Dr Christine O'Malley
Relief rather than surprise was my dominant feeling after reading the new Scally report “Nothing would surprise me,” Dr Gabriel…
Dr Christine O’Malley gives a personal account of the IMO AGM 2019 in Killarney Once again, CEO Susan [Clyne] and…
Dr Christine O’Malley recounts the difficult experience of deciding upon a medical specialty and when she knew geriatrics was for…
Dr Christine O’Malley says the most important factor in choosing a consultant is how good they are at their job,…
Dr Christine O’Malley comes up with some wishes for the next 12 months
Dr Christine O’Malley finds it hard to keep her cool in the face of the latest healthcare controversies
A teacher was giving out over a cup of coffee. She asked her class to do their maths homework in a copy book. Next day, a mum said her child was tired so she told him to do it in the workbook instead. “What’s wrong with that?”
My friend sighed. Parents don’t realise the task isn’t just about arithmetic. She wanted the children to organise themselves, assemble pencils and ruler, draw lines.
Aha! I get it. It’s the magic of good teaching.
When I told this story to some teachers, one said: “We call it ‘the Hidden Curriculum’.” It was just after the Dromineer Literary Festival and the Committee was celebrating a very successful event.
It was also the weekend of the Rural Doctors Conference; in between poetry and prose, I had given a talk. Now I was pondering the unexplainable qualities of general practice. People understand surgery, but they haven’t a clue what physicians and medical wards do. As for general practice, I know there’s some magic between patient and GP that allows most people to be treated without a hospital.
It’s the Hidden Curriculum.
In preparation for the GP conference, I dug out my box of old health service reports. It’s important to realise, no-one reads reports; media stories may be based only on a press release. So it was interesting to have a look back and delightful to have the distraction of literature.
At the Festival, there were debates between writers – Julian Gough, John Connell, Ruth Padel, and John Banville. Later in the bar, there were debates about health. A poet (from a medical family) said: “Didn’t it all go wrong with Mary Harney?”
That’s when the health strategy – more beds, more staff – was abandoned. Instead we got the health reform programme: The Brennan, Prospectus and Hanly reports.
Prospectus gave us the HSE.
The Brennan Report says that clinical independence of consultants is a budgetary problem. No mention of patients or quality; controlling consultants is a cost issue. So the new consultant contract obliges consultants to obey corporate policy.
I didn’t sign it. Doctors need clinical freedom to act for their patients.
The Hanly Report, supposedly about doctors working hours, is actually about centralisation into large hospitals. In the Mid-West we were told that Limerick inpatients would become day cases, so the wards in Ennis and Nenagh wouldn’t be needed.
That didn’t work. Our patients are treated on trolleys instead.
It was the end of the magic of small hospitals. Our Hidden Curriculum was that, while treating the primary illness, we fixed as many problems as possible. Tests were done, consults with other teams and all in a short time. My job was to assemble information and make decisions, get the patient sorted.
No more; only the primary illness is treated now.
On discharge, the patient goes on multiple waiting lists for tests and clinics. Often it’s not clear whose job it is to put it all together afterwards. So the GP chases results and clinic appointments, trying to make sense of the jigsaw of information. It’s the GP who makes the hospital system work for patients.
Looking at the reports, there’s been a decade of flip-flop policy on private patients. Co-located private hospitals meant apartheid between public and private patients. Under universal health insurance, everyone’s private; now with Sláintecare, they’re all public.
The Sláintecare Report is also very keen on something called “integrated care”. I puzzled over it for a while. Then I got it! Integrated care actually means fragmented care, even more than it is now.
Instead of admission to hospital with pneumonia, the patient will get antibiotics and physiotherapy, x-rays and scans all done from home. Apparently, it’ll be just like hospital care, because somehow it will be “integrated”. It’s the latest cure for the trolley problem.
It doesn’t say who’ll do the “integrating”, so presumably it’ll be the GPs. That means patients will need free GP care and a new contract will have to control and direct the work of GPs.
But it seems to me that clinical independence is what makes general practice work and I reckon having paying customers is an important part of that freedom.
Anyway, if GPs are doing hospital work, they can’t do the work we can’t see, the Hidden Curriculum. The magic will be lost. And that’s not good for patients.
Back at the festival, it’s a beautiful autumn day out on Lough Derg. We’re on a boat, listening to readings about hammering through ice to go lake swimming.
I let the tangle of thoughts in my head float away across the water.
Dr Gabriel Scally has done a great and kind service to the women caught up in the CervicalCheck crisis. He personally listened to their stories and he has highlighted the excruciating experience of many women when they were finally given full information by their doctors.
