I have decided in my retirement to write a brief account of certain aspects of my years in practice, just for my own records, to clarify my thoughts and impressions of this period. I was stimulated to do this because I had done a little research for a talk I had given at the local historical society on the doctors of Bedford, since its beginning in 1854. In this connection, I had read in the archives in Cape Town some of the annual district surgeon reports by these Bedford doctors, and was struck by the similar problems I wrote about in my own reports many years later.
When I retired in June 1983. I had been in practice for 43 years, 34 of these in country general practice. I suppose we all think that we have lived in a period of tremendous change, but I do think that the years 1949 to 1983 saw a particularly sharp change in medicine and, for that matter, in most aspects of life. As a student, the antibacterial era had not begun and lobar pneumonia was still treated by nursing care alone, the temperature falling by crisis on the 8th day and death or recovery ensuing. The first antibacterial, a sulphonamide, emerged shortly before the second world war, Prontosil being the first and effective against the streptococcus only. Then came sulphapyridine (M&B 693), effective against a wide spectrum including the pneumococcus. My father was amongst the first doctors to be involved in a clinical trial of M&B 693, using it to treat lobar pneumonia amongst African mine workers in whom the disease had a very high mortality. I remember his amazement at the efficacy of this drug. seeing the temperature fall in a few days with resolution of signs and symptoms..
The first antibiotic, penicillin, came during the war and I saw it used in hospital just after the war in a slow, continuous, subcutaneous drip of 1 000 units per day – the usual dose today being in the region of one million units intravenously 4 hourly. By the time I was in private practice in January 1949, there were very many antibiotics available and the whole picture of treating infection had been altered. At this stage we still wrote prescriptions for cough mixtures and carminatives, etc. but very soon this practice ceased and doctors prescribed proprietary mixtures, pills and capsules. In the African practice where I dispensed all the medication, I still continued for many years to make up cough mixtures, mist rhei co, mist pot cit and belladonna with an infusion of buchu, mist gentian acida and gentian alk, mist alba and other useful mixtures. With the end of doctors’ prescriptions of this sort, undoubtedly a certain mystique went out of medicine. For me, the idea of a doctor’s prescription, dispensed by a pharmacist, wrapped in white paper and sealed on top with sealing wax, most certainly had an edge on the modern equivalent, but possibly the mystique was all it did have as against the potent effect (and possible side effects) of the modern prescription..
When I joined Dr Willem Vosloo’s practice in 1949, the African and coloured patients were seen in a room in Dr Vosloo’s garden. The fee asked was 3/6 for an adult which included medicine, and 2/6 for a child. A home visit was 5 shillings. The hospital at that stage had 12 beds for white patients and 16 beds for coloured and black patients. All black and coloured confinements took place in their homes, attended by untrained “midwives” and I was very often called to attend these for complications. Very often these were trifling, a so called retention of placenta, where I found the placenta was actually separated and just needed abdominal pressure for delivery, or where it was out with membranes protruding and only needed a little coaxing to come away. This fear of interference, a valuable fear to have, seems to have been with the primitive blacks for generations, especially on the farms. My grandfather, practising in the 1860’s and 70’s, described attending these cases in native huts in just the same way I saw them 90 years later – the patient lying on the floor, the hut full of smoke so that one had to crouch low to escape it and be able to see; rows of old women sitting around, the placenta lying between the patient’s legs with its string of dried up membranes reaching up into the vulva. Nothing is touched until it is all over. Sometimes of course the problem was not insignificant and, if I could not deal with it there and then, I would bring the patient into hospital for forceps extraction or caesarian section. Occasionally I applied forceps in the native hut on the farm, if bringing her in because of urgency or distance proved too difficult. My wife, Joy, on some occasions gave chloroform on my directions, using a Schimmelbusch mask with a layer of lint and a chloroform dropper bottle – “just one drop at a time in an area no bigger than a crown, just keep it moist.” Occasionally I gave chloroform myself and then scrubbed up and removed the retained placenta, but then brought the patient in for a course of antibiotics. It was only many years later in 1970 that almost all maternity cases could be dealt with at hospital, with a sufficiency of beds for this purpose. There was never sufficient trained staff available for home deliveries..
