Making Australian Doctors
Monday 3 March 1862, was an auspicious day for Melbourne. At two o’clock, the city’s health officer and analytical chemist, John Macadam, in his new role as university lecturer, delivered an introductory lecture in chemistry to three young men in the city’s Chemical Laboratory situated at the rear of the Public Library: the first formal lesson to be given to medical students in Australia.
The students, William Carey Rees, Patrick Moloney and Alexander Mackie, each paid £6 6s for their chemistry tuition, the other subjects of the first year’s course being delivered free to matriculated students.
That the three young men were not the only ones gathered there to hear what Macadam had to say is significant. The room also held many of Melbourne’s medical practitioners, much concerned that the burgeoning city should educate its own doctors who, acutely aware of the weight of this occasion, attended, signifying their support for this long conceived but newborn child of Melbourne’s own university.
The city itself was only 27 years old but the discovery of gold in Victoria had prompted a premature adolescence. Melbourne’s population grew from 80,000 to 125,000 in 10 years. The pace of change outstripped Melbourne’s pretension to civic amenity, that grand, deliberate grid-work of streets, as tightly crammed boarding houses and public hotels overtook and overshadowed other buildings. In winter, Melbourne was a swampy mess, its streets turned to rivers of mud; in summer the hot north winds blew dust through door-cracks, filling eyes and noses with dirt. Lack of drainage throughout the city was a daily menace and sanitation almost non-existent. Canvas slums thrown up by shiploads of immigrants pursuing wealth littered the outskirts of the city. People bathed in and drew water from the river notwithstanding its reputation as a running sewer.
As Dr RT Tracy, President of the Medical Society of Victoria noted, in the Australian Medical Journal in 1861, ‘the maladies which infest large cities where sanitary regulations are to a lamentable extent non-existent [were] becoming permanent residents’. Major causes of death were infectious diseases: typhoid fever, typhus, measles, but most commonly dysentery and gastroenteritis. Even for patients able to afford a doctor, effective cures for most things that ailed them were unlikely.
According to medical historian Dr James Bradley, orthodox medical theories of the day were still unclear about the causes of most disease. Inflammation was popularly blamed for much illness and treatments prescribed included cooling or warming baths and dietary changes to stimulate or calm the patient’s system. One of the most critical clinical skills doctors exercised was their judgement of when a patient’s case was beyond hope, communicating this to the patient’s family, and with them deciding whether the patient also should be informed.
The Gold Rush had pushed Melbourne to its limits yet the city was optimistic, not least in its vision of what it was to become. The University of Melbourne had set down roots just north of the city in 1854. The city had also recently built the public library, a museum, the city baths, the post office, a railway, and had begun work on its own Houses of Parliament.
The University and the local medical establishment agreed that a medical school in Melbourne was necessary. Sending children abroad to study was expensive, parents worried about exposing their unchaperoned boys to the excesses of European society and many doubted that overseas training would produce doctors competent to deal with the diseases peculiar to local conditions.
Repeated appeals by the University for the government to include funding for a medical school in its annual budget were met with faint words of encouragement but no financial support. Perhaps the construction of so many public facilities had drained the public purse.
The dogged persistence of Dr Anthony Brownless, who arrived in Melbourne in 1852 and was elected to the University Council in 1855, was largely responsible for that well-attended chemistry lecture in 1862. Undaunted by the government’s recalcitrance, the University found from within its own budget the means to begin the school. The University’s annual report for 1861-62 reports that expenditure on the grounds would be much reduced and two lecturers from law and one from engineering ‘cheerfully acquiesced’ in a reduction to their salaries so that the medical school ‘being called for by the interests of the University and of the public’ could proceed.
Ensuring the quality of medical practice was also an issue. In its early versions, the Medical Act recognised a broadly unspecific range of qualifications. In the newspapers and law courts, battles over allegations of malpractice, exorbitant fees and professional disputes between Melbourne’s medical practitioners were commonplace. It is significant that bills passed by the Victorian Parliament in 1862, following the opening of the medical school, were the Anatomy Bill, allowing for the legal dissection of human cadavers, and amendments to the Medical Practitioners Act limiting admission to medical registration to graduates of at least three years’ training.
The codification of knowledge was a strong theme of 19th century scholarship. A professionalisation of science corresponded with a move away from an apprenticeship model of medical education to a more formal, academic model.
Major advances in medical science made a profound impact on medical practice as the 19th century progressed: vaccination, anaesthesia, germ theory and its corollary antisepsis, the study of cellular pathology made possible by advances in microscopy and, late in the century, the discovery of x-rays.
