APRIL 18, 1974
Toward Commonwealth Unity through the Sims Travelling Professorship
AN ADDRESS BY
Robert B. Salter, M.D., M.S., F.R.C.S. (C), F.A.C.S.,
SURGEON-IN-CHIEF, HOSPITAL FOR SICK CHILDREN; PROFESSOR, DEPARTMENT OF SURGERY, UNIVERSITY OF TORONTO
CHAIRMAN The President,
Robert L. Armstrong
Mr. Consul General, distinguished guests, ladies and gentlemen: The Constitution of The Empire Club of Canada appears in each issue of the Year Book. The present Constitution states in part that the purpose and object of the Club is to promote the interests of Canada and the British Commonwealth by the consideration and discussion of subjects and events relating thereto and by any other means appropriate to the facilities of the Club.
The message which we are to receive from our guest of honour today represents in classic tradition the purpose of the Club, since his address is entitled "Toward Commmonwealth Unity through the Sims Professorship".
Dr. Robert B. Salter, whose honours and awards literally fill pages, is Surgeon-in-Chief at the Hospital for Sick Children and Professor of Surgery at the University of Toronto. He will report to us on his tour as the 1973 Sir Arthur Sims Commonwealth Travelling Professor. His appointment to the Sims Professorship by the Royal College of Surgeons of England represents one of the highest academic honours in the Commonwealth. It carries responsibility in diplomacy and international relations in addition to teaching. The Professorship was endowed in 1946 by the late Sir Arthur Sims with the objective of establishing "closer links between scientific workers in the Commonwealth and in the older seats of learning and centres of research for the benefit of people of all nations and a contribution to Commonwealth Unity". And who more qualified to fulfil this objective than the internationally renowned orthopaedic surgeonscientist-teacher who graces our meeting with his presence today.
Dr. Salter, a seventh-generation Canadian, was born in Stratford, Ontario, and received his secondary school and University education in Toronto, graduating with the degree of M.D. in 1947. His graduate training included internship at Toronto Western Hospital, Grenfell Mission Hospital in Newfoundland, the Gallie Course in Surgery, Toronto Western Hospital, the Hospital for Sick Children and Sunnybrook Hospital, Toronto, and the McLaughlin Travelling Fellowship, the London Hospital, London, England. His postgraduate qualifications include Master of Surgery, and Fellowships in several Royal and other Colleges of Surgeons. His theses, scientific papers and books are legion.
The caduceus, the herald's wand, which symbolizes to us the physician, was the attribute of Hermes, god of commerce and peace among the Greeks. It was the distinctive mark of heralds and ambassadors whose persons it rendered inviolable. Dr. Harold Cranfield, an illustrious Past President of this Club, who persuaded our guest of honour to address the Club, may place a different interpretation on the mythological and historical significance of the symbol of healing, but I like to think the description I have attempted to give is appropriate on this occasion.
Dr. Salter's Convocation address to the annual meeting of the Royal College of Physicians and Surgeons of Canada in January 1973 was entitled, "Unto Whomsoever Much Has Been Given, Of Him Shall be Much Required". This philosophy together with the theme of the Hippocratic Oath, especially the portion "I will impart this art by precept, by lecture and by every mode of teaching" exemplify his high professional standards. He is the epitome of Hippocrates and the antithesis of hypocrisy.
Dr. Salter is active in the propagation of early Canadian history and has taken great pride in the restoration of a Canadian pioneer log house in the country. He may be seen driving his favourite 1949 Allard topless sports car about Toronto.
Ladies and gentlemen, it is a distinct privilege to present to you Dr. Robert B. Salter.
Mr. President, Mr. Minister, Mr. Consul General, other distinguished guests, members of the Empire Club of Canada, ladies and gentlemen: Thank you Mr. Armstrong for your complimentary introduction. The occasional compliment probably doesn't do any of us much harm -provided that we don't inhale! Thank you, also, for inviting a spiritual companion of mine-Canon Arthur Chote-to say Grace on this occasion. I am cognisant of the traditional excellence of the introductions of speakers by Empire Club Presidents-an excellence that presumably each speaker from this renowned rostrum is challenged to match!
