{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/7h1dj5b69p/manifest","type":"Manifest","label":{"en":["Dr. Julian Tudor Hart"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Date"]},"value":{"en":["1989-12-24 (created)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["Society of Teachers of Family Medicine","Dr. Julian Tudor Hart","family medicine","family physician"]}},{"label":{"en":["Subject"]},"value":{"en":["Dr. Julian Tudor Hart (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["english (primary)"]}},{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer:  The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}}],"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150640/file/277822","type":"Canvas","label":{"en":["Media File 1 of 2 - Hart_Julian_Tudor_1989.12.24_-_Side_1.mp3"]},"duration":3670.184,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150640/file/277822/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150640/file/277822/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/277/822/original/Hart_Julian_Tudor_1989.12.24_-_Side_1.mp3?1750277143","type":"Audio","format":"audio/mpeg","duration":3670.184,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150640/file/277822","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150640/file/277822/transcript/81261","type":"AnnotationPage","label":{"en":["Dr. Julian Tudor Hart interview transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150640/file/277822/transcript/81261/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Side 1\n\nThis recording in Glencarrig, Wales, 24 December 1989, Julian Tudor Hart. \n\nI know something about why you chose this particular village and a new kind of doctor. There’s a lot of information I think about what was leading up to your choice of Glencarrig. What I want to ask about first is what surprised you … You practiced in London and then came here? That’s right. What were the major differences in your perception of your relationship with your community when you practiced here in, say, contrast to your London practice?\n\nDr. Hart: Well, it was much simpler because the community in London was really too … You could divide the population rather easily into … A local community really was a community. And the occupied section on the records, I think the communists’ occupation was the dealer. And the dealer is a person, if anything, from a straight-forward -- to a store holder in Portabello Road Market. But they were all handlers. They were all trying to get things cheap. The dealers were people who were, in a very small way of business, very clannish, big kinship networks. Great people to be in with. They were very classy (?). They knew it was important to have a doctor on their side. But they were good, fun people. They had a class culture of their own. And the working class people, those people, the dealers. They had a working class culture. -- Creek sort of thing. But their relations with means of production, they were not industrial working class people. But they provided the sort of cultural core for that community in Oxendale. Then there were the industrial workers working all over the place, mostly in factors further west in London. So the 1930’s, -- factor mostly. They were good people, solid sort of people. And there was something like one-third of the practice were people in the advancing age of --. All kinds of graduates, intellectuals, middle-class people, London University people. A lot of prostitutes streets coming in. But they were changing the law, so prostitutes were cleared off the streets. So prostitutes were operating from rooms and --. A big western migration was taking place precisely at that particular time, so there was a big shift. They were coming in with --claims and so on. A  period of --, so English people weren’t --. Now, the westerners were potentially a new community but I wasn’t there long enough to see that really establish itself. But I got a very unstable half of the practice and a stable half. And I related to the stable half pretty much the same way that I related to the practice here. The stable half in London didn’t have any institutions that you could relate to. You could relate to big families and get a hold of big kinship networks, but there were no formal institutions. Here things like the Urban District Council and the Mine Workers Lodge, the union. There were all sorts of local organizations that embraced the whole community and that wasn’t really accessible in London. But they weren’t all that different. And the workload, other than the very hard workload in my practice in London … So there was a big difference between working there and working here. It was partly because I could get my hands on the community here in a way that I couldn’t there. But mainly in the availability … There was a huge diversity of -- and if you didn’t like one hospital’s department, you didn’t use it anymore. You sent people somewhere else. Here there was no choice. Which I thought was actually better, really, because it forced me to face up to the problems we’ve really got instead of evading them by going off somewhere else for a better department.\n\nWas the status or the position of the physician in the community … You lived in the community in London where you practiced? Yes, I did. Was the status of the physician in that community similar to or quite different from what …\n\nDr. Hart: I would say it was very similar in both. I think people were a bit more critical of a doctor in London. They made more sophisticated demands. I’m talking about comparable people, working class people in London, they’re living in a capital city, they’re going to teaching hospitals. I think their expectations were higher. But not all that much. I mean general practition in slum areas of London at that time, it was very rough indeed. People half the time didn’t expect to be examined. You know, you did a rectal examination on somebody, they expected to pay you for it because they thought that was outside the normal … \n\nWhat year was this?\n\nDr. Hart: It was early 1950s. I was practicing from 1952 to 1958.\n\nSo when you came here, the workload was as heavy as it was … But the character of the community was similar to that stable community but different in some ways?\n\nDr. Hart: No, the work I took over in London was appalling. But by introducing some practical organization which  hadn’t existed at all before, by introducing an appointment system or something. Not for --, we were always prepared to see people, but staggering their arrival and so on. Employing a secretary/receptionist so I wasn’t completely alone, which was unusual at that time, for a doctor to employ a receptionist. They did absolutely everything themselves, so they didn’t keep any notes at the time. But by doing all those things, I actually reduced my workload quite a lot in London. I was increasing the size of the patient list. But the pressure of work, even in that five years, was substantially reduced. I think a lot of work was being done by hospitals, which wouldn’t be here. Here, the workload, compared with what I had left in London, was about twice as high for the same number of people and it didn’t change. Here I introduced more organization, though there was, in fact, already more organization here than there had been in London. This practice had always employed a receptionist, since 1948. And it was a kind of industrialized practice. It was designed for rapid thru-flow. But unlike here, there was a huge pressure of consultation that was essentially administered, that was around legitimation of the work --. Far more than in London. I got a lot of unaccompanied children coming, not necessarily for themselves, but also with a long list they wanted for their parents, including certification of work absence – which was illegal. But obviously they were expecting --. I think the use of the doctor was a lot more casual here than it was in London because people tended … You got this feeling that the people used the doctor at the drop of a hat more than in London, much more.\n\nWhen you moved here, you and Mary moved together, right?\n\nDr. Hart: I didn’t stop courting Mary … We’d worked together with the MRC (?). I wanted to get out of the practice. And then we started courting after a year after I came here. And we got married about a year after that.\n\nBut she grew up in a farming community, so she was somewhat familiar with small towns?\n\nDr. Hart: She wasn’t familiar with the valley communities at all. She’d had social contact with them, with the people that came down for holidays at their campsites where a lot of them were without any families. So culturally she was able to relate to them very easily, but she’d never even been to the valleys (?). And the only reason they would come up here was to play rugby.