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This issue’s interviewee is Richard Ballon Goldbloom, (O.C., B.Sc., M.D., C.M., F.R.C.P.C., D.Litt (Hon), LLD (Hon), a paediatrician who has always advocated for closer ties with psychiatry. In 1967, he was appointed Professor and Head of the Department of Pediatrics at Dalhousie University, and Physician-in-Chief and Director of Research at the Izaak Walton Killam Hospital for Children in Halifax, Nova Scotia. He held these posts from 1967 to 1985. He was appointed Officer of the Order of Canada in 1987 in recognition of contributions to regional health care for children. He has authored over 120 original papers in the medical literature and numerous textbook chapters. He edited (with Dr. Robert S. Lawrence) a book entitled “Preventing Disease, Beyond the Rhetoric”, published in 1990. His second book, “Pediatric Clinical Skills”, first published by Churchill-Livingstone, NY, in June 1992, has been extremely popular with medical undergraduates and postgraduates. A fourth edition will be published in 2010. He achieved international recognition as a pioneer of family participation in the care of hospitalized children, having introduced one of the first Care-by-Parent Units in Canada. He has held visiting professorships and distinguished lectureships throughout the world, including Litchfield Lecturer at Oxford University and Visiting Professor of Pediatrics at Shanghai Medical University, Tel Aviv University and other universities throughout Canada and the United States. In 1986, he was named Sir Arthur Sims Commonwealth Travelling Professor, and visited universities and hospitals in India, Hong Kong, Singapore, Australia, New Zealand, South Africa, Zimbabwe and the United Kingdom. In 1997, he received the Ross Award, the highest recognition of the Canadian Pediatric Society. He served as Chancellor of Dalhousie University from 2001–2008 and is currently Chancellor Emeritus.
In terms of community interests he has served as President of the Atlantic Symphony Orchestra and VicePresident of Symphony Nova Scotia; he was the first Board Chairman of the Water front Development Corporation in Halifax and founding Chairman of the Discovery Centre, an interactive children’s museum of science and technology in Halifax. In 2003, he received a Canada Post National Literacy Award, in recognition of his work to promote child literacy. In 2005, he was honoured by the IWK Health Centre with the naming of a new building as the Richard B. Goldbloom Pavilion for Research and Clinical Care.
Good day Dr. Goldbloom and then you for agreeing to do this interview from Florida!
Q: Can you describe a little about your family’s background (mother and father)?
A: Both my parents were born in Montreal but my grandparents were immigrants from what is now Lithuania, but was then part of a narrow band of Tsarist Russia, known as the Pale of Settlement, within which Jews were confined. When I was born, my parents lived on Crescent Street in Montreal which at that time was largely a “doctor’s street.” Physicians typically had their offices on the ground floor, while the family lived on the two upper floors. My dad had started his professional life as an actor (initially a child actor in a stock company) at a time when his family was living in Worcester, Massachusetts. His parents (my grandparents) wanted him to be a doctor. Before he was born my grandmother had lost two children in early infancy, probably from pneumonia. And when my father was very young, he too developed pneumonia, and was treated by Dr. William Molson, of the Molson brewing family. Dr. Molson took care of many impoverished Jewish immigrant families, frequently charging them nothing. My father recovered from this illness and my grandmother decided then and there that she wanted him to become a doctor when he grew up, “just like Dr. Molson.”
Q: What happened to your dad’s acting career?
A: He continued acting professionally until he entered medical school (at McGill). As a matter of fact, he did one final tour on the RKO vaudeville circuit after finishing first year medicine. My father’s acting experience undoubtedly enhanced his extraordinary talent as a teacher, since he was an extremely effective speaker and story-teller and had a great sense of timing. Incidentally, his sister Eva was also a professional actress for many years.
Q: Could you describe for me any eventful experiences in your childhood that may have influenced you or your career choices.
A: The thing that jumps to mind immediately was the physical environment in which my brother and I grew up – we had to walk through dad’s office to leave the house to go to school. I remember distinctly the smell of acetone as if it was yesterday. Also, my parents insisted we ate together as a family as often as possible, a tradition my wife and I tried to maintain when raising our own children. Many fascinating guests were invited to our house for meals, many of the guests were physicians, but the roster also included actors, musicians and a host of fascinating people and these dinners generated plenty of interesting discussion. One event that stands out for me indelibly took place when my father and my uncle (a surgeon) were looking after a little girl, I think she was 7 or 8 years old. She had been desperately ill for months, with recurrent fever and empyema (pneumococcal, I think), and nasty abcesses which had to be drained. They were sure she would die. They had heard about a promising new antibacterial drug developed in Germany called Prontosil, (an early ancestor of the sulfonamides). They somehow managed to acquire a small supply of Prontosil. When it arrived they administered it to this girl. Her fever disappeared precipitously in 48 hours and she became symptom free and recovered completely. They published the account of her miraculous recovery in a medical journal as that was an unusual case for those days. I was exposed to innumerable patient stories throughout my childhood and adolescence like that.