It is an honour to have been invited by your President to address the prestigious Empire Club of Canada. The invitation was initiated, however, by one of your illustrious Past Presidents, Dr. Harold Cranfield, a long-time personal friend and medical colleague for whom I have such great respect that I really had no choice but to accept and indeed was pleased to do so. Dr. Cranfield graciously gave me a bound volume of The Empire Club Addresses 1970-71, that is, those delivered during his Presidency, and as a potential speaker to this Club I found these addresses particularly stimulating and even awe-inspiring! The fact that since 1970, bound volumes of the Empire Club Addresses have been presented annually to every Secondary School Library and every Public Library across the Dominion of Canada is a tribute to the generosity and farsightedness of those among you who have created the Empire Club Foundation-and in particular, the late Mr. John Corrigan who was also a Canadian leader in "World Literacy".
The choice of subject for my address merits explanation. When Dr. Cranfield suggested to the President that I address you he was aware that I had recently returned from a four-month teaching assignment as a Visiting Professor in universities throughout the United Kingdom and South Africa. He felt that some aspects of this assignment would be of interest to you in view of your abiding enthusiasm about Commonwealth affairs-an enthusiasm that is well documented in your publications.
In an excerpt from the Empire Club Year Book of 1903 one reads that: "The Chairman in a brief speech pointed to the desirability of an organization following the plan of weekly meetings, to be addressed by prominent men, or men speaking with authority upon issues of the day, and having also a distinctive basis of British Unity in its work and policy." In lighter vein, since this statement would almost seem to mean either prominent men or men speaking with authority, any invited speaker can only hope that these two criteria are not mutually exclusive!
In the 1967 Amendment of the Empire Club's Constitution one reads that the "purpose and object of the club is to promote the interests of Canada and the British Commonwealth by the consideration and discussion of subjects and events relating thereto". Although all of you are familiar with these statements I repeat them to put this address in perspective.
Speaking firstly of Canada, I wonder how many Canadians are aware that the name of our country arose from an instance of mistaken identity. While an Indian Chief called Donnacona was showing Jacques Cartier his village-near the present site of Quebec City-he used the word Kanatta, an Iroquois word meaning a collection of huts. Cartier mistakenly assumed than this was the Indian name for the entire country and he entered his own spelling of the name- Canada -in his records. This instance of mistaken identity, however, does not justify the confusion among many in our country about our Canadian identity. Fortunately, the "identity crisis" for many Canadians, and our previous national inferiority complex were overcome by our Centennial Celebrations as we came to appreciate that the only justification for a national inferiority complex would, in fact, be a national inferiority-an inferiority as yet unproven.
Because of your dual allegiance to Canada and the Commonwealth I have chosen to speak on the subject of "Commonwealth Unity Through the Sims Travelling Professorship". But first a few definitions, for as Voltaire has said, "if you wish to converse with me, define your terms".
The Commonwealth, being unique, almost defies definition. As you know, it is not really the successor to the British Empire, but rather it is a completely voluntary, international association of thirty-three self-governing nations of diverse races, religions, economies and political systems. Each and every one of these nations, having gained their independence from the British Empire, chose to be members of the Commonwealth because they felt that they shared common principles and goals. In this vast association, which comprises one quarter of the world's population, there is, in effect, neither central authority, nor political structure and yet all thirty-three nations recognize Her Majesty the Queen of England as Head of the Commonwealth.
And so, among the Commonwealth nations, competition has given way to communication. No longer can one Commonwealth nation say "Hurrah for our side" except, of course, in Commonwealth Games. The expression "Hurrah for our side", by the way, did not originate as you might have thought from the playing fields of Rugby and Eton but rather from a group of bystanders in Coventry-when Lady Godiva rode side-saddle down the main street!