The patient advocates spoke too: Vicky, Stephen, Emma, Lorraine. Despite the painful stories we were hearing, I was struck that they also focussed on the issue of quality in cervical screening.
As the harrowing details of meetings between patients and doctors emerged, I wondered if I could be that doctor. Could I use those hurtful words?
Such meetings are extremely difficult for the patient and family, but also for the doctor. The women are distressed, confused and, of course, angry.
What about the doctors? There’s no formal response from doctors, neither those that did it unkindly, nor those who acted with grace and compassion.
This is how it seems to me.
I’ve had meetings with families, perhaps after the death of a loved one, and it is emotionally exhausting. If I do a good job, if it goes well, both sides benefit.
If I make a mistake, if I say something wrong, I can poison the relationship forever. The family may lose trust in me, the hospital, and healthcare generally. Afterwards, I wonder how I could have said such words; I can’t forgive myself.
The CervicalCheck meetings were rushed because the story was out in the media. Some 220 patients and families had to be told that perhaps cancer could have been diagnosed sooner, based on an audit of their tests. There was no preparation for sudden disclosure of distressing information. No guidance or training for the doctors. No counsellors to support the women.
From media reports, it seems some doctors had to do more than one meeting; I can’t imagine doing that. It’s all an unlikely basis for grace and compassion.
Maybe the doctors were angry too.
After all, the doctors were not responsible for delays in diagnosis. And the botched ‘audit’ was done by CervicalCheck, not the doctors.
I don’t know why it was called an ‘audit’ because it’s not. There were no stated standards, no summary statistics, no cycle of change and re-audit.
In 2014, CervicalCheck (not doctors) decided to do a look-back at cytology slides of some (not all) women who were diagnosed with cancer over the years. When the slides were reviewed, there was a new interpretation in over 200 cases.
Doctors were not told. The labs knew: From the report there were heated debates in some cases. We have not been told which labs reported the original slides or how often the diagnosis changed dramatically.
CervicalCheck held this information for a year, then decided to send it to doctors. Which doctor? They picked the last doctor recorded on their system, whether relevant to the patient or not.
Appendix 3 reproduces the letter sent in Vicky Phelan’s case. It’s very peculiar. It’s not from the Clinical Director, it’s from an administrator. It does not say there is cause for concern.
The letter says to file the information in the patient’s record. Okay.
It says if the review is different to the original result, consult with the original pathologist to assess the relevance. That’s weird. CervicalCheck did the review and had already communicated with the labs.
The letter then says: “If open disclosure is indicated in this case, please follow the local hospital guidelines.” According to the report, the doctor was also sent a three-page document about the pros and cons of disclosure, which more or less advised non-disclosure.
I should mention it’s increasingly common to receive confused communication like this from health bureaucracies. You can spend your time fighting to try and make sense of it all, or you can file it away and go see the next patient.
My view: CervicalCheck did the ‘audit’ and had all the information. They should have alerted the patients. The doctors could then appropriately have carried out the disclosure meetings. A lot of chaos and distress could have been avoided.
But failure to disclose audit findings is not the same as failure to diagnose cancer.
The report raises many issues. The companies were chosen largely on price not quality. The labs all have different processes; they appear to have different results.
So why not tell us which labs reported the 220 problem slides? The report confirms that cervical smears were outsourced (legally) to labs across the US. Apparently Irish lab staff knew the companies were doing that.
Ten years ago, when Irish tests were first sent to America, I knew one of the US companies had a lab in Mexico. And I heard an Irish manager with that company was travelling to Mexico once a fortnight.
Irish cervical smears have been sent to Orlando, Las Vegas and Honolulu. Why not Mexico!
Like buses, life events come in threes.
I had a significant birthday this year. Since then, if I can’t remember a word or a name, I presume my mind is going. Overnight one end of life looks much nearer. I’m beginning to understand the elderly patient who was afraid of dying and begged her daughter to come with her. The exit is closer and more real.
Then a friend commented acerbically that he was in his 80th year so I kept quiet.
I’m officially retired too. That makes me feel really old. Still, after a year without pay, it’s nice to get a payslip again. No, I won’t be getting the back money owed to consultants – I stayed on the old contract.
Retirement is odd. I don’t know who I am anymore. Medical life is so intense, all-absorbing, overwhelming. It takes over everything and then it’s gone.
I miss the patients and their relatives. I miss the family of Nenagh Hospital staff and being part of a small centre of excellence.
I don’t miss the whittling away of services needed for ill patients. I don’t miss the increasingly centralised bureaucracy.