My father was atypical for English-speaking Quebecers in that he understood the importance of bilingualism many decades before it became fashionable. He insisted that my brother and I learned to speak French beginning as pre-schoolers. This was a time when few anglophones believed this was important. At that time it was possible to live an entire lifetime in one of Montreal’s English enclaves and never hear a single word of French spoken.
The other memory that stands out is that my parents also took us to Europe every summer, at a time when most Anglophone middle-class families were shipping their youngsters off to summer camps with great sighs of relief. Of course the mode of travel in those days was by ship. We saw most of Europe…its great museums, historic sites, theatrical performances etc. Despite my father’s busy schedule, he insisted on taking this time off, as he thought it was important for himself and for the family.
Q: Any adventures as a young man before entering medicine?
A: When I was a teenager my father began to take my brother and I (as silent observers) on his Sunday morning ward rounds at the Montreal Children’s Hospital. I suppose doctors are not allowed to do that these days. But this was a different era. My father was the first fully trained pediatrician to practice in Montreal. During my pre-med years at McGill I worked as an assistant (unpaid) lab technician at the Montreal Children’s Hospital (then known as the Children’s Memorial Hospital) on Cedar Avenue, on the slopes of Mount Royal. I learned how to do blood counts, urinalyses, and other routine lab tests and assisted at autopsies. When I obtained my driver’s license, my father would often have me drive him around Montreal as he made house calls. He would talk to me about youngsters he had seen, and this too began to shape my perspective on children and their families. Most modern trainees never get to make a single house call and I’m sad that they are denied this invaluable experience.
Q: What was your training like? In your 2003 presentation at the CACAP in Halifax you describe your internship experience at the Verdun Protestant Hospital (now the Douglas) and influences by psychiatrists Drs. Lehman, Stern and Kral.
A: It was an amazing experience to have such mentors. Most were Jewish refugee physicians from Germany and since they could not get jobs in the university teaching hospitals and many Canadian-born doctors did not want to work in “mental hospitals”, many of them ended up working in huge psychiatric institutions, such as the Verdun Protestant Hospital. Also, you did not have to be a psychiatrist to get a job at a chronic mental hospital. This was around 1949–1950. I often drove Vladimir Kral to work since he did not have a car. We had amazing conversations. Another psychiatrist whose thinking affected me greatly was Karl Stern, Professor of Psychiatry at McGill during my undergraduate years. He too had a brilliant, cultured mind, and an unforgettable way of describing psychiatric and behavioral phenomena especially the role of ritual in reducing anxiety. He would remind us of the silly ritualistic games we would play as children (e.g. never stepping on cracks in the sidewalk…) and would proceed to show that, while we might abandon such “silly” practices, in fact, we simply substituted other rituals, e.g. our individual sequence of sleeping positions when we go to bed at night, morning rituals, etc., and that these rituals were an important part of our defenses against anxiety.
Another psychiatrist from whom I learned a good deal from was Dr. Jerome Schulman a child psychiatrist from Chicago. To help improve their interviewing skills, he would ask trainees to audiotape a couple of their own interviews with families, then listen to the tapes by themselves. Initially it often took some persuasion to get them to tape their first such interviews, but the simple process of having them listen to their own conversations with patients automatically improved their interviewing skills. Like Heinz Lehman, Jerry Shulman was also a talented amateur cinematographer. In one film he had documented a young child’s hospitalization experience from the child’s perspective. He did all the camera shots from the places where the child’s eyes would be. The images were memorable, and it was not hard to appreciate why children, especially young ones, became both anxious and frightened by a visit to the hospital.
Of course the most impressive of the post-war refugee physician/psychiatrists I encountered was Heinz Lehman. He reminded me when we first met (when I did a rotation at the Verdun Protestant Hospital in 1949) that my father was the one who had made it possible for him to get into the medical system in Canada by offering him an internship at the Montreal Children’s Hospital. As you know, Lehman would become the first doctor in the world to try chlorpromazine (largactil) in psychotic (schizophrenic) patients. This was truly the beginning of the psychopharmacological revolution. In those days psychotic patents were segregated on religious grounds. The Verdun facility housed 1500 patients, many of whom spent much or all of their lives there. ECT was new and dangerous, and insulin shock was almost equally so. Lehman went on to become the Chief of Psychiatry and the Director of the hospital.
Q: What is the film East House, made by Lehman?
