pre-medical course. The makeup of the membership of the "selection committee" for applicants to the school were a departure too, and this was interesting and wise in some respects. Rather than being composed only of doctors, it was made up of laymen (I am not sure whether nurses or other professionals were included) and possibly one doctor. That a first-year medical student be an essential member of this committee was a little "far out" for me. I saw one applicant who said that the only one who interviewed him was the medical student. 210 As it was some time before the magnificent Medical Faculty Building was available, space was provided by the Foothills Hospital for a multidiscipline laboratory and a cubicle was provided for each student. The anatomy specimens were prepared in part, at least, by University of Alberta students. No dissection exercises were required of the Calgary students. There were no pre-clinical yea.rs, as is generally understood--the course of three academic years was constructed on a "system" method and, as you know, there were no distinct "pre-clinical" subjects, hence the multi-discipline laboratory. I do not know whether any effort was ever made to associate the Faculty with other University Faculties like Arts and Science as was envisioned by the Commission. I do note that the Commission did mention in their report that experimentation in "System" teaching had been tried elsewhere and that the Health Science might possibly ta...1.ce such into consideration. A committee was struck for the purpose of selecting a Head of the Department of Family Medicine. The terms of reference of this committee stated that a "successful applicant must have no other academic qualifications than his primary medical degree". Limiting qualifications seemed unusual to me and I recall that Dr. Dawson (the Associate Dean and Chairman of the committee) , in answer to my question as to whether training in Ophthalmology would disqualify one ... told [me] that this would be so. The student of the late sixties was quite a contrast to that of previous times and often openly rebellious. The broad outlook of the early selection committees brought examples of the extremes of this student attitude. Students might feel no responsibility to attend class and if [one] did [he] might, for example, tum his back upon the lecturer, or openly disagree with any and all statements made. The recourse mechanism provided for the student to voice any 211 objections to teachers or methods, seemed to some of us almost like a state of anarchy rather than a democratic institution. For example, Dr. Brody, when he threatened to fail students who did not attend his teaching sessions, was told by students that he would be reported to the Grievance Committee. I have seen a guest lecturer (a female) dissolve in tears after a session with some of these self appointed "prima donnas" . Some medical faculty had difficulty adjusting to the new system. Some physicians were of the opinion that the 12-month sessions were not desirable. They held that the medical students were prevented the opportunity to separate [themselves] from academia, and experience other people and situations, for a few months each year. This was, in their opinion, a backward step. Dr. Armstrong, whom the Commission acknowledged so strongly in reference to the medical school, resigned very early on. I do not think that this was related to differences with the medical school, but rather to the impossible situation he found himself in with the abrasive and pragmatic Chancellor of the University: the Chief Justice Campbell McLaurin. This was a distinct loss to the University of Calgary. Kirchner: You have given a frank description of your observations and reactions to that very early history of the medical school. Perhaps now you will tell us your assessment of the early academic results and how they measured up to the initial visions of the school's creators? McNeil: The first class, after difficult times, particularly for the Faculty in adapting to this new curriculum, graduated in 1973. This was two years earlier than predicted by the 212 Commission. Two further years of experience were mandatory for licensure. The first convocation was held in the central hall of the new Health Sciences Building, entirely separate from the other Faculties. The makeup of the platform party was interesting. Having in mind the role of the Alberta Medical Association and the College of Physicians and Surgeons in the creation of the school, neither [was] represented. The Foothills Hospital, while not apparently first included, demanded representation in recognition of the fact that they [sic] provided the space for the Faculty when they did not have a building of their own. This might be taken as evidence of the difficulty the Commission envisioned, where the Hospital was not under the jurisdiction of the University. The Dean had some difficulty administering the time-honoured Hippocratic Oath to this class and obviated possible objection by the suggestion that the graduates accept the contents of the oath as they personally perceived it. The graduate[s] of these classes evolved into ... confident and enthusiastic physician[s], who I believe performed admirably in national examinations such as the Dominion Councils. A number have excelled in the profession. I do not think that the General Practice goal was reached, but this has not succeeded elsewhere. When one reviews the recommendations of the Commission, one can observe the following: that the first recommendation was that of the appointment of the Dean; the second was "that the school should be an integral faculty of the University of Calgary" and this, I think you can say, did not result. The third was the reference to the inclusion of a Dental Faculty and the Faculty of Nursing and the facilities for the training of paramedical personnel in the centre, all of which 213 failed to occur. The Dental Faculty has not evolved, and the Nursing Faculty exists entirely separate on the main University campus (more in keeping with what the Commission envisioned for all health education) .... [The] fourth, pertaining to the separate hospital situated on the campus under the control of the University, did not come about. The recommendation that teaching units be established in the Holy Cross and General Hospital was realized. The Dean and the Associate Dean resigned within a year or two after the first convocation. Dr. Cochrane went on to become the President of the University. The deanship torch was passed on to the distinguished Dr. Lionel McLeod. A great number of highly qualified physicians and researchers have come to Calgary, the latter often bringing with them, or attracting, large endowment funds, all to the benefit of Alberta. Citizens of Calgary and southern Alberta, and indeed Canada, have benefitted by great professional advantages that a medical college brings to the community and country. 214 The Alberta Heritage Foundation for Medical Research J.E. Bradley In 1975, the government of Alberta announced its intention to set a.side funds from the Heritage Savings Trust Fund to support the development of "brain industry" in the Province of Alberta. Premier Peter Lougheed stated that the government hoped to enhance the scientific communities in Calgary and Edmonton and attract scientists from various parts of the world to locate in Alberta. Out of this, it was hoped that discoveries would be made that might lead to the development of high technology industries and improvements in the health of Albertans and Canadians. The government had made a commitment to invest several hundred million dollars in the development of health facilities. It was now prepared to set aside funds to support medical research in Alberta. Dr. John Bradley, who had conducted a general practice in the town of Wainwright, Alberta after service with the RCAF Medical Services in the second World War, and served as Special Advisor - Medical Research to Premier Lougheed, was asked to prepare a proposal for the government. Dr. Bradley had considerable experience in the fields of hospital and health administration, at the community level and with the government and the University of Alberta. He had served as Executive Direetor of the Glenrose Provincial General Hospital, a rehabilitation hospital in Edmonton, and as Chairman of the Board of Governors of the University of Alberta. At the time he was asked to develop this concept, he was serving as Chainnan of the Alberta Hospital Services Commission. 215 Over a two-year period, Dr. Bradley consulted with authorities in the field of medical research in Canada, the United States, and abroad, and prepared a proposal which recommended the establishment of a foundation, at arm's length from government. An endowment from the Heritage Savings Trust Fund would be established, the revenue from which would be at the disposal of the Trustees to support the objects of the Foundation. During the development of the proposal, three significant limitations were found to be of importance: the lack of continuity of funding for research in Canada and other jurisdictions, the lack of career opportunity for investigators within the university system due to budgetary cutbacks and fall in enrolment at the universities, and the consequent lack of interest on the part of young people to consider research as a career. Legislation establishing a medical research foundation was approved by the government of Alberta during the fall session of the Legislature in 1979, and proclaimed March 26, 1980. The Act provided for the creation of an endowment fund. The $300 million endowment invested would produce income to support a level of research that hopefully would make Alberta one of the research capitals of North America. The revenue was to be made available to support basic and clinical medical research and the government hoped that this thrust would attract outstanding scientists to carry out research in Alberta and to participate in this exciting program and encourage young people to entertain careers in research. 216 Speaking of the Act during debates in the Legislature, Premier Lougheed indicated the desire of his government to make the province into a "brain centre" with a strong emphasis on creative research in a wide range of fields, including this particular thrust for research in the health sciences. This permanent commitment to medical research on a major scale was to attract truly outstanding research-oriented staff members to the universities in Calgary and Edmonton in Medicine and Science, and in the future, lead to new discoveries which could form the basis of advanced technology industries uniquely suited to Alberta. It was expected that over time there might be some breakthrough in improving health care treatment, and the benefits would accrue to Albertans wherever they lived in the province -- not only Albertans but also Canadians and perhaps citizens in other parts of the world. The objects of the Foundation, as stipulated in the Act, were to establish and support a balanced, long-term program of medical research based in Alberta, directed to the discovery of new knowledge and the application of that knowledge to improve health and the quality of health services in Alberta and, without limiting the generality of those objects, to (a) stimulate research in medical science; (b) implement effective means for using in Alberta the scientific resources available in medical sciences; ( c) support medical research laboratories and related facilities in Alberta; (d) promote cooperation in research in medical sciences in order to minimize duplication in and promote concentration of effort in that research; and (e) encourage young Albertans to pursue careers in research in medical sciences. 217 The Trustees of the Foundation were appointed by the government with four being nominees of various constituencies: Dr. Myer Horowitz, President of the University of Alberta; Dr. Leroy Harding le Riche, Registrar of the College of Physicians and Surgeons of Alberta; Dr. Norman Wagner, President of the University of Calgary; Dr. Robert Francis, the nominee of the MSI Medical Research Foundation of Alberta. In addition, the government appointed Eric A. Geddes, FCA of Edmonton, Chairman; N. Patrick Lawrence, QC, of Red Deer, Vice Chairman; the Hon. William Daniel Dickie, QC of Calgary; the Hon. Mr. Justice Michael Brien O'Byrne of the Court of Queen's Bench of Alberta; and Dr. Gordon Cummings Swann, DDS, of the City of Calgary. The statute established the Foundation to operate at arm's length from the provincial government and it was expected that an atmosphere would be provided to the scientific community that was not subject to fluctuating political pressures. The program was aimed at overcoming the existing shortcomings in research. As the person most intimately involved with the development of the legislation that created the Alberta Heritage Foundation for Medical Research, . Dr. Bradley was appointed Executive Director of the Foundation at its first meeting. The Foundation was to appoint a President, who would be the Principal Officer of the Foundation and a scientist. The President would chair a Scientific Advisory Council, with representatives from Alberta, Canada, the United States and the United Kingdom. This Council would formulate recommendations to the Trustees on such topics as the formation of guidelines for grants and awards and the development of procedures, 218 and approve expenditures from the Endowment Fund interest. They were also charged to establish an International Review of the Foundation every six yea.rs. 219 The McLaughlin Examination and Research Centre D.R. Wilson The emergence of the R.S. Mclaughlin Examination and Research Centre in Canada after the end of the second World War followed a period from the inception of the College in 1929 to the post-war years in which the examination process changed little, if any, in its format and philosophy. Essentially, the examinations consisted of written essay papers and oral and clinical examinations, following the style of examinations conducted by the United Kingdom Royal Colleges. After the end of the second World War, when senior examiners who had done long service both before and during the war began to retire and younger examiners (most with war...-time service) were appointed, serious questions began to be raised concerning the reliability and validity of the existing examination process. This new influx of examiners began to discuss among themselves the lack of established standards or criteria to determine the pass/fail cut-off point. The standards that were handed down from the retiring group of examiners could be best stated in general terms: "you young fellows know the difference between what constitutes a good person who should be given his Fellowship and the inadequate individual who should not." That in essence was about all we had to go on. It might be a little bit surprising that the original impetus for change emerged in western Canada and specifically in Alberta. This might partially be attributed to the fact that in those immediate 220 post-war days, travel to eastern Canada for examinations (where they always took place at that time) necessitated a two or three day train journey. Dr. John MacGregor, who was the perennial College examiner in Pathology, and Dr. D .R. Wilson always travelled east on the old and very well-appointed Canadian of the CPR. They always took adjoining bedrooms and removed the wall, and for a period of two days on the way down, discussed with increasing seriousness what they hoped to be able to achieve in the current year's examinations. The week of the examinations themselves always proved to be frustrating experiences and gave rise to increasing feelings of inadequacy on the part of the examiners because of the relative lack of guidelines in which the examiners could have any confidence. During the train journey home again, post-mortems were carried out and as a result of this, changes gradually began to take place, not only in th eir minds, but in the minds of many of the other younger examiners as well. This culminated in a desire to move towards more objective types of examinations which had then been in existence in the United States for about ten years. A fortuitous meeting took place between Dr. Wilson and Dr. John P. Hubbard, then the President of the National Board of Medical Examiners in the United States, when Dr. Hubbard came to Edmonton as visiting professor in the Department of Pediatrics. His enthusiasm for the adoption of newer methods of examinations was truly infectious and the data that he was able to present convinced Dr. Wilson that the time had come to begin making changes. In 1961 Dr. Donald Webster of McGill University, who was then a member of Council of the Royal College of Physicians and Surgeons of Canada, registered a two-line inquiry in the matter of the Committee on Examinations as to what objective examinations were all about. The reply to that was that 221 Dr. Wilson would endeavour to find out more about it. That perhaps illustrates the state of the art in Canada at that time. Had it not been for the enthusiasm and great generosity of Dr. Hubbard and his group in Philadelphia and, two years later, Dr. Victor Logan of the American Board