It is of interest that the term commonwealth is derived from the medieval English word "commonweal" which means common well-being. Thus it is not surprising that the developed member nations of the Commonwealth-such as the United Kingdom, Canada, Australia and New Zealand-have provided substantial aid for the less well-developed member nations, such as those in Asia, Africa and the Caribbean.
What do we mean by Commonwealth Unity? Obviously we do not mean oneness or uniformity in all matters within the entire Commonwealth for such can lead only to mediocrity. Perhaps what we should be striving toward is the concept that epitomizes the ecumenical movement in our churches-six simple words that say it all-"In essentials, unity; in nonessentials, charity."
Continuing with our definitions let us look at the term Travelling Professor which is synonymous with Visiting Professor and which is sometimes referred to in our current age of air travel as "Airport Professor". It used to be said that Professors were those persons who went to university-and never got out! Actually, many Professors do get out, at least from time to time, as a Visiting Professor, namely "one who is invited to teach and share ideas in another university for a limited period".
The concept of a Visiting Professor is, by its very nature, limited to those fields of endeavour that are not competitive in a financial sense-fields such as the Humanities and Sciences, including the Health Sciences. Indeed, medicine is the only profession that labours incessantly-through research and preventive measures-to destroy the very reason for its own existence.
When a Visiting Professor of Surgery teaches in another university he is expected to share his knowledge and experience freely and completely with his colleagues, to elucidate his latest research work and to explain his newly-developed techniques of surgical treatment. There can never by any place for "trade secrets" or "classified information" within the medical profession, whereas such are an accepted part of commercial competition in business and industry. For example, it would be unthinkable for an industrial research engineer from a corporation such as General Motors to go to Britain as a "visiting engineer" to share his latest industrial research with his counterparts in Leyland Motors-or go to Germany to discuss his company's "trade secrets" with his competitors in Mercedes Benz.
In developing an understanding between people of various countries there is nothing quite so effective as visiting one another-of meeting face to face to discuss mutual problems in the spirit of mutual benefit. Nothing is so helpful in overcoming prejudice as first-hand knowledge; indeed prejudice has been defined as "being down on something we are not up on".
This is why the concept of a Travelling or Visiting Professor has become so effective in strengthening the bonds between individuals and institutions of various countries.
Such international visits are facilitated by our jet-paced world in which it is possible to have one's breakfast in Toronto, lunch in London, dinner in Rome-and one's baggage in Bierut!
What is the significance of the name Sims in the title of this address? The late Sir Arthur Sims was a New Zealand-born industrialist and philanthropist who spent much of his business career in England. In 1946, motivated by his enthusiastic support of the Commonwealth, he donated money to the Royal College of Surgeons of England to establish a Commonwealth Travelling Professorship. The Royal College-in appreciation of Sir Arthur's munificence-named it the Sims Commonwealth Travelling Professorship.
The objects of the Sims Professorship, as stated in the Royal College Notes for Newly Appointed Professors are: "the establishment of closer links between scientific workers in the Commonwealth and in the older seats of learning and centres of research; the benefit thereby of the people of all nations; and a contribution to Commonwealth unity". You will have noticed from this statement of objects that although "a contribution to Commonwealth unity" was considered to be a prime object, an equally important object was "the benefit thereby of the people of all nations": and this is as it should be since medicine must be ubiquitous. The stated duties include the following: "The Professor is required to travel from his own University to other parts of the Commonwealth for the purpose of assisting in the advancement of medical science by lecturing, teaching or engaging in research. The duty is ambassadorial as well as academic." The usual tour of duty is approximately four months.
Since 1946 a total of forty-five Sims Commonwealth Professors have been appointed from among the various medical and surgical specialties in the broad field of medicine. Over half of these Professors have been from the United Kingdom, the remainder having been from Australia, New Zealand and Canada. At this point you may be wondering just how the Sims Travelling Professor is selected. Every year, each of the Commonwealth Colleges of Physicians and Colleges of Surgeons proposes the name of one or more candidates from its College to the Sims Advisory Board which is composed of the Presidents of six of the Commonwealth Colleges. It is this rather impressive international Advisory Board that makes the selection.
