Dr Christine O'Malley
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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!