This is a German trial being interviewed by Derek Hockaday, a fifth of March, June, what really took you to Oxford?
What brought you to Oxford? Well, I came to Oxford at a stage of my career when I'd been at the Hammersmith Hospital and interested in hepatitis B,
and at that stage, fright was in Oxford and working and having come back from the states on what was then called Australia antigen,
I completed my post at the Hammersmith, but as at that stage, I was also getting married and my husband had a university appointment in Oxford.
It seemed reasonable to approach raths and see if between us we could put a grant
application into the MRC so that I could transfer the research work I was doing to Oxford.
And that's in fact what happened. What we hadn't quite predicted was that within a month that the MRC giving us a
five year grant Ralph applied for and got the chair of medicine in Southampton.
And at that point, the MRC said to me, well, we won't leave you high and dry, but this isn't going to be five years.
It's going to be one year. So I then had to become somewhat more resourceful and look for other forms of
funding and ways of staying afloat through the early years of my time here.
So initially you'd have been a lecturer in the anatomy department.
I was in the Nuffield Department at the stage. Orbison was the professor and Ralph at that stage was my reader.
And I stayed on.
And when Ralph moved to South Hampton, I was adopted, as it were, by Sidney Truelove, who was the father figure of all gastroenterologists at Oxford.
That's I mean, my feeling is that really Sidney was running into part of the is that Sidney was running a Department of Gastroenterology.
And his words to me were, you know, something about liver disease.
I don't why don't you take on the liver patients when Ralph goes?
I mean, it was as casual as that. And I was grateful for the opportunity.
I mean, from the personal point of view, I might not have looked for that level of work and responsibility as I think I was pregnant at the time.
But, you know, you don't turn up offers like that. And I was grateful for his support.
And I'm very grateful for the way in which he continued to take an interest in what I was doing, but not actively interfering or really directing it.
How did you get on with him? He he's an incredible blow for these very late hours of work and this very slow way of talking.
He he was a great character.
He if you got on with him, he was very supportive and very affectionate and very casual and relaxed in his approach to work.
But he actually achieved a lot and worked very hard.
And people who saw him meandering into the hospital at 11 o'clock hour past eleven in the morning had completely missed the idea that he was,
you know, working until well after midnight. And I think the after about two years, he'd started doing his annual January courses in gastroenterology.
And Derek Jeter helped him with the first one. He invited me to help him with the second one.
And at this stage, I think I was pregnant with number two.
And he said, well, given that you're pregnant, Joan, he said, we'll have a slightly later start, come for lunch and we will work late.
So I used to arrive home at about half past and it was very incredible.
But unfortunately, I had a long suffering husband who understood what I was doing.
And based on what your memories of him and his place, Basan, I think, came to Oxford having established his reputation really.
And I think that by the time he came, he adopted what I saw as the American model of really chairing a department rather than directly leading it.
He was very happy to allow me desk space and whatever I needed in the way of other supporting facilities.
But he never took more than a very passing interest in what I was doing.
I think, um, I think that the Nuffield Department at that stage had quite a number of very distinguished senior members.
And I think my initial impression was of being slightly overawed when, for example,
the door that said AHJ Krebs on if this had happened to me, but you would be getting on rounds with this.
And I went I went to his one sort of general round.
I didn't go on his. Clinical ward round around the ward, I went on Sydney's, which inevitably started at half past four in the afternoon,
but the basin had a Thursday morning session in which students presented cases and they were discussed.
And I was went to that, which was the sort of departmental meeting.
And, you know, we ended up drinking coffee together and generally meeting each other and I think provided quite a nice focus for the department.
And you would have had admitting rights to beds? Technically, no.
My patients came in with Sydney True Love's name on the sticker.
At that stage, I had a senior registrar contract and I had in fact, I had the senior registrar contract for ten years as it worked out.
But it you know, nobody counted years at that stage.
And defacto Sydney was giving me the management of the patients and supporting me when I needed, you know, somebody more senior.
But they'd be seen on Sydney's water. And I did a ward run on Monday.
He did his on Thursday. And if I had anything of interest, I would show it to his research fellows and discuss it with him.
But I don't remember him ever interfering or in altering things at all.
But he used to ask me, you know, to produce anything that he thought would be informative or educational for the sort
of United Nations team is because he had a large number of overseas research fellows.
And you would have been live about so it was well established by then?
No, no, it wasn't. I had done liver biopsies both as a husband at the Royal Free and as a registrar subsequently.
So I came to Oxford knowing how to do liver biopsies. But apart from Rouf, there was nobody else in Oxford who had ever done liver biopsies.
And I think, to be honest,
RAF hadn't done as many as I had at that stage because he'd very much only picked up his livers during his year or so in the States.
But what we did do was to establish a weekly liver biopsy session and persuade the pathology department that
it was a good idea to have at least one state pathologist who saw the liver biopsies and gained an expertise.
And in turn, those mortgages. Er and Harry Sandler, who also went to Southampton, subsequently took on that role.
So we used to review all the liver biopsies done in the hospital because they would all end up going to the one pathologist.
I mean, all the needle biopsies would I would know about anyway because I used to do them and then trained registrars to do them.
But the other biopsies would be surgical ones.
They'd be which biopsies taken by surgeons at operation. Yes.
Knowing there were three and the Hammersmith, how do they compare in your mind with Oxford in your first when you came in first year or two?
Well, the all there are three. I was there as a clinical student and as a house officer and I moved on from there very quickly.
But I was aware that Sheila ran a very active research unit, but it was entirely focussed on liver disease.
At that stage. There wasn't a great deal of academic work going on in other fields.
I think the exception to that would have been standard children who had really the first.
Dialysis unit in London. And I can remember as a student being pulled in to help with dialysis there,
so I was trained a little bit on on sort of electrolyte management and renal failure type problems and.
The Hammersmith, of course,
was the complete opposite because every department had its academic professor at its heads and I'd been a house officer there,
I'd done a registrar job in Cambridge, a general registrar job for Lawrence Martin.
And then I was invited to go back to Hammersmith as a registrar and a lecturer.