of Internal Medicine, then based in Rochester, New York, the advent of units such as the R. S. McLaughlin Centre in Canada would have been delayed many years. They generously provided unlimited assistance on all phases of mounting objective examinations, and I the American Board of Internal Medicine made it possible for the Royal College of Physicians and Surgeons to hold the first objective examinations in 1963. From that point on, examinations in other specialities were quickly added: general surgery, orthopedic surgery and obstetrics and gynecology in 1966, and six more later, until the point was reached at which no further objective examinations were viable because of the limited number of candidates. On the surgical side of the house, however, this was circumvented by the introduction of the general principles of surgery examination pioneered by Dr. Barber Mueller of McMaster University. This general principles examination took a formal place in the examination process and Canada had the only one in the world. Other countries tried to mount such examinations but the efforts always foundered on the rocks of inter-specialty jealousy and political considerations. Special mention must be made of Dr. Fred Kergin, who during the years from 1965 to 1967, constantly needled the Examinations committee and more specifically Dr. Wilson, to get on with the business of requesting funds to set up an institute parallel to that in Philadelphia. This 222 finally culminateD in 1967, when Dr. Kergin, then one of three members of the Board of Directors of the R.S. McLaughlin Foundation, took a request to the Board for $250,000 to begin a serious effort in Canada in the objective evaluation field. The other two members of the Board, Mr. Jack Fraser, legal counsel, aged 83 and Colonel Sam McLaughlin, aged 86, were both deaf as posts and when Fred Kergin presented the original submission, he had to shout at the top of his lungs. On the conclusion of his presentation, Colonel Sam with a twinkle in his eye said he had heard every word that Fred had said, but didn't understand a bit of it. He concluded by asking Fred whether he thought it was a good idea or not. Fred said it was and Sam said, "well good, that's passed; now let's get on to the next item on the agenda." Such was the birth of the R.S. McLaughlin Examination and Research Centre. From that time on, things began to happen fairly quickly. At the request of the Medical Council of Canada, Dr. Wilson carried out a nation-wide survey of Medical Council of Canada examinations and was able to report to Council that the whole examination process was in considerable disarray, varying widely from one examination centre to another, with no notion of national standards. No attempt was being made to address seriously the thorny problem of who should pass and who fail. As a result of this survey, the Medical Council decided to approach the National Board of Medical Examiners in the United States to obtain objective examinations with the long range goal, as soon as Canada was able to develop its own examination processes, of gradually repatriating the examinations to this country. This was eventually achieveD in stages and completed in 1979. 223 In 1968 , a further major contribution to the development of the R.S. McLaughlin Examination and Research Centre was provided by Dr. Bryan Hudson from Melbourne, Australia, who was the first J.B. Collip Visiting Professor in the Department of Medicine at the University of Alberta. During his year at the University, he was instrumental in setting up the computerized basis for storage and retrieval of all test items and he was also able to make a beginning on the I development of computerized patient management problems. During this time at the University I of Alberta, the Centre enjoyed a very generous and fruitful collaboration with the Division of Research and Experimental Psychology under the direction of Dr. Steve Hunka, who made the computer facilities of the University available to the Centre. The Centre was able to have access in an unlimited manner to the only University computer dedicated for educational purposes. This happy collaboration with Steve Hunka's Department continued thereafter. On July 1, 1969 the Centre appointed its first director on a half-time basis, with assistant directors for the Western Bureau in Edmonton and the Eastern Bureau in Quebec City. Dr. Wilson assumed the role of director, while continuing as Professor of Medicine in the Department of Medicine, with Dr. W.C. Taylor, a colleague in Pediatrics, assuming the direction of the Western Bureau and Dr. Jean Beaudoin on a comparable basis in Quebec City. For the next ten years, the Centre expanded extensively, and, in the context of Alberta's medical history, it became an integral part of the University of Alberta's Faculty of Medicine with extensive computer and service facilities provided in a building immediately adjacent to the campus at little cost. 224 During the 1970s, medical examinations were developed for all of the French-speaking schools and McGill University in the province of Quebec, and for the Faculty of Medicine of the University of Alberta. The Centre took over the total production and scoring of all of the examinations for the Medical Council of Canada for ten of the major specialities within the Royal College of Physicians and Surgeons of Canada. Eventually, the Centre developed screening examinations for the Medical Council of Canada to administer around the world for all candidates wishing to come to Canada to pursue internships and subsequently to practise in this country. In 1973, the Gladys and Merrill Mutt.art Foundation made a very generous grant of SJ00,000 available over a five-year period to develop the concept of totally computerized examinations with the assistance of Dr. W.C. Taylor and Dr. Tom Taylor, a consultant from Glasgow. This examination was put together over a two-year period, and for the following three years, totally computerized examinations were run over a national computer network in both the English and French languages. The experiment was considered to be successful and not any more expensive than the average cost of formal pencil and paper tests, but the examinations were discontinued because the concepts and capability of the system which had been developed were ahead of the network capabilities available for comprehensive use in this country. The computer programs did lend themselves extremely well to continuing explorations in the field of continuing medical education. 225 The Centre also made its facilities available to other Commonwealth countries, specifically Australia and New Zealand, giving them in tum the assistance which the United States had given Canada to set up their own objective examinations in the field of internal medicine. It also branched out to develop a nation-wide network of evaluation for St. John Ambulance, which yearly trained some 300,000 Canadians in various grades of first aid. The former Director of the Centre acted as a consultant and liaison officer between St. John Ambulance and the Centre. This program was expected to constitute a very major improvement in achieving national standards of excellence in this most important field of first aid to the injured and ill right across the land. It would benefit all Workers' Compensation Boards and many major industries, such as the Bell Telephone system. It was expected to provide a world's first service comparable to the development of computerized examinations for the Royal College. Once again, a substantial grant from the Gladys and Merrill Muttart Foundation made the initiative possible. Also during the 1970s, the Centre provided considerable assistance to many of the paramedical organizations, including the Canadian Association of laboratory Technicians, to establish their own objective evaluation techniques. Similar services were envisioned for the Centre in producing examinations for an increasing number of other groups as facilities and manpower permitted. From very meagre beginnings in 1963, when the American Board of Internal Medicine generously gave the Royal College 300 test items in internal medicine, the completely computerized bank of test items grew to about 25 ,000 items by the late 1970s, making it one of the largest repositories of test items in existence. 226 During the 1960s, the concept of global examinations for some specialities was seriously considered on the grounds that an international standard would greatly facilitate the movement of specialist physicians and surgeons throughout the world. Over a four or five year period, an international sharing study group was established under the auspices of the Ciba Foundation of London, which had members on it representing England, Scotland, Ireland (through the Royal College of Physicians of London); Australia, New Zealand and the Australasian part of the world (through the Royal Australasian College of Physicians); the United States (through the American Board of Internal Medicine), and the Royal College of Physicians and Surgeons of Canada. Over a three-year period of time, the R.S. McLaughlin Centre assumed the responsibility for distributing all the examinations of the above-noted countries to each of the other countries, where they were reviewed by test committees as to their appropriateness for global utilization. This was done annually for a period of three years,and the results were analyzed and interpreted by members of the McLaughlin Centre. The international committee concluded that such examinations were completely feasible and that all the test items from the various countries were appropriate, depending on the time at which the examinations were set. Little of the material under consideration proved inappropriate: about 5 percent. This study, which showed great . promise at the outset, began to founder as the increasing supply of physicians resulted in negative political pressures in wealthier countries where doctors were concerned about being inundated by physicians with global certification from countries where opportunities were not so attractive either financially or professionally. The fact did remain, however, that international examinations in any given specialty were easily within reach, provided that political considerations did not prevent them. 227 The Centre had become firmly established on the Canadian medical scene, with headquarters based in Edmonton at the University of Alberta and with two divisions, one in Edmonton devoted to the English speaking activities of the Centre and one to French language services in Quebec City. The Centre's bilingual capacity in two major world languages promised future international potential. Developed as an integral agency of the Royal College of Physicians and Surgeons of Canada, with its continuing growth it raised the prospect of a free-standing entity capable of providing services not only to all fields of medicine but to other professions as well. 228 The Alberta Medical Association from 1906 to 1980 H.E. Harper In 1905, the new Province of Alberta passed a Medical Profession Act under which the College of Physicians and Surgeons was formed in 1906 to succeed its Northwest Territories predecessor. At the first meeting, special committees were appointed to cover the various facets of medical organization with special reference to licensing and disciplining members. Shortly after this meeting, a 1906 convention formed the Alberta Medical Association, chiefly as an educational body but with involvement in the standards of medical care. The College and the Association would act in concert until 1969, despite the formal recognition as early as 1923 of the need for separation. The society in early Alberta was vastly different from what evolved three quarters of a century later. Railroads served only a very few points in the vast area. Roads were for the most part rough tracks that joined widely scattered settlements. There were only eight hospitals in the new province, some with only a few beds and minimal equipment. The majority of doctors had no access to hospitals and treated their patients in their. homes, often travelling by horseback, democrat or sleigh. Seventy-five years later, many doctors would practise a lifetime without seeing cases of some infectious diseases that were the chief causes of death in the first decades of the century. In those days the physician treated the symptoms and had none of the specific therapies which allow the modern doctor to treat the cause of the disease and try to eliminate 229 it. Surgery was elementary, and apart from the few simple emergency operations performed in the homes, more complex surgery often meant difficult transportation to distant hospitals. The new medical organizations dealt with many problems. The College was immediately called upon for the basic principles and provisions of a Public Health Act in 1907. The College also requested a bacteriological laboratory in each of Edmonton and Calgary. In the treatment of any infectious disease, rapid recognition of the causative organism was essential. Over the years, Alberta's medical profession contributed to much health care legislation: more recently, a new Mental Health Act in 1968, a new Cancer Act in 1970, and the Fatality Inquiry Act in 1973. One of the early functions of the College was the examination of doctors for licensure to prevent unqualified, self-styled healers from preying on the new settlers. In 1912 these examinations were turned over to the University of Alberta. The following year, when the University started instruction in medicine, the College awarded two scholarships, which were later increased to five in number, in addition to a valuable research scholarship. As more doctors came into the province, local medical societies formed. The College integrated these and awarded grants of $50 to all incorporated medical libraries plus an annual $100 maintenance allowance. The number of doctors in the province was not sufficient to carry out the important preventive care and education of the public in health matters. At their urging, a Public Health Nursing Service was established in 1918. At first these nurses were involved in annual examinations and health education in the schools in the central areas of the province. Later, often under great 230 hardship, they performed invaluable service in isolated areas without doctors. Alberta's doctors also urged the Government in 1922 to support hospitals in maintaining satisfactory nursing schools. As the pattern of life in Alberta became complex, so did the interests of the central medical bodies. In 1923 the functions of the College and the Association were delineated. The College of Physicians and Surgeons continued to be the licensing body and was also responsible for discipline within the profession. The Alberta Medical . Association became responsible for education and public relations. Committees dealt with new situations arising over the years: maternal and infant welfare, cancer and mental health, the medical aspects of transport accidents, hospitals, alcoholism and drug abuse. The government of Alberta received representations to reduce speed limits and to enforce the use of seat belts. Much was also done to promote an understanding of sexuality among teenagers, parents and community groups. Under the leadership of the Association, the Alcoholism Foundation of Alberta was formed. Diseases calling for special measures beyond a single physician's capacity received collective attention. In 1911, for example, a letter from the Association encouraged the College to set aside funds to establish a provincial sanitorium to treat tuberculosis. The College responded with $3,000 to support the project. Further grants, like the $500 committed to the Anti Tubercular Society in 1924 for a tuberculosis survey, helped to lower the Alberta death rate from tuberculosis to the lowest in Canada. It remained in 1955 to recommend formally to the 231 Minister of Health that appropriate measures be ta.ken to cope with "non-cooperative" cases of open tuberculosis. Other diseases received similar attention. The Albena Medical Bulle£in regularly carried advice during 1945 on the diagnosis and treatment of the venereal disease proliferating at the time. The same Bulletin in 1967 was familiarizing doctors with the services of the Cancer Clinic. The Association helped the College, that same year, in establishing province-wide standards for x-ray and laboratory facilities in both hospitals and physicians' offices that would ensure both accuracy and safety. The provision of health services to the broader community, beyond those consulting physicians individually, took a variety of forms over the years. In 1922, the profession looked into the possibility of hospitals hiring interns, and the Association proposed a government program to permit municipalities to keep aged and incurable patients in their own areas. This was consistent with the College's participation in the Canadian Medical Association's 1926 investigation of health services. The Workmen's Compensation Board was a continuing source of interest. The Association recommended appointment of a physician to the Board in 1921, and recommended a Medical Appeal Board for dissatisfied workmen in 1924. By 1946, the Association was stressing the importance of industrial medicine to prevent cases that would wind up as matters for the Workmen's Compensation Board. Between 1956 and 1962, the Alberta Medical Bulletin carried articles by the Board's Chief Medical Officer that improved attitudes to injured workmen and facilitated liaison between the Board and the profession. 