Irish Medical Organisation

Keynote Addresses

It was a remarkable honour to receive this chain from Dr. Paul McKeown. I am sure many people have stood here and said how they believe their predecessor would be “a hard act to follow”. Well I can guarantee that no one could say that with as much sincerity as I do now.

To say that this organisation is in a different place to where it was twelve months ago is an understatement. While I feel that tonight is not the place to go over those issues, I will say this; this organisation could not have had a better leader for the last year than Paul.

It is through Paul’s commitment to openness and honesty, transparency and accountability that I am taking over an organisation that is not just functioning well but one that is well on the road to recovery and renewal.

It was heartwarming through this weekend to hear members say how they feel that over the last three months, the IMO has been more responsive and has worked better than it has in many years. The response to the “24 hours is enough” NCHD campaign, the response to Croke Park II and the ongoing battles against the cuts in General Practice show that despite the internal issues which are being dealt with, the organisation has remained able to maintain focus on its primary role of representing doctors.

And a lot of that is down to Paul’s leadership. So I want to acknowledge that and, on behalf of us all, I would like to thank you Paul.

My own journey through medicine started in very similar circumstances I imagine to most people here. Furtive conversations with career guidance teachers, multiple mind changes and eventually a January evening deliberating over a CAO form and which code to write down before posting it off to Galway.

For me the choice was not a straightforward one. From an early age I knew that my interests lay within the sciences and my choice was between following a more pure scientific role or a career in one of the applied sciences. In the end what attracted me most to medicine was that at it's core, it allows for the best scientific principles to be used with empathy, compassion and humanity to benefit patients and society.

The fast moving pace of medical innovation meant that it would always be a changing and evolving environment which would allow me to be working at the cutting edge of discovery for the duration of my career.

The other thing that attracted the younger me to medicine was the broad range of career options that were available all within the sphere of medicine. The difference in work life, career-path and individual talents required for a General Practitioner to someone working in a laboratory based specialty through to those in full time research or the pharmaceutical industry is as great as probably within the working world altogether. Yet each of these roles are as vital as the other in the healthcare chain …fighting the ongoing battle against disease and disability.

This variety, I feel, requires a variety of personalities and aptitudes among those who enter medicine. This variety is something that I have seen as beneficial as I made my way through my career and one that I sincerely hope will not be undone by the introduction of aptitude tests to medical entry.

Over the past number of years I have campaigned against these tests as you can see from motions passed at successive AGMs. If such aptitude tests are so successful at identifying future careers I wonder how come they are not being introduced for other disciplines.

As before, I call on the government to either introduce them across all college courses in order to prevent the current raft of veterinarians, dentists, lawyers and other professionals who have been allowed to be unselectively chosen or withdraw them from medicine in the interest or equality

The argument that doctors should be chosen based on some innate ability of communication or caring is nonsense and, I feel, based on very flimsy evidence. The doctor patient relationship - as any practitioner is aware - is far too precious and delicate to be left to chance and varies from specialty to specialty and from patient to patient. Like other medical skills such as life support or cannulation, it is one that needs to be honed and trained according to evidence based principles and not left up to inherent abilities.

For those very rare graduates who are not able to master these skills many opportunities remain open to them to participate in health care over the length of their careers.

I also feel that this variety of roles and personalities is a core strength of the Irish Medical Organisation itself. As medicine necessarily becomes more specialised it is easy for us all to retreat to our individual silos. This is where I feel the IMO plays a vital role in Irish medicine.

This Organisation - representing doctors from medical student through to NCHD and on to whichever career path medicine and life may take them - can derive great strength in its unity. I believe that this unity will be a critical part of the renewal agenda over the next twelve months. This organisation needs to become a melting pot to allow for doctors of different specialties and grades to mix both professionally and socially. This mixing I feel can only be of benefit to our careers and our patients.

One of the other critical roles of this organisation - that I feel can get overlooked from time to time - is our dedication to the improvement in the science of medical practice through the publication of the Irish Medical Journal. Great thanks must go to Dr. Murphy and his team who have managed consistently, month after month, to publish a top quality journal highlighting the pinnacle of Irish research.

Medicine, as I said previously, is an applied science, which needs to combine both the best of scientific principles and humane compassion at all times. Neither can take precedence over the other if we are to avoid either quackery on the one hand or insensitive patient care on the other.

My own interest and involvement in the IMO started following graduation and I joined on the intern night like many did.

It was only when I had started working that the importance of service organisation became apparent. As an undergraduate, medicine seemed relatively simple and straightforward; the basic sciences had taught us how the body worked and operated, pathology taught us about how diseases developed among the various biological cycles and our clinical training taught us how to diagnose and plan treatment.