One of the most surreal moments was watching two senior managers debate how to replace a specialist nurse. The post and budget were already agreed. Nurses had expressed interest in the temporary post. My colleagues spent 15 minutes trying to find a way through the bureaucracy to make it happen. They failed.
When I first came to Nenagh, we didn’t have specialist nurses. But Matron (who happened to be a man) could fill a vacant post. Now there are Managers and Nurse Managers, but they have less authority.
As for the HSE at national level, I don’t understand the structures at all. I wonder who does.
Of course, I’m much too young to retire. It’s just that my eyesight isn’t up to the job anymore. I’m very short-sighted, minus 20 in both eyes, with retinal distortions. When I became long-sighted as well, it was a struggle to read quickly under pressure. The final straw was having urgent surgery for a macular hole; I can’t read with that eye.
Maybe I could have coped in the old system. Life on the wards was orderly and efficient. Patient safety started with the doctor and nurse knowing each case well, often over several years. In the new regime, patients move from hospital to hospital to find a bed; nurses change from ward to ward. It can be hard to know a patient’s name, whatever about a detailed clinical history.
A patient may be stabilised in University Hospital Limerick, then transfer to Nenagh accompanied by an inch of photocopied records. The results are on two laboratory IT systems, one each for UL and Nenagh, and two x-ray IT systems. Reconciling medication is difficult when you don’t know if a drug was omitted by accident or on purpose. Within a hospital it’s easier to ask someone.
Some people think the answer is electronic records, but often the real problem is too much unprioritised information. Hospital medicine is fast-moving and we use a lot of verbal information. It’s the quickest way to assemble complex data in order to make decisions or take action. The written record follows afterwards and is not necessarily complete.
I’ve always regarded it as part of my job to check details in order to catch potential errors. Unfortunately, when patients move a lot, there is so much more to check. I got slower and slower and I got scared.
A colleague in a similar situation said the solution is to develop central neuropathy and peripheral neuropathy and continue.
The third life event is coming up: A letter from the Medical Council reminds me I haven’t paid my registration fee. I’ve almost, nearly decided not to. It feels like a bereavement. Being a doctor has been part of me for so long.
The problem is Continuing Medical Education (CME). I’m attending conferences and reading. I’ve been told I’m meeting the requirements. But I get addled when faced with forms and anyway, how can I do an audit? I don’t even know if CME is different for my sick leave. I’m so pathetic, I don’t deserve to be on the Medical Register.
I’m still Dr O’Malley or Dr Christine to a lot of people. People continue to ask for advice, or expect me to attend to a seriously injured neighbour in a dark field.
Feeling old? Get over it. Retired? Now that Annie is happy in Cardiff I wonder what I’ll do this winter.
It takes a village to rear a child. It takes a village to keep my house and garden going.
When I moved to Dromineer 20 years ago, I was told there were a hundred houses, about half being holiday homes. We’re a small community. The numbers have gone up a bit, but that split is much the same. The summer people say, “Dromineer must be so quiet in winter”. And we residents agree cheerfully.
Within the village, there are some demarcations. A resident complained about badly-parked cars. A neighbour commented that her own brother parked his truck anywhere and everywhere. The answer: He was born in this village. So that’s clear: 20 years or forever, I’ll still be a blow-in.
Down by the lakeshore, there are divisions too.
Dromineer Boat Club is for fishing folk; Mayfly season is serious. Lough Derg Yacht Club is for sailors, like me, and some fishermen too. There’s the Marina and a public harbour too.
But we all hang out in the Whisky Still and the Lake Café, which both serve great food.
In our small community, there are many useful people. We have a couple of judges and a school principal. When Tom got into a battle with An Bord Pleanala, he went to Liz for a legal chat. Noreen has advised on endless school problems over the years. The ex-head of An Taisce lives here too, and a former President of the IMO — yes, that’s me. Another neighbour has a connection to US Immigration at Shannon Airport, which is handy in these troubled times.
They all play a part in village life, but I rely on some other very important people.
Across the road lives Willie, who built my house, taking a long break in Mayfly season. This year, he’s building me a tiny garden house. In the great snow of 2018, Dromineer was cut off from the world. But within the village we had no problems: Willie and his digger cleared the snow from roads and driveways, so Noreen could walk up to my house for coffee, and later we got to the pub for a hot whisky.
Anthony, who plumbed this house, lives round the corner. The day the water tank burst in the attic, and water poured down my kitchen walls and through the light fittings, he was here within minutes.