Frequently one was called by the magistrate to go out to a farm for a difficult labour – a labour which had been going on for three days – to find an exhausted patient who was not in labour at all, grossly swollen from pushing with cervix tightly closed. On one occasion I was called out to see such a case of prolonged labour to find that not only was the patient not in labour, but not actually pregnant. The poor soul was so desperate to fall pregnant that her periods had ceased and she distended abdominally to convince everyone with her false pregnancy..
In these early days I went out to farms in the district a great deal, sent by the magistrate, and being paid one shilling a mile travelling allowance. The majority of these calls, at least once or twice a week, were to small farms occupied by farmers on the Fish River at Middleton and Ondersmoordrift. Many were legitimate but some were totally unnecessary. Confinements constituted the major call and invariably the patient had had no antenatal supervision at all. When the farmer’s wife was a nurse or interested or helpful, this did help tremendously. For example, she could check whether a retained placenta was indeed that and, if separated, could express it on my directions and so save a trip. On one occasion, I went out at 2a.m. to a farm some 30 miles out to find a girl who had a retained placenta and had suffered a massive post partum haemorrhage and was dead; so one went out to them all..
Asthma was another constant source of worry. Seeing the African patients now being prescribed salbutamol inhalers on prescription to the chemist and authorised by the magistrate, one realises what a tremendous boon this is. Some of my local African asthmatics used to have a relative come to the surgery where they were given a syringe with adrenaline drawn up. If this did not work I would go and see them. Asthma still remained a great worry in practice, even with the availability of inhalers and steroids. The only fatal case I had was in this latter era, a white woman who died in hospital despite the benefit of drips, steroids and everything including the help of a visiting consultant from Port Elizabeth..
In my early years, cases of diphtheria, poliomyelitis, typhoid and typhus occurred every year and were reflected in the annual health report I did from 1954 to 1982 as assistant and, later, as district surgeon. In the ten years 1954 to 1964 I had 45 cases of diphtheria to treat, using immune serum, and there were 14 deaths. Before my time and prior to the use of immune serum, 2 out of every 3 cases died and so serum treatment only halved the death rate. Diphtheria still remained an extremely serious illness. After 1965 no case occurred. By this time all children were protected with the 3 in 1 vaccine against diphtheria, whooping cough and tetanus. Although the vaccine gave good control against diphtheria, its tetanus component – whilst invaluable in preventing tetanus in older children – could not help the new born infant infected at birth. Tetanus of the new born was a great killer of African babies as a result of the traditional habit of applying mouse droppings to the cord at birth – a habit that persisted even in the more educated African families – probably a traditional cord handling technique of the woman handling the confinement. The sight of a baby brought on the 8th day of life with pursed lips was a tragic one, because death invariably followed in a day or two. Only with hospital delivery of almost all town Africans and many of the farm ones has this ceased..
Poliomyelitis was also an ever threatening problem if an epidemic occurred. I only had 15 cases prior to the vaccine – initially by injection and latterly by mouth – but one saw in the later crippling how many cases must have occurred regularly throughout the preceding years. I once had to go and break the news to an old couple that their much beloved, 14 year old grandson had died of bulbar polio, having been sick for a few days only. The father had phoned me from Durban asking me to break the news..
When, with immunization, whooping cough ceased to be the greatest killer of black babies, measles took over and epidemics occurred every few years – wreaking havoc with malnourished babies, who died from secondary complications. Death also occurred amongst well nourished breast fed babies early in the disease. There is no doubt that measles was introduced into Africa from Europe and is a much more severe disease amongst blacks than in whites. Since 1978. with the vaccine available for general use, there has been a tremendous improvement but, even so, laziness and carelessness in getting this immunization still results in cases being seen in unprotected children. The usual excuse offered is that the child was sick and could not receive the injection..
Typhoid fever was a great problem for my predecessors in this practice, due to the water supply to the town being via open furrow. With animals wandering about, an indigenous population living in the same area and doubtful sanitary provision, contamination of this water was inevitable. With piped water this ceased, but I still saw an occasional case – 24 in the earlier years and none since 1973..