\n\nDo you remember, in the first two or three years that you were here, what you would see, found to be the most different about living in this community? Something you didn’t expect, whether it had to do with …\n\nDr. Hart: Well, there were two sets of … There were the different things that we had expected and there were different things we hadn’t expected. I mean things were very different. The most big differences were predictable and the ones we expected and had come for. We were coming essentially … The first year was a good, cohesive, definable community we could relate to and where you could have a rather relationship subtle with. You could get  hold of a community and you were --. You knew who its leading personalities were. It was an entirely working class community, so the leading personalities were not, in general … They weren’t in gentry (?), they were workers. Well, we wanted that. But that is quite different. I mean coal mining communities are different from other communities and most of the differences were predictable. I think what we didn’t predict or we predicted falsely, definitely I, and I think to an extent Mary must have shared this, I think the universal relief. People outside my communities are either poor or -- miners. Miners evoke responses from other people as a social group and people tend to identify with the miners as either heroes or villains. That’s a very common characteristic in Britain anyway, British politics. But most outsiders see them as a relatively uniform group of people. They think they’re sort of the ranks of soldiers in uniform who are either seen as uniformly a gullible rabble or follow incendiary closed union leaders and communist agitators and so on. That’s one way of seeing them. Or they’re seen a varied ranks of revolutionaries who are the vanguard of proletariats. But either way they’re seen as a uniform group of people who act together, who think together, who are always united. Now the real mining community is extremely diverse, full of characters who actually are designing their own personalities. Many of the characters are so theatrical. They want to be different. They want to be individuals. They want to be personalities. Like the nicknames, they relish their nicknames. Rachel (?) told us a new one the other day, --. He got married in church in -- in basketball shoes and you couldn’t hear him come down the aisle. (Laughter.) So his nickname became --. People play up to this sort of thing. They want to be distinct. I think this is extremely positive. They’re always wailing about how all the characters are gone, they’re all old and so on. It isn’t true. I’m a character. I know that I am and I enjoy being a character.\n\nSo in a sense you moved to a place that relishes that as much as you do.\n\nDr. Hart: Yeah. I think working class people, and particularly mining people, want more than anything else not to be looked through. They hate being ignored. They hate the way that snobby English people ignore the presence of some people – if you don’t say hello. They behave as though you were working on them at table and you don’t say a thing. And I think that’s true for the left perception of miners. It’s been as wrong as the right wing perception of miner. In both cases they haven’t seen them really as people. They’ve seen them as forces for which they’re either against or for. But either way they’re stereotyped and they’re not … I mean -- is not exactly what I went after because these characters are also stereotyped. I mean people act rough and they’re not terribly --. I mean people go in for being various characters. They’re very unpredictable – and that makes sense. So it’s not stereotyping so much as it’s ignoring individual people. You know, you asked what surprised me. I think that … It took quite a long time before I really learned – and I think Mary took the burden (?) of that … That it’s extremely difficult to categorize people and very dangerous. It’s very difficult to make judgments about people – and yet you have to do it. \n\nOne of the things that got this whole project started in my mind, I think, was the rather remarkable difference for me between the boundaries of living and practicing in a community that seemed not to exist as clearly in the village here as it did where I was practicing before I came. But my perception is that those boundaries … And it’s a small town phenomenon as much as anything else … That those boundaries of patient, doctor, neighbor, friend are a lot less distinct, for a variety of reasons, in a town like this. Was that something you were aware of before you moved here?\n\nDr. Hart: Well, yes, I was aware of it. And I think actually it’s a big more complicated than that. It isn’t that the boundaries aren’t there. You actually have to be very conscious, because you are interacting with people much more, the boundaries become more important, not less important.\n\nMeaning in many more context than before?\n\nDr. Hart: Well, if you live in your community, the doctor or the teacher or anybody else, they are actually seeing people. You can, but it’s not polite just to cross the street whenever you see anybody coming that you might have to meet. That’s a reality. I mean you can choose to drive rather than walk because it does reduce the number of non-professional contacts you have. And I had times when I was doing that probably just to save time. I mean I haven’t got time to walk to the surgery from my house, not because I couldn’t do that in a short time if there were no people, but if there were people you have to stop and say “how do you do,” and ask them how they are and they will tell you things. So it takes quite a while to get to your destination and I haven’t got the time to do that. But, in general, if you live in a village, you are actually meeting people in all different sorts of concepts (?) within which you can’t ignore the special stages that you have. It’s not a question of arguing about whether it’s right or wrong for the doctor to have a special power (?), they just have it. You’ve got power. You’ve got certain powers that other people don’t have. And if you pretend you don’t have them, people will humor you by pretending along with you that you don’t have them, but they all know damn well you have got them. So it isn’t only a power of life or death, it’s a power of legitimation or not legitimation. People have to keep coming to ask you for your signature …\n\nI think the other power that people talk about is the power of information.\n\nDr. Hart: Sure, yeah, yeah.\n\nYou have information about people that other people don’t.\n\nDr. Hart: That’s right. So, for example, every small town doctor finds very early on that there are people who present themselves, offer themselves as the doctor’s friend. You’ve really got to be very careful …\n\nWhat was that like? Do you remember when it was first …\n\nDr. Hart: Oh, yeah, absolutely. I mean I made some enemies because people who had been the previous doctor’s drinking companions, because he had a big problem, they wanted to be my drinking companions. And the people who wanted the immediately -- doctor, not the drinking one but the one who … there was a short interim one. He’d been staying at the lodge – and they expected me to be their lodger. Well, I wanted a free choice as to who I was going to lodge with and they were very offended that I didn’t lodge with them. They wanted the power, the second power that derives from being the doctor’s landlord or landlady.\n\nIs that something you knew at the time or you’ve thought about in retrospect?\n\nDr. Hart: Oh, no, no, I knew it at the time. I mean I wasn’t that wet behind the ears. I knew a few things. The other thing is I came as a communist. I think the thing that went around faster than anything else … There were several important things. One of them was I was a communist. That sent a shock around even though this is not an area where being a communist made you ostracized, but it created fierce antagonism by some people, of course. If I was going to live in the village and base, recall the practice to the village … The village had been leaking out on the verge of being … The previous doctors, two of them, had tried to downgrade the -- surgery in favor of the common (?) surgery. They were trying to centralize --. They wanted to make --. It would have made a lot of sense from the point of view of getting a bigger practice and making more money. It would also have thinned out the workload probably because it would have been difficult for you to get them there and that would reduce the pressure on consultations. Well, I reversed that. I reintroduced dispensing, which had been taken away. The other doctors passed up dispensing, they couldn’t be bothered with it. They weren’t making much money on it and they gave it up. Well, I reinstalled it. That was a very popular move and I knew it was. I planned my move. On the other hand, I made some absolutely gaffing mistakes. I had a lot of patients -- because all the doctors were competing with each other and they’d all got patients all over the place. Doctors had patients in -- and I had patients in --. I went around to the other doctors, first of all, to get a router because there wasn’t one and everyone was on duty all the time. Everyone was on duty 365 days a year, twenty-four hours a day, with no time off because they were all stealing patients from each other and they wouldn’t trust each other to see each other’s patients. From time-to-time, of course, they would have to leave the village to go to do some shopping or to go to the pictures or something like then, they would just slough off and hope that nothing would come through. And if it did, one of their competitors would get it and if lucky that patient would change to this other doctor. Now, I changed that and I got an agreement that we would have a router. And as part of that, I also said to the other doctors, look, why don’t we rationalize this? Why don’t you encourage your patients to register with me and I’ll encourage my patients to register with you. They said, oh, yeah, that’s a great idea. Well, you can imagine the rest of that story.\n\nIt’s like votes in grade school where everyone says no one should vote for themselves, everyone should vote for somebody else. And when someone ends up winning, you wonder if …\n\nDr. Hart: Sure. In fact, I did encourage my patients. And because they didn’t know me, lots of them took advantage and they did nothing of the kind.\n\nBut you said there was something else, when you first moved here, that kind of went around the village quickly. You being a communist, bringing the community here …\n\nDr. Hart: I was a communist staying in the community. I’m sure what went around was that I was single. I don’t know how many people realized I was divorced. But, anyway, there was no visible wife, so I’m sure I was the main subject of conversation. And I was very aware of the fact that it would be a good thing for me to be married again. I think anyone with any intelligence at all knows that. Certainly in those days because, in fact, the doctor was two people. You had to be two people. I couldn’t have functioned without Mary. The National Home Service normally got two people for the price of one. I think that seemed to be the case because it was a very, very top drawer challenge.