Really, I thought at the time not to do to the disease at all,
but to work with Graham intestinal absorption and small bowel disease, which is what he wanted.
And this is where fate takes over and people's lives, because about a fortnight after I'd started their.
The Lancet published the first paper on Australia antigen from Bloomberg,
and it was summoned to Crispus office and he said, you know, you trained at the Royal Free.
You probably know more about this than the rest of us. Start a little clinic.
And I had the rather unusual privilege of having an active virology department, including Jude Alvida, who was very expert,
biological electron microscopist, wanting blood samples from people with liver disease, looking for viral particles in their blood.
And so, in fact, within a very short time,
I had a large and flourishing referral practise because we were the only service in London that if you sent somebody up jaundiced,
say, has this person got hepatitis B, we could give you the diagnosis in three hours.
The vast majority of the referrals inevitably didn't have hepatitis B, and I was then left to sort out what was wrong.
So when I came to Oxford, I got a certain amount of experience of that kind of referral pattern.
Oxford at the stage. I came here, got an active liver service at all.
Ralph was only really months back from the States. What year was that?
I came in 1970. Yes. And he'd become a reader, I think, the previous beginning of the previous academic year.
And he had certainly started.
With what he took to be a growing referral practise,
but he was much more interested in the immunology of liver disease, that was his particular field.
And the idea was that I could bring some of my experience with the virologists and work
perhaps with some of the electron microscopist to try and continue some of the work here.
How did you think the clinical standard would compare to, say, the Hammersmith?
It was high in both places, I think.
I think in both places, there was a tradition of all the technicians doing some technical work and being actually clinically trained,
but the big advantage in those places was that if you didn't know the answer to something, there was always somebody around who did.
And people were very happy and very willing to give opinions and see each other's patients.
The Hammersmith, perhaps if you made a diagnosis, you more readily handed somebody on to a specialist service, I think in Oxford,
because we take physicians and certainly most of the general surgeons were generalists as well as specialists.
They were quite happy to keep control of what one did was to give opinions and not necessarily take people over.
But I know I found from the clinical point of view, the standard of practise in both places was high.
What about the nursing practise?
At that stage, Oxford had its own nursing school and most of the nurses here were Oxford trained and Oxford brought up,
as it were, I think the Hammersmith being in West London was a much more cosmopolitan practise of nurses.
Certainly the senior nurses on the wards that I was responsible to work with were extremely competent and very good.
Some of the other nurses. The standards were perhaps a little bit more tenuous in that some of them didn't perhaps have
the language and communication skills and the understanding of sociology that was necessary.
But of course, even then, West London was a much more cosmopolitan practise of patients as well.
And I don't know if you had patients on the heights you wouldn't have except now and then.
What did you think about the buildings and the cleaning and the food?
That I did have patients in the heart because Sydney, in fact, used to admit that at the very end to Wall Street.
I mean, they were bizarre. They they they really were.
But you see, when I trained at the Royal Free Sheilas, world famous research unit was HUTZ on top of flat roofs.
And in the wet weather, you had to walk on duck boards, you know, just to avoid the puddles on the roofs.
So I was kind of used to working with distinguished people in slightly primitive circumstances.
You mentioned immunology. Was McClellan still there? Is that the right name?
There was an even ologists that Bissonnette brought in who worked above Crib's on the floor above Graham's.
And I think he interacted a bit with Derek Jeter.
He did, but I think he did. Didn't he leave to go? Didn't he go to he went to Birmingham.
He could have left before you went about a year or two after I came back, he was around because I do remember him in those early years.
But I think by the time Raafat moved on, he probably moved on the next year.
And so the liver scene was dominated by alcohol or hepatitis, while I think the liver scene in Britain is dominated by alcohol.
I mean, what we became aware of was compared with West London, where we saw quite a lot of hepatitis B in Oxford.
Hepatitis B was virtually unknown.
And I realised very quickly that if I was going to have a research interest, it had to shift somewhat to something that,
you know, had the clinical patients available and readily visible and referred.
And that was where alcohol being the commonest toxin in our society became one line.
But in fact, my research in the early years was very much around anaesthetic,
drugs and agents, because, again, very shortly after I arrived in Oxford,
there was a series of rather unfortunate deaths of women who had had repeat anaesthetics,
and you only had to read their notes to realise that had repeat halothane, anaesthetics.
And there was considerable conflict between the anaesthetic fraternity and the
logical fraternity nationally as to whether halothane was the poison or not.
And I remember going to national meetings in which senior hepatologists and senior anaesthetist virtually came to blows on stage.
I mean, it really got very, very heated because halothane was thought to be a very good anaesthetic agent,
which I'm sure from the point of view of the patients comfort unit compared with the sort of chloroform, it was comparatively safe.
But in fact, the professor of anaesthetics at that time, Alex tinsmith, I realised, I think, as he said to me,
having had to go and give evidence at two successive coroners inquests, that this was a topic for research.
And as I was then the sort of free lance hepatologist in Oxford, I was pulled into that very quickly.
And with help from Sydney and from Richard Peto, we set up controlled trials,
looking at different agents and had some interesting experiences, randomising patients for repeat anaesthetics.
I think trying to explain to people who at that stage, it had very little exposure to controlled trials,
that when a patient was randomised to either having a halothane anaesthetic or a non halothane anaesthetic,
and this information had been stapled to the front of their notes, we would be grateful if they didn't just pull it off.
If they disagreed with this, the surgeons were better news to know.
And then I think the surgeons had very little to say and what anaesthetic was given.
But, you know, one of two seminars with the anaesthetic department and I think they were very supportive.
I mean, they realised the advantage of looking at this objectively.
And within a year and a half, we got very convincing evidence that the liver damage at that stage was in there.
People with repeated halothane, roughly how many patients would have been in that?
It was 42 patients, but that's not a lot.
Wow. What I did was to look at where the liver damage had been.
And it was very obviously in the people having repeat anaesthetics.
And the commonest group of repeat anaesthetics were the women with carcinoma of the cervix
who were having weekly or fortnightly anaesthetics to have regular insertion stuff.