My Aga is serviced by Jim. He doesn’t bother with appointment times, just calls in on his way home — he lives down by Dromineer Castle. When I dropped the big Aga kettle, and the handle broke off, he fixed that too — all part of the service.
My garden was planned and planted by Ger, whose sister has a holiday house in Dromineer. With a team of helpers, he’s kept it going through storms, snow and sun.
When Donal retired from teaching, his wife volunteered him to walk my dogs. Even though he’s busier than ever, he finds time for them most days and they get so excited when they see him.
Sometimes deliveries need help too.
On Mother’s Day, Annie sent flowers from Cardiff, but the delivery man couldn’t find me. So Biddy hopped in to show him “the doctor’s house” and to confirm they were from “Tom’s daughter”. She has dozens of flower pots outside her own house. A few years ago, on a dark winter’s evening, we were all summoned to the pub to celebrate Biddy’s 90th birthday.
There are some slight problems: village people don’t bother much with schedules, so they can turn up at any time.
I used to tell guests there’s no-one around outside; just a field with bullocks. I don’t say that anymore, since a friend took me a bit too literally. Fresh out of the shower, she threw up the window-blind of the downstairs guest room… just as a lawn-mower was being pushed past her window.
Bank holidays have no relevance either.
On New Year’s Day, my sister and I were having a late breakfast in our PJs when a truck pulled in. It was just Sean delivering a load of wood. He’s another Mayfly man. He once told me a story about ghillying for some useless people; they nearly capsized his lake boat and the shock of it set off his intra-cardiac defibrillator.
At the June weekend, I was at Bloom helping a neighbour sell gardening gear. Surprisingly, a career in hospital medicine has made me a star seller of hats and gloves. Noreen called up each day to feed the cat. Ger and friends were in the garden cutting back shrubs. Then Donal checked on my flower pots, and phoned me.
I’d left my keys hanging in the back door. That’s village life. That’s Dromineer.
he referendum pushed CervicalCheck off the front pages for only a short time. Even while it was rumbling away in the background, it was rumbling in my head too, stirring-up old thoughts.
When I was 12, people didn’t believe me when I told them of ideas I had years earlier. Being a peculiar kid, I decided to keep a diary to show myself that I really did have such thoughts.
Now I write columns for Mindo instead. I can look back and see my thoughts laid out in black and white. Oh dear! I can also see when I’m repeating myself.
What follows here is conjecture and opinion, not necessarily fact.
Since the CervicalCheck story broke, there have been calls to reinstate the Board of the HSE. Interesting. It brings me back to the foundation of the HSE.
When Mary Harney became Minister for Health, I felt as if I was ‘marking’ her, as on a sports field. I listened to her words: More hospital beds and consultants needed, but silently, I added ‘in the private sector’ as co-located private hospitals were announced. I looked at what she did — close cancer units in public hospitals, while welcoming private cancer units.
At that time, the CEO of the HSE said more private hospital beds were not needed and the ceiling on recruitment was a significant problem. He was publicly reminded that the role of the HSE is ‘operations’. ‘Strategy’ is the job of the Department of Health.
The health Budget increased rapidly.
It was all very clever — but that’s just my opinion. If money pours into healthcare, but you’re not allowed recruit staff, the only way to develop services is to privatise.
So the NTPF diverted patients from public waiting lists to private hospitals. And commercial companies lined-up to take on chunks of Irish public hospitals.
Companies looked at outsourcing whole radiology departments, or running minor injury units in public hospitals. There was talk of Quest Diagnostics running ‘cold’ laboratories for the whole country.
In the end, the financial crisis killed off all that commercial enthusiasm. We’re left with some oddities from that time and the contract for cervical smears is one.
The HSE Board was in place when CervicalCheck used a public tender for the cervical smear contract — an unusual step at the time. That first contract went to Quest Diagnostics; all smears from Irish women were sent to the US — another unusual step. (A second US lab and the Coombe were added later.)
I was quite distressed about it at the time, but not surprised. It fitted with my view that cancer care was to be outsourced to the private sector as much as possible. I knew several Board members personally, but they never seemed anxious to talk to me!
Back to the present.
Recently, Fergus Finlay said he couldn’t work out what sort of a corporate entity CervicalCheck is. I’ve heard it’s an ‘independent business unit’ within the HSE. That fits with privatisation; it could be cut loose at a suitable time.
I watched a Health Committee meeting on TV. Stephen Donnelly said that medics were involved in the tender result, so outsourcing to the US was not a political decision. That’s a bit naive from a former management consultant. He should know that a tender can be designed to pre-select the outcome.
The CervicalCheck tender had three elements. Accreditation was required; Irish labs had almost completed theirs.
