Balancing clinical commitments with educational work is something Prof Mary Horgan knows about. The President of the RCPI is Consultant in Infectious Diseases in Cork University Hospital, and she also has commitments in University College Cork. Speaking to the Medical Independent (MI) in an exclusive interview, Prof Horgan said she strongly believes that there needs to be greater flexibility in the manner in which clinical posts are structured in Ireland to make it easier for doctors to conduct research and undertake other roles. It was a point she made in a recent meeting with the Minister for Health Simon Harris on the consultant recruitment and retention crisis.
“We told him that this is a global problem and that there are solutions,” Prof Horgan told MI.
“The solutions include moving from a ‘one-size-fits-all’ consultancy post where you are supposed to do everything and then do extra on it, to making the role more 80 per cent clinical, 20 per cent educational. If you want to work four days a week, you should be able to work four days a week. So that flexibility is what our millennial workforce want.”
At the same time, Prof Horgan believes that medical postgraduate education needs to be professionalised. This means there is a need for more academic clinician posts in the College for doctors to oversee training, particularly with the recent sharp increase in the numbers of trainees.
“Up until now people were doing it as a bit extra,” she explained.
“But the number of trainees have increased substantially. We have over 1,400 trainees in this College; it is the largest postgraduate training body. We have to have doctor/clinician leadership, that is my vision.”
Before starting her three-year term as President of the RCPI in October 2017, Prof Horgan was Dean of the School of Medicine in University College Cork (UCC). This has given her a unique perspective into the continuum of medical education from undergraduate to postgraduate level. Prof Horgan had been a clinical lecturer at the School of Medicine when she became Dean in 2013. She is very positive about her time in overseeing medical education in UCC.
“It was a great experience,” according to Prof Horgan.
“It was another leadership opportunity for me, the medical school is the biggest school in the university. It was bringing my vision and rolling out what I felt was important for medical education in the region and nationally. We train a lot of international students too and aim to make them as good doctors as possible.”
During her tenure, Prof Horgan said she worked with the business school in order to develop doctors’ skills outside of pure medicine, which resulted in the development of two masters programmes between the schools.
“Healthcare is a business, it is a business of giving quality and safe care to our patients,” Prof Horgan said.
“We have, as I said before, a finite budget and I think the onus is on us as doctors and healthcare professionals to spend it in the best way possible for our patients. And I think that a knowledge of business and understanding how you can do that is really important. Not everybody needs to have the skills, but I think more and more people need to have those skills.”
Prof Horgan said doctors also have an important role in integrating digital healthcare within the health service, which should be reflected in their education and training.
“This means collecting data and having the data inform us of how we can better provide it as opposed to trolley numbers which, in isolation, don’t mean anything.”
Prof Horgan does not believe Irish undergraduate medical education is in need of significant reform, but thinks that students can be “a little cocooned” in how they are taught.
“I think more interaction is needed with not only other healthcare professional undergraduates, but also undergraduates in engineering where they can come up with innovative ideas on medical devices, or undergraduates in business and IT,” according to Prof Horgan.
“That people can leave their comfort zone a little bit and come up with innovative ideas. Because it is all about innovation and using a lot of the big tech companies that are all here. I think we probably under-utilise our ability to interact outside our comfort zone of just doing medicine.”
In her time as Dean, Prof Horgan was keen to expand exchange programmes, where medical students went to other countries, such as Oman, Thailand, France and Sweden.
“It gave them experience of working and observing in another healthcare system,” she said.
“You pick up ideas, but sometimes you also see our system is good.”
One aspect of the Irish medical education system Prof Horgan would like to see reformed is the HPAT, believing there is a lack of evidence about the benefits of the examination.
“I don’t see any evidence that it has changed the type of student that has come into medical school, or has had any impact on the type of doctor we get, certainly into this college, in training,” Prof Horgan argued.
“I think it is an extra stress on students. And if there was evidence that it made a difference one way or the other I would say yes, but that data isn’t there. So do I think it is a good idea? No. It was brought in by the Department of Education. But I think there needs to be a critical review. A lot of parents spend a lot of money on courses trying to ensure their children have the best opportunity of performing well, which shouldn’t be the case in a country that provides free education other than the university fees.”
The fight against HIV in the 1990s
Prof Mary Horgan, who hails from Kerry, graduated in medicine from UCD in 1986. Her brother, Tim Horgan, was in the same graduating class and many of her family work as doctors or in healthcare. An interest in microbiology prompted her to train in infectious diseases, which was not a specific specialty in Ireland at the time. After working in the US, Prof Horgan returned to Ireland and in 1997 she was appointed as the second consultant in infectious diseases in the country (the first was Dr Gerard Sheehan who was appointed in 1992), taking up the post in Cork University Hospital (CUH). It was a time when treatment for AIDS/HIV had only started to improve dramatically with the advent of highly active antiretroviral therapy (HAART).
“I came back in 1997, and I had the privilege of having access to treatments that weren’t available,” Prof Horgan said.