\n\nIt’s not just true here. All the other interviews I’ve done in kind of the same age group, it’s very similar actually.\n\nDr. Hart: At that time, true. \n\nOnce you got here and you said the complexity of boundaries was more than I was trying to describe … What were some other aspects of boundaries that you became aware of as time went on or difficulties? Boundaries in every sense. \n\nDr. Hart: I’m not sure I’m answering your question, but there were a couple of signals I had to send out early on. I mean don’t forget, this was my second practice, so I knew central things that you needed to do right, which I hadn’t known when I started in London. I had to send out a signal that I didn’t drink, particularly with previous -- being an alcoholic. So I drank very little and never in public. I wore a white coat. I was the first doctor in the area ever to wear a white coat. \n\nWhy did you do that?\n\nDr. Hart: I did that to advertise here comes some sort of medical scientist. I’ve got something to do with science. I washed my hands. If I picked my nose, I did it privately. I was generally a hygienic doctor who examined people. And a way of saying that was to wear a white coat. Now, I was aware of that in the Ukraine, they were wearing white coats. But I thought it was important to announce that that was the kind of medicine that was going to be practiced. It was especially important for the physicians much later on to start wearing a white coat, but I’d worn a white coat for about ten years now.\n\nAll of those were changes, obviously, and I want to know what the changes were.\n\nDr. Hart: I was a tough certifier. A lot of people who had obviously been having certification of work absence very, very easily, even by sending out their children and so on, all that stopped. I wanted to have a reputation as on the whole being strict. I preferred to work back from there rather than to start with a reputation as being a laxer or a … and that paid off. So, in general, although, in fact, I bent all sorts of rules, and I think probably as life has gone on, I’ve bent more and more rules, but probably more selectively … But I wanted to start off with a reputation as being very tough because I knew that I would need that. So I think those are the three things …\n\nWhen did you stop wearing your white coat?\n\nDr. Hart: I stopped wear a white coat for a very precise reason. The BMJ carried an interview with me called “New Kinds of Doctors.” So that will give you the date. Really? Yeah. I can’t remember, but it’s in the file somewhere. They had a little picture of me wearing a white coat, examining a --. And somebody wrote in a sarcastic letter saying, oh, yeah, here’s this big new doctor, you know, still wearing a white coat. You, big doctor, you, little patient. \n\nSo somebody else wrote in, in my defense and said, no, not at all, Dr. Hart is a hero. He’s working in very --conditions. And he was quite sure, if I wore a white coat I wore it for very good reasons. Well, I thought, yeah, it’s very nice of you to say that, but actually the first guy is on target. And I decided it was silly to wear a white coat.\n\nHow long in the practice was that?\n\nDr. Hart: I think it was about ten years ago. I probably wore a white coat for about fifteen years, something like that. And it was quite true. I mean I got a lot of children who did cry. A white coat doesn’t make a child cry. It’s the doctor who hurts them, who promised he wasn’t going to. So what used to happen was that going for having their tonsils out, or something like that, learned to fear doctors. And then because I was wearing a white coat, they feared me as well. Whereas I found that if I was in civilian clothing that I was not contaminated in this way. So in effect what I was doing was distance myself from the hospital doctors. \n\nWhat about the other part, the fact that you didn’t drink in public and at some level you didn’t …\n\nDr. Hart: Well, that reversed. After I established that I didn’t drink, after about five years then what I had to establish was that I could drink. That also took a characteristic, a theatrical form. My big came out was New Year’s night. And I drank only vodka. And what I used to do was to have an arrangement with the man at the bar that after I had as many vodkas as I really wanted to have, that from then on he would give me glasses of water and I would knock them back the same way. But it had to be a very well-kept secret because people would be offended at having bought me a drink of vodka if I didn’t drink it. But then I was sending out signals that I could handle large quantities of liquor, which I am quite incapable of. \n\nThat’s the kind of thing that … What comes up frequently with folks that I’ve talked to is the kind of signals they would send … And, again, you were a lot more conscious of what you were doing, I think, than many people. But one of the signals that tends to come out retrospectively is when I ask people about the boundary of privacy. You know, where is it that you can be whoever you decide you want to be and not, in a sense, be on guard, be on call and so on. And they will often describe situations and have only thought about that at some point down the road and realized that’s what happened. Do you remember, at any point, the whole issue of privacy for you and Mary both?\n\nDr. Hart: I don’t think we always agree about that. I think Mary thinks it’s more important than I think it is. \n\nWhat’s the nature of that?\n\nDr. Hart: I don’t think privacy is all that important. First of all, I think it’s inevitable that you lose your privacy. I mean being gossiped about doesn’t worry me much. It does worry Mary. And malicious gossip, although I find it depressing, obviously, I don’t see the point of being angry about it. I would rather people didn’t have those feelings, but if they’ve got them, then there’s not much point in being angry about it. I’ve always been a controversial doctor. I wasn’t aiming to be the best loved doctor that had ever been. That never was my aim. I knew it wasn’t possible. I think the other thing is, I mean I’m rather unapologetic about this whole sort of role playing because I do really think that people actually do role play all the time. I think they should act. In the end, I don’t quite see the distinction between performing and just behaving. I don’t see why a certain theatrical content, that you behave in a way … You’re behaving in front of other people. If we were completely isolated in the world and nobody ever saw us, life ceases to have any meaning.\n\nBut I would interpret your description of people kind of becoming characters as a way of performing.\n\nDr. Hart: Absolutely. I don’t see it as a bad thing. What I’m getting at is, it’s like the accusation of being two-faced. I think it’s one thing to be treacherous to betray people, to mislead people, I think that’s very bad. But I don’t think it’s wrong to be two-faced. I think you need 150 different faces in order to live in a community where you actually relate to other people. And to solve that by living in London and not relating to anybody is no salutation at all. My paradise is London as a whole other village. Which in many ways … It really could be …\n\nIf you and Mary had some disagreements about the nature of privacy or the need for privacy, how did you resolve that?\n\nDr. Hart: Well, I, in general, would concede to her opinions.\n\nBut did that practically work …\n\nDr. Hart: Well, I think it’s much easier for me not to be bothered because I have a lot of power in the community – and it’s rather easy to not be not part of it if you’ve got a lot of power. I think, also, I mean I think Mary would tell you that a lot of people would take things off on her that they wouldn’t on me. And they certainly did on my staff. I mean patients will be quite abusive to my staff and then turn around and come in, having abused the receptionist, come in and put on a completely different personality with me. And in most circumstances, it’s my job to back my staff, to support them. Not to allow people to manipulate me in that way. And I think, to some extent, when Mary and I have disagreed about privacy, there’s been a little bit of that feeling about it. And I think I ought to, if there is a disagreement, I should side with her because she usually gets … I think she’s had the worst end of the deal on not having privacy. But I’m rather conscious of the fact that I’m very interested in everything that happens with my patients. I’m nosey. So how the hell can I expect to know all about them and them not know about me?\n\nBut there have to be some places where you can, I mean, literally get away. When did you buy the cottage?\n\nDr. Hart: Oh, yes, yes, getting away. Probably getting away … At that time Mary was much keen on getting away than I was. At the time I really wasn’t much in favor of it at all. I was quite willing to lead my whole life here. It was an enormous relief to get away on holiday, but that was more … It wasn’t getting away from peoples’ lives. It was clinical. It was, at last, not to be … You know, somebody else could make mistakes for a while. I found the pressure, the burden of responsibility was terrible. And I think it gets worse the day before you retire than it did at any other time. \n\nWell, there’s another side to privacy which maybe is one that also impressed me here, that little piece I wrote in the BMJ (?) where I mentioned the full sense of confidentiality as something that was in the state anyway. But at least in my practice, up until that time, and I wasn’t exactly green but I had no experience in a small town … The sense of who knows what and how is something that really is quite intimidating in some ways. And my question, I guess, is, you know the flip side of privacy. How do you and Mary and the family and everyone else deal with issues of confidentiality?