A Lifetime Commitment to Social Justice and Health Care Access.
Carol Herbert is Professor Emerita of Family Medicine at Western University (London, Canada), and Professor Emerita of Family Practice at UBC (Vancouver, Canada). Past Chair of the University Board of Trustees for the American University of the Caribbean and a member of the Board of Governors of Simon Fraser University.
She served as Dean, Schulich School of Medicine & Dentistry at The University of Western Ontario (1999-2010) and was Royal Canadian Legion Professor and Head of the UBC Department of Family Practice (1988-98). At UBC, she was founding Head of the Division of Behavioural Medicine and a co-founder of the UBC Institute of Health Promotion Research. She is former Editor of the international journal, Patient Education and Counseling. Dr. Herbert is a UBC graduate in Honours Biochemistry and in Medicine. She was a full-service community-based family physician and clinical instructor at the REACH community health centre, a UBC teaching facility in Vancouver, from 1971 until 1982 when she joined the full-time faculty in the UBC Department of Family Practice.
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I’d like to take it back to the very beginning, because you had a very interesting childhood. You didn’t want to do medicine, you wanted to be a writer…
Carol Herbert: I think I was probably destined to be a generalist from the time I was tiny because so many things interested me. But it became clear as I got older that the direction that I would like best would have some balance between the science and humanities. It was particularly challenging because I got to decision points fairly young and had to make a choice. But I’m a strong believer in that, whatever road you take, there are often pathways where you can branch off. And, I suspect that while I got to where I was going down this particular route, I might have taken another route and still arrived at the same place.
DMacA: Was science a feature of your schooling?
CH: Yes, it was. At the time when I was going to school, it was just on the cusp of the time where girls were not directed towards the scientific professions. But it was the Sputnik era and everybody was looked upon as potentially adding to the scientific armamentarium of the country. By late high school, I think there was more encouragement of science choices and a group of us of around the same age went into university and some of us went medicine but most went into the basic sciences or the hard sciences. Some of them came around later and did medicine because it was a better career path than becoming, as for one guy with a PhD, joining the Dow Chemical production line. I still maintain that medicine is an amazing professional choice because it combines so many opportunities and there are so many ways in which you can move as you go through career.
DMacA: But, you did science first…
CH: I did. I did my undergraduate degree in biochemistry. And, I did my undergraduate degree combined with my first year in medicine as I finished my fourth year in honours biochemistry. Its interesting, and this came up just this week, when I was visiting a chemistry lab with my grandson who’s thinking about studying chemistry. One of my colleagues on the board of governors at Simon Fraser University offered to take him on a tour of the lab and I was listening to the presentation and looking at the periodic table that they have on the wall with examples of all the chemicals. I got really excited and thought about how I chose to do biochemistry, because I had an amazing teacher in high school who was very encouraging. And, when you’re interested in so many things, how someone directs you or advises you, or just gives you an opportunity to look at what life might be like, makes a difference to what you choose. There’s absolutely no question that that one teacher was instrumental in what I chose to do. That was when I was aged about 16, I was just a kid, how was I going to choose? Well, I chose because of him.
Later I chose again, because my older sister, who’s seven years older and had just completed her PhD in psychology said, ‘I think you should do medicine because I don’t have the same access as you’ll have to patients and we can then do research together’, and actually, we have done research together in our careers.
DMacA: You then moved into medicine. Tell us about your undergraduate medical education because I don’t think family medicine was a big part of that.
CH: There was no family medicine at the time in in Canada. It was just getting started when I was finishing my training in the late 1960s. I was fortunate to be at UBC at a time where Jim McCreary was the Dean. Jim McCreary was a visionary. He saw the potential for interprofessional education when it was really just a light at the end of the tunnel. We had the opportunity to do some of those things that are variably effective, and we did actually sit in the same room with the dentists and the physios and so on. But, more than that was the philosophy, the idea that there was a team. This is a long time ago when he was talking about that. And also, it was the 60s, a time when many of us were involved in looking at social change and trying to figure out our place in it.
I also had the opportunity to have two different but very important experiences. One was that I was a World University Service Scholar. At the end of first year medicine, I spent the summer in Turkey. There were two of us who had finished first year medicine and we were the senior medical personnel in the group. So, I had the opportunity to look at the health care system, and to see things that I never would have seen, international health issues, people with leprosy and tuberculosis for example, which I hadn’t seen in Canada.