232 More broad! y, the Association in 1950 advised physicians in each community to establish an Emergency Call Service to facilitate constant access to a doctor. By 1968, it was obvious that public access to medical services was becoming a government issue. The Association called for a committee of the provincial cabinet to meet with representatives of the profession to reach a mutual understanding of how to provide the best medical services to the people. The result was a joint Formal Planning Committee. Association representatives also met with their counterparts in Saskatchewan and Manitoba and the three provincial governments in an effort to find ways of reducing the costs of medical care. They agreed to study more effective use of health personnel. At the same time, the Association cooperated with the Alberta government's Blair Commission on mental health services, leading to a new Mental Health Act. In the early 1970s, the Associatio n contributed to further develop ment of health care policy, in 1971 supporting the principle of psyc hiatric consultative services for communities needing them, and in a 1972 brief to the Hastings Commission, advocating principles of good health care for all citizens. World War II called for unusual collective measures. To distinguish which doctors could be spared to join the armed services, a Medical Procurement and Assignment Board was set up in 1943. The Association proposed to cope with the wartime shortage of physicians by preventing relocation of doctors from current geographical positions of minimal hospital and auxiliary care to larger, better equipped centres. Two years later, a Medical Placement Board pointed doctors returning from the services to the areas or communities requiring physicians. 233 The maintenance of educational standards in a rapidly changing profession was always an Association priority. As early as 1919, the College granted the Association $5,000 to aid country members to get to community lectures and extension courses provided by the University. By 1931, the University established annual refresher courses subsidized by the Association. In 1970, the Association voted $5 per member per year for continuing medical education, dividing the funds pro rata between the universities of Alberta and Calgary. On the other side of the equation, medical audits introduced in 1963 determined the quality of patient care. The computerization of physicians' accounts permitted professional peer review as of 1971. An unusual pattern of practice could result in a call for the physician to explain and justify it. Looking to their own security, Alberta's physicians and surgeons had been interested in group life insurance and in protection of income during loss of time resulting from accident or illness long before their College entered into a contract with the North American Life and Casualty Company for preferred rates late in 1940. When the first policy under this contract was written in 1950, the high earners in the profession bought the maximum disability benefit of $125 per week for a maximum death benefit of $10,000. Dick Garrett, North American's agent of record for the College of Physicians and Surgeons during the 1960s, toured the province and "wrote up" many doctors, but the College's Council and Board of Directors decided that the insurance should be handled centrally, in-house, in an unbiased manner and without commission. Eld win K. Speer was appointed Coordinator of Membership Benefits as of July 1, 1968. He travelled with the President-elect's tours and also solicited business by mail and personal interview, steadily increasing the number of contracts. In 1969 the billing and collecting was 234 transferred from the company to the College office, and sponsorship of the plan moved from the College to the Alberta Medical Association. In the 1970s, coverage of office overhead during disability was added; then accidental death and dismemberment; and finally spousal life insurance in 1980. The wisdom of the change to in house operation of the insurance scheme had by now become apparent. By the end of 1979 there was a reserve of $3,000,000 in all plans, which was held by the AMA instead of the insurance company. As a result there was a return of premiums to policy holders, amounting in 1980 to 6 percent on the Disability fund, 12 percent on the Life Insurance fund, and 37 percent on the Office Overhead fund. The Association interested itself at an early stage in prepaid medical care or health insurance plans for the general populace. It supported the Health Insurance Act of 1942, which the Government passed but did not implement. However, following extensive investigation and a canvass of the medical profession, an Act was passed by the Legislature of Alberta which created Medical Services (Alberta) Incorporated in 1948. This organization proved to be very successful and provided prepaid medical care to the people of Alberta until the institution of compulsory federal Medicare forced it out of existence in 1969. By that time more than 90 percent of the citizens of the province were covered by MS(A)I. Mindful of their trust, MSI and its sponsoring medical association turned the residual funds over to the Medical Research Foundation of Alberta, newly formed to grant research funds to develop the most effective and 235 practical medical and allied health services possible. This followed a tradition as old as a 1922 grant to Dr. J.B. Collip toward studies leading to his discovery of insulin. With the growth of the province, the membership of the Alberta Medical Association grew to more than 2,500 by 1980. Along the way, in 1962, CMA Alberta House was built to house the AMA and the College of Physicians and Surgeons of Alberta. Though sometimes apparently at odds with the government, the Association continues to carry on its tradition of guarding the health of the citizens. More recent concerns included such issues as the ethics of advertising physicians' services. In some fields the work done by the physicians of Alberta began to command world interest, while the general care offered to citizens became the equal of that in any other part of the western world. 236 The Colle~e of Phvsicians and Surgeons and the Alberta Medical Association 1948 - 1968: The Separation M. Sereda In the beginning there was one profession, one secretariat and one fee. To many of us, it seemed a most sensible and efficient way to conduct the affairs of the profession in Alberta. Every practitioner in the province knew where to go with any kind of problem - from licensing to refresher courses. And the price was right: one modest fee collected by the College, out of which it made a very modest grant to the Association to run its affairs. We were, of course, aware that in all other provinces except Saskatchewan, the College and Association were separate, or in the process of separation. But we were also . aware of the frequent tensions and outright hostility that occurred between the two bodies. Too often, even in Alberta, physicians became identified with, and became advocates for, one organization or the other. Ours was a fairly successful operation, but only because we had a good number of "statesmen" who were dedicated ro the ideals of the profession as a whole. It would be very difficult to do credit to the list, but certain names immediately come to mind: A.E. Archer, Morley Young, Mac Parsons, Ken Thomson, Ted Donald, Hugh Arnold, Rupert Clare and many others. Then there was Bill Bramley-Moore. "That S.O.B. will walk out of here once too often," whispered a councillor to my right, as Bill, having delivered a tongue-lashing to Council, left the chamber. 237 The long-time Registrar of the College, and Executive Director of the AMA (then Alberta Division of the CMA) was not very tolerant of wishy-washy actions when there was a question of discipline or the integrity of the profession. He was generally feared, especially by the younger practitioners, and he wasn't averse to writing on paper what he felt like saying personally. We in Council often expressed the opinion that in some particular instance a grade-4 letter (on the basis of 1-6) would suffice as a reprimand. Whether we liked him or not, agreed with him or disagreed, we all respected him. He did, through those times, exert a stabilizing influence. In the fifties, anomalies became increasingly apparent. On the one hand, membership in a supposedly voluntary organization was in fact mandatory; on the other hand, a statutory body created by government for the protection of the public was setting fees for medical services, and would, in due course, be negotiating or bargaining on behalf of its members. There were three causes of increasing irritation and tension. First, committees proliferated on both sides, often with rather general terms of reference, often overlapping, or even duplicating work already being done. Jurisdictional boundaries at times became increasingly blurred as some 44 standing committees attempted to define their areas of responsibility. Second, College councillors and those working at Council's direction received a per diem allowance. Those on the Association side worked gratis, for the good of the Profession. Late in this era, regulations were amended so that Association workers received an allowance after a certain minimum number of days. Even so, there was at times the feeling of 238 being treated as second class members. Then, of course, medicare was in the air, and it was obviously only a matter of time before a professional organization unfettered by statutory ties would have to represent and bargain on behalf of its members. But the prospect of separation also raised fears and uncertainties. What if too small a percentage of doctors (say fewer than 70 percent) chose to belong to the AMA? Would third parties, especially government, accept it as representing the profession as a whole? Would advocates of the College on the one hand and the AMA on the other in fact become adversaries? Would separation lead to divorce with the likelihood of bitter wrangling over responsibility and authority? In this atmosphere of uncertainty and unease, the College Council and the AMA Board of Directors jointly set up the Committee on Medical Organization (CMO) in 1966. Drs. L.C. Grisdale, Leo Lewis, A.A. Dixon, J.E. Moriarty, Don F. Lewis and J.D. McCutcheon served as members and I as Chairman. The Committee presented the following terms of reference to the Council in September 1967: a. To study the. terms of reference of Association and College and all of their Committees in the light of present and foreseeable needs of the profession and the public. b. To recommend such changes as may be necessary to delineate function and responsibility, and to minimize confusion and duplication. c. To report as necessary to a joint meeting of Council and Executive. 239 We were given no deadlines and even we had little idea of how long it would take to complete the assignment. The Committee set its own priorities and procedures. My initial fears that members would take sides as advocates on contentious issues were soon eased. While discussions were sometimes heated - on one occasion even the Chairman found it necessary to leave the chair to cool off - at no time did they become bitter or personal. After eight formal meetings and "innumerable interviews with interested parties", the Committee presented its First Interim Report in September 1967. By then, the Committee had adopted the following basic principles: a. The College is concerned with the competence, performance and behaviour of each individual physician, and the welfare of the public and is established by government to ·carry out these functions. b. The AMA is concerned with general performance and behaviour of all physicians and the well being of the profession and is established by the profession to carry out these functions. c. The work and responsibilities of the profession are such as to justify the maintenance of the two bodies, each with a meaningful role. It also identified 17 functions or problem areas faced by organized medicine and presented them in three categories: problems primarily of interest to the AMA, problems of concern to both the AMA and the College, and problems of concern primarily to the College. 240 A second Interim Report in May 1968 took notice of the absence of significant dissent. This was interpreted as evidence of acceptance by the profession of the proposals made in the first report. This second report contained a proposed organizational and functional outline for College, the AMA and Joint Assembly. This, of course, was the most important result of the work of the CMO. There remained only some more detailed delineation of jurisdictional detail, a framework for committees and suggested terms of reference for them. Part of this appeared in the second report and the remainder in the final report, presented in July 1968. While the CMO was unanimous in its stand that the AMA must be separated from the College, incorporated and made strong enough to represent the Profession in dealing with government and third parties, the worry persisted that premature or precipitate action in this respect might split and weaken the Profession. The Executive and Council emphasized this concern by resolving in June 1968 to defer action on the principle of incorporating the AMA. The CMO naturally complied with this directive. However, believing that separation was eventually inevitable, the Committee proposed certain actions to help maintain harmony within the profession. First, during a transitional period of one year, such matters as economics and negotiations with third parties should remain under joint jurisdiction. Second, certain matters should remain indefinitely under joint jurisdiction and that a Joint Executive and Joint Assembly should remain as a mechanism to carry this out effectively as well as help maintain a high level of communication between the executive bodies of the College and A~1A. 241 With the mailing of the final report, the CMO had completed its assignment and was dissolved at its own request. The final report presented to the Annual Meeting of the College in September 1968 was adopted with little discussion and no opposition. Beyond fulfilling its terms of reference, the CMO had helped to stabilize organized medicine in Alberta at a time when great changes occurring inside the profession as well as in society generally exerted significant pressures on the profession. 242 Formal Initiatives in Public Relations, 1957 - 1979 W.B. Parsons Traditionally, the only public relations required by the medical profession were good relations between the doctor and his patients. The public took it for granted that the medical profession monitored and governed and improved itself, weeding out misfits and rascals. With the advent of prepaid medical care this situation changed. As participation in prepaid schemes increased, the problems of organized medicine multiplied. A few years after the formation of Medical Services (Alberta) Incorporated, complaints of extra billing started to come in. An early sign of concern on the part of the College of Physicians and Surgeons was the publication in 1957 of a pamphlet, "Winning Ways with Patients", which was given high praise. Several other steps in public relations ranged over different issues. In 1959 and again in 1961 the Alberta Medical Association entered the controversy over fluoridation of water, officially supporting it. In 1964, the year after the introduction of the Alberta Medical Plan, the Committee on Ethics and Public Relations made itself available to help any doctor who wished to give a talk on medicine, or to help any organization that wanted a speaker. There was also an element of public relations in the College initiative of 1968 to control the quality of laboratory work throughout the Province. This was a pioneering project in Canada, and was later followed by quality control in x-ray techniques. 