Of the infectious diseases, pulmonary tuberculosis has remained the one where the incidence has in no way decreased throughout the years. This has spanned a period when all one could do was to note down names and wait for the patients to die – to the early treatment period (which seemed such a breakthrough) when I treated cases in my surgery with streptomycin and isoniazid, with my surgery nurse keeping the records. This was followed by a period when all early cases could be admitted to a SANTA centre in Fort Beaufort and, later, by the present period when a shortened course of treatment (instead of the two year course) is available at the municipal clinic – using a wide range of drugs under the guidance of a visiting consultant. For the individual sufferer who complies with treatment, the outlook is much better, but the disease remains a most serious public health problem in this country. No doubt, it is a good monitor of socio-economic conditions and, as in Europe, will not be mastered until housing, income and nutrition of the black and coloured communities improve..
Meningococcal meningitis occurred fairly frequently, but never as an epidemic in my experience. It has continued unchanged throughout the years, treatment improving as antibiotics improved. Very often it was simply diagnosed as purulent meningitis because of the delay in getting cerebro-spinal fluid specimens to the lab in Port Elizabeth or East London by train. By the time they arrived, they invariably gave no growth on culture. The cases were probably meningococcal meningitis and were treated as such anyway. Sending a smear by Gram’s stain of the centrifuged fluid would probably have been helpful, but the time factor and one’s reluctance to handle this highly infectious fluid put one off. I did this on occasions, in particular in one case of meningitis in a four month old white baby I had delivered. I stained the slide with methylene blue and saw diplococci. The lab reported diplococci which could be either pneumococci or meningococci. The culture as usual yielded no growth. My father came and stayed with us just after this and I showed the slide to him. “These are meningococci,” he said without hesitation. “The cocci are parallel with concave surfaces facing each other and not in chains, as pneumococci would be.” I sent his comment and the slide with some hesitation to the lab. They phoned me back to say they had asked the chief pathologist to look at the slide and he quite agreed with your father. This was a relief to me knowing that it was not a pneumococcal meningitis, with its much greater likelihood of complications; also a relief to the parents, who would now obtain free hospital treatment of their child as this was officially an infectious disease. What a tribute to Dad and his generation of doctors..
One ‘side-room’ procedure which I continued to do in practice was the white cell count. I had become experienced at this while an army doctor. I had earlier bought a good haemocytometer, took my microscope with me on active service and learned to do these quickly; also to stain blood smears and look for malaha parasites in the many cases of relapsed malaria we had after the North African and Indian campaigns. This stood me in good stead and, throughout my medical career as a GP, I found the white cell count invaluable as a diagnostic aid. This was particularly so in cases of appendicitis and in babies with fevers and nothing else found to determine whether the infection was pyogenic – requiring antibiotics or not. On one occasion the pointer it gave me as an acute appendicitis, I ignored at my cost. I saw a little girl with pain in the right iliac fossa for 24 hours – she had vomited about 8 times. There was no fever, a clean tongue, no increase in pulse rate, very slight tenderness in the right iliac fossa with no guarding and no masses or tenderness rectally. The child had walked into my surgery without discomfort. When I did the rectal the glove was covered by a loose slimy stool on removal. The only disquieting thing was a white cell count of 25 000. I wanted to admit the child but the mother asked whether they could not spend the night at her in-law’s farm, only 15 miles away, keep me posted about progress and bring in the child the next morning. I felt the chance of it being appendicitis wasn’t very great, so consented. The child was slightly better when I phoned that night and when I phoned the next morning she had slept all night, though restlessly. I saw her when they brought her in at 8.30am and it was quite obvious that she had a very acute appendix which had probably perforated. The problem was what to do. It was the 2nd January, Dr Vosloo was away on holiday, as was his brother in Somerset East. In those days Adelaide had no hospital so I knew nothing of the operative competence of Dr Louw. To get someone up from Port Elizabeth would take time, even by air, and everyone would be busy the day after the holiday. So I phoned Dr Hofmeyer in East London and asked him to get everything ready and then took the child down in two and a half hours. She stood the journey well, and had a gangrenous appendix which had perforated. The base of the appendix was normal and the tip gangrenous – surrounded by a loop of bowel which had probably prevented it from being tender and caused the diarrhoea. I felt dreadful about it, not insisting that she stay in hospital. It taught me two lessons – to insist on hospital if I am worried and, especially, not to ignore a high white cell count. Fortunately she did very well but I did not really feel relaxed about this until in due course the patient married and had a baby and I knew that peritoneal adhesions had not caused sterility..