So they just needed to be rendered unconscious for long enough for the cervix to be dilated and
the radium inserted and say they were short procedures and they were in and out of hospital.
And I thought that if I was going to look for a toxic reaction, I needed to look where it was most likely to have.
Yeah, yeah. And so we got in fact, we we had tried to set up a trial just looking at anybody who had had an anaesthetic in the previous six months,
and that did produce results. And he went on doing it in Southampton.
But he had to put several hundred patients because we looked at the women who had
carcinoma at the cervix and were having weekly or fortnightly anaesthetics and had three,
four, five. And we picked up four women out of 21 whose liver function tests were bizarre after the second anaesthetic.
And we set up with with cooperation of the biochemistry department, we set up a speedy service.
I mean, in those days, you couldn't get liver function tests of the day. You asked for the play, only did them once a week.
But we managed because I got money for a Années technician to take the blood and to actually run the tests.
If we saw the patients at half past nine in the morning, we could know by noon whether the liver function was still normal or not.
But we picked up these four and we're able to warn the anaesthetist so that these were high risk patients.
And the procedure, the the gynaecologists very kindly agreed to cooperate on that one.
And I think we probably saved four women from, you know, just by doing this research for four women from having severe liver failure.
It was Richard Wilkinson. Yes, yes, yes.
It was Richard Wilkinson who was head of the biochemistry department.
And I got a receptionist who worked just the two mornings a week that the patients came in and and learnt how to do,
you know, operate the necessary biochemistry equipment under Australian supervision.
So it really worked extremely fast.
And we were very fortunate to have prepared minds, people who are prepared to look at what needed to be looked at.
And I took I, I got these numbers not being at that stage, a very skilled statistician.
They seemed even to me to be fairly obvious. But, you know, one one, they did the right statistics.
And I knew that if I could get it right, it would probably get published.
But I was running out of research grants at that stage. So I took my results up to the top floor where the richest professors department was
thinking that was where the highest density of statisticians would exist if they had left.
By then, Hikaru had left it to and I went into the professor's secretary and I said,
Do you have a statistician at who would have a few minutes to just look at these numbers, you know, to advise me on something?
And she was sort of looking up and hesitating slightly on the voice from the inner sanctum, said, do you have the data on you?
And I said, yes, I do. And he said, come in. The average adult properly got out his calculator and sat down and did the number cracking great.
You know, which again was the accessibility of people in Oxford. But then you switched to Peter.
What do you see? Well, what happened was that Richard Doll said, I'm quite sure these are convincing numbers,
but I chair the Committee of Safety on medicines and I ought not to be your co-author on this, but I'll get.
To have a look at the data for you and Richard took it on the next day and co-authored the paper, which The Lancet sort of took two weeks later.
Did you think at the time that was the most important paper published?
I think it got me a job in Oxford. You were talking to the right people?
Well, I was looking for help. And but I meant I guess I had learnt during my time at the Free and the Hammersmith that if you
didn't know the answer to a question that usually were people who are happy to take it on.
I hadn't expected Richard all to take it on, but I just instinctively knew that that was the place to look for a statistician, I think.
So life is full of fortunate chances. As far as I'm concerned, then how did the move to up the Hill to heading to affect you?
Well, about the time that we moved up, Richard Doll had given me a coin collectors post in his department as a result of that publication.
That's what I say. It got me a job out of the end of it.
And so I moved into the R.P.M. And then when Richard retired, I was given a post and David was forced to,
partly because he inherited the clinicians from Richard's department.
And basically that was Robert Turner, Jim Mann and myself.
Those were the three of us. And we had a.
Small office up in Richard's department at the old Raclette,
and we transferred to a medical secretariat in the new hospital and a shared room up on the top floor in the Nuffield Department,
but not by that stage. My collectors post was coming to its end,
which was when there was a fairly new university statute that you couldn't just keep renewing clinical entrance posts indefinitely.
So I can remember talking to Sydney Truelove about it and asking him if I should start applying for consultant posts around the region.
I said, I think there's one coming up. And I wake up and you know that from where I live, this would be quite comfortable.
Uh. And he looked at me and he said, I think I'd better talk to one or two people about this,
but I was then very fortunate because a combination of Rosemary Roux at the Regional Health
Authority who realised I was basically providing a regional service for hepatology by that,
and David was more prepared to fund between them.
I think Rosemary put a lot of the money into it at the specialist hepatology purse, which was advertised in Oxford, and I got it.
So that was when I got my consultant for Untravelled. And the move up the hill was at about the same time, sort of nineteen eighty six.
So I got admitting rights to a bet on the gastro ward in my own right.
At that stage I think that was the first time that my name actually went on patients and stickers.
So you say a regional service. Did you travel to the region.
I done quite a lot of going around the regional hospitals, talking to colleagues about liver disease, giving lectures at postgraduate centres.
And I used to do quite an active line in sitting on consultant appointment committees for the College of Physicians.
I think that was where for the first time in my life, I realised that being a woman probably was an advantage rather than a disadvantage in medicine,
because both the College of Physicians and the university woke up to the fact that they had to have some sort of diversity on appointments committees.
And I think I was appointed senior staff in every academic department, clinical academic department in Oxford,
because there weren't very many senior academics, because we had to sit on appointments committees.
But that was really how I got to know consultants around the region as well.
Let's say liver biopsy that would have started in Northampton reasonably early after.
Oh, no, no, they didn't provide the histology service at all.
And it really only began to happen in regional hospitals when some of the registrars I trained moved out to work there.
And at that stage, we quite often used to get the histology samples, Dorset back to Oxford because there was no astrologist in the regional hospitals.
You could read them. You know, it's a specialist office and it is it is somewhere where good discussion between
the clinicians and the pathologists straightens both sides and actually,
to that extent, multidisciplinary working amongst medicks as well as amongst other.
Yes. Branches in that could work, I think is terribly important.
And we did have supporting facilities in Oxford in the surgeons were prepared to take on the high risk patients that might get a while.
And Julia, Britain would be very willing with discussion with me and we would talk about what the risks were
in operating on some of the bleeders or some of the patients who needed better interventions.