\n\nDr. Hart: In a way, I think confidentiality here is a much bigger issue than where people have apparently more respect for it. I mean the absolutist about confidentiality, that’s easy for them because they don’t really meet people and don’t really know them. They’ve got a very separated professional life where it’s not difficult. But if you’re really inside a community, the conventions of confidentiality are unworkable. For example, if you accept that alcoholic problems are an important aspect of practice, everybody knows that you can’t get your information about alcohol from the patient, you get it from their wife and their kids and from neighbors and workmates and so on. \n\nHow about for your wife and your kids? \n\nDr. Hart: I get it from all sources. I normally operated on a principle of triangulation. If I get information about a patient, that he never works or that he never has worked, that’s an important statement. Oh, so-and-so, he never worked, like before you came here. For twenty years the doctors have been trying to get that man to work. Now, if only one person says that, then you can discount it. But I always found that if three separate sources of information, all of them say that man’s got a drink problem, it’s almost certainly true.\n\nWell, that’s the way reporters report things. They can’t go on a single source, they have to have at least two to support …\n\nDr. Hart: Well, I’ve found three seems to be critical. After all, the two sources might not be as independent as you thought they were, but three, it’s not likely. Now, if I’m doing that, of course admittedly that’s information coming in. But that’s also, in a way, a breach of confidentiality. You’re using evidence that does not come from the patient and which they might very much resent the information that’s been drawn from that. Even from their own spouse. But I’ve got to use it. And, anyway, I’m not just treating the patient with an alcohol problem, I’m treating their whole family – they’re all suffering from his alcoholism. You’re getting into the social dimension. Being ill is a social act and it’s got social consequences. How can you possibly put the whole weight of it just on two people, yourself and the patient? You can’t do it. Now, how you handle confidentiality in that is really about how, I think, how do you preserve a doctor/patient relationship which is one of trust? That’s really what you’re after.\n\nBecause it’s the breach of confidentiality that’s probably the greatest single threat to that kind of trust. That’s right.\n\nNow, if trust can survive … I mean I had a principle, I would say to every trainee coming into the practice, now, be careful how you write records. Every time you see a patient, you’ve got to write something down. You must. You’ve got to have the record, when you see the patient, and you’ve got to put something in it. And when you’re writing something in it, don’t put down subjective feelings like stupid bastard, or something like that. You can say that to yourself, if you want to, but it doesn’t belong in the notes. First of all, it doesn’t belong in the notes because it’s not true. He was not born illegitimately. He is not stupid. Your writing down your feelings – and check them out. The test of this is if any patient in this practice wants to see their records, they must be allowed to see them. They may have a fair warning first that they’re doing it at their own risk because the records are not written for them, they were written for the doctor’s own use, that they’re full of mistakes, that we are aware of that, that they’re full of wrong judgments, judgments that turn out to be wrong. But they’re working tools. And if people want to see them, at their own risk, they are entitled to do that. We’ve always had that rule. And I try to hold the trainees to it. And I think they ignore it quite often. But if I find they’ve written stupid bastard down in the notes, or something like that, \n\nI have called them on that. Because I used to do things like that. But I stopped doing it because I felt ashamed, that I would feel ashamed if I gave it to the patient. It actually happened to me in London. I referred a woman who was a very hyperchondrafical (?) woman, who was always pestering me and always wanted to be referred. And I wrote a nasty letter to a consultant saying I’m very sorry to burden you with this impossible woman who is always around, you know. Well, of course, she opened the letter. And she came around to see me and she was absolutely furious. And I felt very ashamed and I said, look, I’m sorry, Mrs. So-and-so, I really do apologize for writing that. I agree with you, it’s a nasty letter. She said, how would you feel if you had this letter that you felt, in good faith, was going to help you and it actually was poison? And the man reads it and he doesn’t have an open mind at all. And I said everything you’re saying it true. But on the other hand, I really am trying to help you. I hope this will help you to see how I’ve come to feel about you. I know it’s a very painful thing. But it is true, that it isn’t helpful, this sort of referral. I did tell you that this is not the solution to your problem. Actually, we ended up good friends over it. And I felt the only way to handle it was to be open about it. I had been wrong, but I admitted I was wrong. She actually … I can’t remember the details. But in a way she got turned inside and I think she felt a bit -- as well. So what I wanted to do with confidentiality, in that book that we tried to get for you but we haven’t been able to get a hold of one because it’s almost impossible to get them … But “The Surgery of A Fruit (?),” it’s a little book, about that thick, that was published more or less privately by some microscopic publisher somewhere in Canada. It was published by the son from a manuscript he inherited from his father and it’s an autobiographical. It was written as a book by a doctor, he was going deaf with otosclerosis --. And I think partly because of his increasing deafness, he became very … He was a good writer and it became his hobby, to write about practice. He wrote two books. One about the experience of practice as a junior partner and in various practices in south Wales during and just after the 1st World War. And then he wrote a second book called “A Doctor In The Black Country” where he practiced up near --. Now in “The Surgery of a Fruit (?)” he describes an extraordinary … An -- fruit, which is a pseudonym for some --, the surgery was conducted in a sort of village hall place, a very large room. Everybody was there in the room and there were three different doctors are different points in the room, each with their own little cleared space among the crowd. And people would come forward, one by one, to be examined or to say what their … The doctor had a little table and a chair. The patient was standing up next to him. And he had an examination --. The patient would state their problem with the doctor. And there were people in a circle around watching all this and listening. And if the patient would say something, say the patient is getting diarrhea, or something like that, on a Monday. So the doctor would say, did you have a -- last night? And the patient might say, well, I might have had a drop or two. Well, people from the audience would go off … (Inaudible.) Well, the whole thing was conducted in this way. The whole village participated. Now, I’m not suggesting that’s inherently good, but that’s where we’ve come from. That you can actually see that although there is a very strict set of rules that you must abide by regarding confidentiality, it isn’t the extreme simplicity that we were taught where you just never talked to anybody about anything. It’s that you talk to people but you follow the rules, which are not available in writing. You’ve got to find out about it by trial and error. And it’s extremely complex and it’s real. I think the most is, you’ve got to start with a respect for confidentiality. You start with a respect for the patient and their family. If you really respect people, then, for example, you’ve got to do something about their alcoholic problem – even if it’s just damage limitation and the patient’s got to go down the tubes, you’ve got to do something to save the other people from drowning with him. Now, that is more important than confidentiality and your defense against a breach of confidentiality has to be that you felt that it really was in the patient’s own best interest or their family’s best interest that you acted in the way that you did.\n\nBut I think one of the characteristics … I mean my impression is that you’re able to say that because you have not only a relationship with that entire family but you have a knowledge of them and how they would react. You know, you’d be selective about that. So to say something like that as a general statement would probably … Ethicists would go mad. On the other hand, what some people who are ethicists don’t understand is that we have histories with people that are as long as histories, in some cases, with our own families. So you know people well enough so that if you say I really think this is in your best interest, that’s not acting in a condescending, unethical way. That’s acting, in fact, in their best interest. But sometimes they can’t see that.