IMO Doolin Memorial Lecture 2023
On 2nd December, I attended two functions. Firstly, I met with colleagues from the IMO for their annual Doolin Memorial Lecture in RCSI. The President of the IMO, Dr John Cannon, who recently graduated MICGP, introduced Dr Brian Turner, Economist and Senior Lecturer at UCC, on the subject “Paying the Piper our Cloth? Funding Ireland’s Health System into the Future”. Brian made the point, that the year, there are no exceptional payments to the health services in Ireland, we are going backwards, and he discussed the challenges of funding health care in Ireland in the future. I also spoke with Susan Cline, CEO of the IMO and her team and met many GP colleagues, including Dr Tadgh Crowley, the chair of the IMO GP committee.
RCGP ROI Faculty Winter Meeting
Later that evening, I attended the Winter meeting of the Republic of Ireland Faculty of the RCGP. It is worth remembering that the RCGP was established in 1952, and a Faculty was established in Ireland in 1954. There were eventually four Faculties in Ireland. At the time of the foundation of the ICGP in 1984, the East, South and West Faculties merged to form the Republic of Ireland Faculty. Many of the members of this Faculty have dual membership with the ICGP.
The first part of the meeting was given over to the Sheppard Memorial Prize winners. Jack Sheppard was a well-known GP in Dublin in the 1950s, and a foundation member of the RCGP. Following his death in 1962, in 1969, his family gave the Faculty a substantial amount of money. The Board established the Jack Shappard Memorial Trust, which annually awards a postgraduate prize and an undergraduate prize for an essay on a subject relating to general practice. I have been involved on the adjudicating committee since 2010, and each year, we see papers of great quality; this year was no exception.
The undergraduate prize winner was Éilis Russell, a medical student in the University of Limerick GEMS program. Éilis presented a thoughtful paper on the potential future application of AI in general practice in a paper entitled “The ‘doctor’ will see you now”. Her paper was well-researched, being appropriately aware of the current challenges facing Irish GPs. She provided potential pragmatic solutions for the future. General Practice is, amongst other things, a social science; AI can help augment this.
The postgraduate prize winner was Dr John Travers, who read his essay “It’s hard to be invisible”, a tour-de-force of his experience working in an inner-city drop-in clinic for the homeless. Jonn’s astute observation of the real humanity both in the clients of this service and those providing the service was very powerful. In the follow-up questions, when asked what he would suggest addressing the issues, he said, “If society wishes to have poorly paid workers provided the hard, dirty work, then society has a responsibility to house them”.
The new President of the RCGP, Dr Richard Vautrey, spoke to us about his journey as a working GP in Leeds, to being both on the General Practice Committee of the BMA and now President of the RCGP.
Finally, Prof Louise Dubras, the Foundation Dean of the newest medical school in Ireland at Ulster University, spoke about the journey over the last century of the place of GP training in the Medical School curriculum. She set as her starting point the report by Abraham Flexner, funded by the Carnegie Foundation, in which he proposed setting up formal education pathways (which still exist in some universities to this day) for hospital specialists and less formal training for general practitioners. Louise is determined to keep the undergraduate general practice experience very much to the fore, with, not behind, the hospital specialities.
Thanks for the night must be given to the Board of the Faculty, the multi-tasking Dr Diarmuid Quinlan, the Provost of the Faculty and Suzanne Manning, the hard-working administrator of the Faculty.
MInTFM graduation and visit to Malaysia.
On 16th November, 2023 I travelled to Kuala Lumpur with Fintan, the CEO; Brian O’Malley, Executive Director of GP Training; and Dr Tom O’Callaghan, CEO of iHEED, the technology partner. The primary purpose of the visit was to officiate over the graduation of the first cohort of trainees to complete their training with MInTFM.
It is worth briefly recapping the history of MInTFM. Malaysia currently has 800 FMS (Family Medical Specialists = GPs) for a population of 32M + This equates to 1FMS:40,000. The Malaysian Government asked for expressions of interest in providing FMS training. A partnership was formed in 2019 between the ICGP, RUMC (Royal College of Surgeons in Ireland and UCD Medical Campus) and iHEED. The ICGP brought 40 years of experience in GP training. RUMC is a private medical institution onsite in Penange since 1996. iHEED provides postgraduate medical education.