For Brownless, buoyed on the century’s scientific and scholastic tide, the opportunity to design a course that would set a new standard in medical education was compelling. He designed the medical curriculum to avoid the errors he saw in the old style of medical teaching, by fixing a five-year course – two years more than the norm. The Medical Society of Victoria protested at the length of the course but Brownless insisted, the curriculum was upheld, and some 30 years later Britain mandated a five-year course as the requirement for entry to medical practice.
This year, the Melbourne Medical School celebrates its 150th anniversary: a good time to pause and consider what the school’s founders would think about the medical challenges our current graduates and students face.
Just as in the 19th century, the health of individuals is still influenced by a complex interaction between their unique inheritance and their environment and by their doctors’ scientific understanding about this complex interplay of mechanisms and the practical skills they apply to intervention and prevention.
When Rob Moodie graduated in medicine in 1976, road trauma, cancer and cardiac disease featured largely throughout his internship in Albury. Professor of Public Health and former Chair of the National Preventative Health Taskforce, he sees non-communicable diseases as the biggest health issues for the foreseeable future. For local communities these include ‘all the conditions resulting from our modern lifestyle – tobacco, harmful consumption of alcohol and an ageing population, diabetes, cancer, cardiovascular disease, obesity, and dementia’.
International health challenges will still involve infectious diseases to a large extent – tuberculosis, HIV, malaria and the neglected tropical diseases in sub-Saharan Africa – but as regulation makes life increasingly uncomfortable for global food, alcohol and tobacco companies, they move into deregulated countries, adding to the burden of disease in developing societies. In addition, the ravages of war continue to extract a terrible toll on vast populations across the globe.
“War not only kills people but it ruins infrastructure,” Professor Moodie says.
For Geoff Donnan, Professor of Neurology and Director of Florey Neuroscience Institutes and a 1972 medical graduate, the challenges we all face as we get older are writ large on the future.
“With an ageing population we face an emerging epidemic of brain disorders: stroke, Parkinson’s disease, Alzheimer’s and other neurodegenerative conditions. Medical practitioners of the future will be crucial players within the wider community, destined to deal with this issue.”
Professor Donnan is also hopeful that improved treatment of psychiatric disorders – “such a blight on our community” – will be possible through greatly increased understanding of the basic mechanisms of these conditions.
Fellow 1972 medical graduate Jim Bishop AO, Professor of Cancer Medicine and Executive Director of the Victorian Comprehensive Cancer Centre, foresees more people living with cancer, which their doctors will manage “like a chronic disease”.
Just as the microscope became the quintessential tool of medical science in the 20th century, he describes genomics as “the new tool of medicine for the 21st century.”
Eminent immunologist and global health expert Professor Emeritus Sir Gustav Nossal, AC CBE, is confident that future medical students will have better tools to fight disease and the development of new vaccines will be a key to that future. He also warns of a new, non-communicable pandemic.
“While developing countries are still fighting AIDS, malaria and TB, they will encounter unprecedented levels of obesity, diabetes and cardiovascular disease. As communities move from agrarian to urban lifestyles, so these diseases will follow them,” Sir Gustav says.
He also sees mental health and issues in Indigenous health, caused in part by remoteness, as other challenges.
“None of these problems is insurmountable however,” he says. “I have great respect for Gen Y and the idealism they demonstrate.”
When Jane Gunn, 1987 graduate, general practitioner and Professor of Primary Care Research trained, specialisation was increasing along with a concurrent rise in health expenditure. She has experienced the growing complexity of the work GPs do and their growing role in health promotion and preventive medicine. Specialisation has seen the general physician and surgeon almost disappear, at least in the large cities. She notes the increasing importance of the generalist primary physician in meeting the needs of the ageing population.
“Personalised medicine will require the GP of the future to interpret genomic risk profiling as it becomes the norm,” says Professor Gunn.
In educating medical students to meet these health challenges in the future, the priorities of 1862 still echo through the years. The first medical school building was not completed until 1864 and ensuring the best possible facilities requires constant review and renewal.
The school’s first professor, George Halford, was described as ‘one of the most distinguished experimental physiologists of the day’. Today, the integral role played by researchers across the school, and the many close research partnerships fostered within and outside the University, resonate in the MD program in which students learn first-hand the relevance of research to practice.
In the 1860s a medical school would never have been considered without student access to the Melbourne Hospital. A quality clinical experience still relies on the staff of teaching hospitals, general practices and community health services to demonstrate, counsel and endlessly teach students as part of their daily activities.
Realising the promise of those early medical education pioneers remains a challenge to the Melbourne Medical Schoo – a challenge the school greets with all the optimism of 1862 as it determines to graduate doctors equipped to manage the changing 21st century health landscape, addressing the individual health needs of their patients and their communities, here and across the world.