“First of all there was nobody to treat those affected in the Munster region and I had the privilege of bringing people into Cork University Hospital and had access to any medication that HIV patients needed. And I will say that is one of the great things about this country is you have access to, certainly for HIV care, the medication that people needed without begging to insurance companies and things like that. From a Department of Health policy perspective, the care our HIV patients get is fantastic.”
Prof Horgan did admit there have been challenges.
“When I came back and I walked into CUH, I didn’t have any office or secretary, but in fairness the management did realise that I needed a secretary to answer the phone and to help with the clinics. So I built up the service relatively quickly. What I felt was really important was that those patients with HIV were really integrated into the infectious disease clinics so they were being seen with people with many other infections. That was my attempt to try to get rid of the stigma around HIV infection, which if you look at the ongoing challenge with HIV in this country, I think that is the major one.”
First female President
Last year, Prof Horgan became the first female President of the RCPI since the College was established in 1667. She said getting elected to the role was an honour, and a continuation of her work in UCC. Prof Horgan said becoming President was made easier because as Dean she “had a leadership position and I was used to running a budget and interacting with a lot of people because the medical school was so big”.
“It was a bit of a transition, but the core business is the same, which is education and training,” she said.
Prof Horgan added that the high quality of education offered to medical undergraduates and postgraduates is sometimes not fully appreciated.
“I believe our training, both our undergraduate education and our postgraduate education is really good here. And I know that from my own personal experience, but also from the number of international students at undergraduate level that can go back and integrate fully to totally different systems very quickly because of the standard of education that we have.”
One difference between the two stages of medical education, which Prof Horgan has identified, is the structure of posts at postgraduate level. Prof Horgan wants to change this and to “professionalise” postgraduate education.
“Most of the people who will work here will be doing a few hours out of their busy clinical practices, so it is work on top of their 100 per cent job,” according to Prof Horgan.
“And that is the big difference. I absolutely think that needs to change. You need to professionalise medical education in line with what we do at undergraduate [level].”
Moves are already being made to do just that. The plan is to create academic clinician posts at postgraduate level in the same way as at undergraduate where doctors would split their time 50:50 between working at the frontline of the health service and teaching and directing postgraduate medical training and clinical leadership. It was recently announced that Prof Anthony O’Regan has been appointed to the role of Foundation Dean for the Institute of Medicine, RCPI. Prof O’Regan had been in the position of Dean of Postgraduate Specialist Training in RCPI. A Director of Training, also in the Institute of Medicine, is also expected to be appointed shortly.
“And the plan is, a priority over the next six months, to put costings around the other positions. Because I do think it is absolutely essential,” according to Prof Horgan.
She said costs of these positions should not be excessive.
“It is absolutely feasible,” Prof Horgan argued.
“It doesn’t require a whole lot of posts. It probably would be four additional posts configured in different ways. That is relatively cheap for the amount of the health budget, particularly with the challenges we have with recruitment and retention. It is absolutely essential that we professionalise the doctors that lead on medical education at postgraduate level.”
Recruitment and retention
Improving the recruitment and retention of doctors is a key focus of Prof Horgan’s Presidency. The RCPI is currently conducting research on doctor emigration from Ireland, with the initial focus being on Irish-trained doctors in Australia. Dr Niamh Humphries, principal investigator for Hospital Doctor Retention and Motivation at RCPI, was in Australia over the summer conducting interviews with Irish-trained doctors in Sydney, Perth and Melbourne. The results of Dr Humphries research was recently brought to the attention of Minister Harris at a meeting, which was attended by Prof Horgan.
“We train about 750 Irish/EU graduates and we do see a trend of them going to other jurisdictions, particularly Australia,” according to Prof Horgan.
“We need to understand why they go and what will bring them back. There is no issue [with] going; it is good to go for a while, but we need to entice them back and we need to understand what will bring them back. And a lot of it is, your ability to come back to a post that will suit what your training is. In other words, if you have trained in medical education, but you are also a very good cardiologist, you should be able to come back to a post like that. Again, it is flexibility in the post and using the skills that they have picked up and bring them back and being able to use them here.”
Prof Horgan said the pay disparity between consultants appointed post-2012 was also raised with the Minister.
“Obviously the pay parity is an issue, that those who were employed [post-2012] feel that they should be on pay parity or at least have some incremental scale where they could reach their colleagues and that needs to be addressed,” she stated.
Although Ireland has historically had a low number of consultants per head of population compared with other countries, Prof Horgan said the current situation is different and worse than in the past.
“There are now unfilled consultant posts,” she said.
“Certainly when I came back, that was never the case. They [the posts] were very competitive and now they are being filled a lot of the time by locums, many of whom are good, but the cost of a locum is very expensive. So on the one hand you could probably use that money when you look at pay parity for consultants.”
Although the RCPI has no direct power in the area, Prof Horgan said the College can help influence policy.
“We can remind them that this is an issue in attracting people back and this is much more effective, bringing in pay parity, rather than employing locums,” she stated.