And the other experience that was very important was that I spent six weeks in the far north, in Inuvik, in the Northwest Territories at the time. That was a hugely important experience for me because I was thinking of doing international medicine and, when I went to my own north I discovered that there were doctors, and there were churches being supported by people collecting money in Belgium to send missionaries to Canada to convert our First Nations population. And it just turned my mind around.
That coupled with the fact that I was emerging in my own understanding of feminism, second wave feminism, so all of that had as much impact on me as the curriculum did in terms of the medical school.
I had a two plus two, standard of the day, preparation for practice because postgraduate training in those days, if you were going into general practice, was an internship, and I really had lots of different choices that were open to me. Again, I was encouraged by a child psychiatry mentor in particular, and I loved pediatrics. But I realized I liked everything.
But I was told very clearly in 1968 or 69, and the expression was, ‘well, you wouldn’t want to be just a family doctor, because you do so well in your courses’. What is particularly alarming to me is that 40 years later, my students were telling me they were still hearing the same thing. But I was able to tell my story and indicate clearly, by my experience, that it isn’t true, and that choosing to be a generalist, choosing to do primary care, is a very active choice. It’s intellectually strenuous, tremendously challenging, and great fun. And I still think it’s a wonderful career choice, in spite of all the difficulties that we have in terms of the organization of health care.
Inducted into the Canadian Medical Hall of Fame in 2023.
“Innovative health care educator and mentor promoting equitable and accessible health care for all.”
“We have the illusion that we plan our career and then we kind of act it out. When you map somebody’s trajectory from their CV, it looks like it’s all linear and going upward. It’s not like that. It’s a spiral. And there are blind alleys and sometimes something that you didn’t plan turns out to be exactly the opportunity you wanted.”
DMacA: Let’s now take you into your professional career and your work at REACH. Tell us first what the acronym means …
CH: So the acronym is Research, Education and Action in Community Health. Initially it was ‘Attack’ on community health. And again, that’s a reflection of the time. It was started by someone who was very important in my career development, Roger Tonkin. Roger had been a behavioural paediatrician in training at McGill, had come back to BC, was the golden boy of the then chair of paediatrics, and started this program in the east side of Vancouver, where three of us, again coming from this interprofessional ethos, had started an information centre a couple of years beforehand. It (the neighbourhood information centre) was spearheaded by a social worker, Darlene Marzari, who later became a member of government. Darlene was a social work student, Ann Hilton was a nursing student, and I was a medical student, and we would provide wayfinding for this community that was organizing itself and had become quite an active community in developing community based, what we would call community engaged, strategies with some really active members in this working class immigrant neighbourhood, of Vancouver. So, REACH was started, initially with one doctor and then with a few family doctors who provided volunteer services and turned whatever money they made over to the nascent organization. The chair of Pediatrics provided some seed money to get started and wanted to bring a colleague of his from Winnipeg who was preparing to move to Vancouver and I was hired to be a locum to develop a practice for him., I was available because I had had my first child while I was an intern, and so my start date for residency in Paediatrics had been delayed which meant I did GP locums for five months-which I loved. After 6 months of residency, I decided that I was going to take a bye. rather than continuing as planned in Child Psychiatry. I took the job at REACH temporarily and stayed for many years, and then went on to the university full time. It’s an example of where, a door opens, you go through the door, and it’s an opportunity and being open to something you hadn’t necessarily planned for.
And, I tell my colleagues, my students, anybody, that it’s important to be open to something you hadn’t necessarily planned for. ‘Man plans, God laughs’. You make a plan and then you see what happens. Sometimes the right thing happens for different reasons. I’m very grateful that I had the opportunity to be at REACH during its early days, in particular, when we were doing things that were really cutting edge. We were hiring people to do health education, we were hiring public health nurses and training them to do things that we now would call nurse practitioner work. We were doing nutrition counselling. I had the opportunity to develop a dental clinic which, fast forward many years later, when I was Dean of Dentistry, I was able to say, ‘well, actually, I know something about dentistry, I bought chair side equipment back in the day.’
How did we do all those things? Well, we were willing to take the risk to look for the information we needed and, if we didn’t have the expertise, we knew how to ask for the help. We knew how to look for consultants. And we did not have a hierarchy. We were very explicitly non-hierarchical, we constantly questioned each other’s work, and we were totally patient centred. That was 55 plus years ago yet it sounds like current thinking around the patient centred medical home. We were actually doing the right things then. We were doctors that were prepared to work on a different payment arrangement because we believed in what we were doing.