So they were providing a specialist service and we had, for example,
specialist dietitians who turned on the special diets and things that one couldn't get elsewhere in the region where the haematologists to go to.
For the rest, the haematologists were very good at providing the blood products we needed very quickly.
And we did meet them very quickly sometimes.
Um, so, you know, I think that over a number of years, the idea that this was an active service that interacted with other people was necessary.
And of course, we we got the medical students through. So a generation came through understanding about the problems of looking after
people with the disease in a way that I think hadn't happened a generation before.
I'm sure this was happening in other centres over the country.
But certainly when I started taking referrals in Oxford, I was taking them from well, the nearest centres were Southhampton, Birmingham and Bristol.
So, you know, between us, there was somewhere around Swindell that there was a Cut-Off point somewhere around Basingstoke that was at that point.
And I was certainly taking patients from Redding and certainly taking patients from Highwood to Aylesbury.
Right. So how many future consultants would you reckon you trained as medical staff, not students?
So roughly, I would say something between five and 10 years old still in this country, but they're active in this field.
That's great. You know, I mean, that I keep in touch with them and they're very generous in their invitations.
And I've been up and visited them in Australia and in Bangladesh. I mean, I said can't you can't work with Sydney, for example.
I've done some sabbatical gleaves working there, which has been very interesting. Did you get into genetics at all the genetic aspects of this?
The only one of our team who worked actively with the molecular geneticist was Guarascio.
And he looked and really got very near to the question of the Hippocratic TotEx and the genetics of that.
Jeff said you did Jack six and he was looking at inflammatory bowel disease.
He didn't look so much at the the livers, although know Jackie is a senior person who was my registrar, but he his work is more as a gut gastrique.
He had something to do with hemochromatosis. I that I suspect when he was helping with my patient is because we did have an active practise of
haemochromatosis who came up regularly to be blad and the blood would go straight to the malaria lab.
This was a little bit of positive interaction that took place because all the patients
with liver disease had a very nice large red liver cells with matricide doses,
which the malaria parasites were quite fond of. That was for the research.
So although I don't claim to have myself done any malaria, I have indirectly contributed to its activity.
And we're interacting much with David, whether I went directly to the idea meetings.
And, you know, he was very much the head of the department, but I was aware that he had a huge department.
And really, I think at that stage, his his national and international responsibilities were quite important.
But John Madigan would have been there to John Ledingham was by that stage, he'd taken over the what had been the major leadership,
the professorship as it was and is and that he was very much the the number two to David Wetherall when David was well,
wasn't that he would lead the clinical meetings.
And I also went regularly to the gastroenterology meetings because when Sydney retired Derek Jeter took over,
we continued to have regular gastroenterology meetings, which ironically have stayed at Sydney's time of for 30 odd.
I don't know whether they are now retired, but we do know some habits die because Derek had been away for a year and come back.
Derek had been a consultant at the Royal Free, came back to work in Oxford and very much inherited Sydney's very large practise
with inflammatory bowel disease and set up his own very active research unit.
But that physically stayed the old. So in fact, Derek was not physically at the John Radcliffe very much more when he was,
you know, did not take possession or part of the active side there.
But when he was supervising all his research, those were based out of the old practise after having say, what was your research topic?
Well, we looked at other anaesthetic agents for four somewhat.
And then I got involved with the haemophilia centre looking at the blood products that were produced.
And we had very much the same story with them that we'd had with the halothane,
which is the when we started looking objectively at the blood products,
even the ones that were being produced in this country, we realised that hepatitis was being transmitted,
that so in fact, I reverted back to my biological past at that point.
And, um, whereas when I first was invited to go and regularly see haemophiliacs,
the belief was that all of the contamination came from commercial products largely made in the states from paid donors.
We realised very quickly that the.
Factor eight that was being made at the Churchill and was being made for a much smaller pool of donors, was also contaminated.
And we did a number of follow up studies there looking at people having their first dose effect.
These were largely either children or young people with mild bleeding disorders who were having their first dose effect.
Right. And we realised that one hundred percent of them had abnormal liver function tests two months later.
This again involved follow up after people have been discharged from hospital.
But we got good at doing Home-Based.
Follow up had set this up when I was doing the same work and having got a small team of researchers who could do it.
It worked quite well, so we followed through and progressively with Charles Ritz's cooperation and he was very positive about this
and the pools of donors from which they were making the fact greatly reduced in size very significantly.
And it meant technically a much harder job because obviously doing it in large quantities was a much more industrial process, much more efficient.
But they did we did, in fact, even follow up down to Truls, about 100 donors.
And even so, we were finding that they were all getting abnormal function tests.
And this was before hepatitis C was described at all.
But we just we predicted on epidemiological grounds that the incidence of the donor population of these were people who
had no history of liver disease that they were aware of and would probably be of the order of perhaps one percent,
something around or up to two percent anyway, which I think is what it turned out to be in the general population.
And of course, most of it is not transmitted, but there are people who many years before may have had an illness with.
Possibly a slight fever,
but not of this jaundice that it would have been at a time that they might have experimented with intravenous drugs as a young person.
And when we look back at the evidence that more and more came to light,
which is how the whole pattern of what the clinical picture of hepatitis C really became of this.
But so as with the hepatitis B,
I was involved with some of the clinical work and some of the epidemiological work around the description of the virus.
How much of a national problem was this with the blood transfusion service?
It's it is a big national problem. I mean, now they can test more.
And so it's much less of a problem to say that blood transfusion is safe.
Always is to turn one's eyes to war against what the next problem is going to be and obviously other things, other transmitted virus.
So viruses and various other things. And of course, then there was the AIDS problem and HIV.
And quite without realising it, I got drawn into the HIV problem because about half of my patients that were haemophiliacs
with hepatitis C or what with that Cordano may not be turned out to be HIV positive.
And we very quickly describe the pattern whereby hepatitis C itself is a fairly benign disease.
And as with the blood, that as you can live healthy for many years carrying hepatitis C, but if you also get cancer today,
date to it alters your immune status and your hepatitis C virus becomes much more virulent and much more active.