The ICGP’s contribution to this endeavour has been significant. A small number of College management, along with some of our education and examination leads, have helped develop a program that, while substantially similar to that undertaken by our trainees, has been contextualised for Malaysia. The Malaysian trainees undertake a four-year training program, with two years based in hospital, with day release and two years attached to training practices. They undertake the same exams as our trainees. If they satisfactorily complete their training, they become full Members of the Irish College of General Practitioners.
The growth in the number of trainees speaks for itself. There were 34 trainees in 2019, of whom 24 graduated this year, mostly due to trainees taking time out for maternity leave, etc. In 2020, there were 48 trainees, over 100 in 2021, and it is anticipated there will be 112 trainees next year. Like our own Scheme, interest has increased greatly, with 310 applicants for next year.
The graduation ceremony in Kuala Lumpur was a joyous and well-run occasion. Credit must be given to the MInTFM staff who handled every detail. Because of cultural sensitivities, I did not shake the hands of the graduates but used the Malaysian greeting of touching the hand to the chest, which was appreciated by all. Tom O’Callaghan provided a wonderful trophy for the trainee who showed excellence; that the candidate’s father had recently been seriously injured but could attend in a wheelchair only added to the delight. The Irish Ambassador to Malaysia, Ms Orla Tunney, was in attendance. Afterwards, she posted on social media about her delight at being present and made the point that the Malaysian Minister of Health strongly supports the Scheme.
More than one of the new MICGP colleagues sincerely thanked me for the training program; and how their concerns and troubles were addressed. The pastoral aspect of the Scheme is strong. These are now our colleagues; means need to be found to foster and support their ongoing relationship with us.
The governance structure of MInTFM is representative of the three partners. Due to my former position as Chair of the PGTC and now as President, I have been Chair of the Board of MInTFM since January 2020. Board meetings typically occur every six weeks and, due to the distances, are usually held by Zoom. As everyone involved was in Kuala Lumpur for the graduation, a face-to-face Board meeting was held on the morning of 20th November. We also met with the Malaysian Ministry of Higher Education on Tuesday 21st. Fintan will report on the outcomes of both these meetings, but from my perspective, they were very successful.
Many people have been involved in Ireland and Malaysia, which has led to the program’s success. However, I would like to mention Dr John Latham, the Foundation National Clinical Director, and Dr Cathy Cullen, the current National Clinical Director. Cathy oversaw the rapid expansion of MInTFM; and will shortly take over as the National Director of Training here. I must also mention Brian O’Malley, Dr Molly Owens and Dr Nazrila Hairizan, Deputy National Clinical Director, who have contributed considerably to the Scheme since its inception.
HSE National Doctors Training Program, National Medical Workforce conference.
On 9th November, 2023 I attended this conference in the morning in Dublin. The first session, “How we work”, laid out how the HSE will be reconfigured (again), this time into six regions. The NDTP Medical Director, Professor Brian Kinirons, punctured a few myths about Irish-trained doctors moving away and staying away. However, there was a candid discussion about the issues and challenges in recruiting hospital doctors outside the teaching hospitals. It was pointed out that there is not just a drift to the UK and Australia but also to Dublin. Dr David Hanlon, the HSE Primary and Community Care GP lead, contributed to this.
The second session, “How we train”, was led by Professor Cathal Kelly, the CEO of RCSI, in which he looked for additional doctors in all specialities and ANPs and PAs. On the panel discussion, which I contributed to, colleagues from RCPI, RCSI, and the College of Psychiatry and Anaesthesiology spoke about the advantages of allowing trainees to stay in one region, at least for the Irish part of their training, but also to increase the number of fellowships in the regions.
I pointed out that training at a regional level, specifically at the scheme level, has always been the norm for GP training. I shared that the intake of trainees increased from 159 in 2015 to an anticipated 350 in 2024. Due to the success of the BEaGP.com campaign, there are over 1,300 applications for these 350 training places. We are by far the largest single training scheme in the country.
Network of GP Trainees conference.
On the same afternoon in Athlone, I addressed the large number of trainees at their annual conference. They had an excellent educational program, which ran for two days. I had the opportunity to point out some of the changes in general practice during my career, but I also looked forward to the central role that general practice will play in Sláintecare. GP training is unique in that it has day release, and the one-to-one relationship between trainer and trainee is not the norm in the rest of the training schemes.
I spoke to the trainees about the likelihood that portfolio working will become the norm for them. I asked them to consider being a part of the College following their graduation.