243 At the annual AMA meeting of 1970 there was considerable discussion of the need for improved public relations because of the increasing criticism of the medical profession and the growing interest of government and other agencies in health care. By this time the AMA had retained a Public Relations firm in an advisory capacity, and set out to inform the people of Alberta on matters of health. The President-elect began to speak on TV to put a better face on the medical profession vis-a-vis the criticisms that were being heaped upon it. By late 1972, the Association had ventured into socio-political areas previously unexplored: fees, disparity of incomes, the provision of health services in isolated are.as, community health centres, restructuring of the profession's involvement in medical education, narcotic addiction treatment centres, the establishment of a foundation to support a chair or chairs on alcoholism and drug abuse in one or more Alberta universities, professional review, and other matters. On receipt of written and personal submissions from its members, the AMA advised government and government agencies on such matters as hospitals, cancer, and private laboratories. Though sometimes seeming to be at odds with the government, the Association carried on its tradition of guarding the citizens' health. In 1974 the Income Tax Department revealed that physician incomes in Alberta were the fourth highest among Canadian provinces. These were gross figures, failing to deduct expenses or to reflect variations among specialty groups. The need for better public relations in medical economics was apparent. Physicians in the province agreed to present audited income and expense statements to a selected firm of accountants to reveal the net incomes and permit the correction of discrepancies in incoming comparisons among the various groups. In another new 244 departure, a new Medical Profession Act in 1975 permitted the appointment to Council of three individuals who were not regular practitioners of medicine. This did much to dispel the image of a closed shop and secrecy. So did medical audits and professional or peer reviews to find out if modified management of a case might have resulted in a better outcome. But the profession also expressed itself publicly in the fields of abortion and birth control, going beyond questions of its own public image to matters of health policy. This dual concern reached a pinnacle by 1978. Under the chairmanship of Dr. R.N. MacDonald, the activity of the AMA Public Relations Committee (renamed the Committee on Communications) increased. A paper that Dr. MacDonald presented to the Board in May listed priorities in the AMA's interaction with three publics: the provincial government, the general public and the profession. It stressed certain basic assumptions: easy communication and a friendly approach by physicians and their office staff to patients and their families; acceptance of the increased public scrutiny and criticism directed at of all modern organizations and institutions; the necessity to express positive values rather than negative defensive stances; the need to match members' economic concerns with the AMA' s responsibility to inform the public and the government on important health issues; and the necessity of involvement in public relations by other AMA committees, physician organizations and individual physicians. These assumptions would be the basis for a three-pronged campaign: to the government through its Ministers and the MLAs via the district medical societies and the individual doctors; to the public by means of office posters, public health symposiums, health documentaries on TV, 245 speakers at service clubs and other means; and to the profession through the annual tour of the President-elect, the President's Letter and the Albena Doctors' Digest. Members of the sections would in turn bring public attention to the activities of the AMA and the profession. In November of 1978 the AMA hired a full-time employee, Robert J. Taylor, to coordinate its public relations efforts. Early in the following year the AMA launched a major public information campaign. By radio, TV, newspaper columns and bulletin boards many of the current issues were discussed: prevention of illness, medicare, physicians' incomes, drinking and safety, use of hospital emergency wards, sex and responsibility, moderation and the festive season, the professional right to charge for services, and the health care crisis. The office posters dealt chiefly with finances. One had a graph with a rising line which indicated office expenses and a falling line indicating doctors' incomes. Many doctors considered these distasteful, though about half the members did hang them on their office walls. In the spring of 1980 a mail-in campaign gave the patients in a doctor's office the opportunity to support the doctor's right to charge a fair fee for his services. Approximately 60,000 cards were sent out and about 5 ,600 reached the Minister.. The reaction to this campaign was difficult to assess. The Minister was disappointed that the decrease in balance billing hadn't been greater. He said that he intended to ban balance billing in favor of opt-out legislation, but if opting-out became excessive it would be stopped by legislation. To the profession this indicated the need for further efforts on its part to protect its freedom. In line with this, a motion passed at the AMA Annual Meeting in 1979 to increase annual dues to put aside $100 per member for costly but necessary public relations. 246 It was further recommended that all physicians become engaged in the democratic process at the political party level. A few months later the board of the AMA commissioned a canvas of the members to determine their public relations concerns. The Committee on Communications decided to direct an intensive campaign at the government, the profession and the public. It selected a campaign on "Care about Health Care", prepared by Dr. Earle Snider, a sociologist. The object was to show, through handout information, bumper stickers and television, that the doctors' primary concern was to maintain the finest quality of health care for Albertans. The main project was saturation television for four weeks · before the next AMA annual meeting to show what the medical profession was doing to benefit the people. Then part of the meeting would discuss the caring that physicians do about health care, possibly under the heading of a "Care In". The cost of this program was to be in the order of $300,000. There was marked disagreement within the Board of Directors as to its value, but the Board voted seven to six to go ahead. The Committee moved quickly to get the required television time before the annual meeting. When information on the "Care" program was circulated to the AMA districts, however, the reaction was largely negative. Then the Membership Survey results in late August showed that the Association's relationship with the public was not a matter of top priority with the membership. On August 28 the Board unanimously voted against the program, though some may not have known the full extent of the $150,000 indebtedness arising from non-cancellable contracts for television time. 247 At the annual meeting, prolonged discussion focused on the reasons for dropping an adopted program in which there was considerable investment, and the extent to which the financial commitment was legal as opposed to moral. The Board had dropped the program because it was a one-time crash program of questionable value in the long run, and because of the negative response from the districts. The Board believed, however, that the medical profession would jeopardize any future programs that might involve public relations professionals. A motion was eventually passed "that this meeting support the principle that all reasonable invoices relevant to the Care about Health Care program be paid as soon as possible by the AMA." The Committee on Communications resigned and further public relations efforts awaited new initiatives. 248 Modern Developments in the Alberta Medical Association R.F. Clarke The Alberta Medical Association became a corporate entity, as a society registered under the Societies Act of the Province, in the fall of 1969. Events which led to this giant step forward began more than 20 years earlier. Background to Corporate Status In 1948, after 15 to 20 years of various bod ies experimenting with different kinds of medical insurance schemes, Medical Services (Alberta) Incorporated was formed by statute of the provincial Legislature. It was a non-pro fit agency, sponsored by the medical profession , intended to provide medical services insurance at reasonable cost. While the College of Physicians and Surgeons of Alberta had primary responsibility for the business side of the profession's affairs, the AMA and several of its more prominent members played a significant role in making MS(A)I a reality. This was the event which, as much or more than any other, was to shape the future of the profession's voluntary body. The advent of MS(A)I meant that, on a large scale, a third party was introduced to the doctor patient relationship. No longer were the doctor and the patient the only participants in the doctor-patient transaction. The physician relinquished significant control to the professional organization in dealing with the agency that provided insurance benefits for so many patients. 249 The Saskatchewan medicare crisis of 1962 had been influential in the direction that the AMA and organizations like it would take thereafter. A key feature of Saskatchewan Premier Tommy Douglas's compulsory medical insurance plan had been that the government would become the patient's agent in relation to financial transactions between patient and physician; the prepaid plans then in existence would disappear. Led by the College of Physicians and Surgeons of Saskatchewan, and supported by physicians and medical organizations across Canada, including the CMA, virtually all Saskatchewan physicians closed their offices on July 1, 1962. Twenty-three days after the dispute began, it ended with the Saskatoon Agreement. The government acknowledged that it would only operate an insurance scheme and agreed to amend the offending sections in the Medicare Act. Physicians maintained the right to deal directly with their patients in relation to financial matters; the prepaid plans were preserved although they could only sell extended benefits and act as "post offices" to pass on claims from physicians to the Medical Care Insurance Commission. A relationship previously based primarily on cooperation took on elements of the adversarial model. The government threatened to remove the licensing and disciplining powers of the College in Saskatchewan and place them in the hands of the University of Saskatchewan, because the College had led the 1962 "strike". The profession in Saskatchewan recognized that there must be a separate and distinct body to protect the interests of the profession and public at large; if the profession was to maintain control of licensing and discipline through the College, the College would have to withdraw from the political-economic scene. The Saskatchewan Medical Association, which had had a role much like the AMA, became an entity separate and distinct 250 from the College and assumed responsibility for the profession's political and economic activities. At the same time, Royal Commissions, task forces, investigative bodies and citizens' groups operating in the 1960s came forward with recommendations that the professional body charged with serving the public welfare (the College) should not simultaneously attempt to serve the vested interests of the professional group in such areas as establishing fees for services, or enforcing compliance to the schedule of fees established by the group. The federal government, led by John Diefenbaker, appointed a Royal Commission in 1961, chaired by Mr. Justice Emmett Hall , to study medical care insurance and made recommendations to the government. In its two-volume Report published in 1964 and 1965, the Commission recommended the introduction of a national medical care insurance plan; it indicated that it was not in favor of direct charges to the public for medical services. In a minority report, Dr. Baltzan, a Saskatoon internist, urged that in any government plan the right of physician and patient to engage in a financial transaction be maintained, a right which was incorporated in every government controlled medical services insurance plan in Canada (though some might consider Quebec an exception). It became clear following the publication of the Hall Report that a national medicare program was inevitable. The Liberal government of Lester Pearson introduced the Medical Care Act to the Parliament of Canada; it was approved, and became law on July 1, 1967. The Act made provision for the Government of Canada to share the costs of provincially-operated medical care 251 insurance programs provided tha1 such programs met the statutory requirements for cost sharing. It would have been political suicide for a provincial government not to institute a medicare scheme consistent with the requirements of the federal legislation, although some provinces dragged their feet -- Alberta did not introduce a plan acceptable to the federal government until July 1, 1969. Consistent with developments elsewhere, this produced a growing feeling among Alberta physicians that the AMA should become a distinct body, sovereign, and with a new and expanded role. At the 1965 annual meeting of the Canadian Medical Association, Alberta Division, notice of motion was given that its name be changed to the "Alberta Medical Association"; the motion . was adopted in 1966. At the 1966 annual meeting, Dr. Crosby Johnston (seconded by Dr. Peter Gregory) presented an important notice of motion to register the AMA under The Societies Act, in order to formalize the Association' s actual (though unofficial) involvement in many areas not the proper responsibility of the College of Physicians and Surgeons of Alberta. The Association acted in many ways to serve the public and the profession. It performed exemplary work in the fields of maternal welfare and perinatal mortality, for example. Because of circumstances, the College had been doing more than was required of it by the Medical Profession Act. For example, the College developed and published the profession's Schedule of Fees; it had named representatives of the profession to act in areas which would otherwise be in the jurisdiction of the body not responsible for licensing and discipline. As a registered society, the Association would be a body corporate, able to enter into agreements and be 252 rf".c.nenizf".ti formally in legislation and by other means as an organization representing the profession. To undertake the necessary assessment and reorganization, the College and the AMA established a "partnership" arrangement. The Committee on Medical Organization was appointed by the Council of the College and the Board of the Association; both bodies were equally represented on the Committee. The Committee was chaired by Dr. Mike Sereda, who was a strong supporter of the Association and who had been a President of the College's Council. Over the two years of its existence, the Committee reported its progress to the Board of the Association and the Council of the College as both separate and joint bodies. Both bodies affirmed the Committee's work as it progressed. Interim amendments were made to the Association's By-Laws in 1968 to put into place proposals made by the Committee which had been adopted. The extensive full set of amendments to the Association's By-laws of 1951 (as amended) were presented to the 1969 Annual Meeting of the Association and approved. The new Constitution and By-Laws provided for an extensively restructured organization and formed the basis for the registration of the AMA as a society under the Societies Act in October of 1969. Organizational and Functional Adjustments The By-Laws, and understandings reached by the Board of Directors and Council, made the Association responsible for economics. The Committee on Fees came under the jurisdiction of 253 the AMA. For a period of two years, to allow for a reasonable transition, the Committee reported to the Joint Assembly (the Council and the Board in joint session). The Board became the "economics committee" for the profession. Liaison and representation to government and other bodies, in many areas, became the responsibility of the AMA. For example, the Liaison Committee with the Hospitals Division (later the Alberta Hospital Services Commission) became a function of the AMA. The Medical Advisory Board to the Department of Highways became a responsibility of the AMA and physician members of the Advisory Board became members of the AMA Committee on the Medical Aspects of Transport Accidents. The AMA named the profession's representative to the Alberta Blue Cross; the AMA nominated the physician member of the original Alberta Health Care Insurance Commission. The AMA became responsible for the mediation of disputes between medical staff and management in hospitals. Several of these changes required amendments to legislation and by-laws; none of the changes met with significant resistance for, in essence, physicians were acting for the profession regardless of what "hats" they were wearing. Within five years of the initiation of these major changes in 1969, the Association was clearly recognized as the "spokesman" for organized medicine in Alberta outside the areas of licensing and discipline. The ability of the Committee on Medical Organization to anticipate future needs was almost uncanny. The Committee proposed that there be a Joint Assembly -- the Board and Council in joint session -- to meet as needed to deal with matters of common interest and to clarify jurisdiction in various areas. The Committee also proposed that the executive committees of 254 both bodies meet together frequently to facilitate liaison and communication on a continuing basis. The system worked very well. The AMA dealt with those matters which clearly should come under the jurisdiction of the voluntary body. Not having to deal with political and economic marters any longer, the College Council was able to concentrate on the responsibilities given to it by statute, such as the accreditation of various aspects of medical practice. It was able to develop and see introduced a new Medical Profession Act in 1975 . As both bodies became entrenched in their new roles, meetings of the Joint Assembly became less necessary, but this vehicle remained, to be used as circumstances warrant, while the chief means of liaison was the Join t Executive. Of course, day-to-day relations among the senior staffs of both organizations did much to foster harmony and cooperation. The new By-Laws provided for a Board consisting of the Officers (three), District Representatives (nine) and AMA members on the CMA Board of Directors (one, then two). The intent was to have a compact, efficient body not unlike the Council of the College. The original amendments allowed for two District Representatives from each of the metropolitan centres of Edmonton and Calgary. However, the Board developed the view that this did not provide for adequate representation by population, and the number of District Representatives from Edmonton and Calgary was increased to four and three respectively through an amendment to the By-Laws. In 1980, to recognize the growth that had · occurred in Alberta's north, District #5 was divided from north to south and a new District 118 was added. 