The Citadel by A J Cronin - Essay Example

Literature and Medicine Introduction: In his book ‘The Citadel”, published in 1937, A. J. Cronin provides an insight into the ills that plagued the medical service in the United Kingdom during the early twentieth century. The essential drawbacks in the medical service in those times were the conservative approach of the medical fraternity to making any change for the better difficult and the avarice oriented medical service that tended to cater to the higher classes of society neglecting those in the lower levels of society. Many decades have gone by and we are in the early twenty-first century, but many of the issues raised by A. J. Cronin in “Citadel” remain relevant in terms of the medical service that is available to the citizens of the United Kingdom. Description: The excerpt for the book under evaluation is a discussion between Manson and his wife Christine regarding Manson’s intentions to change from his current mode of general practice and start a fresh initiative in providing medical service by combining the strengths of his experience as a general practitioner with those of a surgeon (Denny) and a bacteriologist (Hope). Manson goes on to justify this decision of his to his wife in the benefit that such an initiative would deliver in the form of “pooling” the knowledge that each of these specialties in medicine would offer. Such a “pooling” of knowledge would be of benefit in patient care to provide better outcomes. The existing system of medical care was in the form of the general practitioner carrying out all these responsibilities, even in specialized areas with a limited amount of knowledge, to the detriment of patient care. Manson suggests that this association of specialties into what he calls “Group medicine” provides a “perfect answer” to the near impossible tasks that a general practitioner had to perform in patient care. Such “Group medicine would be the intermediary fresh breath of air between the monolithic state medical service and the individual effort of practitioners in several parts of the country. Manson clarifies that such Group medicine had failed to materialize only because of the attitude of those in the medical science power centers not wanting any rocking of the boat so that they would remain in control in the provision of medical services to the people. Manson believes that such an effort in Group medicine by the scientifically oriented unit would revolutionize the manner in which medical services are provided and remove the prejudices and ills that plague the medical system. There are three themes that recur in “The Citadel” by A. J. Cronin. The first is the conservative approach of the medical establishment in resisting any change and thereby ensuring that the power remains in the already established medical power centers. The second theme is the greed and avarice that exists in the medical fraternity, whereby the concentration of providing medical services is to the upper crust of society to the negligence of the lower levels of society. The final theme is the combining of knowledge and expertise by different specialties into a scientifically oriented unit in place of the over-burdened and ill-equipped general practitioner in the provision of patient care so that better outcomes result for the patients (Cronin 1937). Context: The Citadel by A. J. Cronin was written at a time when general practice was in a flux, buffeted by the winds of too many general practitioners competing for patients and the advent of specialists that were cornering the more lucrative part of the patient care. The late nineteenth century and the early twentieth century was the period in which many changes were occurring in the field of medical practice. More and more general practitioners were being churned out by the medical educational institutions and these included women general practitioners, who tended to draw away female healthcare seekers in their direction, increasing the competition among the male general practitioners. Advances in the field of medical science and technology were tending to demonstrate the inadequacies of the GPs in their knowledge and skills in providing the best medical care for their patients. Most of these inadequacies were a result of the concentration on the provision of theoretical facts with hardly any practical knowledge of the diseases they would encounter as a part of their practice as general practitioners. This knowledge provided to them made them competent to handle acute medical situations they would seldom come across in their practice, but with inadequate knowledge and skills to handle common ailments that they would commonly encounter in their daily practice. Thus many of the general practitioners started out with inadequate competencies for their functional responsibilities in the medical care system. This lead to a high mortality rates as a result of the treatment by such general practitioners. To make bad matters worse for the general practitioners, a new class of medical practitioners in the form of highly knowledge and skilled specialists was emerging. These specialists tended to be supported by the elite and the better paying clients of medical service, causing the intensely competitive general practitioner filed of medicine to find them even more restricted in terms of market availability. This led to the general practitioner profession turning out to be a hard grind. Such a situation was to persist till 1913, when the predecessor of the National Health Service (NHS), in the form of the National Health Insurance (NIH) was introduced. The NIH made medical services available to workers, who till that time found it difficult