And these people would get very rapidly progressive liver disease and the complications of liver failure.
And so most of the haemophiliacs who died in the early days in Oxford with HIV died under my care of that idea.
And we used to have two side wards on 57th where we would have people with HIV.
That anyone is probably a stupid question, but did they have clinical HIV?
Because this was often the first presentation.
I mean, in retrospect, they began to realise that some of the other infections were perhaps the early presentations of,
but they hadn't appreciated that this was an act of HIV until the liver became the presenting feature.
And I think this is one of the differences in HIV, in people with blood products,
as opposed to HIV from sexual transmission, and perhaps that they had such opportunity, for example.
So I saw a very skewed view of HIV, but it was nonetheless a pretty lethal form amongst the young people who had it.
Do you think that's why Oxford made such big provision against HIV?
Yes, because of the experience with the blood. We had the experience with the blood products and we realised that we had an unusual catch of HIV.
If you if you go to the London hospital because HIV is a sexually transmitted disease,
if you come to Oxford, certainly the early days it was blood transfusion.
So were you working with David World or to Peter or Ben, Tim, Peter, Chris Kamden and Groff's Alexandra.
I did a morning a week over there. Is is when did you get into the Jamesy world?
That was much later, right? I had I had been very active with the students, I mean, looking back.
About the time no, it was before we moved up to the new hospital, even down at the old Radcliffe,
I was asked if I would take on the role of clinical tutor to perhaps two students a year, which I did, and thoroughly enjoyed interacting with them.
And when I moved when we moved up to the new hospital and I think by that stage, Basil Shepstone was the director of clinical studies.
He asked me because I'd worked with Basil quite a lot on the imaging issues as part of a sort of technical service we were providing.
So we were colleagues who'd work together and he asked me if I would take on problems,
some of the problems that came to him as director of clinical studies that he thought
might be handled perhaps more tactfully by a woman or with a different slant Bible.
And so I would get one or two, in addition to the students with the most clinical tutor, I would be asked to see one or two girls each year.
And the two you had with there, always with the girls next year and.
Sure. But the sort of referrals that I got from Basil were much more the ladies.
And then I was, um. And I suppose I got to know them and, you know, I would obviously talk with them about very personal matters sometimes.
And I'd talk about how much they wanted this to go on the medical school record and how much they didn't.
And Basil respected that to a degree. I was acting as a confidential counsellor.
Really, this wasn't necessarily at all in the public domain.
And then after that, Bassal had moved on and and John Seah had become the director of clinical studies.
I was approached, in fact, by a group of the women students to ask if I would be prepared to do some work, really in a more formal capacity.
And I said, well, I kind of do what I'm asked to do in this case, you know, as part of being a university employee as well as a clinician.
But you don't necessarily choose what arrives on your patch. And I did think about it anymore, but they were obviously highly.
Politically aware that it is because they went to interview the professor, who by then was David Wetherall, to say,
why haven't we got a senior woman in the medical school and quite out of the blue because it was some months later?
I got a bleep in the middle of one of my Waldron's, which I answered at the nursing station,
which was David Wetherall saying we'd like some help in the medical school.
So I said, yes, that's fine, and he said, I think we ought to make you deputy director of clinical studies.
So, you know, that was the nature of appointment processes. I was just wondering, because there's been several women as directors.
Yes. When the directors is there was a man as deputy when I asked about that.
And I never got a straight answer. But, you know, looking back at the early days at my my appointment was completely I mean, it wasn't appointment.
The work I did with Basil was completely Cassilis, you know, so I didn't know who they used.
But that was that sort of percentage of women returning at 30 percent.
You know, by the time I was there, we were much nearer the 50 percent mark.
Forty eight, I think, something like that.
So then I did three years as deputy director of clinical studies, and during that time I'd begun to get more active.
Naturally, I think that my own children were older and I had, um, I had a period as the.
I've tried to think of the order in which things happened, I was locally, I was president, that Gordon's federation in Oxford,
as I think your wife was afterwards, and I then went on to the national executive of the MWF and in due course was national president.
And one of the things that we picked up there, and it was very much due to beauty, beauty,
who alerted us to the fact that there were very, very few women involved with the Jhansi.
I mean, she was one of, I think two or three in a council of more than 100 and that this was not representative of the profession at large and.
You really stimulated by her, we asked people to stand for election to the GMC at the next election,
and if you got a few to get elected, I think three or four.
The other person who was very vocal about this issue, who had been a national president of the MWF was Elizabeth Shore,
and she was a deputy CMO at that Ministry of Health, as it was then.
And she'd been an expert. Yes. And she was on behalf of the chief medical officer.
She was on the GMC, but I think she had built up between them,
realised that actually this was something that, you know, in the future needed to be attended to.
So I think that that was when I became more vocal on the subject and really as I was completing my three years at the medical school.
It was another one of these lovely moments when I went into the office that I shared in the medical school with John C.
And there was a little Post-it note stuck in the corner of the block from David Brown and say, has the Regis spoken to you?
So I thought, well, yes, but not recently. I went in to see David.
And said, is this something I should know or not know?
And he said, Well, I think there's a job for you to do when you finish here, but I'd better let David Weatherall tell you about it.
I think it's something to do with your GMC interests. So, in fact, what had happened at that point, and this was MIT counsel, really,
was that Oxford and Cambridge had a representative on the GMC and did tends to appoint the person.
And the person who had held the post was an academic GP based in Cambridge, and he got the chair of General Practise,
I think in Newcastle or somewhere anyway, that obviously departed from representing Oxford and Cambridge on the GMC.
And so it became Oxford's turn to appoint somebody. And it should obviously become noted.
I think probably it was David Brock that I talked a bit about the GMC and the fact that,
you know, this was one of the things the MWF was interested in and.
Anyway, to story for Dave, David was all asked me to go on behalf of the universities to the Jamesy, right.
So I was in a strange position then, having been a registrar in Cambridge and done my time at Oxford,
that I then had a joint appointment both from the Senate, Cambridge University and the council.
And did you have to report to the universities in any way?