255 Nf':Xt , thP. Ro;i rri recognizei:l that the medical students of today are the physicians of tomorrow. In 1974, amendments to the By-Laws enabled students to participate in the AMA. Each medical student association was entitled to elect one representative to the Board. Students were entitled to all the privileges of membership except voting in elections and referenda; provision was made for students to be represented at general meetings; students had full privileges as committee members. The students proved to be an effective force in the Association and they added a new dimension to its activities. In 1977, the appropriate amendments were made to allow the Professional Association of Interns and Residents of Alberta to elect one representative to the Board. ·while the AMA became a body corporate in 1969, the process leading to its total autonomy as an entity separate from the College was carefully staged over a period of years. The Executive Director and Executive Secretary of the Association continued in their offices of Registrar and Deputy Registrar of the College respectively. During this period it was determined that the Executive Secretary would succeed the Executive Director, who would retain his position as Registrar. In the meantime, the Executive Secretary took greater responsibility for the administration of the Association's affairs. In April ·1972, Dr. Robert F. Clark assumed the office of Executive Director, succeeding Dr. Robert Woolstencroft who continued as Registrar. The two organizations shared office space and office staff, occupying the second floor of CMA Alberta House. In 1973, it was decided that the AMA should have its own quarters. In December 1973, the AMA offices on the third floor of CMA Alberta House were opened. 256 Those staff largely involved in the work of the AMA and the operation of its membership benefits program made the move. Prior to 1969, College members paid dues which covered AMA and CMA membership; the Association operated on grants provided by the Council of the College. In 1974 there was agreement between the Board and the Council that the AMA should collect and control the dues for AMA and CMA membership. In September of 1974, for the first time, the Association sent dues notices to all the physicians in the province for the membership year ending September 30, 1975. Eighty-five percent of all the physicians registered with the College and resident in Alberta responded. On January 1, 1975 , the AMA was a free standing, voluntary organization. As a gesture of good will, and a final demonstration of support, the Council granted the Association S 150,000; these monies were to serve as a reserve and later formed the basis of the Association's Contingency Fund. The AMA staff increased in number to meet the growing demands on the Association. In late 1973, the Secretariat included the Executive Director, the Assistant Executive Director, the Coordinator of Membership Benefits and five secretarial staff. By 1980, a Coordinator of Economics and Administrative Services and a Coordinator of Communications had been added to the senior staff; the secretarial staff had increased to seven. Throughout this period the Association enjoyed the services of Miss Rachel Tasker, Executive Secretary to the Perinatal and Maternal Welfare Committees, who joined the Association in 1954. 257 For some 20 years before the AMA became a corporate entity, the College acted on behalf of the profession in arranging term life and disability insurance for members. While this should have been a function of the voluntary body, the AMA, only the Collage had the capacity to enter into agreements. As soon as the AMA became a body corporate the master contracts with the insurance carrier were amended to make the AMA party to them rather than the College. This move was challenged by a member in 1977. In a referendum submitted to the profession, more than two-thirds of those voting agreed that membership in the AMA should be a requirement for participation in the Association's insurance programs. The programs offered by the Association were refined and increased in number. Office overhead and accidental death and dismemberment programs were added; spouses became eligible for participation in the life insurance program. As well, the range and sophistication of the CMA membership benefit programs and the services offered under them increased significantly. The CMA established a wholly-owned subsidiary, MD Management, to operate the various financial and investment programs developed by the CMA, including the CMA Registered Retirement Savings Plan, MD Growth, the Canadian Medical Annuity Plan, the CMA Home Ownership Savings Plan and Loans to Establish Medical Practice. As well, the CMA developed an expanding series of seminars, offered regionally, on practice management, financial planning, incorporation of practice, and other related topics, for the benefit of both physicians in established practice and those about to enter practice. After 1969, the AMA continued to operate its system of standing, special and ad hoc committees. In amendments to the By-Laws of 1969, the terms of reference of the committees 258 were clarified, and some functions were consolidated. A notable addition to the list of committees was the Committee on Fees, which had previously been a committee of the College. New committees were fonned as the need for them became apparent. The committees formed the foundation of the Association's work. They gave the AMA credibility and clearly ensured that the AMA was a professional association and not a union. The work of the committees had wide ranging effects in such areas as perinatal medicine, prenatal care, child welfare including child abuse, alcoholism and other forms of drug abuse, the organization and delivery of cancer services, pre-operative, peroperative and post-operative care, extended care, the operation of hospitals, transport safety, ambulance services, mental health services, pharmacotherapy, poison control, several aspects of public health, rehabilitation medicine and the medical examiner system. The Association also became a primary motive force in the preservation of the profession's archives. In the late 1960s and early 1970s the abuse of drugs became a serious problem. Youth were experimenting with a wide variety of drugs including marijuana, LSD, and "speed", as well as the long established "hard" drugs or narcotics. There were virtual! y no programs of prevention. Young people were suffering a wide variety of reactions from the ingestion of drugs -- they were "freaking out". Our health care system was not quipped to deal with this phenomenon; physicians lacked information to help them cope with the cases presented to them. Physicians and health care institutions were experimenting, on an individual basis, with various approaches to the handling of the problem. The traditional approaches appeared to be achieving little in the control of alcoholism. The problems were attacked by the profession 's organizations, at the 259 national level by the CMA and at the provincial level by the AMA. The AMA promoted the establishment of the Alberta Alcoholism and Drug Abuse Commission, which came into being in 1970. A study of drug and alcohol use and abuse was undertaken by an ad hoc committee chaired by Dr. C.J. Varvis. One of the Committee's recommendations was that the Association establish a standing Committee on Alcoholism and Drug Abuse to establish clearly the Association's commitment in this area and to coordinate the profession's efforts in the fields of education, prevention and management. The By-Laws were amended to make provision for the Committee in 1970. Under the Chairmanship of Dr. H.A. Arnold, a distinguished Past President, the Committee maintained close liaison with AADAC and other agencies in the field, provided the profession with information and guidance, and promoted education and prevention. The Committee was instrumental in the establishment, by statute, of the Alberta Foundation for University Research and Education in Alcoholism and Drug Abuse in 1972, with Dr. Arnold as its first Chairman. Education, especially continuing medical education, was a major interest of the Association in its earlier years. The Committee on Education was an active one. In the 1960s, the universities developed divisions of continuing medical education which took over most of the direction of continuing medical education programs. There was less emphasis on the scientific side of medicine at AMA Annual Meetings. In the meantime, the Council of the College was asserting itself much more strongly in the fields of undergraduate and post-graduate education. After a study, the AMA Board concluded that the most integrated and efficient approach would be to have the College take on responsibility for whatever role the profession's organizations played 260 in continuing medical education and other aspects of medical education. The College Council established a Committee on Professional Education to which the AMA could name two representatives. In 1973, the Board suspended the activities of its Committee on Education. Liaison with the CMA Council on Medical Education was maintained by ensuring that the AMA representative to the CMA Council was also an AMA representative to the College Committee. With the advent of Medicare and one "paymaster", it became apparent to both the Board of the Association and the Council of the College that a mechanism for peer review would have to be established. The Health Care Plan was capable of providing a wide variety of data on the patterns of practice and the billing habits of physicians , but peer review should not become a function of the government agency. After consultation with the experienced organizations of the profession in Saskatchewan, it was decided that the Association would undertake professional review on behalf of the profession in Alberta, largely because the process was considered educational and not disciplinary. The By-Laws were accordingly amended in 1971, and the first Professional Review Committee, under the Chairmanship of Dr. P.W. Davey, began its work. The Plan's computer would provide data which the Committee would review on a regular basis. The Committee designed a profile; a physician's profile would be flagged if it varied more than two standard deviations from the norm in one or more of several parameters determined by the Committee. The work of the Committee was challenged on the basis that it lacked the legal authority to obtain and review billing data. At the urging of the Association, the Alberta Health Care Insurance Act was amended in 1972 to make provision for the various associations of the professions affected to undertake professional review; the AMA was designated to act on behalf 261 of the medical profession. Once again, the AMA was recognized as the body acting for medicine in a particular area. By a referendum conducted in 1974, the profession confirmed that it wished the AMA to continue its work in this field. After 1972, the Committee refined its processes and, as well as routinely reviewing profiles, it conducted special studies which gave greater insights into the patterns of practice of physicians. The fact that the Committee rarely had to recommend remedial action, such as the prorating of claims, illustrated its effectiveness in ensuring that most physicians regularly utilized the Schedule of Benefits in the intended way. The change in the role of the Association brought a change in the range, character and dimensions of subjects dealt with by the Association. The general meetings took on a new complexity and intensity. The President had great responsibilities, and it was difficult for him to give his various duties the attention that they deserved and chair these meetings as well. It was important that he contribute to the discussions without feeling fettered in his role as chairman. It was agreed that there should be a Speaker and a Deputy Speaker to chair general meetings of the Association. The appropriate amendment was made to the By-Laws in 1972. After that, the holders of the offices of Speaker and Deputy Speaker conducted the general meetings with finesse and dispatch, to the benefit of all concerned. Public Relations/Communications The Association's "father" of public relations was Dr. C.J. Varvis. Dr. Varvis was the Chairman of Public Relations at the time that the AMA took on its expanded role in 1969; he was Chairman of the Committee on Public Relations during his term as President-elect in 1970- 262 71. Dr. Varvis was able to impress the importance of good pubLic relations on the Board of Directors. To begin with, Dr. Varvis initiated a formal consulting relationship between the AMA and an advertising and public relations firm; this achieved wide contact between Dr. Yarvis and the media during his President-elect's Tour of 1971. Quite clearly Dr. Varvis put the AMA "on the map" as far as the public and the media were concerned; the AMA was established as Alberta's voice of organized medicine. Dr. Vanis strengthened this position during his term as President, acting as a credible and articulate spokesman for the profession. Dr. Robert E. Hatfield also served as Chairman of the Committe.: on Public Relations during his term as President-elect in 1974-75. Dr. Hatfield was very conscious of communication, especially with the Association's membership, and did much to improve this process. It was recognized that the Albena Medical Bulletin, the journal published by the AMA on a quarterly basis, could not meet all the communication needs of the Association; there must be a means to communicate important information to the membership quickly and easily. A four-page tabloid, Dok Tok, was developed for this purpose. Dr. Hatfield served as its editor. Dok Tok served its purpose from 1974 to 1976. With the experience obtained through the publication of Dok Tok, the need for continuing the Albena Medical Bulletin was questioned. At that time the Association was publishing the President's Letter, which was an effective vehicle for conveying information of considerable importance to the profession on short notice, together with Dok Tok with its function as described above, and the Bulletin; notices of meetings and the like were also sent to members under the Association's letterhead. It was felt that the Association's publications should be consolidated in a monthly journal which would serve the essential 263 functions of both Dok Tok and the Bulletin. The first issue of the Albena Doctors' Digest appeared in September 1976; the first editor was Dr. R.E. Hatfield . In 1977, an ad hoc committee of Dr. David W. Irving, then President-elect, and Dr. Hatfield concluded that the Association would be better served if its Committee on Public Relations were made up of members at large like other standing committees, rather than Board members chaired by the President-elect. As a result, a revamped Committee began its work in the fall of 1977, with Dr. R.N. MacDonald as Chairman. Under Dr. Macdonald's effective leadership the Committee developed a blueprint for the Association's communications with the profession, the public and governments, which could serve as a model for years to come. In 1978, the name of the Committee was changed by an amendment to the By-Laws to the "Committee on Communications", and the Board authorized the engagement of a full-time Coordinator of Communications. In 1979-80, the Committee conducted a relatively intensive public relations - advertising program using the theme "Let's Talk" to inform the public, the media and the government on issues of common concern. The program was underwritten by a special grant from the Board and a voluntary levy from the profession. While it is difficult to measure the impact of such a campaign, most would agree that it raised the profession's profile and made the public more aware of the Association's attitude on various subjects. It also provided valuable experience to the Association which would be of assistance in future ventures. 