Of the forty-four previous Sims Commonwealth Travelling Professors, seven have been fellow Canadians and I am pleased to have this opportunity to pay tribute to them. They are: Robert B. Kerr, Vancouver, a physician; Walter C. MacKenzie, Edmonton, a surgeon; Angus D. McLachlin, London, a surgeon; the late Robert I. Harris, Toronto, an orthopaedic surgeon; the late Robert M. Janes, Toronto, a surgeon; A. Laurence Chute, Toronto, a paediatrician, and Jacques Genest, Montreal, a medical scientist. Since only three of the previous forty-four Sims Professors had been orthopaedic surgeons, and since each of these men took up their Professorship in Commonwealth countries outside the United Kingdom, it was my privilege to be the first orthopaedic surgeon to serve in the United Kingdom in this capacity.
The invitation to accept this arduous academic commitment came well over a year before it was to begin and this "leadtime" was most helpful because of the number of arrangements that had to be made in relation to one's responsibilities to family, to the hospital and to the university. In the Royal College Notes for Newly Appointed Professors, my wife and I were both delighted to read the following section: "The Advisory Board consider it most important that the Professor's wife should accompany him if this is humanly possible, for she can render valuable assistance in a secretarial capacity and in respect of the many social commitments involved." These, of course, are but two of the cogent reasons why the Professor and his wife should share the exhilarating experience, as well as the combined commitment, of such a remarkable tour as the Sims Commonwealth Professorship. I am pleased to have this opportunity to publicly record my indebtedness to my wife for the magnificent way in which she played her ambassadorial role throughout the four-month assignment. I agree with the adage that behind every successful man there stands a wonderful wife-and also, one might add, an astonished mother-in-law!
Our itinerary included orthopaedic centres in England, Wales, Scotland, Northern and Southern Ireland, South Africa and Rhodesia. But why, you might well ask, South Africa and Rhodesia which are no longer part of the Commonwealth? The answer is that medicine knows no geographic boundaries and must be above international political differences. Thus, from a medical and academic point of view, South Africa and Rhodesia are as much a part of the Commonwealth today as they ever were.
What is involved in the preparation for a four-month Travelling Professorship that will include academic visits to thirty-four centres? In addition to much prior correspondence with each of these centres it was necessary to prepare a total of twenty-one separate lectures-complete with teaching slides. Of these lectures, some concerned clinical conditions, some concerned surgical research and some were combined; most were for postgraduate audiences and some were for undergraduate medical students. The preparation of up-to-date manuscripts and visual aids for these twenty-one lectures was both challenging and time-consuming; indeed a total of 1,500 glass-mounted slides had to be amassed and the weight of these was seventy pounds!
Being fragile, these slides had to be carried as hand luggage in one very large suitcase and this, as you might imagine, stimulated some interesting dialogue with numerous airport officials. Each newly-appointed Sims Professor must decide upon his own personal aims and objectives-both academic and ambassadorial-based upon his particular interests and capabilities. I decided upon the following: First, the academic aims and objectives:
1. Encourage an enquiring attitude of mind.
2. Emphasize a scientific approach to orthopaedic surgery.
3. Teach and demonstrate accurate assessment of patients -and hence, accurate diagnosis.
4. Stress clinical judgment in treatment-the selection of the optimum form of treatment for a given patient as an individual.
5. Exemplify the Art of Medicine-by demonstrating concern and compassion for patients as individual human beings.
6. Demonstrate methods of teaching-both in the lecture theatre and at the bedside.
7. Invite a free exchange of ideas among colleagues.
Secondly, the ambassadorial aims and objectives:
1. Enhance the function of the various Commonwealth Surgical Colleges in their own countries.
2. Strengthen the bonds between these Surgical Colleges and the Canadian Royal College.
3. Increase the links between orthopaedic surgeons in the countries visited and orthopaedic surgeons in Canada.
4. Encourage and support the academic orthopaedic leaders in each centre.
5. Renew old friendships and establish new friendships.
During the four-month Sims Professorship I was constantly aware of serving as an overseas ambassador for many groups-the Hospital for Sick Children, the University of Toronto, the Canadian Orthopaedic Association, the Royal College of Physicians and Surgeons of Canada and, in a sense, all Canadians-all of which serves as a tremendous stimulus to perform to the best of one's ability in order to enhance the Canadian image abroad.