\n\nDr. Hart: That’s right. I think a doctor who doesn’t know patients really only has a right to act if they start off by saying I’m very sorry, time’s short, I’ve just got to kind of dive (?) into this. I may do all sorts of stupid things because I don’t really know you. Now, there is a way of avoiding that. Quite frequently specialists who don’t know patients get more intimate, revealing, damaging information about them in ten or fifteen minutes than the GP who thinks he does know them has gotten in the last twenty years. After all, first of all, people see specialists usually when there’s something pretty threatening going on, which makes things quite different. And secondly, they are a stranger on a train. It’s much easier to talk to a specialist who you’re not going to meet on the street and who doesn’t know your family. So there are all sorts of ways in which it’s quite wrong to sentimentalize a physician or the GP. There’s nothing inherently or unfriendly or ignorant about specialists. Specialists don’t have to behave in any different way, so they don’t care about being ignorant. So I think there’s an obligation on a specialist rapidly to achieve the essentials of … Not to make absolutely gross errors from ignorance of a patient. If a GP’s letter doesn’t contain things like this person was divorced last year and is still in a very fraught state about that and his mate has just dropped over with a coronary, if it doesn’t contain that information he’s got to obtain it. And he can do it quite quickly by saying, well, is everything going alright with you? You know, those sorts of questions. But they must do that. If they don’t do that, then they are likely to do terrible damage. I mean on the confidentiality thing, over things like, say, a malignant disease, who’s told and who’s not told – the specialist must surely find out how this information has got to be handled. They’ve got to have some knowledge of that. They can’t act just according to the emphasis set around – unless there aren’t any emphasis (?) …\n\nWell, they are useful but … The difference is, I think, at least in the states, people have tended to turn over the tough decisions, in some ways, for the -- to sort out. Like they would, say, a surgeon. But that’s not the way they will function if they’re good. They will function by saying you can’t do that. What I’m here to do is, in a sense, be a type of analyst. I’m going to help you think through what it is that’s going on so that you’re clear about what the issues are and what the problems are. And then you and whoever else needs to be involved to make that decision. So I think -- are very good. \n\nBut another aspect of confidentiality has to do with either the arrangements, explicit or implicit, that get made between you and Mary. Do you remember about who knows what?\n\nDr. Hart: Yes. I mean, in general, Mary and I had a sort of running, not a battle but a sort of running skirmish in that I think she always wanted to know a bit more about what was going on than I wanted to tell her. And it’s partly, I think, that in the curious relationship which this double kind of doctor used to have, the doctor and the wife, they had a right to know all the gossip because they were doing so much of the work. And part of the reward of doing the work is to know what’s going on, to give you a feeling that you’re on top of things. So she had a right to know. On the other hand, I would often feel that I was rather selective. I would tell her some things and not others. Or I would particularly not tell her things which I thought were quite likely to turn out to be wrong. There were some levels of decision-making that were so tentative that I didn’t think it was right to share them with anybody at all. And, actually, I think the longer you’re in practice and the more mistakes you’ve made, the trouble is you become more and more convinced on the one hand that all decisions are fraught with risk. And on the other hand, that decisions have to be taken with real people. It just gets more and more impossible.\n\nBut do you remember at some point … I mean obviously, because I know Mary and I know this isn’t the case, but do you remember ever sitting down together and saying in so many words that the kind of information that she’s privy to, because of the nature of your exchange, is something that should not … I mean she should have a respect for the confidentiality in the relationship in the same way that you do with patients?\n\nDr. Hart: Well, I mean, of course, I would quite often say something to her and she would often say things to me. Where you’ve got a woman that absolutely has gotten stuck with you not because of a general edict about confidentiality but because of very precise reasons for this particular case. Because the general edict didn’t work. You must not reveal … I mean when you hear that so-and-so is pregnant, you must express astonishment and delight. You must not say you already knew it. You know, of course you do things like that. We’ve often had arguments where Mary comes to me with information she’s gotten from other people in the village often, for instance, about the phony nature of somebody’s complaint. You know, he’s putting on a roof at so-and-so’s house yet he’s telling you that he’s got pain from his rheumatoid arthritis in his first metacarpal -- joint. Now, actually, I am, I think, on the whole, more current than she is about that kind of thing because I have found that people quite often are able to do little jobs for money they don’t pay tax on, for a short time, when they don’t work eight hours a day for less money which they do get taxed on. I mean the economic incentives do affect what pain people have to put up with. People get fed up with not doing any work, not being able to do any work. And the temptation go off and spend just one afternoon doing some work, which is against the law if you are claiming sickness benefit, but where they can do the work which their skills allow them to do and they put up with the pain for that time … it doesn’t prove that they haven’t got a problem.\n\nBut the issue is not so much whether they … You know, your analysis of why these people are doing things. But it has to do with whether Mary was presenting you with that information in a way so that you could act on it. And you’re acting on it in a different way, potentially creating more ..\n\nDr. Hart: Well, my decision to act on it. Well, I suppose, in a way, it relates to confidentiality. I mean in that particular case I’m saying, no, I’m going to depend on the information the patient gives me.\n\nSo Mary is not a source in that case?\n\nDr. Hart: Well, I can’t pretend that I don’t bear it in mind. And I’m talking about a real person – I think that’s one of the reasons I’m against that decision, really, is I feel it’s too abstract. I want concrete cases. This particular bloke had … What I pinned all my decisions on was that he had had such a consistently good work record until he began to get this pain in his joints. He wasn’t positive for rheumatoid and didn’t have a raised DSR (?). And for a long time the pain was confined to one joint and it was very problematic. But then he developed rheumatoid in his other joints and it was kind of obvious. In fact, I was vindicated, my judgment. But my judgment, for a long time, rested entirely on the fact that he had been a good worker up to a certain point. Now, after that, the reason for him ceasing to be a good worker might have been that he was developing – disease or it could have been something quite different. But whatever it was, it was a real development. It wasn’t that he suddenly decided to be a crook. I had a man with a bad back where it was extremely suspect, the organic nature of his back pain. On the other hand, his wife had teratoma of the ovary and then died. And she had hidden this. She had the teratoma, quite a large, concrete lump in her belly, I’m sure palpable by him when he was making love to her for several years before she presented it. She concealed it and didn’t want anyone to know about this. And I think this could easily have been the explanation for his back pain. So it was real, it was organic. The organic disease was in her, not in him. But this idea that the world’s full of malicious people trying to outfox the doctor, I’m just … You asked how things have changed. I must admit, I think the single thing that I changed most of all about is I’m having to read my records now, because I’m entering them into the computer. And the thing that makes me feel more ashamed than anything else about those records is the extent to which, particularly the first ten years that I was here, I didn’t believe what people were saying. Now, there were good reasons not to believe some of this. The role of the doctor as the legitimizer of work absence was very, very important. Wages were very bad. They were appalling. People were better off … They often had higher earnings when they were off with an injury than when they were working. And that was not because the earnings, the pay was high but because the earnings were low. And mining is a very hard occupation. And I think I was … It isn’t that the people weren’t telling me the truth, but it was that I hadn’t learned how to handle being lied to. I hated being lied to. I still hate it. And I think this was something that I was absolutely not prepared for at all by my medical school. And I think medical school does not prepare people for it. It isn’t such a problem because the role of the doctor as a legitimizer now is less important than it was then. We’ve had some changes in the law. But somebody’s doing it.\n\nWell, I remember my time here, was not that long ago, what struck me was, I kept saying why don’t people just have sick days? Why is it that I have to sign a slip every day? And that was fifteen or twenty years after you’d been doing it. So in some ways I didn’t understand it then. And now there are all sorts of methods coming up. That’s the only way they can compensate people now, is to trust them more with their own …\n\nSide 2: One of the things that I’m trying -  which is a hard thing to focus on, so I’m not sure how to ask this because I know a lot about your family already – has to do with your sense of whether your being a doctor in a small community, particularly the kind of doctor that you’ve been, put your family in a different situation than the children of other people in the village? Either that they’ve express to you or that you’re aware of, what kinds of issues has that …\n\nDr. Hart: I think, first of all, you really ought to interview the kids about that. I will. I mean it’s difficult to say anything that is just … I mean there really were only two positions they could have been in. One was my kids being in this village and relating to other … All the other things, we could have been somewhere else and I could have commuted in. Now, I think if that was the choice, I haven’t any doubt myself that it was better for them to grow up in the village knowing the work that I did and feeling that our family was part of the village organism. I think that was a healthy way to grow up. And I’m sorry for the families of doctors whose family life and work are separated. I think they really miss out on something. What they didn’t have an option to be was children living in the village whose fathers were coal miners or news agents or butchers in town. It wouldn’t have been them then. So of the real options available, living in a neighborhood or not living in a neighborhood, I think the neighborhood is tolerable. I’m not saying that we would have done that if we’d been at the stage that some inner cities are in Britain where the schools are so violent and the streets are so violent and so on that you really just can’t … It’s not a … I have no right to express an opinion about what you should do about that. But it seems to me that things shouldn’t reach that point. But if there’s any choice in the matter, I’m sure it’s best for the kids to grow up, I think it’s a very good way to grow up, the way they grew up.