This week, after 56 years in general practice and roughly coincident with his 83rd birthday, Dr. David Smith is retiring. In theory, at least. Dr. Smith says he will continue to spend two days a week seeing patients at the University of Toronto health clinic, and another couple days a week doing research and medical volunteer work.
At a time when provincial governments across the country are watching as Ontario struggles with its doctors and how much they should get paid, Dr. Smith sat down with Globe and Mail reporter Michael Posner to reflect on the lessons of his long career.
You have the practice of medicine, it seems, in your genes.
Both my father and my uncle were doctors and I always knew I would be a doctor. There was never any doubt. I wasn't the smartest guy in the class. I was a dreamer. My marks were average. But at age 15, the penny dropped. I decided if I was going to get into medical school, I had better get in gear and I started studying. I had to bust my ass to get in. I remember on our first day at university, in 1948, I went with a friend to the second floor of the physics building and they had a computer! All radio tubes. It covered the entire floor. I started practising with my father in 1957, after a year of internal medicine at Sunnybrook Hospital and moonlighting – delivering babies. Our offices were attached to the family home at Dunvegan and St. Clair. We charged $3 for an office visit and $5 for a house visit. I made hundreds of house calls. I was still doing them, until recently.
Who was your clientele?
We saw a lot of Forest Hill matrons – and their maids. After 10 years of treating haemorrhoids and piles, coughs and flu, I was a little bored. The faculty of medicine at the U of T wanted to start a community medicine service, to train family doctors. There was no program like that at the time in North America. So we opened at Toronto Western Hospital – there was no OHIP then – and saw welfare patients three mornings a week, without charge. And the rest of the time, we trained residents in family medicine. And we grew from there.
You also started working at the University of Toronto's student health services in 1957.
I'm still here. Back then, I was hired to do physicals. In those days, every student had to have a physical and do some physical activity. Before the war, you had to be able to swim two laps of the Hart House pool or you could not write your exams – unless you had a doctor's exemption. When I retire, I intend to start an OYA program there.
OYA? I don't know that acronym.
Off Your Ass. There are 73,000 students at the U of T and far too many of them don't do anything physically. No swimming, no bicycling, no fitness. I want to start a study of how many do anything, other than walk. Look, we know that fitness makes you live longer. You can draw a straight line. And they smoke. All these supposedly smart kids in computer science and astrophysics, they smoke.
What about diet?
Don't get me started. I say to these kids, 'I don't care what you eat now. There's nothing wrong with you right now.' But these are toxic behaviour patterns. They eat too much refined sugar, too much carbohydrates, which layers fat on the liver. What will they be like 40 years from now? Will they be able to ski downhill with their grandchildren? You have to be lucky. That's the genes. And you have to work at it.
You're still fit at 83. What's your own fitness regimen?
In summer, I ride my bike – I can still ride it up that hill to St. Clair. And I row. I started rowing about 30 years ago at our cottage at Thunder Bay Beach, near Midland. One of my kids bought me a rowing shell and every morning, I row. Or I'll swim 800 metres or so. In the winter, I walk to and from the office and on weekends, I ski, downhill, and snowshoe. I weight 75 kilos, about 10 more than I did in medical school. I gain a kilogram in the winter and lose it in the summer.
And your own diet?
Bran buds and psyllium in the morning, with a little raisin bran, almonds and nuts, with skim milk only, some fruit and a tablespoon of flaxseed. For lunch, fat-free ham or salmon or sardines, raw vegetables, an apple and fat-free yogurt. For dinner, anything, but easy on the pasta. I have one coffee a day and I prefer beer to wine.
What's missing, in your judgment, in modern medicine?
Three things. First, respect the patient, even if you don't like them. I have lots of patients I don't like, but I never give them the luxury of knowing I don't like them. Two, be polite. I never called a patient by their first name unless they were younger than I was. Three, be kind, always, but especially when you have a patient that is dying. Don't write them off. Show kindness. Show empathy. Think of the Latin word caritas – meaning caring. But you have to care without becoming too attached. That's the art part of medicine. You have to get the patient to tell you what's wrong with them. Otherwise, you won't figure it out.
How do you feel about legalizing marijuana?
We need to smarten up and have these drugs controlled by the government, people under our voting system, not some crook from Mexico. Sell them and handle them through safe havens. These aren't bad guys. They're sick, unfortunate human beings. Can you think of anything worse than being a drug addict? It's worse than cancer. The light comes on so slowly in our heads. I've never used marijuana myself, but I have given it to patients and it helps.
What new directions do you consider promising?
We're starting to get more into mental health. That's important because our jails are full of people who are bipolar, or have attention deficit syndrome, or are depressed. Some stupid doctor comes along and says, 'You're depressed. Snap out of it.' Come on. These people are chemically ill. They can't snap out of it, any more than someone with congestive heart failure can snap out of it. And we finally have started out to figure out palliative care. It took a long time. Doctors want to be very careful giving morphine for pain, but I argued, 'These people are dying. What difference will more morphine make? They're not drug addicts.'
How do you feel about two-tier medicine?
It makes me nervous. People paying $3,500 a year for 24-hour access to doctors. They better wipe your butt for that.
This interview has been edited and condensed.