Looking back over the years in general practice, I think that maternity cases are the most memorable ones in that one has a reminder of these when seeing the offspring over the years – even in some cases delivering these offspring of their own babies many years later. Just the other day in my retirement, I saw a woman in the jeweller shop in the village with a vaguely familiar face. She came up to me and said, “do you remember me?” This is a fatal question for me because my memory for names is abysmal. I said I remembered her face. “I’m the woman with the hangover,” she said. It all came back……..
My partner was out shooting on a Saturday afternoon and I delivered one of his patients, who lived out of the district, of a baby girl. She was bleeding a bit more than I liked and the placenta hadn’t separated. I quickly put up a drip and tried to express it without success. Willem Vosloo came in at this point and we decided on a manual removal under general anaesthesia. I gave chloroform and he tried to remove it – usually not too difficult a procedure – but he only managed to get out a very ragged piece and she continued to bleed. In those days we depended on our panel of local blood donors. I phoned two universal blood donors in the village and both were at the club, this being Saturday at about 7pm. I went there and found them both fairly steamed up at this stage, brought them to hospital, cross-matched them with the patient, took a pint each of their alcohol primed-blood and ran it in. The patient felt fine and later that evening a specialist from Port Elizabeth came up. I anaesthetised her again and he tried to remove the placenta and found it to be a true placenta acreta and decided on a hysterectomy, which he proceeded to do. The next day she not unnaturally felt pretty wretched, which we explained was partly due to the hangover from the blood we gave her……..
The woman in question then told me that the baby I had delivered and not seen since was in the car outside the jeweller shop. I went out and introduced myself to a pretty 30 year old woman with twin babies, born a few months previously..
Anaesthetics became very much a feature of my life in practice though not through choice, but because my partner gave no anaesthetics. So once Mrs Colohan (a former partner) left the practice – which she did within a few years -I was the only one able to give anaesthetics. For this reason, my surgical activity, apart from what I could do under local anaesthesia, withered away. I was not particularly unhappy about this and concentrated on anaesthetics. Fortunately, I had previously had the advantage of a period of apprenticeship with an excellent anaesthetist in Glasgow. Because of this I had become quite happy about induction with nitrous oxide and maintenance with ether, and had learnt to intubate blind – i.e. without the use of a laryngoscope. For some years after this time chloroform was still in use and, being a graduate of Edinburgh where it was first used, I always found it a delightful anaesthetic to give – especially for the fitting eclamptic and for women in labour, as was used for the first time on Queen Victoria. It was also so useful in the native hut, with minimal equipment, and with no fear of fire. I gave all the anaesthetics in Bedford and continued to do so until I retired. For many years this consisted of thiopentone, nitrous oxide and ether which was undoubtedly an extremely safe anaesthetic and capable of being used for all normal surgical procedures. For children I induced with nitrous oxide, having explained before to them what I was going to do, lowering the mask slowly to the face with nitrous oxide alone, and then adding oxygen and having them unconscious before gradually adding ether. With the arrival of trichlorethylene to lessen the impact of ether, this was made easier. A tonsillectomy was the main operation in children and my partner did this extremely well. One never had to worry that bleeding would recur later. In this operation I gave the ether long enough to last the length of the operation once the mask was removed, after which ether was blown in with the Boyle Davis gag. I even used this technique occasionally for adults in the early years, but this was more difficult. In the later years, intubation and halothane made this much easier..
Once relaxants and halothane became available, I needed more training so spent three separate weeks attached for practical tuition, first, at the Johannesburg general hospital with Prof Hugh van Hasselt; then, through his influence at Groote Schuur hospital and finally with an anaesthetist friend of mine in Port Elizabeth. I also went to a GP anaesthetics course at Wentworth hospital in Durban. With this help, I was able to make use of modern anaesthetic techniques, which undoubtedly made it easier in some ways but more worrying and complex in other ways. The occasional anaesthetist has really become a thing of the past Anyone doing anaesthetics today should first have done a full time anaesthetics job for at least 6 months and probably have a DA. In those early days all doctors were expected to be able to give anaesthetics and did so. I remember when I was in the army, stationed in the Scottish Highlands, I had a young soldier with an acute appendix. I brought him into the hospital town of Granton-on-Spey and the local GP decided to operate in the local cottage hospital. He naturally asked me to give the anaesthetic which I did with chloroform and ether..