A: East House was an old, uninviting building on the hospital grounds which housed the most severely regressed psychotic female patients. Many had been there most of their adult lives. Most refused to tolerate clothing, smeared feces everywhere and basic hygiene was impossible to maintain. Many were violent. Frankly, I found the place repelling and downright scary. But, as always, Lehman could see light where the rest of us saw only darkness. He took on the unfortunate patients of “East House” as a personal challenge. Even before antipsychotic medication was available he showed that even the most severely regressed patients could be conditioned through behavioral interventions to accept greater order, conformity and even some degree of tranquility in their tragic lives. He repeatedly clothed women who had previously rejected all such attempts. Gradually, after repeated attempts they accepted the clothing. He would have their hair brushed repeatedly, and after a while they would stop messing it up. He installed mirrors. He taught them to apply make-up. He recorded his accomplishments cinematically in a silent, amateur film entitled, simply, “East House”. This amateur, black-and-white film is a memorable record of how it is possible to condition even the most regressed patients to more acceptable behavior, and even to regain a few basic social skills.
Q: You indicated as well that he was very interested in creativity and its therapeutic role in mental patients?
A: Lehman was deeply interested in encouraging the creative work of psychiatric patients, particularly painting. He documented the often striking evolution in subject matter that accompanied changes, for better or worse, in patients’ mental status. This inspired me to encourage the arts in hospitalized children as a therapeutic tool for them.
Q: To be blunt, and I say this more tongue in cheek, why did you not go into child psychiatry?
A: In fact, I truly believe that I did go into child psychiatry, at least to a considerable degree. One of my medical heroes, the late Dr. Harry Gordon, a pediatrician who later became Dean at Albert Einstein Medical School, once said that “the doctor’s mission is to relieve anxiety….and everything we do by way of diagnosis, treatment (and even research) is only a means to that end.” By that definition we are all, or should be, to a considerable degree, psychiatrists.
Simply put, when I was training, child psychiatry only existed in an embryonic stage. However I was always aware of psychosocial issues interacting with physical conditions even when I was in med school-My father had appointed the first child psychiatrist to join the staff of a Canadian children’s hospital…the Montreal Children’s Hospital. This was Dr. Taylor Statten, who had trained at Johns Hopkins. My father organized weekly pediatric rounds with the child psychiatrist. These rounds were designed to focus specifically on the psychosocial aspects of a particular patient’s illness. These were pediatric (“medical”) patients, e.g. with rheumatic fever, osteomyelitis, or tuberculosis but the psychosocial and family aspects were the only issues discussed. In my opinion this type of clinical rounds should be revived.
Q: Tell me about the family therapist Nate Epstein? How did that affect your views of families? How does that fit in with pediatrics and I quote you from the 2003 lecture, “And to this day I find myself applying the principles of family therapy, irrespective of whether the presenting clinical problem is primarily biomedical or psychosocial - a distinction that is becoming progressively fuzzier in any case.”
A: I met Nate in the 1940’s, when I became his children’s pediatrician. In fact, his daughter Nancy, a fine ophthalmologist, is now my daughter-in-law, having married my youngest (psychiatrist) son, David. Nate Epstein came from the same Nova Scotia coal-mining town as my wife, Ruth i.e. New Waterford in Cape Breton, and his ideas about families greatly influenced me. He was interested in the dynamics of how families operate. This may sound simple now but no one had looked into this during that era. From him I learned to understand some of the fundamentals of family homeostasis. I learned that each family develops its own unique equilibrium (or dysequilibrium, as the case may be). I also learned from him the specific elements of family function that determine emotional health in children. His landmark studies, carried out in collaboration with Dr. Bill Westley, a sociologist at McGill involved a long term detailed study of 100 ostensibly” normal” families, published in a small book entitled, “The Silent Majority.” They showed that 3 critical elements of family function played key roles in conferring emotional health on children, namely: warm, open communication; shared labor, and leadership. An example of how I apply this is if I have a child with a chronic condition I ask both parents to come in. In some families one caregiver is shouldering the whole burden, producing a dysequilibrium in the family. Another element of family therapy I learned from him was his insistence on time-limited results (as opposed to open-ended psychotherapy). Families under treatment were “required” to produce results (i.e. improved family function) in short order if they were to continue in treatment. I suspect this kind of “toughness” may have been partly related to growing up in a rough and tumble coal-mining town.
Q: How did you balance career and family life, always a difficult issue for physicians?
A: There is a growing literature that family dining is vanishing. In my family we had special times for meals and these times were sacrosanct. On Friday night I brought my whole family over for dinner at my parents. Now, even if there is insistence for the kids to eat with their families, with the new toys such as television, video games, cell phones, MP3 players etc…, it seems everything is being done to discourage conversation. At the family dinner table it is important to lay down some behavioral and conversational rules- it must not be a forum for criticizing each other, but a time for focusing on everyone’s positive qualities- personal qualities and achievements.