However very quickly after graduation and working in an Irish hospital you realise the difference that exists between that theory and reality. The reality was that working in hospitals was a seemingly endless stream of compromises; compromises over where patients were being treated (because the hospital did not have sufficient beds despite the fact that the number of admissions remained at a predictable and consistent level); compromises over patient dignity and privacy; compromises over the correct level of expertise that patients received (because there were insufficient specialists); compromises over diagnosis (as the necessary equipment was not available or had a waiting time).

Medical textbooks are excellent at laying out the stages in a treatment plan however they are not so good at telling you what to do for the four hours as you are waiting for the CT department in the hospital down the road to receive your referral and decide if the scan would be performed or not.

This frustration may have never led to anything if it wasn’t for a chance meeting in the old emergency department at St Vincent Hospital in Elm Park; with Mick Molloy. Mick challenged me to put my money where my mouth was, not to waste empty words and to get involved with the process of meaningful change.

Thanks to that meeting my ten-year journey on the NCHD committee started; a journey that has lead to me standing here in front of you now.

It’s a journey that has been laced with frustrations and setbacks as well as victories and celebrations; a journey that has lead to the development of friendships and a deeper understanding of not just Irish medicine but also of humanity, communities and groupings. While it is probably unfair to pick out any individuals from all of those I have met and have helped me along this this journey (many of whom I see sitting before me) I must thank Mick who has been a constant source of advice and support and a good friend and without whom I definitely would not be here today.

Of course I’m of that generation of graduates were emerged about the time of the publication of the Hanly report. That report promised us all a health service fit for purpose. No longer would we have to compromise patient care, no longer would NCHDs be forced to risk their own health working inhumane hours, no longer would NCHDs have to make decisions beyond their experience and expertise simply because there was no one else available. However despite this and the many other reports which followed on subjects like training, undergraduate education, and the implementation of more humane working hours for doctors - little has happened.

Despite this constant litany of disappointment and occasional incremental victories the energy and enthusiasm for change among NCHDs remains heartwarming. Due to the transient nature of most NCHD careers it is crucial that the NCHD committee undergoes constant renewal and recruitment. Earlier this year I was delight to see the groundswell of activism amongst NCHDs which has moved to the new media world of Facebook and Twitter and which was followed by over 400 NCHDs attending a meeting in Dublin. That showed me clearly that the NCHD committee is in safe hands.

Like many doctors my own career has not travelled along a straight path. In the last 13 years I have worked in 7 different specialties in a total of 19 different hospitals. Statistics would say that somewhere in the region of a third of doctors do not finish their careers in the initial specialty that they choose. Although I am aware of the need for more streamlined training schemes, there must also be flexibility for those who move between specialties.

From my own experience I feel that I brought different ideas from each training scheme to the next; for example how to structure consultations from General Practice training into psychiatry. This cross pollination is often where great innovations come from and can challenge beliefs that have been long held.

Most of you know that after a career encompassing General Medicine, Surgery and general practice I settled in a career in psychiatry. Like many things in life I almost stumbled into psychiatry having to complete a six-month rotation as part of General Practice training scheme.

However not long after starting the rotation I found that this specialty was one in which I felt that I would remain within. It suited my skills and despite what I had previously heard psychiatry was a specialty where I saw patients get better and where I saw the great differences that can be made to the lives of the most vulnerable in our society through properly planned multidisciplinary working.

At this meeting we have launched our position paper on the role of the doctor as advocate. While this is an important role in all branches of medicine I feel that this role is most required in the sphere of mental health. Society has made remarkable progress over the past century regarding equality for those with different skin colour or sexuality. Thankfully, pejorative terms are no longer tolerated in society. Yet we still allow the misappropriation of mental health terms such as schizophrenia being used to describe someone with “Split personality” or Psychotic to mean someone with either extreme illness or violence. Until these words are seen by society in a similar light to racist and other demeaning terms - and we adopt a zero tolerance approach to their use - the stigma of mental health will remain.

As well as advocating for individual patients I feel it is essential that the medical profession act as advocates on a societal level. It is in this role that I feel the cross specialty representation of the IMO puts it in a unique position. The IMO has had great success over the years in regard to areas such as alcohol and smoking policy, however sometimes public risk can be more difficult to evaluate.

One of these areas I feel is the thorny issue of the reporting of medical stories and evidence in the media. In my opinion the media needs to take great care when reporting on new medical research and always give a balanced approach. From my own experience, sensational news stories can lead to changed behaviour among patients such as stopping medication, which may lead to adverse outcomes. This is particularly true when we address the thorny issue of the reporting of suicide, which we discussed yesterday.

No other issue shows the importance of balancing "public interest" with that of "public risk".