In the early days in Bedford the patients tended to want surgical procedures done locally and, with more complicated procedures, surgeons were quite willing to come to Bedford to operate. The tempo of surgery varied quite a bit but one usually had one or two major operations a week. In a letter to my parents in 1956,1 mentioned that we had been rather busy lately with 26 major operations in the preceding two and half months. By 1959, Adelaide hospital had become fully functional and, as Dr Ie Roux gave no anaesthetics, I did all the anaesthetics there for Charles Louw who was a keen and excellent surgeon. This added significantly to my work load but I always enjoyed going there and the atmosphere of the Adelaide hospital. On rare occasions I also went to Somerset East to give an anaesthetic for Dr Andries Vosloo..
When any outside surgeon came to Bedford, the anaesthesia and post-operative care was left to us, so I gave the anaesthetics for all the usual emergency procedures as well as for many hysterectomies and occasional cholecystectomies, gastrectomies, and on one occasion a thyroidectomy. A lot of these were worrying but oddly enough the most worrying were tonsillectomies, multiple teeth extractions and caesarian sections – the worry being compounded by knowing the patient and family intimately, and the patient sometimes being a very special only child. Fortunately nothing awful ever happened, but one sweated blood on many occasions with emergency surgery in fat. florid, heavy drinking males. In fact on retirement, I was quite thankful to see the end of it at the time when we acquired a new, modern, rather terrifying Boyle’s machine at the hospital, with its complicated safety features, bleeps and monitors. I felt much happier with my old familiar Boyle’s machine..
The black practice constituted most of my work throughout my period of practice and, although it was a heavy burden, I did enjoy it. As patients, I enjoyed their cheerfulness and humour and patience. Nutritional problems featured significantly, particularly kwashiorkor amongst babies, which often persisted despite milk being available at the municipal clinic. It occurred usually in eariy weaned babies left in the care of grandmothers, and responded to hospital treatment. Although treatment was necessarily prolonged, the response was certainly better than with marasmic babies, who probably suffered from total starvation as against the high carbohydrate, low protein malnutrition of the kwashiorkor babies. In older children and adults one saw many cases of pellagra, which appeared to be a manifestation of a general vitamin deficiency rather than a specific nicotinamide deficiency. A more specific deficiency was scurvy. Initially I did not recognise these cases who presented as adult men with painful calves. These seemed to occur mostly in men employed on the roads, away from their wives and responsible for their own feeding arrangements. They responded dramatically to 1 gram of ascorbic daily for 10 days..
With much of the black practice one had to deal with the impoverishment associated with unemployment and inadequate housing. This obviously applied to those in the village and not to the farm labourers. This was particularly so during the full spate of Verwoed apartheid legislation and Joy, as a town councillor at that stage, saw more of this than I did. The influx control law was in full operation and the hardship it caused has left its bitterness today. In a letter to my parents in February 1962 she wrote: “At a municipal meeting we received a reply from the Bantu administrator in King William’s Town in answer to our letter asking him to visit Bedford and explain the influx control law and, if he could, suggest solutions to the problems its implementation poses. A negative reply was received from the administrator – pressure of work being the excuse. At this point a councillor, who happens to be a secretary of the Nationalist party in Bedford, said. ‘He is afraid to come; there is no solution as the law stands today.’ …….So the problem of human suffering piles at our door………We have 7 families who have been told to get out of the town by the Bantu representative and the magistrate…….they have already been told to get out of Cradock, Adelaide and Somerset East. They ask in all humility where must they go. When one goes to the authorities and asks them where the 7 families must go they have no answer but just reread the ordinance. So we have little groups of corrugated cardboard dwellings underneath the mimosa trees on the exits of the town. By law if they move 100 yards per day they cannot be taken by the police.”.
An interesting dinical condition I came across was the occurrence of amoebic liver abscesses in blacks who had never left the district. Amoebiasis is not supposed to occur in this district but it obviously does, as these cases without doubt were genuine amoebic liver abscesses. I probably would not have recognised them had I not worked in Durban at King Edward VIII hospital, where they were incredibly common. The first case I saw looked just like a terminal liver cirrhosis with a grossly swollen, hard liver and marked cahexia. He had come as a last resort from a neighbouring town. There was one point of marked tenderness and he had a raised white cell count. With some trepidation I pushed in a large needle and out came typical anchovy pus. He responded dramatically to repeated tappings and a course of emetine injections. I continued to see cases of this sort until I retired, about one or two a year. Later, when emetine was no longer used, metronidazole was dramatic in its effect..