Finally, it gave me great pleasure to publicly thank Dr Martin Rouse, both on behalf of the College, the training community and myself, for his enormous work over the last three years as the National Director of Training. He has focused on what is important; what is good for the trainees.
MInTFM
On 3rd November, 2023 the College hosted a small function at headquarters for five graduands of Malaysian Ireland national Training program in Family Medicine. This program was launched in 2019 with 34 trainees. Due to much hard work by the College, iHEED, and RUMC (who are equal partners), and a small number of our colleagues and staff in Malaysia, the Scheme has an intake of 100 trainees a year after four years.
In 2017, the Malaysian Government sought expressions of interest in establishing a national training program to increase the number of highly trained Family Medicine Specialists in line with national requirements. The College and the partner organisations were successful in their bid. The trainees in this program undergo the same training as Irish trainees, adapted where necessary for local circumstances, and sit the MICGP exam. These graduates will all have MICGP, which is expected to be recognised as a specialist qualification by the Malaysian Medical Council.
What is being recognised is that these trainees are operating at a very high level. They more than hold their own with graduates of other family medicine programs.
A program was arranged for their visit, including some Day Release training, tailored talks on leadership and other areas of interest, observerships with GPs and participation at the Trainee conference. At the trainee conference, they presented the differences and similarities of primary care in Malaysia and Ireland.
And they had some time to experience the Irish country and craic!
The newly appointed Malaysian Ambassador, the First Secretary, and Dr Declan O’Callaghan from iHEED were present at the function. The Ambassador was very gracious in praising the Training program and the College.
Many colleagues have contributed to the success of MInTFM. I want to thank Dr Molly Owens, who could not attend the function due to ill health.
RCGP Annual Conference 2023
On the 19th and 20th October, I attended the RCGP Annual Conference in Glasgow. Though I attended in a personal capacity, it is always educational to see how our nearest colleagues are doing. Dr Diarmuid Quinlan was there also. These are a few random observations:
Prof Lucy Easthope, Professor in Risk and Hazard: “The tail of disaster is very long – decades. The heroes of all disasters become the villains as blame is laid out. The sympathetic/empathetic are much more prone to burnout. Remember, it is just a job, and things will get worse before they get better. Move from the big resignation (leaving work) to a big epiphany – “I do not want to do this piece of work over here, but I will do that piece of work over there”. Above all else, look after yourself.”
Drs Jonathan Griffiths / Peter Chamberlin: the Primary / Secondary Care interface: Key elements for all; clinicians should see to undertake any required actions themselves, without asking other teams or services to do this. Principals for Primary Care – make yourself available and provide the direct number to allow hospital colleagues to contact us without joining the queue. Principals for Secondary Care. Finish your own jobs. The key is dialogue; it is a two-way stream.
Dr Kevin Fernando – Diabetes management: “There is no such as a sudden heart attack – it takes years of preparation”.
NHS Question Time (CMO Scotland, Chair RCGP Council and others): To attract GPs to failing practices, see what additional things they could do that they might be interested in. It is not the money that attracts doctors. Provide infrastructure. Think outside the box. Put surgeries where the patients go (think shopping centres). Reward outcomes, not process. How do you help support people to remain healthy instead of just treating illness? Make the distinction between episodic and continuity of care; reward the latter.
On a personal note, the highlight for me was to meet the very bright people who are members of the Over-diagnosis group, a group of mostly GPs who look for examples of over-diagnosis, over-treatment, and the impact this has on the workload of GPs and the health of our patients.
The Autumn Conference 2023
On 14th October, the Autumn Conference was held in the Galmont Hotel, Galway, formerly the Radisson, where many College AGMs had been held. There was an excellent range of speakers, a very large turnout (400 registered) and a great buzz about the place. It was my pleasure to speak to many friends, old and new. For some, this was their first face-to-face conference since before Covid.
Dr Machteld Huber pointed out that the healthcare system is a disease care system. The current model (worldwide) supports a large hospital system, where most health funding ends up with very little spent on prevention, resilience, and self-care. She wants to see this pyramid inverted.
Our own Suzanne Kelly provided us with an excellent outline of the current state of diabetes care. It was the best summary I have heard in years.
Later in the morning, I attended the session by David McConaghy, who spoke about everything important about men’s health – not just about the prostate. Stephen O’Leary from Medisec took us through the evolving area of Assisted Decision Support.
In the afternoon, Tony Foley again gave us an excellent summary of the diagnosis, current management, and future possibilities of dementia care. Brendan Kelly gave us an overview of the management of anxiety.