Q: Any themes emerging in your early career- any unexpected twists or surprises that changed any preconceived ideas you had?
A: Not really, I enjoyed my practice a lot but most of all I enjoyed house calls and learned a huge amount from seeing and talking to children and their families in their natural habitat, a totally different perspective than when you see people and kids in the office.
Q: You have three grown-up children. How do you think your influence affected them?
A: The pediatrician-well that’s a family tradition…though after becoming Associate Physician-in-Chief at Sick Kids in Toronto, Alan gradually morphed into a senior hospital administrator, and is now President and CEO of Childrens’ Hospitals and Clinics of Minneapolis-St. Paul in Minnesota. Our youngest son, David is a psychiatrist, and is Senior Policy Advisor at the Centre for Addiction and Mental Health in Toronto. Our daughter Barbara also works with kids: she is a teacher, former school principal, and now an educational consultant (who works with pediatricians) evaluating and remediating youngsters who are experiencing school difficulties.
Q: I guess later on in life you started to travel more. How do you see medicine, pediatrics from an international perspective i.e. borderless medicine?
A: Travelling and experiencing first-hand how medicine is practiced in many other parts of the world has been very important to me. I had two 6-month sabbaticals, during which I travelled widely. I was impressed how doctors in Africa and many parts of India could practice high quality medicine with minimal lab backup. It convinced me of the importance of clinical skills. Also, one gains a new respect for people of different cultures and backgrounds. Becoming sensitive to cross-cultural issues becomes more important with each passing day, as the populations we serve become progressively more heterogeneous.
Q: You are a great supporter of the symphony in Halifax and an adept pianist. What is role of music in your life- how do you see it affecting your approach to medicine, patients?
A: Several people in my family were musical- my mother’s sister was a well-known professional concert pianist, one brother was a violinist (he became a surgeon) another sister was a cellist but I was too lazy to think about a career in music for very long…aside from not having enough talent! Still, music for me remains very therapeutic and I still like to play as much as I can. The most fun I have is when I can highjack one of our symphony musicians to come to the house and play duos with me.
Q: Any patient or family that really influenced you in your professional or personal life? You published an article entitled “Unforgettable Patients”.
A: Quite a few patients have affected me deeply –usually the ones I have not been able to cure. These “kids”, now in their 30s, 40s and fifties are people with whom (in many cases) I still keep in touch, and/or they still keep in touch with me. These kids, grown up now, in some cases are like part of my family. They come to visit when they are in town, they send me birthday cards
Q: You appear to be in favour of strong ties between pediatrics and child psychiatry. What could pediatrics and child psychiatry improve on?
A: For over half a century- several well-spoken authorities have held forth on the contemporary functional (I believe it is more often dysfunctional) relationship between psychiatry and pediatrics and have suggested practical ways in which it could be improved. Unless I’m badly misinformed, I believe there is still a long way to go in closing that gap for the benefit of our patients. Dr Anders of Stanford’s Dept of Psychiatry surveyed 56 pediatric training programs and concluded that, “the major function of child psychiatry continues to be the provision of sporadic consultations to pediatric inpatients on request”. One of his striking findings was the absence in pediatrics of courses on interviewing and family counseling. Barbara Korsch at Children’s Hospital in Los Angeles audio-taped 800 interviews of 800 different patients, questioning the mothers afterwards. In about 25% of cases parents had not revealed their main concern to the doctor-a shocking indictment of our recurrent failure to root out the hidden agendas that so many families find too menacing to verbalize spontaneously. Many years have passed since these papers were published and I believe that not much has changed.
Q: So what do we do? Any suggestions?
A: One suggestion is that the department of pediatrics should have one or two child shrinks on staff and vice versa - a pediatrician could keep child psychiatrists on their toes about developmental issues. This is a matter of principle- and I believe it was Sir William Osler who said that when doctors speak about matters of principle, they usually mean money. But with joint appointments everyone would benefit and the cost should be shared by both departments. The second issue is location, location, location. The physical separation of many mental health services from other pediatric services is wrong. Functional integration begins with architectural intimacy and money. Thirdly, child psychiatrists should be obliged to attend and participate in weekly joint clinical pediatric teaching sessions when decisions about patient care are made-the kind my late father instituted over 70 years ago. Pediatricians should reciprocate at child psychiatry conferences. If child psychiatrists and allied pediatric mental health personnel really want to make their lives less frantic and less frustrating, the surest and quickest way will be to teach medical undergraduates and pediatric post-graduates to be better psychosocial diagnosticians and therapists.
Thank you Dr. Goldbloom and enjoy the rest of your vacation in Florida!
Thanks also to Dr. Aidan Stokes for suggesting Dr. Goldbloom’s name.