I used to. I used to do an informal report back in Oxford because I could make people talk.
But I did send a little written report back to Cambridge. It was Keith Peters who was the that.
And I'd worked with Keith at the hospital, but that was quite useful.
Getting back to the early days. Did you think gender discrimination was a big issue at the student level in Oxford when I came here?
I was not aware of it.
I mean, it it's again, it's very strange looking back, because now that the intake is, if anything, slightly in favour of women rather than men.
But, you know, if you're looking at hospital staff or general practises, you know, there are as many women around practising as men.
But certainly in my early years, I was quite used to being the only woman in a group of men.
And it it was quite lonely and isolated sort of existence.
I mean, you just must have found. Yes. But, you know, I think that you of you were obviously 40.
There were at every stage of my career, I was very lucky to have male colleagues who were supportive of my position.
And I got a circle of women friends, most of whom inevitably were doctors, just because, well, that was a World War I was working in.
And the S.H. registrar appointment, did you think there was gender discrimination?
I think that's a difficult one to answer. I think as one got more severe and I was certainly aware of this on appointments committees.
There was a tendency sometimes of some of the men still not to be happy with the idea of appointing a woman called,
um, without saying which hospital it occurred.
I can tell you that I was on an appointments committee for a senior gynaecology post in an establishment with no women biotechnologists.
And there was considerable opposition to appointing a woman amongst the other people on the appointments committee.
I think that was the most florid example I ever encountered.
But by and large, in Oxford, I thought that the problem was more one of encouraging the women to think that they could play a role,
because we've had some very able women.
And as you've said, we've had a number of women as director of technical studies since I went into the medical school office,
you know, who've done a very good job and really done what was necessary.
Do you think there is racial discrimination and appointments, etc.?
Registrar. I think that's what I would find very difficult to handle.
I was not aware. In Oxford of many non-white long British colleagues, on the other hand, I worked with a few who've been.
Senior and very distinguished, and you mentioned Jack Society, for example,
and Jack was superb and obviously excellent to what he did and his career has reflected that.
Um. But I think that somebody will have to ask them whether they had felt that they were being discriminated against.
I suspect at times they may have felt a bit what I felt,
which was that they were a bit isolated and a bit lonely and could have done with a bit more support.
It's very easy if one is banging the drum and not many other people are,
that you've become the eccentric rather than perhaps what you're saying is common sense.
And I didn't feel that often, but one just got the feeling occasionally.
Do you think the male students need counselling or do they get enough money with what I read, if there's trouble that they get looked after?
During the time I was in the medical school offices,
I certainly had quite a few male students coming to me for advice and just personal conversations.
One colleague. Both of whose parents died, for example, while he was a medical student.
I got to know very well and still keep in touch with us.
I mean, he's now happily married with his own family, but it was obviously for him a fairly.
Meaningful relationship. I became very aware that because we have a slightly higher proportion of clinical medical students in Oxford who are older,
you know, because they've done high degrees often before they come out doing their critical mass and.
There was two to be quite a high. And a surprisingly high bereavement rate,
I think I worked out that something over 20 percent of the students lose a first degree relative during the three years they're a student.
This is either a parent or a sibling. Occasionally this and that.
That came to me is completely I hadn't expected movement counselling to be part of my role in the medical school.
So what research did you go on to after the haematologists?
Well, the the work that really started through until I got on to the medical school work.
And I suppose that to some extent, although I was still actively looking for folks with the alcoholics and still
with Jeremy Shravan at that stage at the haemochromatosis and the genetics,
we got much more onto the educational side and I became much more interested in the curriculum development and the skills training.
So was there another liver consultant? Liver disease? By that stage there wasn't a liver consultant as such.
There was still initially only Derek and myself as the two gastro consultants.
But then Dr. Chapman was appointed, having been our senior registrar,
and Roger was very happy to involve himself more with Liverpool Plains and and obviously maintain that side of it.
I kept a small number of my patients that while I was in the medical school office, I still had a full and active clinical practise.
But once I was on the GMC,
I recognised that it was slightly irrational to have a acute inpatient practise in Oxford and be more than 50 miles away in London.
It was verging on the irresponsible. So I asked if I could hand over my impatient practise and that was where for
a while Jack Zigzaggy took over my practise and he did it for about a year.
In fact, Jack had worked with me and we got on very well and he used, you know,
he quite often rang me up and asked me about things and still talked about things.
But he was notionally acting as the only consultant.
And the other person who did something similar was William Rosenberg, who subsequently went down to Southampton as a consultant hepatologist.
So both of those two acted, as it were, as my locum while I was otherwise involved.
I kept up. I stopped my inpatient practise when I was 60.
I decided that was not unreasonable to stop getting up a lot in the middle of the night and, um,
but kept my outpatient practise going initially to clinics a week and then latterly just once a week.
And I used to see the patients who I had known for many years.
I kept a group of about 200 who I looked after for sometimes a decade or more, who knew that they could always ask for help.
And they understand they were all told quite clearly that if they needed an inpatient admission, I would hand them over.
And that was the day for Giancola. I was appointed and took over the.
I just don't think the cardinals are demanding of time as the Medical Women's Federation championship when I was doing it initially,
really not, I was probably in London about once a month for half a day off and into the evening.
I mean, we would arrange all council meetings so that people could work a morning and then come up.
And it took a lot more in the way of evenings and weekend work, I guess.
I mean, I. By that stage, my children were older.
I got time to do other things and I was involved, you know, doing things in what might be regarded as my own time, if you like, um.
The other thing that I took on at about that time, initially when it was still in prison,
was that I was on the prison board for a while, something over 25 years in the air.
But the Oxford prison, I started with the Oxford Prison. I mean, the cynics said it was because I wanted free parking in the central box.
But actually, it was a fascinating subset of society, many of whom were by patients,
because I thought that I was going in there because my Marignac and the first time I appeared in the witness box in prison,
I heard a voice shouting to trial. What about the day and everything?
I could go to that particular represented amongst the alcoholics or not.
I've looked after some of the senior academics, undoubtedly so, but whether it was a high risk activity, I'm not sure.