We finished the day with the presentation of the Gertrude Ronan Award to Dr Rita Doyle, who is hugely deserving. Gertie’s husband, Joe, and their daughter, Niamh, presented the award. Rita touched us all with her talk on the “Bank of Tears”, a powerful commentary on the core of general practice, which comes from years of experience.
The workshops I did not attend covered breastfeeding, shoulder issues, antimicrobial resistance, and sepsis.
Deirdre and Clare discussed the proposals to re-invigorate the faculties throughout the day.
Thanks for organising the meeting must go to Diarmuid, Claire and Helen, the educational team, and especially Carmen Egli.
And that is the last major, face-to-face, educational meeting for the general membership until Wonca Europe next September.
Graduation Ceremony 2023
On 23rd September, it was my very happy task to speak to 113 graduands at the College Conferring Ceremony. A further 26 graduated in absentia. This ceremony was held again in the Mansion House, packed with the new graduates and their families. It was delightful to see so many small children! In my speech, I touched on themes such as the central role of general practice in delivering medical care in Ireland (2.2 million consultations in hospitals, 29 million in general practice in any given year). I referred to expanding training and establishing the Strategic Task Force. I reminded our newest members that the College is their College; it supports them throughout their careers. I reminded them of the Health in Practice Program, that they cannot solve all their patients’ problems, and look after themselves.
I spent a while afterwards speaking to individual graduates and their families. One of the graduates is going abroad for a year due to her husband’s work, but they plan to return to Cork next year. Every other young colleague I spoke to is already working across the country.
The ceremony’s success was due to the hard-working College staff: Brian, Martina, Jana, Pauline, Lisa, and Janvier.
I was also very pleased to see the scheme directors present. It must be very satisfying to see their recent trainees moving onto the next part of their careers.
There are many hard-working staff members, but one of the hardest working must be Martin Rouse, our National Director of Training, who has worked tirelessly to co-ordinate the production of fit-for-purpose GPs.
28th WONCA Europe 7th – 10th June 2023
It is just over a year until the ICGP hosts WONCA Europe in September 2024 in the CCD. The College had an excellent team in Brussels raising awareness for next year’s event. The team was led by Claire (Collins) from the front. She had several robust discussions with WONCA senior management on issues that needed to be resolved. Carmen and Ivana worked tirelessly at our stand. Aileen (O’Meara) was there to record everything and get a sense of what WONCA was about. Academically, Andrée (Rochfort), Ed (McSwiney), Oisín (Brady Bates), Ivana (Keenan) and Alina (Zidaru) shone.
Andrée, with EQUIP, won the WONCA Europe Special Project prize – huge congratulations to her on this achievement.
John Cox, Pat Durcan, Rukshan and Ahmeda Ali were also there to fly the flag.
We all agreed that the standout presentation of the week was by Alexandra Brandt Ryborg and John Brandt, speaking on the topic “Overdiagnosis: Soon we will all be patients.” This lecture was a tour-de-force by two speakers at the top of their game. To paraphrase their lecture from the BMJ’s Too Much Medicine initiative:
“The initiative aims to highlight the threat to human health posed by overdiagnosis and the waste of resources on unnecessary care. Causes of too much medicine include expanded disease definitions, uncritical adoption of population screening, disease mongering and medicalisation, commercial vested interest, strongly held clinical beliefs, increased patient expectations, litigation, and fear of uncertainty and new technology. Winding back the harms of too much medicine invites clinicians to focus on those who are sick, and only intervene with those who are well when there is a strong case to do so.”
Ongoing
While not strictly a role of the President, I have continued in regular (typically fortnightly) meetings of the Training Directorate. GPTAC sets out training policies and standards; the Directorate implements these policies. The Directorate includes the National Director of Training, CEO, Executive Director of Training and Manager of GP Training. These are troubleshooting meetings translating policies into actions. Issues addressed include sabbatical leave requests, requests for an extension to training, recognition of prior learning, trainee in difficulty and occupational health issues.
GPTAC has a huge workload ahead of it, but a substantial start has already been made. There are 21 policy documents on the College website, and the Criterion Document dates from 2016, long before the transfer of training. I believe there needs to be an overarching standards document with buy-in from all the stakeholders and a smaller number of specific policy documents. I hope that as these standards and policies evolve and become embedded across the whole breadth of GP training, there will be less and less need for Directorate meetings.