264 Schedule of Benefits Negotiations No one drafting a Constitution and By-Laws in the late 1960s could have predicted the magnitude of the effects that Medicare would have on the profession and the Association and the depths of feelings that members would have about government involvement in the system and the Association's relations with the government. The AMA assumed responsibility for economics m the fall of 1969. Medicare had been introduced in Alberta a few months earli er, on July 1, 1969. While Medicare justified a special meeting of the Association in Red Deer on July 9, 1969, the profession entered the new era peacefully. The Alberta Health Care In surance Act made provision for the establishment of a government-administered, comprehensive, compulsory, universal insurance program for basic health services including all medically-required services. All Albertans were eligible for coverage on registration. Premiums were charged; those who couldn't pay them had all or part of the cost paid by the government. Tne Alberta Health Care Insurance Commission was established under the legislation to administer the program. The profession's organizations were asked to name a representative to the Commission and did so. The government adopted the profession's Schedule of Fees as its Schedule of Benefits and paid for services at a level equivalent to 100 percent of the profession's 1968 Schedule or 93.5 percent of the 1969 Schedule. The provi der of service retained his right to have a financial arrangement with his patient; he could bill the patient, the Plan or both except that he must have the agreement of the patient before serv ice was rendered if his charge exceeded the benefit 265 payable by the Plan. Unfortunately, the advent of the Alberta Health Care Insurance Plan saw the demise of all carriers of basic health insurance including Medical Services (Alberta) Incorporated -- MS(A)I. The residual funds of MS(A)I were transferred to the Medical Services Research Foundation of Alberta, which was established by statute for the purpose of funding research on the delivery of health services or such other health research as its board deemed worthy. A relative handful of physicians stayed out of Medicare. They billed their patients directly and a group of physicians in Calgary even established a billing agency to facilitate their collections; their patients had to seek reimbursement from the Commission. The government found the billin.g of patients irksome. For this and possibly other reasons, the government offered to pay physicians 100 percent of the current (1969) Schedule effective July 1, 1970. The profession accepted the offer. Shortly afterward, most physicians who had tried to remain independent from the Plan found that it was more practical to bill the Commission directly, and within a year or two virtually all physicians had "opted in". There was a "honeymoon" period. The Plan had some difficulties in processing accounts but these did not cause any major hardships. The incomes of physicians increased significantly in 1970, the first full year of operation of the Plan; services previously provided free were now being paid for, and services provided to pensioners and welfare recipients which had been paid for at 50 percent plus were now being paid for at 100 percent. Physicians were receiving what they were entitled to. There was an increase in utilization of physicians' services but the 266 increase was not dramatic because most Albertans had some form of coverage for medical services before Medicare was introduced. On examining the incomes of ph ysicians in retrospect, the increase in income of physicians from 1969 to 1971 was only marginally greater than that for the public as a whole. Honeymoons always end and the profession was to pay dearly for this period of "pleasures" in the years to come. In an inflationary environment in which the Government of Canada urged the public to show restraint, the profession did not in 1971 or 1972 press the issue of appropriate Schedule adjustments and accepted the status quo (unfonunately, most of the rest of society did not) . In 1973, the Association felt that an increase in the Schedule of Benefits was needed. Representatives of the Association met with the Priorities Committee of the Cabinet of the fledgling Conservative government. Shortly after, negotiations began. The AMA team was led by the President, Dr. James Oshiro; the government team was led by Dr. Graham Clarkson, who was a special consultant to the government and a past Deputy Minster of Health, first for Saskatchewan and later for New Brunswick. The agreement concluded by the Executive Committee on behalf of the Board allowed for a 4 percent increase on October 1, 1973, and a second 4 percent increase on October 1, 1974; the agreement was for a 27-month period ending on December 31, 1975. The agreement was not well received by the membership. There was a long and bitter in-camera meeting at the Annual Meeting in Calgary in 1973. Among other things, the meeting demanded that the Board appoint a Negotiating Committee from the members at large; the Committee was 267 to be provided with whatever assistance and resources that it required. After the Annual Meeting, the Committee consisting of five members was appointed; the first chairman was Dr. R.H. Wensel. In May of 1974, in recognition of a growing need, made much more acute by the negotiations of 1973, the Association retained the full-time services of a Master of Business Administration, with a background in labour relations and statistics to serve as Coordinator, Economics and Administrative Services. Feelings were running so strong that a special meeting was called for January 9, 1974 in Red Deer, at which an amendment to the By-Laws to require referenda for the ratification of agreements with the government was introduced, as was an amendment to allow the Board to conduct referenda on various issues of significance. Even though this meeting was held some three and one-half months after the Annual Meeting, the issue still generated much passion. The meeting decided that a two-thirds majority of those voting in a referendum would be required to ratify any agreement with the government or other agencies relating to benefits for physicians' services. Members felt that the Association must state categorically that it was the intention of the profession to protect the doctor-patient relationship. The following object was added to the Constitution: "the .continuation of the traditional unwritten contract between the medical practitioners and any member of the public and the protection of the principle of this contract from any third party interference." In 1975, cooler heads prevailed. It was clear to most that a minority of members should not have control over the financial destiny of the majority; a successful amendment to the By-Laws 268 required that only a majority of members be needed to ratify an agreement. The fate of the profession, at least in regard to the benefits paid under Medicare for physicians' services and related matters, was largely in the hands of individual members. In 1973, the AMA team had been at a considerable disadvantage. There were basically only two kinds of data available -- net income data from National Health and Welfare, the basis of which could never be clearly determined and which was nearly two years out of date, and gross payment data from the Plan ..,,,,. hich did not give any indication of physicians' overhead. The National Health and Welfare data plared Alberta physicians at the top of the heap in Canada, a difficult position to bargain from. The negotiations and their aftermath were very painful, but the Association never again entered negotiations unprepared. Inflation became pronounced at just about the time the 1973 negotiations were concluded. In late 1974 the government was convinced by the Association that matters were serious and that an interim adjustment was necessary to tide the profession over until the end of the existing agreement, December 31, 1975. In its maiden effort, the new Negotiating Committee, led by Dr. Ronald H. Wensel. extracted an offer of 6.2 percent, to be effective March 1, 1975, from the government side. The offer was put to the profession by referendum, the first, and accepted by the then-req_uired two-thirds majority. From the negotiations of 1973 it was very apparent that the Association lacked good, up-to-date economic data to support its position at the bargaining table. In 1975, the Association 269 commissioned Price Waterhouse and Company to undertake an income survey of the profession. Following a good response, the data received was deemed statistically valid. The Association's negotiating team, from that point on, was able to go to the bargaining table better armed with data than any of its counterparts in Canada; other divisions of the CMA were to follow the Alberta example. While the government would continue to hold the "balance of power", the AMA was able to negotiate with greater strength. The Association continued the income surveys on an annual basis; the overhead data obtained continued to be most valuable. To provide the Negotiating Committee with a further dimension of assistance and additional expertise, the Association retained the services of Mr. Ross McBain , a senior lawyer with considerable experience in the industrial relations field. Mr. McBain worked with the Committee from its beginning and helped the Committee to understand the legal and tactical nuances of bargaining. The Committee operated under several disadvantages. The Association had no direct, formal recognition in legislation to bargain on behalf of the profession. The Alberta Labor Act specifically forbade · groups representing the medical profession from being certified as bargaining units. No recognition was provided under the Alberta Health Care Insurance Act; in fact the original Act of 1969 provided for an agreement between the government and the College for an index to be used in adjusting the Plan's Schedule of Benefits. The Association asked the government to amend the Act so that the Association \l{Ould be formally recognized in statute as the organization which would represent the profession in relation to matters 270 affecting the rate of payment for physicians' services. In 1977, the Act was amended to remove reference to the College but no reference was made to the Association. The Act made provision for the Minister to appoint a Benefits Review Committee which "may" consult with representatives of an association of persons who provide the services concerned. The Act did not outline details of the consultation process. The AMA was not able to attain recognition by agreement. It gained a small foothold when the Honorable Gordon Miniely, Minister of Hospitals and Medical Care, indicated in a letter dated October 21, 1977, that he recognized the AMA as the body representing the Association for financial matters and that he agreed that th e annual review of the Schedule of Benefits should be carried on with the AMA. The letter did not bi nd as much as legislation or even an agreement would have. As well , the Committee had little clout. It did not have access to the various means of resolving disputes, such as mediation and arbitration, provided to other "bargaining units" by statute. Most forms of graded response which could be considered only served to "hurt" the public. The majority of the profession was very reluctant to consider withdrawal of services after the bitter experience of Saskatchewan of 1962. In any case, while the practising physician had the right to deal directly with his/her patient, a strike was not a realistic alternative. The Committee's most effective bargaining tool was balance billing. The government's concern was that balance billing be kept at a relatively low level; the Committee could use this to achieve better settlements for the profession. Also of assistance to the Committee were briefs presented to the Cabinet and the Priorities Committee of Cabinet, public relations activities and campaigns, 271 presentations to the media, approaches to MT.As hy the Association, District Societies and individual physicians, and some degree of public support. The Committee's most effective weapon would have been the full and unreserved support of the profession. The Committee was never certain that it had such support or that it could be attained. Through the years of negotiating with the government it became clear to most -- the Negotiating Committee, the Board of Directors, and many members -- that collective bargaining in the generally understood sense was not occurring. It was felt that the Minister or the Cabinet established a maximum figure that the government team could offer at the bargaining table; the task for the AMA Committee was to extract that maximum. The view expressed was: if the Association is not negotiating, why name the AMA Committee the "Negotiating Committee"? The Alberta Health Care Insurance Act referred to a review of the Schedule of Benefits. Therefore, the name of the Committee was changed by the Board of Directors to the "Corn mittee to Review the Schedule of Benefits" in 1979. The first full-fledged negotiations between the government and the AMA were scheduled for the fall of 1975. There was a new Minister, the Honorable Gordon Miniely, and a new Chairman of the Commission, Dr. B.M. ~facLeod, who had previously served as the Medical Officer for the Plan. Dr. MacLeod led the government team. The results were not what the Association and its members hoped for. The Association's Committee prepared a comprehensive position paper which documented that the profession was entitled to a well-deserved catch-up increase in the order of 35 percent. Government was not prepared to entertain such a possibility. Its 272 final offer was a mere 8 percent! The Negotiating Committee reported to a shocked Board of Directors on the day before the 1975 Annual Meeting. The Board agreed to recommend to the members that the government offer be rejected. A hastily called closed meeting was arranged for the last morning of the Annual Meeting; 300 members attended. When the facts had been presented, and after a heated discussion, those present voted overwhelmingly to reject the government offer and recommend to the membership that they "opt out" of Medicare and bill patients directly. The Minister was scheduled to address the noon luncheon on the same day, which he did. The new President-elect, Dr. Bryce Weir, on behalf of those present, thanked the Minister for attending and speaking to the gathering and then indicated to him that Alberta physicians were not "lambs to be led to slaughter" . The conclusion reached at the Annual Meeting was conveyed to all members. There was an impasse. On Thanksgiving Day of 1975 the Prime Minister, the Right Honorable Pierre E. Trudeau, announced to Canadians that anti inflation controls would be introduced effective January 1, 1976. The government and the Association were both saved. The Minister agreed to enter negotiations once again and also agreed to give the profession the maximum p<:>ssible under the anti-inflation guidelines: an overhead pass-through and an average increase in net income of $2,400 per annum. An increase of 9 percent, effective January 1, 1976, was accepted by the profession. The anti-inflation controls were in effect until December 31, 1978. Increases of 7 percent and 6.5 percent were negotiated for January I, 1977 and January 1, 1978 respectively. Under the 273 anti-inflation controls the data from the Price Waterhouse income survey was most valuable to the Association in obtaining a reasonable increase for physicians for overhead. During these years the Association outperformed all the other divisions of CMA in terms of dollar increases obtained for members. It was nevertheless apparent to the Board of Directors that the economic position of Alberta physicians had deteriorated dramatically in the years prior to and during the anti-inflation controls. The Board agreed that it must take whatever steps possible to remedy the situation. The Association asked for an audience with the Priorities Committee of the Cabinet. A meeting with a committee of Cabinet was arranged for June 29, 1978; the Premier attended the meeting. The AMA representatives made a strong case for the profession. In its brief the AMA made the following points. Total Medicare costs represented 1.22 percent of GDP in 1970 and 0. 73 percent in 1976, a fall of 40 percent; since 1971, the average annual rate of increase in per capita Medicare costs in Albert.a had been approximately one-third lower than the average for Canada. Increases in per capita Medicare costs in Alberta since 1970 (6.3 percent annual average) had not kept pace with several basic economic indicators. In the same period, the Consumer Price Index rose at a 6.9 percent annual rate; average weekly wages and salaries averaged 10.9 percent annual increases; and the Gross Domestic Product increase averaged 17.2 percent per year. 274 Turning to the doctors' own situations from 1970 to 1977, while average gross AHCIC payments increased at an average annual rate of only 6.1 percent, overhead expenses had increased altogether by 73 percent. In that period, therefore, the increase in average annual net payments was 4.9 percent whiie the average annual increase in average weekly wages and salaries was 10.9 percent. The critical factor was what had happened to real net AHCIC payments -- these fell by 15.4 percent in the seven-year period, which meant that physicians could purchase 15.4 percent less with their net income in 1977 than they could in 1970 while, in the meantime, real average weekly wages and salaries had increased 28 . 