I mean, certainly the top risk without any doubt for Republicans.
Right? I think I could probably put a flag for every single pub in Oxfordshire and Ordnance Survey map,
having looked after a public in there at some stage or other in my career. But the.
Oxford, certain senior Oxford servants had quite a high incidence college,
is it because they could finish off whatever was left and nobody asked too many questions?
But no, I mean, I had a number of academics and Scots college students because that's the nature of the Oxford population.
But it was probably a reasonable cross-section of others in the 70s, living in somebody overseas with a great diagnosis.
We don't have to say something about epidemiology and the management as you go through your career.
Well, I was trained to look after them by Sheila Sherlocks unit and was a housemate and has such an effect on the unit that did the operating.
So I knew quite a lot about the perioperative care. But the I mean, the epidemiology is,
is that people with severe liver disease will bleed from their varices and it's
serious and can be lethal if it's if it is accompanied by a degree of liver failure.
And such as with the alcoholics who were present with epigastric started bleeding from viruses,
it's probably carried something like a 25 percent mortality on the first hospital admission.
You know, if the patient was jaundiced at the time they came in. So it's it's a condition that has a poor outlook,
but it's one that if people are treated energetically and properly and it really does require sometimes 10 or more units of blood,
a lot of blood, it can be controlled.
Sometimes it requires acute surgery. And that was where having a group of surgeons who were willing to take on these people was very helpful.
Initially, the approach to the oesophagus was with trans abdominal fat,
and that led to a lot of complications with fistulas and intestinal leaks and leaking itis, which doesn't suit the patients at all.
And that a particularly good like Kettlewell, he would do some economists and approach the oesophagus directly, which actually,
although it sounds more horrific operation had a much lower mortality rate and they did quite well with his skilled care if the patient survived.
They have as good a chance as anybody else. If they stop drinking, if that's the aetiology.
I mean, the ones who didn't do well with, for example, the celiacs who got basically no,
they not be out of the HIV and the bleeding disorder and that they were really in a bad way.
Did it become less frequent with time or was it just they were being siphoned off into a special unit?
I don't think it became any less true, but I think the incidence has increased or decreased during.
What should I have asked you about? What would you like to say?
I don't know whether the university wants to know anything about what I did, the GFC or not.
Is this it? Well, I did a decade on the GFC and I did a variety of posts that I found it very interesting.
I was on the education committee and I found it particularly interesting to have
the privilege of getting around several other medical schools as an inspector.
And seeing how they handled problems and situations that we were only too familiar with, because, you know, that common diseases,
these sort of issues occur across the board, so that that was an interesting aspect of the work that I did with them.
And this was by this stage, I had given up my inpatient practise.
But as an active member of the GMC, I was also invited fairly soon after I joined actually to become a primary screener for Complaint's.
And I must have looked at about 5000 complaints over the decade that I was on the GMC and our job was really merely to say whether this was an issue,
which prima facie it looked as if there might be a problem that needed to be looked at further.
Um, we probably closed something like four fifths of the complaints we looked at and then they would go all through a process.
I did that job through the first three years. I was there three or four years.
And then when the council was reconstituted and I was part of the working group that devised the governance for the new much smaller agency.
I had we had abolished the idea of appointed members by that I had to stand for election,
but I was elected, I think I'd become notorious enough by that.
And that was very interesting because it was during the period that the medical profession was under a lot of media criticism
and really around the period of the problem with the neonatal paediatric surgery in Bristol and how Shipman's problems.
And almost every day they would be very anti medical newspaper cuttings, I'm sure you remember it,
and we were under close scrutiny as counsel and had to, I think,
think fairly fast about our own fitness to practise processes and what they were about.
And I think a certain amount of the sort of intellectual and academic rigour that I had been trained in.
It was very helpful there in trying to look at really what we were there for and what the purpose of the organisation was.
And in working towards rebuilding the respect of the medical profession and public confidence in the medical profession,
one has to look at patient safety and the issue of colleagues who,
for whatever reason, are perhaps falling below the standards that we would regard as generally profession that required,
um, it enabled us to completely rewrite a new set of fitness practise processes.
And I think I had never expected when I qualified as a doctor, to spend as much time with barristers and politicians as I spent with patients.
But it was an interesting insight into how one draughted acts of parliament generally change statutes around professional governance.
And I chaired the first practise committee that that brought all that into being.
And we were really of a race against time because we managed to not only devise it,
but get it through parliament and implemented in practise a good two months before then,
John Smith produced her voluminous reports on the shipment limits.
So it at least, I think, allowed us the credibility of say, we realise there have been problems, but they've been very actively addressed.
I think the world is not a perfect place, and as long as we have a profession,
we're going to have people in the profession who probably shouldn't be there. Just as you know, as an academic,
we have historically always weeded people out for academic reasons who couldn't cope with with the level of the academic requirements.
I think we have to look at their personality requirements and whether they're
able to maintain the personal standards that are required of doctors as well.
Do you think the smaller Jamesy is an advantage? It allowed it to operate much more as a.
Structure board and sort of governance terms, the bigger GMC didn't really do it in the in the in the policy making sense.
The if it had a plethora of small subcommittees,
but the main function of GNC members was to sit on fitness to practise hearings as the sort of judge and jury, as an expert panel.
And I've done a certain amount of that during my time there. And it's quite interesting.
And I was based on what we call the conduct hearings, which were the people whose behaviour had been publicly a disgrace to the profession.
But I was also on the performance panels,
which looked at whether people are kept up to date and whether their standards of professional practise were acceptable to the rest of us.
And that was a very complex set of assessments that were devised for the GMC,
looking at people whose practise standards were poor and believe you me, the ones that came to us were very poor.
I mean, you know, there's no doubt at all that the shock horror element was really quite strong and that
I was peripherally also involved with the health committee with six doctors who also,
particularly if they're addicted to drugs or alcohol or have mental health problems, can become a risk to patients.
And we have to incorporate all of those in our new hearings and structures.