to seek such medical services. However these services continued to be denied to the families of the working class. Nevertheless the general practitioners benefited from the introduction of the NIH, as a new market opened out to them (Digby 1999). One of the key issues for general practitioners in those times and in modern times is the relative intellectual and social segregation that impact upon general practitioners in the face of advances in the field of medical science and technology. Removing these inadequacies in general practitioners through the dissemination of appropriate knowledge and skills becomes a significant factor in improving the standards of health care provided to the people (Honigsbaum 1979). Interpretation: The Citadel was written with the medical fraternity and the administrative authorities as the target audience, so that pioneering changes in the provision of patient care could become a reality. This can be seen in these words of Manson” One of the striking themes of The Citadel is the concept of health centers in place of large hospitals to make healthcare more accessible and more equitable to the people. This can be seen in Manson’s words “Even in quite a small provincial town you could have a clinic, a little team of doctors, each doing his own stuff”. Manson’s concept is of a small group of doctors having different skills to provide a multi-skilled ability for the small health center. This concept of a different means to meeting the health needs is a reflection of such experiments being started by pioneering medical professionals and thinkers after the First World War. The Pioneer Health Center, Peckham founded in 1926 and the brainchild of Dr. George Scott Williamson made the families and not the individual the target of their healthcare activities (Lewis & Brookes 1983). This was because the perspective of those medical professional associated was that the medical practice of those days was more oriented to the treatment of illnesses and not focused on health promotion (Hall 2001). Such pioneering thoughts were in contrast to the mainstream and established healthcare systems and were starting to emerge in these times and The Citadel reflects this in its theme related to the change required to enhance the quality of healthcare delivered and to ameliorate the difficulties that the general practitioner faced. A major inadequacy that was felt by the general practitioners at that time was the education system that they passed through did not prepare them for the responsibilities that they faced in providing actual patient care in their practice, as a result of the conservative approach of the medical establishment, which is another theme of The Citadel and demonstrated in Mansons words “Perhaps you remember all Denny’s arguments- and mine too – about our hidebound GP system- how the general practitioner is made to stagger along, carrying everything on his shoulders, an impossibility!” This lament of the general practitioners still remains with the perspective among general practitioners that the education system that they go through seldom prepares them with an “adequate understanding” of what they are likely to experience in their actual practice. (Murdoch, 1997). This makes the observations of A. J. Cronin in The Citadel relevant in present times. General practice was becoming more competitive and less remunerative. The more lucrative practice of caring for the upper class of society was being cornered by the specialists and larger hospitals and retained by them. The general practitioners needed to collaborate with other specialties to give more relevance to their practice to all segments of society, including the upper classes. This is reflected in these words of Manson, “the only reason we haven’t had it here is because the big men like keeping everything in their own hands. But oh! Wouldn’t it be wonderful, dear, if we could form a little front-line unit?” In modern times the general practitioners continue to be essential to the primary care provisions for the people. Over these several decades since A. J. Cronin aired the theme of inadequate knowledge and skills being provided to the general practitioners in the medical science education curriculum with regard to their actual requirements and the advances in medical science the general practitioners still remain a deficient lot in this respect (Lord, 2003). Conclusion: The themes of inadequacies in the medical care provided to the people in the early part of the twentieth century have been brought out vividly by A. J. Cronin in his book The Citadel. The importance of this book and the themes in the book lie in their relevance to medical care services in the United Kingdom even in modern times. Literary References Cronin, A. J. 1937. ‘The Citadel’. Digby, A. 1999. ‘The Evolution of British General Practice, 1850-1948’. Oxford University Press. New York. Hall, A. H. 2001. ‘The Archives of the Pioneer Health Center, Peckham, in the Wellcome Library’. Social History of Medicine, vol.14, no.3, pp.-525-538. Honigsbaum, F. 1979. ‘The Division in British medicine: A History of the Separation of General Practice from Hospital Care 1911-1968’. Kogan Page. London. Lewis, J. & Brookes, B. 1983. ‘THE PECKHAM HEALTH CENTER, “PEP”, AND THE CONCEPT OF GENERAL PRACTICE DURING THE 1930s AND 1940s’. Medical History, vol. 27, pp. 151-161. Lord, J. 2003. Future of primary healthcare education: current problems and potential solutions. Postgraduate Medical Journal, vol. 79, pp. 553-560. Murdoch, C. J. 1997. ‘Mackenzie’s puzzle – the cornerstone of teaching and research in general practice’. British Journal of General Practice, vol. 47, pp. 656-658. Read More