1 percent. The Cabinet Committee was sympathetic but raised the following points. Per capita health care costs in Alberta remained the highest in Ca.n ada, and it was not necessarily appropriate that health take a constant share of GDP. The iss ue boiled down to what physicians should earn in relation to the rest of society , a very difficulty judgement for anyone to make. The provincial government replaced the an ti-inflation controls with its own "guidelines" for increases in wages and salaries. The Associati on's representations did not have much effect, for the government expected the medical profession to stay within the guidelines. For January 1, 1979 the Association was only able to achieve an increase of 7.88 percent to the Schedule of Benefits. It was becoming increasingly apparent that the profession's hopes for a "catch-up" were not going to materialize. 275 Recognizing that the profession was not likely to attain justice at the bargaining table, the Board considered the alternatives. It was apparent that the profession was likely to turn to balance billing, especially when the anti-inflation controls ended, in order to achieve fair remuneration for services rendered. In anticipation of this, the Association initiated a program of in formation for the public and the media in the fall of 1978. The response from the media and pro-Medicare groups was, on the whole, very negative and very emotional. The Association was accused of using the threat of balance billing as a lever to obtain a better deal at the bargaining table. There were charges that the AMA was trying to undermine or destroy the government-operated medical insurance program. The President and other Officers of the Association were inundated with enquiries and statements of protest, and re{juests from the media for . comments and interviews. The reaction was so intense that the Association had to publish an open letter in all the newspapers in Alberta in February of 1979 to explains its position. The settlement for 1979 had hardly been implemented when the Minister started to make statements to the effect that if balance billing wasn't controlled, legislation would be amended to affect the right of physicians to balance bill. Statistics released by the government for balance billing in January 1979 showed that only 7.7 percent of services were balance billed, the average amount balance billed was only $5 .38, and the total amount balance billed represented only 3.3 percent of total AHCIP payments for insured services. There was no indication that balance billing was affecting access to medical care or that anyone was being denied care because of an inability to pay. The physicians of 276 Alberta were using the right to balance bill with discretion and in moderation. The statistics did not cool the zealots but only inflamed them more. There was a provincial election in the spring of 1979. David J. Russell was appointed to the office of Minister of Hospitals and Medical Care. In April 1979, shortly after taking office, the new government appointed a special Caucus Task Force to study balance or extra billing and make recommendations. The Association presented a brief to the Task Force in the spring of 1979. Naturally, the Association defended balance billing and warned that removal of this right would have far reaching effects on the delivery of medical care. The report of the Task Force was not made public but its influence on the government became apparent in two or three ways. The Minister issued a directive that physicians report balance billing on all claims (even if only the number "O" were inserted); failure to report would mean no payment of the claim. The threat to legislate balance billing away was repeated on many occasions. The government changed its attitude about increases to the Schedule of Benefits; this was to become apparent in the negotiations for an increase for 1980. During the 1970s, structural changes in the government bureaucracy occurred which were to affect physicians and, to some extent, the "politics" of health care delivery. The Conservative government had never had any affection for commissions or other Crown agencies which operated at a distance from the political process. The government had the view that if it had to take responsibility in an area of activity, then it must have full authority in that area, especially if the activity had a relatively high political profile. The Department of Hospitals and Medical 277 Care was formed in 1975. The Minister of the Department had had responsibility for the Alberta Hospital Services Commission and the Alberta Health Care Insurance Commission, two relatively autonomous bodies. From the time the new Minister, Gordon Miniely, took office, the writing was on the wall for the two Commissions, especially the AHSC. The AHSC was dissolved effective December 31, 1977, its operations were absorbed i..nto the Department, and Gary Chatfield, formerly of the Ontario Ministry of Health, became Deputy Minister. The Health Care Commission had to follow and it was dissolved on April 1, 1978. The former Chairman of the Commission, Dr. B.M. MacLeod, became Deputy Minister for the Plan. In May 1979, Dr. MacLeod resigned as Deputy Minister for personal reasons. Shortly afterward, G.J. Chatfield became the only Deputy Minister for the Department. Mr. Chatfield headed the government's negotiating team in the discussions for an increase to the 1980 Schedule of Benefits. He was joined by the Deputy Minister of Labour, the Assistant Deputy Minister of the Treasury, and support staff. When he came to the bargaining table, Mr. Chatfield stated that he had full authority to negotiate a settlement and he had not been given an upper limit on the offer that he could make. It was a breath of fresh air. After very fair and open bargaining, the ·government made a final offer of a 15.5 percent increase (14.1 percent as a general increase and 1.4 percent for a number of rule changes that the profession had wanted for some time). For the first time the profession had received an increase which did not erode the economic position of the practising physician. 278 Again, the increase had barely been implemented when there were renewed threats from the Minister that he would take action on balance billing if it wasn't controlled. The government published monthly statistics on balance (extra) billing. The statistics varied little: about 38 percent of the profession balance billed; less than 8 percent of services were balance billed; balance billing represented less than 4 percent of total payments. In the meantime, there was growing unrest within the profession across Canada, especially in Saskatchewan and Ontario. The number of physicians who had opted out of Medicare in Ontario was hovering between 15 and 20 percent. More physicians in Saskatchewan were using the mode 3 option: billing the patient. At least one province had introduced user charges in its hospital system. There was a growing clamour amongst the labour movement, the NDP and other pro-Medicare groups, that Medicare was being seriously threatened. The Minister of National Health and Welfare in the short-lived Conservative government, the Honourable David Crombie, ordered a review of the health insurance system; he appointed the "father of Medicare", Mr. Justice Emmett Hall, to undertake the review. Mr. Hall agreed to receive briefs from all interested parties at locations across the country. His review was interrupted by the campaign for the federal election of February 1980. A wide variety of groups presented briefs to Mr. Hall. The CMA and all its divisions, except Quebec, made presentations to Mr. Hall. The AMA presented a brief to Mr. Hall on April 14, 1980. A common thread in all briefs from the profession was that the costs of health care were not escalating unduly. In fact, health care was underfunded, and it was this underfunding which was 279 creating most of the difficulties. The AMA emphasized that Medicare must be operated according to sound insurance principles. The Association recommended that an insurance program be maintained through which the recipients of health care could insure themselves against the costs of basic health services, that insurance principles be observed in the operation of the program, that the contract for insurance be between the carrier and the receiver of service, that the insurance benefits provided by the carrier be negotiated between the carrier and its subscribers, and that insurance benefits be paid to the recipient of service, or to the provider of service if so directed by the recipient. The AMA indicated that if the profession was to be pressured to accept the benefit paid by the Plan as payment in full, then the public must recognize that the position of the profession would change. In order to safeguard medical care, the profession would be forced to reassess its traditional ethics and evolve into a more union-like position from which confrontations would be resolved by strikes. Mr. Hall reported in August 1980. He confirmed that the health care system was underfunded. For medical care he recommended that direct charges to the recipients of services be ended on the condition that there be compulsory arbitration to settle the differences of governments and the profession in relation to payments for medical services; Mr. Hall's report was debated at length at the meeting of CMA General Council in September of 1980. A formal response to the report was endorsed by an overwhelming majority. It was clearly indicated in the CMA response that if Mr. Hall's recommendations were adopted, the practising physician would become a dependent contractor to government or a de facto "civil 280 servant", which the profession could not and would not accept. Those present at the Annual Meeting of the Alberta Medical Association in October accepted the CMA response to the Hall report. The Minister of Hospitals and Medical Care, the Honourable David Russell, quickly accepted Mr. Hall's version of arbitration. None of the ministers in the other provinces accepted this recommendation. The new Minister of National Health and Welfare, the Honourable Monique Begin, was left with a major problem: how to eliminate direct charges for services and protect the profession from unfair treatment at the hands of the provincial governments. The CMA offered the federal Minister the advice that she should take steps to correct the funding shortfall; ifs.he did so, most of the problems that were of concern would be alleviated. In the meantime, all was not quiet on the balance billing front in Alberta. The Minister, the Honourable David Russell, continued to threaten that legislation would be introduced to affect the right of physicians in Alberta to balance bill. He indicated that the approach he was most likely to take would result in a situation which left the Alberta physician in a position similar to that of his counterpart in Ontario: if an Alberta physician wished to direct any charge to any patient he would have to opt out of the system and bill all his patients directly for the full amount of his fee. The dreaded legislation was expected to be introduced during the spring 1980 session of the Legislature. 281 Interested parties were not idle. The Friends of Medicare, which included the NDP, the Alberta. Federation of Labour, the Alberta. Teachers Association, and several other groups, presented a petition containing over 50,000 names to the Minister, demanding that balance billing be ended. Elements of the media took a similar view. The Association conducted its "Let's Talk" public relations campaign through the summer of 1979 and into 1980. Individual physicians and District Medical Societies met with their MLAs and contLTiued to press the profession's case. A large group of physicians attended the convention of the Progressive Conservative Party of Alberta. held in Edmonton in the spring of 1980 and participated in a lively session on balance billing; a large element of the party was sympathetic to the profession. The AMA initiated a postcard petition campaign and over 5 ,000 Albertans sent cards to the Minister demonstrating their support of physicians. There were signs that at least some in the media were becoming sympathetic to the profession. In an editorial in its April 11, 1980 issue, the Edmomon Journal preferred balance billing to forcing physicians to opt out. Late in the spring session of the Legislature, the Minister announced that he was delaying legislation until the fall; he wanted to accumulate more data on the extent of balance billing and he wanted to give the profession another chance. The profession's organizations, both the College and the AMA, continued to reiterate to the Minister that forcing physicians to opt out would be worse for the system: it would increase costs and be inconvenient to all parties concerned -- patient, physician and government. There was no evidence that balance billing was affecting access to care or creating hardship. If there were cases of abuse of balance billing, each case should be dealt with on an individual basis; 282 the whole profession should not be punished for the "indiscretions" of a few. Data was gathered by the Ministry for the Party Caucus which showed that about 100 physicians were responsible for almost one-half of the balance billing that was occurring. This information had a significant effect on a caucus which was softening in its attitude to balance billing. A compromise was achieved. The Minister introduced legislation to the fall session of the Legislature to amend the Alberta Health Care Insurance Act and allow the College to establish a five-member committee to review cases of what might be inappropriate balance billing; the Committee would be the final arbiter in these cases. The Committee of five persons -- three physicians and two non-physicians -- was established on January 1, 1981. The Patient Services Bureau, which the Association had established one and one-half years earlier to handle balance billing complaints, and which had formally dealt with some 50 cases, was disbanded. The profession had been given more time. Discussions for an increase to the 1981 Schedule of Benefits began in September 1980. The Association was represented by its Committee to Review the Schedule of Benefits. Gary Chatfield had resigned as Deputy Minister in the summer of 1980 to return to Ontario, so the government's team was led by K. G. Moore, Assistant Deputy Minister responsible for the Plan, and included the Deputy Minister of Labour and an official of the Treasury once again. Discussions were interrupted for a three to four week period to await the Minister's legislation. When it was tabled they continued. While the Association clearly documented the need for an increase of 31. 3 percent to match the Schedule's real (corrected for inflation) value of 1970, the 283 government made a final offer for a 12.5 percent increase, determined that any increase in net benefits would not exceed government guidelines for wage and salary increases in the public sector. The government offer would have allowed for a 10.4 percent increase in net payments and a 15 percent increase in overhead. The conclusion of Mr. Justice Emmett Hall that the system was being underfunded had not seemed to alter the attitude of the government in any substantial way. After reviewing it on December 3, 1980, the Board sent the government offer out to referendum with the recommendation that it be rejected; it was rejected by 60 percent of those voting. Discussions were resumed in January 1981. The government offered an increase of 15.4 percent to be .effective March 1, 1981. If implemented, this offer would increase gross payments from the 1980 level by 12.8 percent; in effect, the offer was only 0.3 percent higher than that rejected earlier. Further, the base used for the application of any settlement in 1982 would be adjusted so that it would be the same as that which would have resulted from a 12.8 percent increase effective January 1, 1981. The AMA team gained the clear impression that there would be no increase if this offer was turned down by AMA members. The Board sent the offer out to referendum indicating to the membership that the Board had accepted it on the basis that it was the best offer that could be obtained. The referendum was counted on February 16, 1981: 77.4 percent of those voting accepted the offer. Once again, the increase to the Schedule would result in an erosion of physicians' purchasing power. Prospects for the 1980s 284 While economics appeared to be a major preoccupation of the profession and the Association in the Medicare era, the AMA continued good work in many other areas. The standing committees, for example, continued to be active and productive. An outstanding achievement for the AMA and the profession as a whole was the International Medical Symposium held in Edmonton on September 22, 23 and 24, 1980. The Symposium was organized as a most fitting way to celebrate the 75th Anniversary of the Association, the College and the province. It was spearheaded by the AMA and sponsored by the Association, the College, and the Faculties of Medicine of the University of Alberta and the University of Calgary; it was hosted by the Edmonton Academy. Essential financial support came from the Government of Alberta, the City of Edmonton, the two Faculties of Medicine, the Calgary Medical Society, the Medical Services Research Foundation of Alberta, the Alberta Heritage Foundation for Medical Research, and several other companies, foundations and charitable organizations. Dr. R.K.C. Thomson, an esteemed Past-President of the Canadian Medical Association and the AMA, served as the Chief Executive Officer for the Symposium, which was an unqualified scientific and organizational success, the most outstanding event of its kind ever organized by the profession in Alberta. Delegates heard speakers from three continents and four countries address subjects in two areas: "Immunology in its Clinical Approach" and "Health Care Delivery in the Next Decade". Speakers for the social events included Premier Peter Ll:lugheed; the Minister of Hospitals and Medical Care, David Russell; Edmonton Mayor Cec Purves; and the Parliamentary Secretary to the Minister of National Health and Welfare, David Weatherhead. The Symposium demonstrated to Albertans and people across the world that the medical profession in this province "care about health care". 