A brief summary of academic activities during the four-month assignment may be of interest to you. Of the thirty-four cities visited, twenty-four were university centres. Of course, in each centre, there was more than one medical institution to be visited-the total number being eighty-nine. The total number of lectures delivered over the four months was one hundred and five. More demanding even than the lectures, however, were the clinical case conferences in which an average of six "problem patients" were presented by the local surgeons for discussion and resolution by the Visiting Professor. A total of sixty-seven such conferences were conducted and approximately four hundred "problem patients" were discussed in detail. In addition it was necessary to review and offer advice on twenty-two research projects and seventy-five clinical papers presented by colleagues.
While the days were filled with teaching, the evenings were filled with social engagements. Indeed at the end of each long day of teaching the role changed from that of a Visiting Professor to that of a Visiting Fireman-the latter being defined as "a visiting dignitary whom it is desirable to entertain impressively". Nevertheless these nightly social commitments afforded us the opportunity to achieve some of the ambassadorial objectives of the tour.
Moving continually from one centre to another and meeting an entirely different group of orthopaedic surgeons every three to four days can be fatiguing; it is somewhat comparable to the situation of "one horse and many riders". Thus, one of the many qualities a Sims Professor must possess is stamina. My wife and I found that by living in moderation and in what Sir William Osler referred to as "day-tight compartments" we were able to finish the tour with as much vigour and enthusiasm as we had brought to its beginning.
In approximately half of the centres on our itinerary we stayed in the private homes of orthopaedic colleagues whom we had known previously and in the remaining half we stayed in hotels. The youngest of our five children-Luke, a ten-year-old boy-accompanied us to the United Kingdom and was enrolled for the four-month period in the Dragon School, a well-known British boarding Prep School in Oxford. Consequently, on Sundays whenever possible, we journeyed to Oxford to visit him and were consistently delighted with the high calibre of his English education. As he rapidly became bilingual-that is, Canadian and English expressions such as "Mom" and "Dad" soon became "Mothah" and "Fathah".
One of the duties of the Sims Commonwealth Professor is to prepare an extensive report-approximately one hundred pages-for the Royal College of Surgeons of England. Although the commitment, as already mentioned, is mainly academic and ambassadorial, the Sims Professor is expected, in addition, to assess and report on his impressions of a number of important issues in each country visited-issues such as patient care, medical education and research. Such impressions, of course, are likely to be somewhat subjective rather than objective being based on relatively incomplete factual information.
1. PATIENT CARE.
I am favourably impressed by the continuing high standard of orthopaedic patient care-even in smaller communities-throughout the United Kingdom, Southern Ireland, South Africa and Rhodesia despite the relatively low ratio of orthopaedic surgeons to patient populations in all of these countries, that is, relatively low compared to the ratio in Canada and the United States. It would seem, for example in the United Kingdom, that an individual patient with an urgent clinical problem, either an acute illness or a serious accident regardless of his financial or social status, or his place of domain-is likely to have as good or better access to the system of health care than he would have in all but the major centres in Canada. I was particularly impressed by the high standard of care of the injured in the troubled area of Belfast! Because of the relative paucity of orthopaedic surgeons as well as the inadequate number of associated specialists and the inadequate number of hospital beds, however, the size of the waiting list (and consequently the length of wait) for elective or non-urgent orthopaedic operations remains excessive in most centres.
The majority of university centres visited demonstrated a realistically progressive, and even innovative, approach to orthopaedic problems. Indeed, British orthopaedic surgeons, lead by Professor John Charnley, have been the world pioneers in the development of the "total artificial hip joint" operation for adults with disabling arthritis of the hip-one of the most significant technical advances in orthopaedic surgery in this century.