\n\nHave you heard from them over the years any concerns about what the problems would be?\n\nDr. Hart: Oh, they had terrible problems at school because I was the doctor. I mean Ben certainly was bullied because his father was -- and well-educated and it was presumed that he was following in my footsteps and would go to university. He had quite a tough time, which he never told us about. A couple of months ago  he was talking to us about it. I mean he’s got quite a bit of memory, so he’s not idealizing his youth at all. And I think he would resent it if we did. And I think Robin probably had even more pressure at that time and he succumbed to it and his way of dealing with it was to be, he simply didn’t achieve maximally. Ben was keen to it, he liked being at the top of the class and worked hard and wanted to succeed. And he saw success in terms of growing out of this community and escaping from it in much the same way as anybody else who’s grown up in it and who gets to university, assumes that they’re going to leave. Robin, I think, identified much more with the kids who were going to stay and I think deliberately non-achieved. I don’t think he achieved his full potential as a scholar. But I don’t think that was the end of the world. He’s doing alright and enjoying his work. The fact that he’s able to teach -- to very seriously disturbed, almost uneducatable children, 80% of them are Muslin, Indians, in a very rough area. And yet he does actually enjoy his work, teaching them about --. Well, I think he’s doing alright.  I do too. I think Rachel had less of a problem than the other two did. Really, they’re the ones that could obviously talk to you about it. \n\nAlso, I think the relationship of sons and fathers is different than the relationship with daughters with the process\n\nof  the pressures …\n\nDr. Hart: I think Mary had a status in the village that was in some ways much better than mine. I think Mary earned her status not just from being the doctor’s wife but from being the parent of these children and being seen as a good parent, a hard-working mother who did a good job on her kids. So I think she’s got the status in her own right, very securely.\n\nOne of the things I’ve heard from, which really surprised me in some ways, a number of different people was that the physician’s role in the community became one, and this certainly applies to you and a lot more consciously, one of almost becoming a social change agent by virtue of who you were. Yes. What they often talk about is that their activities in that regard may or may not have been perceived in the same way by their children who, in fact, were kids. I mean they wanted to be kids. They wanted to be part of things. They wanted to be the same as rather than different. And I’m wondering with your very conscious choices and all the reasons why you came here and all the reasons why you stayed here, if that type of thing put, you know …\n\nDr. Hart: I’m sure it did put a sign on them and I think you’ve got to ask them. But on the other hand … I mean I think it’s quite true that I think doctors and teachers are agents for social change. Or, equally, they can be agents of social stagnation. I mean if they don’t act to change things, they can actually inhibit change. And whatever they do, they’re prominent. They have great social power. So they’ve always got it and they are always using it even if they are only using it to sit on things and prevent things from happening. You see what I mean? Yes. They’re always a positive force, whether it’s conservative or a radical force. I think what mitigates that, what reduces the pressure it puts on kids is perhaps the actual, the change that I’m trying to bring about. Because everybody should feel that they have got power which they should be using. You know, I think every school of the state (?) is, in the end, the only way we will ever have a decent society to live in. So you are really saying everybody ought to be doing this. You’re not saying I’m bloody marvelous, listen to me. You’re saying have a little bit more confidence in yourself and, you know, everybody’s got brains. There aren’t any -- people. There are people that can’t listen to each other and don’t understand what each other are saying, and so on, but stupid people are rare. We all know stupid people and they’re not that stupid. We actually recognize them as having a problem. Look at the type of kids with Down Syndrome that we recognize. If we can recognize the cleverness in them, why the hell can’t we recognize it in the people we call stupid? So I think if people are active democrats in a community, intellectuals in the community who are active democrats, on the whole I think the pressure it puts on their kids is good pressure. I’m not saying, I don’t want to deduce about it too much. But I think on the whole they’ve had a good childhood.\n\nWe talked a little bit about confidential and so on. Do you remember when you started letting the kids into the practice? When did you feel it was appropriate for them to know something more about what you did than just that you went off and did surgery?\n\nDr. Hart: Well, I think what you actually do is you start telling them when you know that they will accept the rules of confidentiality. How do you know that? I mean do you remember … Yes, I do. I mean I don’t remember … Mary might remember better than me. I can’t think of a … I mean I would say to this in front of the kids if somebody was dying, because that is something that got around the village pretty quickly and it didn’t matter if they knew a bit sooner than somebody else. If it was a matter of who was sleeping with who or somebody got venereal disease or something, I wouldn’t say anything about it. I’d keep absolute silence about that in front of the kids. \n\nSo you were aware of what kinds of things might compromise them in their social relationships?\n\nDr. Hart: Oh, yes. I used to get information from. I mean they knew lots and lots of things that I didn’t know. On teenage drugs and things like that, of course, I was totally brainless. And they respect confidentiality, so there were lots of things they wouldn’t tell me. So, again, it’s a social definition of confidentiality.\n\nIn some ways, as I said early, what I’m interested in are points of transition. And those points of transition in other discussions I’ve had have been the points generally that coincide with major family transitions like when your kids are having to choose educational … In the states it’s always been kind of the junior high school, when they get to the secondary school level then the parents are much more aware of the differences among schools and so on. Or there have been situations where then the children leave. Or the fairly normal life transitions have been times where the family has, in essence, assessed its presence in the community and made decisions.\n\nDr. Hart: No, I don’t think it was like that with us.\n\nCan you reflect back on some of the times, the crises, if you will, about saying should we or shouldn’t it?\n\nDr. Hart: Our crises didn’t revolve around those things at all. We had, I think, two sort of crises points. We had a crises point in about 1965 when Rich Saxton (?) came here as my partner. And that was a very important development because he took over … You remember Tumi (?) who got --? Well, Tumi was my adversary. He even, for a short time, set up a branch of surgery in the village saying that all the patients were going to leave the red doctor and join his panel. And he got the backing of the Catholic church. The priest had gone around and got all the Catholics, all but eight of them … There were twenty-four Catholics, something like that, and eight of them stayed on my list and all the others changed to Tumi because they were told to by the priest. They told me about that afterwards. And then Tumi died. Rich Saxton arrived as my partner in the practice. Rich was rather an aristocratic kind of communist, but a very devoted communist. I mean he’s willing to follow instructions --. But, still, people saw him as not a red. I mean his redness appeared to be a private thing more than a public thing whereas I was standing to the council and dividing people that way. Well, so what Rich did was to bring me the rest of the village and have them register with me. And, really, it was only from 1965 onwards that I really had virtually every family in the village registered with me. He was here for five years and during those five years he’d come deliberately, partly, to make things easier for me to actually get elected to the council and give time to that – and I did. Towards the end of that time, I knew he was only going to be here for five years, he agreed with his wife that he would do five years and then he would retire at sixty and they would leave. I knew it was coming to an end and I more and more felt that what we were doing was wrong. It wasn’t something that we could maintain. It wasn’t reproducible, nothing was really growing. Everything revolved around the doctors as