Saudi Arabia and finances
Recently, MI reported that the RCPI, along with the RCSI, did not wish to comment on whether they will review their relationships with Saudi Arabia, in light of the recent murder of journalist Mr Jamal Khashoggi or ongoing human rights violations sanctioned by the Kingdom.
Both the RCSI and the RCPI have strong ties with Saudi state bodies in the area of medical education. Under an international training initiative involving the HSE and postgraduate bodies, 16 state-sponsored doctors from Saudi Arabia are training in medical specialties in the Irish health system. RCPI also offers the MRCPI examination in general medicine and paediatrics in Saudi Arabia.
Prof Horgan pointed out the RCPI is guided very much by the Department of Foreign Affairs, with whom it maintains close contact.
“So we have been liaising very closely with the Department of Foreign Affairs and our international office has also been in very close contact with the Irish ambassador in Saudi Arabia,” Prof Horgan said in response to questions on the College’s links with the country and concerns about human rights violations.
Speaking specifically about women’s rights in Saudi Arabia, Prof Horgan stressed the importance of training female doctors from the region.
“I think it is very important to know that half of the trainees that we have from Saudi – it is a fairly small number – are women,” according to Prof Horgan.
“So these are women that go back and treat other women. And I’ve worked with two of the trainees. They are absolutely fantastic people. And I think there is an onus on us to understand the people as opposed to what the regime is, it is quite different. And when you have that one-to-one contact and see how these women and men treat our patients with respect, with dignity and give them quality care, you are talking about people, you are not talking about regimes. We could talk about regimes to the east and west of us, but we won’t. And I have seen it, because I have worked in the States and not everybody is treated equally there. There is quite a disparity between lower and upper income. I am passionate about education. As a College we will change any policy in line with our Government policy here.”
When it is put to Prof Horgan that the relationship between the RCPI and Saudi Arabia is purely financially motivated, she again referred to Government policy.
“The Government policy for all educational institutes in universities and the likes of us, as postgraduate [bodies], is to bring in diverse income by bringing in international students,” Prof Horgan argued.
“The reason for that is that, certainly for universities, the capitation fee has gone way down, about 70 per cent, since the last downturn of the economy. And the funding that we get for training from the HSE has not increased despite having a 25 per cent increase in trainees (since 2014). If it is about the money, the money goes straight back to training Irish doctors. And I think we have been required to look at how we do that and I have absolutely no problem training people from any jurisdiction, once it is in line with Government policy and particularly training the female doctors. If we didn’t do it, maybe nobody else would.”
Speaking about funding more generally, Prof Horgan said “it is important that we get funding to support innovations that we want to do”, such as “supporting the wellbeing of our trainees and funding various bursaries”.
“So like everybody else in the country we need extra money too.”
Overall, Prof Horgan said she has enjoyed the first year of her Presidency and is looking forward to the next two years of her term.
“It has been a great learning experience,” Prof Horgan said.
“The staff here are great. They come in every day knowing their work makes a huge difference towards the health of the population. Not many people can say that.”
The public health agenda
Prof Mary Horgan is a strong proponent of vaccination, which along with recruitment and retention, and women’s health, is one of the main issues she is passionate about.
“Immunisation prevents diseases,” Prof Horgan said.
“We forget often how bad these diseases were. Polio, TB, diphtheria, all of those, they were really bad [until the development of vaccines].”
She believes that the flu vaccination should be made mandatory for health professionals, and the College recently published a position paper making this argument. She also welcomes the extension of the HPV vaccine for boys, which was recently announced. The extension of the vaccine was one of the outcomes sought by the College following its conference on HPV vaccination in July.
The College also recently held a meeting titled ‘Lessons from the Scally inquiry’. Prof Horgan said the RCPI has many faculties responsible for areas targeted by Dr Gabriel Scally in his report into CervicalCheck. Following on from the report, the RCPI is developing an education initiative about screening. The College is also working with HSE Chief Clinical Officer Dr Colm Henry, to develop communication modules for doctors.
“We have communication and open disclosure throughout our curriculum,” Prof Horgan said.
“It is a skill, that sometimes you learn by interacting with patients and having your trainer supervise you and guide you and also by our trainees having role models in their consultants and seeing how communication is done well. It is never easy for anyone to say ‘look, we did something, there was an issue around it, this is what we have done to correct it’. And I think that culture will need to increase within our health service.”
However, Prof Horgan does not believe there is a culture of “paternalism” or “misogyny” in medicine, which some have claimed following the Scally report.
“That is not my own experience and certainly it wouldn’t be my experience of what I would see around me as a very busy clinician in Cork University Hospital. My colleagues come into a very chaotic health service every day and do their absolute best with the resources and support to deliver quality healthcare.
“Are we absolutely perfect? Absolutely not, nor is anybody else. But we absolutely strive to be perfect and when things go wrong it has a personal and professional impact on any doctor. They carry it with them and what the health service needs to be better at doing is supporting doctors, having peer support and not having a blame culture, because that doesn’t help anybody.”