A. Undergraduate Education.
In general, the undergraduate medical curriculum in the twenty-four Medical Schools visited is somewhat less highly structured and along more traditional lines than is the current curriculum in many Canadian universities. Nevertheless the skill and enthusiasm of the individual teachers is outstanding. The use of peripheral or Regional Hospitals outside the University centre for the teaching of medical students-a venture already embarked upon by the University of Manchester and others--is a new and imaginative concept that may have to be adopted by some of our Canadian Medical Schools since many of the established Teaching Hospitals in major cities are experiencing a progressive decline in the numbers of patients being referred with the more common types of disorders and injuries that are most appropriate for undergraduate teaching. Furthermore, if we continue to increase the enrolment of medical students in each of our Canadian Medical Schools-it seems inevitable that we will-the present number of established Teaching Hospitals will be inadequate and we will have to follow Britain's example of using additional hospitals in communities outside the University city.
Many of the British and South African university undergraduate teachers seemed to feel that their current medical students "are not of the calibre they used to be in the good old days". This has undoubtedly been a common feeling among teachers throughout the ages. We must remember, however, that the expression "the good old days" is the same expression that will be used in the year 2000 to describe the 1970's. Personally, I found the medical students with whom I had discussions to be just as bright, alert, keen and receptive as our Canadian students. Furthermore, it is encouraging to observe that throughout the world medical students of today exhibit a much greater social conscience than did students of a generation ago.
B. Postgraduate Education.
The time-honoured apprentice-type training of surgeons in the United Kingdom and South Africa is rapidly changing to a system more comparable to the highly structured and intense postgraduate surgical training in Canada. During the last few years it has been my privilege to be a Canadian representative at two Joint Conferences of Commonwealth Surgical Colleges -one in Scotland and the other in Canada. The main purpose of these conferences has been to develop some degree of uniformity in the training and examination of young surgeons and hence some hope of reciprocity in their surgical qualifications. This is another example of Commonwealth unity within the medical profession.
The current climate for either basic or applied experimental investigation is not favourable in any country because of the relatively inadequate amount of government funding of research. This problem is compounded in the United Kingdom because of the dearth of young surgeon-scientists who can find the time from their heavy clinical responsibilities to work in research laboratories. Nevertheless, in the United Kingdom there is some excellent research being conducted by orthopaedic surgeons in collaboration with engineers in a relatively new field known as bio-engineering -with particular reference to the development of artificial joint replacements for knees, shoulders, and elbows. The standard of surgical research that I did see was very high indeed.
In concluding this address I would like to make a few philosophical comments. The following reference to the Sims Commonwealth Travelling Professorship from Sir Arthur's obituary in the Annals of the Royal College of Surgeons of England in 1969 is particularly pertinent. " . . . the visits permitted a free exchange of ideas, and the Travelling Professors gained as much as they gave, besides enjoying what was for many of them the most memorable experience in their lives." With this statement Mrs. Satter and I heartily concur!
The following quotation from the mathematical genius, Albert Einstein is also apposite: "Many times a day I realize how much my inner and outer life is built upon the labours of my fellow men, both living and dead, and how earnestly I must exert myself in order to give in return as much as I have received."
Nineteen centuries before Einstein, St. Luke, the beloved physician, expressed this concept even more simply when he wrote, "Unto whomsoever much has been given, of him shall be much required." Mrs. Salter and I feel that in having been appointed the 1973 Sims Commonwealth Travelling Professor and his wife we have been given much. In return we have endeavoured, to the best of our combined ability, to meet that which has been required of us. In doing so, I trust that we will have served as reasonable ambassadors for our fellow Canadians-including each of you-and that we will have fulfilled the previously quoted objects envisioned by the late Sir Arthur Sims, namely "the establishment of closer links between scientific workers in the Commonwealth and in the older seats of learning and centres of research; the benefit thereby of the people of all nations; and a contribution to Commonwealth unity"!
I thank you.
The appreciation of the audience was expressed by Dr. Harold V. Cranfield.