We worked with a community board, and again this is a long time ago, but it came out of that early experience of team based care as an undergraduate medical student, and being a 60s kid, part of that generation. And, recognizing that I was fundamentally a primary care person, that’s where I wanted to be on the front line, and I wanted to work across the system. I wanted to be able to be a generalist. All these things came together.
We have the illusion that we plan our career and then we kind of act it out. When you map somebody’s trajectory from their CV, it looks like it’s all linear and going upward. It’s not like that. It’s a spiral. And there are blind alleys and sometimes something that you didn’t plan turns out to be exactly the opportunity you wanted. I’ve had those conversations with more than one student who has been in my office in tears when I was a Dean, telling me that their life was over because they didn’t get the residency they matched to, or the city they wanted to go to, and being able to say to them, you know, there are other ways to get to where you’re trying to go.
“My idea was that everybody needed to understand the role of research and their role in asking questions, whoever you were, in whatever part of medicine, and particularly in primary care. It came from that realization that the facts just weren’t there, we needed to generate the facts.”
DMacA: Another opportunity opened up for you, and you went to UBC, and you’ve talked about relationships, and that was always very important in your academic career.
CH: I went to UBC full time in 1982. I started teaching as soon as I went to REACH. I was a clinical instructor when I was still wet behind the ears. And, some of my early students have pointed that out. I was pretty young but we had a lot of fun. Back in the day, in the early 1970s, we were writing objectives. We actually demanded from UBC, as a group of doctors in the community, that we have access to a consultant so we could write objectives. It was something that nobody was doing at the time but we thought was really important.
We began to read the educational literature and as time went on, with my experience in practice and I loved what I was doing, I felt like I could have more influence if I was working on a different stage, particularly in a more formal education environment.
The other thing was that I’d begun to do research and was, absolutely, a bootstraps researcher. I’d done some research as an undergraduate, and took whatever opportunities I could to learn about research. I mentioned that I’d done some work with my sister, but I thought that if I went to the university, I would have more access to research experts. On the one hand that was true outside my department. But, within my department I discovered that, just like when I had gone to Turkey as a medical student, I was seen as the one with the expertise. I knew how little I knew but Cinderella syndrome has never stopped me. We organized, we brought in people who could form a research nidus within the department, and we were indeed able to enhance our own understanding and develop a research path and, viewing research in the broadest sense.
I was part of the group in the College of Family Physicians at the time that looked at- how do we teach research and make that meaningful to residents. New groups of people were training in family medicine so transforming the idea of research into scholarly activity was really important. Later on, I think we transformed it back because we recognized that the word ‘research’ needed to be seen as useful and important and not as something to be resisted. But, in the early days, we wanted to get people thinking and realize that they could generate questions. And, again, we would tell our own stories of being in practice. So, why did I start doing research? I looked for answers to those questions that I had in practice where I couldn’t find the answers because they didn’t exist. The questions that were being asked, for example, about back pain, were being asked in a specialist clinic – they weren’t about my patients who had the kinds of symptoms that I needed to address. So, it came very much out of practice. My idea was that everybody needed to understand the role of research and their role in asking questions, whoever you were, in whatever part of medicine, and particularly in primary care. It came from that realization that the facts just weren’t there, we needed to generate the facts.
It was very interesting that, from time to time, something that we’d observed in practice and that we’d talked about in our small group within the practice, would appear in the literature a few months or a year or two later. Somebody would have studied such a thing and we’d say, ‘oh, my goodness, we thought of that, but we didn’t act on it.’
As a busy practitioner, you can’t go out and get grants and do big research, but you can always ask questions. People like Ian McWhinney, and some of the historical characters that we didn’t learn about when I was a medical student and we teach about now, were writing about that. And, those historical characters began became more important to me as I learned more about family medicine, primary care. Those people who had studied their practices didn’t wait for someone else to tell them the answer. If I could write my own epitaph, that would be a good epitaph. I’d like to think that I’ve never looked for someone else to give me the answer. I’ve always looked for the answer, and if it wasn’t there, I’ve gone to find it and figure it out.
“…that you need to think big and not be constrained by resources because, if you’ve got the right idea, you can mould that idea and you’ll find the resources. If you don’t have the idea, doesn’t matter what resources you have, you’re not going to get there.”
DMacA: You had immense achievements at UBC and then mid-career, you began look for an answer somewhere else, you moved right across the country.