personalities. We were doing everything ourselves and we hadn’t really gotten any mass activity going on. And actually what we were running was the doctor’s party. It was the doctor’s party which was a party of reds. But I actually failed to get across the idea, you can do it. It wasn’t people’s power at all, it was doctor’s power. And on the other hand, I had begun to get a renewed interest in research. I had gotten very much off of research when I came here. I can’t remember exactly, but I began to get interested in -- disease and at that time I thought we had much more hypertension here than anywhere else. It was really because I was looking for it. I don’t think it was much more. But the impression I had was that we seemed to have an awful lot of hypertension and I started looking at the coronary mortality rates and found that we’ve got these exceptional MI (?) rates and began looking at more systemically all the data. Then got terribly excited when I found that I actually discovered something that other people hadn’t seen. The information was there but nobody had really looked at it. And we found that we’ve got this huge, excessive mortality, particularly in the youngest age groups for both stroke and coronary disease in -- Valley compared with either the Bay of -- or within \n\n--. And that was absolutely not predicted. So having discovered something, I suddenly really thought the research really important. And it had a big affect on me politically as well. I began to realize that … I think politics is like other kinds of science. I don’t think you should think that you know the answers before … You’re not looking for evidence to back up conclusions that you’ve already reached. You should genuinely be looking for something new. You don’t know everything, so you’re not a person who’s full of knowledge pouring into empty vessels and all that nonsense. So I could see, at last, that all this stuff we’d been told in medical school, which I thought might be hokum, which I think it is actually, that it was so important to be involved in research because then you could teach. I mean my perception of that on the whole was that it was a lie. The people who were keen on research didn’t care about teaching and weren’t very good at it. And for all I knew, they weren’t even very good. And for all I know they weren’t even very good at --. Has that changed? It’s like lots of things that have been ruined by people just mouthing them, who don’t do them. It is actually true that research must go hand-in-hand with teaching. If you want really creative teaching, you’ve got to have people who are discovering new things. So research, in that very broad sense, that you’re only advancing as your knowledge … And curiosity about causes and … Well, I think you’ve got to know that you don’t know. So knowing that you don’t know and the excitement that what known is discoverable. I mean knowing you don’t know and thinking what you don’t know can’t ever be known, that’s no good either. But the idea that we could be less ignorant than we are if we work in the right way is very, very exciting. And I got a hold of that and never let go of it. And it was so much better than what I was doing on the council where I really hated a lot of my work on the council. I didn’t like the feelings that I got about other people. I saw the worst of people. I could see that a lot of the people on the council were actually not bad people but they’d been made bad. They were very corrupt and they got corrupt because they weren’t operating on a theory of any kind. They were unprincipled because they didn’t have any principles. Not because they ratted on principles but because they hadn’t had them. So I got after that and I said to Rich before he left, and I think he felt rather betrayed by it all … I made it clear more and more instead of his working allowing me to do politics, his work was allowing me to do research. And by the time he left, he realized, I think, that I rather turned the tables and I’d become a different kind of doctor and I wasn’t being a political doctor by being a councilor. It was solved for me in a way because in 1974 the boundaries commission reorganized all the councils, so the -- ceased to exist. (Inaudible) and, actually, if I’d gone on being on the council I wouldn’t have been elected again, I’m sure, because I’d been talking -- all the time. It was difficult to get elected. I mean after the second or third time I contested, I won. And from then on I was getting returns, top of the poll every time. I don’t think I was, in fact, a very good councilor. I was quite a good politician but I wasn’t all that good at the GP side of sort of handling peoples’ personal problems. I then had a choice that I would either have to become a full time councilor, on a bigger authority, or get much more back into medicine. And there really wasn’t a choice. I mean the thought never really crossed my mind. The communist party rather had a --, I think, because we had very few councilors. And it was because -- can’t have a councilor. But it wasn’t negotiable, as far as I was concerned. And then I really began to get, grow towards the decision I reached now, which is that by  far the best, the most telling test of left politics in medicine or teaching or anything like that, if you’re working with poor people, which is where you ought to be anyway, is just to deliver … If you conscientiously deliver really good, all around medical care or really good, all around education to a neighborhood of poor people, there really isn’t any higher form of politics than that. And being elected to the council and so on, it’s very, very difficult for that not to be a diversion from your main political work. \n\nWas that about the time … When the council was dissolved, your decision was clear …\n\nDr. Hart: Yes, and then all those things changed. By then I published this paper on coronary mortality, which although it’s had very little citation in the --, it was recognized by some very important people. Quite a lot of people paid attention to it. And at that time, research money was, compared to now, readily available. And Tom Meade (?) was just setting up his unit. He had just become independent from Jerry Morris (?). And I got in the ground floor of that. I mean I suggested to Tom that the MRC should develop an association with the practice. We actually had an agreement on that for a year before it was implemented because you couldn’t find anyone to do the job. You know, Scott was the first to come here. But we had about a year, the job was vacant. But from then on, our lives changed. Mary had stopped being … She had originally been employed by the practice in 1966. She stopped being employed by the practice partly because we had kids and she didn’t have the time. But also because a 70% reimbursement of staff was not … You weren’t allowed to employ your wife and we couldn’t afford to employ her and not have a 70% reimbursement. So we felt it best to employ somebody else, so therefore we did. But from after ’74, she was employed by the MRC. So it was simultaneously a very big political shift. And although that wasn’t when I left --, I left there about three or four years after that, it was, in fact, the decisive turn in our all out political life. I had been spending a lot of time down in Carver (?) in the World Committee --. A lot of my time had to go to political work. So that was one turning point. The second turning point was … Well, actually, in a way it was close to that time. They weren’t separated that much but they were two pivots (?). The pit (?) closed in 1971, I think it was, and we were rescued from immediate downcast and that’s because of the first miner’s strike. There were two miner strikes. I can’t remember, I think one was 1971 and the other one was 1973 or something like that. The one, again, the -- government. Now, they were times of great optimism. Although the PIT had closed, lots of miners were working out of --. They were liberated from their really poor minimum wages. The mining wages had gone rock bottom. It was the oil crises. In ’74. Okay, in ’74. We had a tremendous wave of optimism which affected the whole village. Although the pit had closed, we felt we have our future after all. The mining industry has got a future. We’ve been proven right all the time. We said the Arabs weren’t always going to live in tents. You’re bloody fools to be closing pits all over the place. There will be an oil crises. Well, it was an oil crises and we were proved right. And the same thing might happen again actually. You know, it keeps repeating itself. So we weren’t thinking about leaving the village then, but somewhere around ’75, ’76, something like that, things began to really go down again. By then we were really losing people. We were having tremendous unemployment. Everyone in the village was losing --. I was invited to go … Well, the department of medicine at Calvary asked me to apply for the chair of general practice there, which was flattering. You know, I quite fancied the idea. In fact, finally when I was faced with that if I did that, I would have to give up the practice here, I wouldn’t do it. We never actually did it, but we did consider it. We were to Milton Kanes (?) in Newtown. I got an invitation to go there and set something up which would have got connected to the university. And we thought very seriously about that and went out and looked at it. But we came back and in the end, after a lot of agonizing, we decided it was wrong to do that, we wanted to stick it out here. But we nearly did. We came quite close to it. Subsequently, although we did look at various other jobs occasionally, we never did it very seriously. I wanted to take up … I was offered the chair at Sawford (?). I wanted to take that but Mary didn’t want to take it and the kids didn’t want me to. \n\nThat was right before we came. It must have been seventy …\n\nDr. Hart: We really disagreed about that. She was quite angry about it and I was quite angry about it. I would have been prepared to have tied things up and gone, but we didn’t. \n\nAnd her reasons for not wanting to go?