285 In 1980 the Board of Directors commissioned a consult.ant, expert in surveys and statistical analysis, to conduct a survey of the views of all physicians in the province on several aspects of the Association's activities. The keystone question was: "On balance, to what extent do you feel satisfied with the AMA's performance in serving the welfare of Alberta's physicians?" The survey was conducted in July 1980 and the results were available to the Board and the Committee on Communications in the late summer. The members perceived that the AMA lacked credibility with the government in terms of the failure of increases ~o the Schedule of Benefits to address the deteriorating economic position of the profession. The members concluded that the AMA was relatively ineffective in negotiating increases to the Schedule of Benefits. They wished to have greater influence on decisions made by the AMA on their behalf, a more representative Board of Directors, and generally better response to the needs of the membership. While they feared that Albert.a physicians' economic positions would continue to deteriorate, and that their balance billing rights would be removed, they wanted the AMA to take on a less union-like posture and develop more effective communications with the public and the government. Although the members expressed satisfaction with the quality of the Association's elected officers and appointed officials, with its efforts to protect their professional freedom and, on balance, with its contribution to their ability to practice medicine effectively, they urged more clear-cut goals and objectives. Although they were generally satisfied with the AMA's organization work, especially in keeping members informed on issues affecting them, in the work of the standing committees, and in the program of membership benefits, they were clearly concerned about the Association's limited impact on financial dealings with the government. 286 In sum, the Association's future seemed to depend on how effectively it handled the profession's political-economic affairs and how well it provided for, and was influenced by, the expression of views of individual members. There was an historical context for this. Generally speaking, the profession welcomed the participation of the third party in the doctor-patient relationship with the advent of MS(A)I and other private carriers. It accepted and then tolerated the government acting as the third party, despite the relative misfortune it brought to the practising physician and the negative effects government involvement can have on the health care delivery system. The situation that physicians found themselves in at the beginning of the 1980s could have been very much different if, relatively early, they had recognized the dangers of dealing directly with government instead of their patients. However, they acknowledged and enjoyed the security of receiving the regular cheques from the government "paymaster" . The effectiveness of an organization like the AMA depends on the support of its members. To change direction, the AMA would need a clear-cut indication from its members that they would be willing to return to the practice of dealing directly with their patients. If they expected their organization to protect their individual interests without being prepared to assert their independence and make significant sacrifices in the process, they would only receive what they deserved. They themselves could be identified as the basic cause for the profession's failure to achieve economic justice, not the organization to which they would not provide the support vital to success. 287 The College of Familv Practice Author Unidentified This organization has been an important factor in the elevation of the status of the general practitioner and in the quality of his or her work. The College was formed in 1954 with the first national meeting in Toronto. The five objectives were: to attempt, through study, to define the terms "general practitioner" or "general physician" on a functional basis; to survey medical training for general practice at both the undergraduate and graduate levels; to assist in returning the place and status of the general practitioner in the large general and university hospitals consistent with the ideals of practice, education, and hospital care; to advance medical science, and private and public health, by encouraging clinical research by general physicians; and to encourage and assist young men and women to qualify themselves to set up in general practice. Largely due to the work of Dr. Pat Rose of Edmonton, with considerable help and encouragement from Dr. W.C. MacKenzie, Dean of Medicine at the University of Alberta, a chapter was organized in Alberta. Its first meeting, the first one of a provincial chapter in Canada, was held in ·Red Deer in 1955. Dr. Murray Stocker, of Ormiston, Quebec, a founder of the College, was present. Attendance at the meeting was good and the excellent scientific program was matched by the success of the social events and the Ladies' program. Dr. William Eadie was elected first president of the Alberta Chapter. Dr. Rose became a national officer and in 1958-59 was National President. 288 The College of General Practice continued to be successful. The annual meetings of the Alberta Chapter had excellent scientific programs and were well attended. The venue for several years was Banff, but it was later transferred to Edmonton in alternate years. Dr. Walter MacKenzie was very helpful in the development of educational programs. An early decision of the College was to award Certificates in Family Practice to whose who had proved their competence by examination. The development of evaluation techniques was the result of intensive study by two Alberta physicians, Dr. John B. Corley of Calgary, and Dr. J. Alan Gilbert, an internist who became a professor at the University of Alberta. Dr. Gilbert's interest was manifest in his statement that "family practice represents the guts of medicine." Financial help for the project came from the Alberta Government, which paid for a 6-week course in evaluation techniques for Dr. Corley at the University of Illinois. The first examinations for certification were held in Hamilton, Ontario in 1969 with Dr. Corley as Chief Examiner. Coincident with his work on evaluation, Dr. Corley headed a 3-year residency program at the Calgary General Hospital to train young medical graduates specifically to become truly competent family physicians. This program was initially funded by a grant of $150,000 from the federal government. At the end of the three years, Dr. Corley was honoured with a banquet in 1969. Awards were presented by Dr. John Zack, President-elect of the College of Family Practice, Dr. J. Donovan Ross, Alberta's Minister of Health, and other dignitaries in the field 289 of medicine. He was further honoured that year by the College as recipient of the W. Victor Johnston Oration at the annual meeting. Dr. Corley went on to become professor and Chief of the division of evaluation in the Department of Family Practice at the University of South Carolina. In 1967 the name of the College was changed to the College of Family Physicians. Its ideals remained the same: to continue to train family physicians at all levels to ensure that the family doctor is at all times responsive to the needs of a changing society. The College also acknowledged the need and the wisdom of maintaining close and cooperative liaison with all members of the health community and hoped to pursue vigorously programs designed to strengthen unity within the medical profession. 290 The Alberta Thoracic Societv Author Unidentified This group was organized in Alberta at the suggestion of Dr. Wherrett, Executive Secretary of the Canadian Tuberculosis Association, in the hope of developing an Alberta section of that organization; but throughout its life the local group remained independent. The Superintendents of the three sanatoriums, Dr. R.H. Stephens, Dr. Matt Matas and Dr. Les Mullen, discussed the proposal with their associated chest surgeons and with doctors interested in the chest, both at the University of Alberta and elsewhere. The response was enthusiastic. The Alberta Tuberculosis Association was asked if it would arrange for the initial meeting and defray the expenses. The ATA readily agreed to this on the basis of its educational value. The first meeting was held in Red Deer in March of 1957 with an attendance of 40 doctors. They drew up a constitution for an independent body, the Alberta Thoracic Society, with Dr. Stephens as President. The meeting 's social host was the Alberta Tuberculosis Association. The society held these Red Deer meetings for 20 years, always with the Alberta Tuberculosis Association acting as .host. The meetings were open to any doctors who wished to attend. Many from Calgary, Edmonton, Red Deer and intervening points did, and heard excellent programs and discussions, from both the medical and surgical points of view. About 1975, attendance by local doctors started falling off, so in 1977 the meetings were moved to Banff and their nature changed. The frequency of meetings was reduced to one per year and 291 each lasted all day Saturday and Sunday morning. The membership became almost entirely specialists whose chief interest was the chest. The Society became affiliated with the Canadian Thoracic Society and constituted a sub-division of the Internists' Section in the AMA Residents took a large part in the function of the Society, and the only financial part eventually left to the Alberta Tuberculosis Association was to supply transportation for the residents. 292 The Alpha Omega Alpha Honour Medical Societv D.R. Wilson The Alberta Chapter of the Alpha Omega Alpha Honour Society (AOA) originated at the Dibgy Pines Hotel in Nova Scotia in the early 1950s when Dr. Harold Orr, with two guest speakers, Dr. Walter MacKenzie and Dr. Donald R. Wilson, made his Presidential tour of the Maritime provinces on behalf of the Canadian Medical Association (CMA). During one sunny afternoon, the two guest speakers had the opportunity to spend a few leisure hours talking with Dr. T. C. Routley, Secretary General of the CMA, about a great many things that interested him during his time in office with the CMA. As the discussions went on, Dr. Routley turned to one of his pet hobbies - the development and expansion of AOA in all Canadian medical schools. At that time, the University of Alberta did not have a Chapter of AOA, although it had been discussed off and on informally and at Faculty Council meetings. When the two guest speakers from Alberta showed interest in this possibility, Dr. Routley in his usual energetic way went to work on it, and subsequently during one of his visits to Edmonton, the groundwork for the establishment of a chapter of AOA in Alberta was completed. AOA became a reality on November 27, 1958 at the installation banquet held in the Edmonton Club. Dr. E.P. Scarlett of Calgary, acting as Chairman, welcomed Dr. Walter L. Diering as the National President of AOA to present the charter to Dr. Walter Johns, the President of the University. Charter memberships in the Alberta Chapter were extended to the Dean of the Faculty of Medicine, the Assistant Dean and the Clinical Department Heads, along with a few 293 members of the part-time staff. Dr. P .M. Crockford, later a Professor of Medicine at the University of Alberta, the first President of the undergraduate Honour Medical Society, was inducted into AOA at this banquet along with Dr. R. W. Mallen , Dr. D. W. Fawcett and Dr. Lois Stayura. Faculty members from other chapters of AOA were present: Dr. W.S. Anderson and Dr. T.S. WilSDn of Ontario, Dr. A.W. Downs of Pennsylvania and Dr. S.T. Norvell of Illinois. At the first meeting of AOA held on February 23 at the home of Dr. W.C. MacKenzie, Dr. W.S. Anderson presented the framed charter of AOA to the President, Dr. P.M. Crockford. Dr. Bill Parsons of Ontario was invited to attend the first meeting but was unable to be present owing to conflicting engagements. In reviewing the papers presented by undergraduate medical students throughout the year, one cannot help but be impressed with the high quality of the presentations and the stimulating discussions which followed each individual presentation. The first scientific paper to be presented was entitled "Ionizing Radiation" and was given by Dr. Lawrence Harker, then an undergraduate student and later a prominent member of the faculty of medicine at the University of Washington, where he established himself as an acknowledged authority in the field of Clinical Hematology. Over the years, a number of distinguished physicians and surgeons throughout North America addressed the annual meetings of AOA , which were open to other members of the Faculty: 294 Dr. Owen Wangenstein [?] of the University of Minnesota, Dr. W.B. Bean of Iowa, Dr. Robert B. Howard of Minnesota, Dr. Eddie Rynearson from the Mayo Clinic - who incidentally was the first guest speaker - Dr. Bob Glaser, Dr. Brock Chisholm, Dr. Barry Pearce, Dr. Bob Williams and Dr. Don Graham. Dr. T.S. Wilson was the counsellor to the local chapter from its inception until September 1962, when he requested that a successor be appointed. Other distinguished speakers who also addressed the local chapter were: Dr. Carlton B. Chapman, the Dean of Dartmouth Medical School; Dr. Tom King from University of Utah; and, Dr. Eugene Stead, Professor of Medicine at Duke University. One of the early guest speakers in the late 1950s or early 1960s, Dr. Wendell McLeod, requested reimbursement of $38 to cover return airfare from Saskatoon to Edmonton. After about ten years of successful activity, interest in AOA began to wane, both from the student point of view and from the standpoint of attendance by the Faculty staff at regular meetings. This coincided with the period of student unrest which swept through all campuses in North America, indeed throughout the world. It finally culminated in six undergraduate students writing directly to the President of AOA requesting that the local Alberta Chapter be withdrawn from the organization on the grounds that they felt that elitism was being practised and that they objected to academic rank ordering as a means of consideration for election of undergraduate students to the society. In his reply, the President, Dr. John Z. Bowers, acknowledged with regret this letter from the undergraduate students and pointed out that they 1111111 1111 1111 11 11 11 1111 11111 11 1111111 111 11111111 111111 000094110293 295 were perfectly free to resign individually but that the policy of AOA as a whole did not permit the closure or withdrawal of chapters. The upshot of this state of affairs was that the chapter became totally inactive until 1978, when faculty members began to display new signs of interest in resurrecting the local chapter. Dr. Ted Schnitka and Dr. Edward Johnson were the prime movers in breathing life into the organization again with the result that, in 1981, formal activities of the chapter resumed with a display of increasing interest on behalf of the medical students. The earlier they were in their undergraduate careers, the more enthusiasm they displayed. This new interest stimulated the hope that the chapter would again flourish, particularly in view of the fact that the AOA was such a strong force in other parts of North America, most particularly in the United States. There, AOA chapters were extremely active and productive and very encouraging to all aspects of scientific excellence in the undergraduate body.