Evidence has repeatedly shown that irresponsible reporting of individual suicides and can lead to the spread of tragedy. I implore all media outlets to consider published guidelines on reporting on suicide as well as considering the consequences and the possible public risk when publishing all medical stories.

This morning we had a joint meeting of the NCHD and consultant committees to discuss the cuts to new entrant consultant salaries.

We are all aware that the country is facing a difficult economic future. However we must be careful to prioritise public spending and not do generational damage to our health service.

I feel the recent dramatic salary reduction for new consultants may just create this situation. Whether our politicians like it or not the medical workforce is international and mobile one. Those who are trained and qualified to specialist level are in huge demand. Ireland competes for this workforce mainly with other English speaking countries. Due to historical links Ireland the UK, Australia, New Zealand and - to a lesser degree - Canada not only share language but also how their medical systems are organized and this means that Irish specialists can easily walk into posts.

Talking about the remuneration of medical specialists in other EU countries is largely irrelevant as very few doctors choose (due to linguistics) to work in Finland and Hungary or Ireland. However many doctors including myself are faced with working in Ireland or the UK or Canada/Australia/NZ.

Despite some disinformation Ireland is now the lowest paid medical specialist within the English-speaking world, which I feel will cause significant impairment to our health service. Ireland has always relied on recruiting Irish graduates back who had trained abroad to return and lead innovation within our service.

The policy of graduating increasing numbers of doctors from our own medical schools will not solve this problem either as almost 50% of graduates are leaving after their first year of practice within Ireland.

I would like to make one or two short points before we end.

Firstly - we are often told that we are living in the information age but you would not realise that walking into an Irish hospital where the recording and dispersal of information is not that different from when Victoria was sitting on the throne.

With the mobile phone sitting in my pocket I able to ring an astronaut orbiting the planet in the international Space Station however when a patient attends a Health Care facility, such as an Emergency Department, it can take hours – or, if its outside office hours, days - to get their health records from either their General Practitioner or another hospital they attend. This leads often to critical decisions being made by the patient o their family on remembered treatments at what is often a very critical time. In one of the smallest countries in the developed world this is a disgrace.

We need a robust countrywide electronic medical record system that would include a unique patient identifier for every man, woman and child in the country. These innovations could significantly improve the quality and safety of patient care in the country. I don't believe these measures would require huge cost but the do require will and determination at both political and managerial levels.

In addition to the improvements this would make to individual patient decisions, proper information gathering would facilitate proper health planning and service delivery and hopefully remove opinion as much possible from health care decisions. For too long far too many of the most critical decisions about our health service have been reduced to little more than political footballs to be kicked around at elections with promises and services delivered based more on the wishes of politicians then the on the grounds of reality.

A proper linked information system with each patient having unique identifiers would allow us gather huge amounts of and very useful information on mortality, morbidity, prescribing practice side effects and other measures which would potentially lead to a better service. In addition to using such information to benefit Irish patients in health organisation the opportunities for epidemiological research could have global benefits and allow Ireland to publish meaningful research.

Before I finish I would like to express my thanks for the effort and dedication shown by all the members of the various committees that I served alongside in the organisation. I feel that each and every one has operated with the best intention and with both the interest of the profession and the organisation foremost in their mind. I would especially like to thank Mark, Trevor and Mary for their efforts in leading their craft groups. I wish to congratulate the new Chairs of the Committees elected today.

I would especially like to thank my colleagues on the executive committee, Paul (McKeown) Sean (Tierney) and Ray (Walley). Since December we have had a very difficult job to do and one which I feel would not have been handled as well without the calm resolution, integrity and determination of these doctors who I can attest have gone beyond the normal call of duty to resolve what is – to say the least - a very difficult position. I would like to thank the staff of the organisation who have also put in monumental effort.

I would like to thank my own parents and family. I would especially like to thank my parents - my father who is here today and mother, who I'm sure is looking down on us. They taught me not only the principles of right and wrong but also the need to not just sit back and observe but also to actively participate.

On a final note despite my argument that we do not record enough data in the Irish Health service there is one medical statistic that is recorded and often quoted - and it’s the infamous trolley count. This number I think shows me the two sides of the health service one of which is often neglected. On the one hand it shows us the impact of the decision-makers and politicians who have given the frontline staff a service with inadequate resources to meet the demand despite the fact that this demand is often predictable and constant.

However that statistic also highlights the reason that I am proud to work alongside my other frontline health service colleagues. And it’s the fact that despite the poor quality of the facilities that we operate in, no one gets turned away from an Irish hospital. Frontline staff constantly battle to provide the best care for patients - often improvising and compromising - not because we want to, but because we have no alternative.

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