\n\nDr. Hart: Well, I think you should talk to her about that. I’m not quite sure, really, what the reasons were. I’m not saying she was wrong. I think probably she was right. I think she felt that I really might not be much good if I was working in an office, trying to run a university. And I think she was probably quite right. I mean I was reasonably opened to that idea. I’d been running my own show so long, I’d been a one man band, I don’t believe that single-handed practice is the right way to work. I do believe in teamwork. But it is a fact that I’ve never been in a big medical team and I don’t really know how to operate that way and I don’t know how to run a department. And probably me, as a professor, would have been a disaster. I had a feeling that she knew that and she didn’t want to go. She knew if I stayed here I would make a success and she didn’t want to take a chance. And I think that’s probably right. Anyway, those are the only two times, I think, that we really made pivotal decisions. And overall I think I have changed a lot. I think the other changes have been evolutionary. They haven’t been disjointed. They haven’t been abrupt changes. \n\nI haven’t been around for, I guess, ten years in this activity and I forget exactly when they … I think the Manchester decision had just been made right before we came, so it was about ’78 or ’79. We came in August of ’79 and I remember that being fairly fresh. You had just gotten back, I think, and it was actually a possibility that you wouldn’t be here when I came on. But, I think … I mean it helps me to hear you talk about the kinds of transitions. The way I would summarize it, not to do that, really, but in my own mind would be that that first crises or change was around, in a sense, what were your priorities. I wouldn’t say whether those priorities were political organizing and political work or, in a sense, not that your priory didn’t become political work but it was political work that was more tied to your day-to-day practice.\n\nDr. Hart: In a way, things are much clearer now than they were at the time it happened. It was a change from one kind of politics to another kind of politics. The first kind of politics, I really was saying, well, let’s stop pretending. The first kind of politics was continually trying to put life into something that was quite clearly dying. A hope from the 1930’s that no longer had any kind of credibility. And I think other people saw me as turning to clinical medicine – and I didn’t see it that way. I always thought I was turning to a different kind of politics – and I still think that. And I think that’s very evident now with the collapse of communism in the east and everything. I think the only kind of socialism we’re ever really going to get is a peripheral socialism where, although central power is important and it’s stupid to deny that, but it’s peripheral implementation that will depend on peripheral initiatives. And I think every doctor, every teacher, every sort of community worker who believes in some kind of a socialist future should be doing their work in a way far beyond the call of present duty. That’s their politic worry, is to show how things could be actually on the ground, with their own hands, so that people have got working models. The new society has got to be born within the old society and it’s got to actually be … It will reach a considerable state of development before it breaks the mold within which it fits, before the shell breaks. And we’ve got to do that. And I think that is as true in America as it is here, perhaps even more so. I think the other thing that is quite interesting is we had quite a lot of discussions, Mary and I, about what sort of life we were giving the kids. We argued about the pros and cons of taking -- and going to Milton Kanes. We weren’t falling out over that at all. We were in agreement. We thought either we go to a sort of university center, which both of those were, where we have a rather conventional background for the kids that intellectual has, that you can travel and you meet interesting people and you read books and all those things. We can have that. Or the other thing we can do is we can go back where we’ve been all the time where we’ve got a good, solid social base. Although we haven’t got high earnings, we’ve got a cheap house. We’re not meant to send them into private schools, so we’ve got the money that could have been spent, frittered away on that. We’re going to spend that on traveling. We won’t stint the kids on anything that broadens their horizons. And that we would use the idea, you belong somewhere, you’ve got roots in this neighborhood. This is where we work, this is where we live. And yet we live in the whole world. You know, the center of the world is Glencarrig because that’s where we live. So we use all of it.\n\nYeah, but the other thing … I always felt like this was not something you had control over but something that you and Mary both fostered very actively, was this constant flow of the world within --. \n\nDr. Hart: That’s why we brought people here. We deliberately … That’s right, your desk book is a history for the kids about who it is that they had seen and met. I mean it is contrived. We wanted to … We courted certain kinds of publicity. We wanted to make contact with people. We wanted people like you to come. We were very excited that you came. The kids grew up in a world in which people were coming from all over the place and being interested in us here and thought Glencarrig was important. And it isn’t any more or less important than any other point on the globe. But I think, really, the opportunity … What we’re trying to say to all people in general practice is that\n\nonce you’ve got registered population, once you know who your population is then you’re in the position, there’s a war on against disease and misery and all that. And you’ve got this section upfront which is your responsibility. Don’t tell me about how much you care about humanity and all the rest of it. I’m not interested. What I’m interested in is what you’re going to do about this section, your responsibility. This is the list of people, their addresses and telephone numbers. You’re responsible for their medical care and their health. Or you and them jointly. But it’s a small world which is definable where you can actually verify peoples’ commitment. People don’t get to talk, they’ve got to do something. And this idea of a very definite neighborhood or a very definite group of people for which people are responsible and not for everything is a liberating idea. At last, you know, it’s something that’s achievable. Now, the tragedy of Sam Hill (?) was that, you remember, he said that he was responsible for a million people in Borneo and couldn’t cope with it. And he thought that if he had 2,000 people in --, that he could cope with it – but he couldn’t cope with it. Now, if you’ve got the idea that a really good GP is an internist operating at sort of higher than the old level, who’s looking after a number of people, that it’s possible to provide that kind of medicine for, you find that you can’t do it for 2,000 people, I think they’ll find they can’t do it for 1,000, they can’t do it for 500 and they can’t even do it for five people. Because that kind of medicine actually is really, as a personal thing, just on one person, is an illusion. Those doctors function as a huge machine which needs large numbers of people in it to make it work. It can’t be done for small numbers of people. It doesn’t mean anything for small numbers of people. But if people have appropriate training and an appropriate philosophy or appropriate, corrective training, then it becomes a liberating idea that, yes, I know what I’m responsible for and I know what I’m not responsible for. The next village is not my concern. You know, I’m interested in what goes on there and so on, but my loyalty is to Glencarrig. And I think this idea of loyalty to a group of patients and loyalty to a neighborhood and to be prepared to see positive things in it that other people can’t see, to be angry when people come from outside and say how needy it is and how ignorant it is and how stupid people are, you mustn’t think that. You mustn’t think that about anywhere in the world. Everywhere has to have a doctor. And the doctor has to really believe in that place and they’ve got to have a sort of local pride and people have got to be proud of themselves and feel that their health is important. So that’s one thing that I haven’t … I mean I don’t think that was just romance. I feel it more now than I did when I came here. So I’ve got a feeling it must be true. I probably agree with a lot of the romantic idea, I suppose. But you’ve got to have it.\n\nIn a sense, putting all the decisions you made and the reasons you made them and the things you learned from that, what’s the reason you’ve been doing it for all the years you have? And why do you stay here?\n\nDr. Hart: Well, I think as you become more and more fitted for the work in a place like this, you become more and more unfitted for work anywhere else. I think that’s true. If you become a better and better heart surgeon, I suppose you’re less and less capable of becoming a brain surgeon or a marionettist or a high wire trapeze artist. \n\n(End)","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150640/file/277822#t=0.0,3670.184"}]}]},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150640/file/277821","type":"Canvas","label":{"en":["Media File 2 of 2 - Hart_Julian_Tudor_1989.12.24_-_Side_2.mp3"]},"duration":2465.984,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150640/file/277821/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150640/file/277821/content/2/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/277/821/original/Hart_Julian_Tudor_1989.12.24_-_Side_2.mp3?1750277143","type":"Audio","format":"audio/mpeg","duration":2465.984,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150640/file/277821","metadata":[]}]}],"annotations":[]}]}