Cervical smears had to be turned around very quickly. Irish labs had long delays and the ceiling on recruitment prevented them from fixing the problem.
The third item was cost. Ah yes, cost. When I heard the US lab was one-third of the price of the Irish labs, my Trinity MBA training kicked in. How could this be possible?
I’ve heard it’s because of pension costs, or because Irish lab scientists are more highly trained than US smear-checkers, and therefore more expensive. But I really can’t see how an American lab could be so cheap.
Then I learned there was a sister lab in Mexico. Ten years on, we know that outsourcing to the UK is allowed under the contract. I’d love to know if any smears went to South America.
And it was all done under the governance of the Board of the HSE.
I wonder who designed the tender? Did the HSE Board sign-off on it? Maybe Board members had concerns about sending Irish cancer tests overseas, but a tender result is legally binding.
There’s no open disclosure for commercially-sensitive information, so we’ll probably never know.
That’s just my opinion.
“It always rains on my birthday,” I said, aged 10. A kindly adult answered, “it only seems that way”.
To me it was a truth, an observation. I decided to make a mental note of the weather on my birthday each year. After 10 years of rain on 1 May, I felt the case was proven.
I take a long view and I respect evidence.
When the CervicalCheck story burst into our lives, my thoughts went back 10 years. That was a strange time.
US firms lined-up to replace public services but the details were secret, because it was “commercially-sensitive information”. The new consultant contract was clearly based around co-located private hospitals, but doctors’ concerns were dismissed as “vested interests”. Health watchdog HIQA was set up and had no oversight role in the commercial sector.
Ten years ago, the Mid-West was a pilot for outsourcing cervical smears to the US. My GP friends said that, compared to the Irish hospital labs, there were too many low-grade abnormalities reported. Lots of anxious women had to be referred to hospital clinics, but were in fact healthy.
We know now that the head of quality assurance for cytology also had concerns. He had evidence that high-grade abnormalities were not being picked up in the US; cancers would be missed.
This is not my area of expertise, but like everyone else, I’ve had the radio on constantly and I’ve bought stacks of newspapers.
I’ve also looked at any data I can find, including Programme reports from the early years. Quality assurance is mentioned constantly. However, CervicalCheck seemed to regard lab accreditation as a guarantee of quality.
I don’t think a doctor would get away with that in a court case, or in front of the Medical Council. We’re expected to look at evidence. Health administrators can’t, so they use external measures of quality.
I remember thinking that CervicalCheck was set up like a postal service, sending smears to the US and results to GPs. Issues such as quality and liability were outsourced with the contract. The US doctors reporting on Irish tests didn’t even have to be on the Irish Medical Register.
In those early reports, over-reporting of minor abnormalities is noted. I didn’t see efforts to address the more worrying issue — under-reporting of major abnormalities.
As the days went by, personal tragedies emerged one by one, each woman, each family.
The media pointed at doctors for not telling patients; the politicians said mandatory disclosure was the answer. I wondered about lab quality.
Very slowly, information is coming out.
In 2014, an audit was done of 1,480 women who developed cancer since the start of the Programme. When those smears were reviewed, 209 cases should have been reported differently. That’s 14 per cent.
Yes, the test is imperfect. And mistakes happen too. The issue is how frequent those mistakes are, and how bad, and whether there is variation among the labs.
Why wasn’t the audit done before 2014? It should be routine in a national screening programme. Maybe that’s “commercially sensitive information”.
We heard about the US labs: Legal case, gagging orders, legal letters preventing disclosure.
One US company sent Irish smear tests to a sister lab in the UK. The lab is accredited and it’s all within the terms of the HSE contract, but the effect is a fragmented system. Questions are being asked about the oversight by doctors, and whether Irish smears have been sent to labs anywhere else.
Then there’s the debate about cost.
When Vicky Phelan told us her shocking story, she pointed the finger of blame at then Minister Mary Harney for outsourcing cervical smears to the US.
I remember Mary Harney saying we had to, because the US lab was one-third the price of the Irish labs. Most people thought, ‘rip-off Ireland again.’
To me, it simply didn’t make sense. How could an American lab be so cheap?
That was the time when Mary Harney said cancer units in public hospitals around the country had to close because patients deserved a centre of excellence.
Cost versus quality: Are the rules different for commercial contracts?
On Morning Ireland, a senior lab scientist said one lab appears to be finding fewer high-grade abnormalities. We know it’s not the Coombe.
If the labs differ in quality, surely Irish women deserve to have their tests read in a laboratory centre of excellence.