CH: It was a mentor again at UBC. Back in the day, there were not many women in the mix, but David Hardwick, who was the ‘eminence grise’ behind about five Deans at UBC, professor of pathology when I was a student, he just understood the system and wanted to be the advisory guy. He never wanted to be the Dean. But David, did two things. He opened up the idea to me that I could actually aspire to a senior position in academia. I hadn’t thought of that before. He said, basically, if not you, then who? I had this illusion that there were all these very wise people and I could just go and find the wise people. Well, no, actually, they weren’t any wiser than me. And perhaps I could do something they couldn’t do because I had some particular understanding.
The other thing David did was, sitting beside me at the Deans dinner very early after I had been appointed to be chair of family medicine, he asked me the following question: ‘ So what’s your vision for your department?” and I said, ‘Well, I have a five year vision. We’re doing strategic planning and so on.’ And then he said, ‘I don’t mean the near term, what’s your 20 year vision for the department? ‘ So it was very much, using the analogy of the Mohawk Creed, the kind of thing that Ann Macaulay talks about, thinking about what you would want to see when it’s no longer you in charge? What are you building for in the long run?
And that was a very important question. It really started me in thinking systems, thinking about the larger construct and the way in which the small things we do can have impact. There’s a Jewish saying that you are not obliged to finish the task, and I’m paraphrasing, but we’re each obliged to take those steps that we can take along the path towards the vision.
So, getting this idea that you need to think big and not be constrained by resources because, if you’ve got the right idea, you can mould that idea and you’ll find the resources. If you don’t have the idea, doesn’t matter what resources you have, you’re not going to get there. So, I am incredibly grateful to him for taking the time to spend a few minutes with a new leader and do the kinds of things he did. And again, I’ve paid that forward, or tried to, throughout my career. And I still do with anybody that’s interested in medicine or interested in career development, I always open the door to see if, maybe by having a conversation I can help someone have that experience I had. Just like in practice, you don’t know how the conversation you had is going to impact directly. But, what I do know is that having a conversation may have a tremendous impact on somebody. You don’t know which butterfly’s wings are going to flap, but I’m open to doing that with people.
DMacA: What’s been absolutely wonderful, Carol is talking not just about the different steps in your academic career, but your general philosophy and your overall view of where you’ve been and where we are at the moment. So, let me ask you about the future. Building on that ‘seven generations philosophy’, how would you like people to remember what you’ve achieved?
CH: Oh, that’s a very hard question. I think the major impact I’ve had is seen in my students and the people that have worked with me. I think that, if I’ve been able to open up opportunities for people, and I did that as department chair and as Dean it’s what you do as an administrator, is that ideally, you make it possible for people to do their best work. There have been some amazing things done that I know I had a hand in doing. I don’t appear in the story of that outcome, and that’s okay. I know that I had that impact.
I guess the area where I’ve probably have had the most direct impact would be around participatory research. I became involved with community engaged research long before it was named as such, certainly in primary care. I was able to bring it to NAPCRG (The North American Primary Care Research Group) and to my colleagues, and talk about the work we were doing in the late 80s, early 90s. And, it then took off. And people like Ann Macaulay, and later Vivian Ramsden and others, have really built that into a mainstay in primary care. I think that’s really important and I’m very glad to have done that work. That’s probably the main contribution. There are lots of projects but they all come down to sharing power, working with the team and, and being open to asking questions and finding innovative solutions to solving problems.
“We have 20% of our population that do not have access to a family doctor or indeed to any primary care provider. That’s unconscionable. If that is where we sit, then we have to change the way that we’re doing things because we’re not delivering the care that people need.”
DMacA: Before we go, Carol, Let me ask you a question that’s on lots of peoples lips. What’s the future of family medicine in Canada?
CH: I would like to think that it has a rich future, assuming that we take the opportunity to deal with some of the really huge issues in health human resources within our country. We have 20% of our population that do not have access to a family doctor or indeed to any primary care provider. That’s unconscionable. If that is where we sit, then we have to change the way that we’re doing things because we’re not delivering the care that people need. We know people need a primary care provider. I would like to see family medicine at the College, actually leading the charge to developing a team based approach which recognizes that you can have multiple points of access, that you work in partnership, and that at the end of the day, you’re serving a patient, their family, the community. And, not to be protecting our turf. I think that as the disciplines evolve, that’s the challenge. Interprofessional education is no longer the issue, the challenge is actually truly interprofessional practice. We can’t deliver care if we don’t do that.
DMacA: Carol, it’s been absolutely wonderful talking to you. Thank you very much for sharing so much of your life, your philosophy and your thoughts on what the future holds. Thank you very much indeed.