I suppose we all have some rather dramatic experiences during our professional life. I think my most dramatic was when a little coloured boy of about 2 was brought to the house with stridor which had come on suddenly. I took the child up to hospital and was about to examine him when I was suddenly called to the maternity delivery room where an arm had presented. While dealing with this I was suddenly called back urgently to the stridulous child – the airway had blocked completely. I just seized a scalpel and incised the neck – blood everywhere. I reached the trachea and made an incision into it. Air did not suck in as I hoped and prayed it would. Then I saw a bean blocking the trachea below my incision. Luckily I could hook it out and air rushed in. The wound healed without problems despite total lack of sterility and I still see this patient, now an able bodied seaman in the navy, when he visits the village and tells everyone at hand the story..
One of the most time-consuming and frustrating exercises as a district surgeon was the annual statistical and written report submitted every February. It took countless hours of preparation and, based on the number of hours spent in the year on the many different facets of one’s work, so one’s remuneration was determined. It always struck me as a senseless method of deciding this – where a doctor was left to judge his own worth – with the conscientious and painstaking record keeper coming short, compared with the unscrupulous. Since my retirement, this has altered. An irritating feature was that nobody seemed to read these reports or, if they did, act on them. For example, in 1969 there appeared an excellent article in the SAMJ about the clinical syndrome of endemic syphilis – appearing in a Karoo practice. I realized that I had been seeing these cases and thought that they were cases of congenital syphilis, and that this was a new syndrome as far as I was concerned. I pointed this out in my annual report that year. Some years later, this particular article in the SAMJ won the award as the best article by a single practitioner, so its merit was recognised. However, no recognition was made of the syndrome by the health department, although I reiterated it each year and specifically notified cases occurring. In 1973 there was still no recognition of this and a further article appeared in the SAMJ, this time by Prof Scott of Bloemfontein, in which he stated that this syndrome was still unrecognised in country practice. I wrote to him and he suggested that I write to the health department, enclosing his letter to me. No reaction followed, and endemic syphilis only became notifiable in 1980..
Partnership in medical practice has many advantages and notably the possibility of proper holidays, which as far as I was concerned, were absolutely vital if one was to give of one’s best. One only realized the shortcomings in the service one gave, after returning from holiday with a totally different outlook. On the other hand a partnership is not an easy relationship. My father told me that a partnership with a brother was not easy and should be avoided – wives often being the stumbling block. Wives are very conscious and concerned with disparity of work load. My uncle, Dr RL Girdwood, asked a very important question about prospective partners when a partnership was first mooted. “Is he jealous? If so don’t join forces.” I think this is a very vital question and if each partner could be free of jealousy and wives equally so, it would be plain sailing, but I should not think this happens very often, Looking back, our partnership had many good points. I became a reasonably competent anaesthetist. He became a competent surgeon, but did know his limitations which is so important. He never tackled anything he could not cope with completely. I could never have worked happily with a courageous GP surgeon who took on things he could not handle completely, complications and all. Charles was an excellent surgeon but this aspect of him worried me. He did things and they worked, I must admit, when I felt a GP surgeon should not have tackled them. We got on extremely well and he is one of my greatest friends, but I preferred Willem as a partner. I realized this on rare occasions when asked to give an anaesthetic by Charles but declined because it was not an emergency. He was fed up with me for this decision. Willem under similar circumstances went along with me completely. In any life threatening situation, when not to operate would have been fatal, I always gave the anaesthetic, phoning up the magistrate and explaining my action beforehand. All in all our partnership was a happy one. Willem was a first rate diagnostician and I had complete confidence in him as a doctor. Instinctively we kept our distance from each other. Living in each others’ pockets could have been disastrous and, since our retirement, we see more of each other than we ever did in practice, playing bridge weekly with two rather special patients, a mother and daughter; one was his patient and the other mine. .
Looking back would I choose this life again? Unquestionably I would but would have liked to have been better prepared for it. My son and son-in-law with their 5 year hospital training after graduation acquired so much expertise that, with the war, I never could get and missed out a lot on that account. Of all medical practice, a country practice has been most rewarding, living in the country, having tremendous job satisfaction despite all the pressures and worries, the reward of countless friends of all ages, and being part of an enduring community.
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