So I think that the GMC had functioned really as a source for panel members and the new GMC has become very much more
attractive sort of board with a combined role as trustees of a charity and also the board over at a public order.
Yes. Which would you leave the GMC? I left roughly when I left when I was very nearly 60,
some said would be 90 at 2008 and which year to do so up in Oxford Hospital, I had I had stopped in the September.
My academic appointment came to a conclusion in September of the year that I retired from the GMC at the end of December.
Yes. So I only did three months after I had completed stopped to person.
Inquisitive questions. Yes. Which you don't have the answer. You mentioned Stan show that when I was a medical student at the middle.
Yes. And I mean, what did you think of him? And do you think he was hard done by or did he get what he deserved?
He was a difficult case. Yes, he was a very difficult character.
But ironically, at the time that he was introducing his renal dialysis, he did initially meet a lot of opposition.
And ironically, like a number of difficult,
difficult characters I've encountered throughout my career and what they were standing up for is now accepted as the norm.
You know, and in a way, one wonders whether people who weren't difficult characters would have made those pioneering.
Processes. But he was at and I was in I mean, I was a student, I was incredibly junior at that stage,
so I was very much just an observer of the political machinations, but a bit like one or two characters who I'm sure you could name here.
You know, they get preferred lives by their colleagues just because they're too hot to handle, too difficult.
And for the gym and I of it, then I get to.
Jim. I think was somebody who was a very sound academic and whose work I think has stood the test of time.
I think he found finding a clinical role and a clinical niche very much harder.
And I think he never felt the Oxford had given him the credibility.
He deserved it. Robert, I think.
Was also somebody whose academic work has stood the test of time and again,
I found it very difficult both to involve himself with the patient end of things and.
Had very few students or colleagues, probably perhaps you didn't find that because you were working closely with it,
but he was much more interested in the physiology and biochemistry.
I suspect the patient and these people have that place in that unit and make very real contributions.
One of the skills of the Oxford faculty has been to actually contain them somehow and find the muscle to.
I'm not sure what would Robert have gone to do if he hadn't died so tragically and suddenly, I don't know, um,
he'd have gone on mainly with the epidemiology of diabetes and management trials, comparing one man with another, I think.
And he would go on doing clinical medicine for which every now and then he, I thought, had real involvement and flair.
You see, he was the the right hand man to David whether when he first came.
And I'm sure he handled that pretty well. I've always felt that whatever I take it, that I'm sure he was a capable clinician.
Yes, I know that. Not in any way. I had questioning that.
I'm just trying to think of interest in this case.
Where is. No. And I think Jim would have welcomed a more general clinical trial in Oxford and never got into it.
Had perhaps, you know, got a bit more of that. And you see anything and anything else, because otherwise, I mean, at the end of the top of my head,
I think you've covered most of the things that I would that I would like to have talked about.
I've been very lucky, I think, looking back to have had the role I've had and a career that's progressed and
been so diverse and has given me so many expanding and different interests,
I suppose what I should just mention is that, of course, it's just at the time I retired and was the leaving the GMC,
I took on for six years chairing the trustees for the Royal Medical Benevolent Retirement, and I've just handed that over.
I actually have just become a lady of leisure.
And that has been fascinating and in a strange way has has built on both my professional interests clinically and the work I did with the GMC.
Because the Dramatical Benevolent Fund over, gosh, what is it now?
One hundred and seventy seven years has provided Stocklands for doctors who get into financial difficulties and has been
largely supported by doctors and their families and looks after doctors and their families who get into difficulties.
I mean,
last year we looked after we gave money to something over 350 individuals and we had an age range that went from the neonatal to one hundred one.
Now, initially, it was doctors who became ill and didn't have pensions before the NHS.
Now, rather sadly, it is much younger doctors who come to us because with the fragmentation of the health service and the fact that people
have gone back to having the very short contracts of employment that perhaps we recognised from our early years,
and we thought that somehow it got out of the health service and come back again and people can be ill while working for one trust.
And when that rotation takes them to another trust, find themselves unemployed because the other trust won't take the form of.
It's a it's a it's a fund that has, over the nearly two centuries it's been in existence, got substantial financial resources.
I mean. Nearly 70 percent of the money we give away and it has a budget of well over a million pounds a year and more than 60 percent of that is from,
uh, interest on our investments, even with the low interest rates at the present time.
And to have that resource, I think, is something that the profession should be kept aware of because the great many groups have got it as well,
set up and organised, and it's a lovely bunch of people.
Again, it's taken me working with people all over the country.
And when I started as chairman, Barry Jackson, who would be president of the College of Surgeons, was the president.
And more latterly, Dave Detriot has been our president.
It's an organisation which, again, had to dig itself out of the past because the charity commission got interested in the
structure of the National Benevolent Funds and wanted to abolish all charitable status,
which we didn't think was a very good idea. So we had to very rapidly dig out our legal credentials.
And I discovered that we were operating in 2010 on.
Legal documents that have been devised in my team and which had terms like pecuniary necessity for supporting people,
we've got the SEC having redraughted acts of parliament for the GMC.
We draughted all the articles that would be in your hand.
Well, we give away just short of a million pounds. Yes.
So it's a significant sum of money. And about a third of this is still collected and donated.
You know, quite a lot of it comes to standing orders and things.
That's what we'd like people to do, because that's in the contemporary world, how those people give to charity.
But we also have an annual appeal at a number of parts of the country, still run social events where the support comes due.
And I got the impression that if you'd formed a considered opinion, you were never loath to declare it in a discussion.
And where how far back in your life do you think?
I've always been outspoken. So I said certainly considered in there.
You didn't hide it under a bushel, I think, but I.
I think from being quite a young schoolgirl, I learnt that if I could.
The reason something. And it had any sort of logic behind it and was not.
Immoral, illegal, or totally off the wall? It was worth expressing at.
I think that I've had the opportunity of working in fairly liberal academic environments where to be somewhat of a
nonconformist over things or being prepared to express a contrary point of view wasn't a reason for ostracise against it.
And I suppose that may have encouraged me to continue to express my views.
And that's a super interview. Thank you very much indeed for that. Thank you.
Because coming.