Fronting-up in a crisis – Prof Mary Horgan interview

President of the RCPI Prof Mary Horgan is at the Covid-19 coalface as an infectious diseases consultant at Cork University Hospital and continues to advocate for doctors through her College role. She spoke to Catherine Reilly about clinical practice and doctor retention in these challenging times

Infectious disease consultants, virologists, microbiologists, public health doctors and other health professionals have long sounded warnings of emerging viral threats, including in these pages. Now these warnings have become all too real.

Prof Mary Horgan, RCPI President and Consultant in Infectious Diseases at Cork University Hospital (CUH) told the Medical Independent (MI) that doctors had feared a virus with the characteristics of SARS-CoV-2.

The virus is associated with a lot of asymptomatic infection, it involves mild symptoms in many cases, it makes a minority of people extremely ill, and it is very infectious.

All of these factors have contributed to its rapid spread around the world and considerable morbidity and mortality. In other words, SARS-CoV-2 is “very successful as a virus”, according to the RCPI President.

Prof Horgan is on the Covid-19 frontline alongside colleagues at CUH and continues to advocate for doctor recruitment and retention, and health and wellbeing, in her role as RCPI President. Her three-year tenure began in October 2017.

Doctor retention has assumed an even greater importance as healthcare professionals face into major demands over the coming months, if not years.

Public efforts

Speaking to MI on 28 April, Prof Horgan firstly praised the commitment of the public and their adherence to social distancing measures.

“What the public do has a huge impact upon us in the hospital,” according to the RCPI President.

The public efforts have been buying time to allow for increased healthcare capacity and, it is hoped, an apparatus capable of rapidly testing and contact-tracing.

But an upward shift in community transmission and increased hospital attendance may result from a gradual lifting of measures. In tandem, there have been reports of more people with non-Covid-19 illnesses presenting to hospitals, having delayed seeking care due to the fear of contracting the virus.

In these contexts, is the College advocating urgent recruitment of more doctors?

“Yes, absolutely,” answered Prof Horgan. “The health service here was busy anyway, and with Covid continuing for the foreseeable future, there will be a requirement for additional doctors and other healthcare professionals… I think we are going to have to have the traditional non-Covid pathway, or the way life used to be before Covid, and in parallel with that we are going to have the Covid pathway. It is bringing an extra percentage of work onto the health service for the foreseeable future, so it is absolutely necessary that we have additional people on the ground.”

According to Prof Horgan, the RCPI has been working with the HSE to inform them of the recruitment requirements and the opportunity to retain doctors.

“A lot of our interns have gone to Australia and New Zealand for the past decade or so; with Covid-19, a lot of them have decided to stay here. Likewise, a number of people at the other end of training coming out as SpRs would have traditionally gone to the States or Australia or the UK to do fellowships and they are unlikely to travel too, so that is another group [where] we have been working with the HSE, trying to say ‘look, these are doctors well trained within our system, how can we work with you to identify posts of need in this Covid/non-Covid health service… ‘

“If we can retain Irish graduates, or people who have trained in Ireland, within the system and thereby increase training posts, we wouldn’t be dependent on recruiting people from overseas because we haven’t had enough of our graduates stay within the system.”

In respect of doctors completing their internship this year, Prof Horgan said these must be retained.

“Now, not all of them may choose to stay here but we would be very supportive of having as many as possible staying and looking at expanding the training posts so that then when it comes to the following year, and you have all the extra interns coming out…about an extra 300 too, that we would be looking to expand our training programmes.”

In April, the HSE announced a rise in the annual intake of medical intern places from 734 to approximately 1,100, to help with the Covid-19-induced pressures of increased workload and staff absences through sick leave and self-isolation. In very sudden circumstances, these incoming interns had their medical school exams brought forward and they will enter the workforce sooner than envisaged, on 25 May, following their induction.

However, the Executive has not yet confirmed if extra training places will be available in 2021 for this enhanced intern take (a HSE spokesperson told MI on 23 April the number of training posts “is kept under constant review and normally informed by medical workforce planning projections”).

“It would be fantastic for our health service if we got to keep all of those extra interns within the system, entering training programmes,” said Prof Horgan. “Because we know with training programmes, they are funded by the HSE, they are supervised, there is the support of the postgraduate training bodies, and the care that they give is of a very high standard, so the more trainees we have in training posts, the better for our health service and for our population.”

SLA funding

The level of State funding of medical postgraduate training under service level agreements (SLAs) with the HSE has been a source of concern within many colleges and training programmes. As an example, the RCPI Institute of Obstetricians and Gynaecologists (IOG) annual report for 2018/2019, which was published on the College’s website in January, said the amount received from the HSE under the SLA “has remained static for the last four years, despite an increase in the number of trainees”.

Prof Horgan said: “If you want to give quality training, you have to pay for it. In the long-term, it is cheaper because if you have good-quality trainees, you deliver good-quality medical care, so it is the cost-effective thing to do. So yes, we would be looking for our usual SLA grant we get from the HSE to fund these additional posts so we can deliver the training that is required of us.”

The RCPI has been responsive to the crisis in how it delivers ongoing professional education. Its weekly webinar, ‘Clinical Updates on Covid-19’ , has been very popular across specialties. Does Prof Horgan expect educational activities to stay online for the foreseeable future?

“Every challenge has an opportunity, and this is a very difficult time for our health service and for the population of the country. But it also allows us as a training body to do things differently,” she outlined.

“I have always been a huge advocate for delivering as much education and training [as possible]to the frontline, and I have done so by opening offices in hospitals, linked to Hospital Groups, and that has worked out really well. Online delivery of education will become normal for us… we have had a huge uptake on those weekly webinars, and as things evolve we will also evolve them, so that we will not only be doing Covid-19 but also other important aspects of medicine.

“So this is the way forward. This is our opportunity to deliver it to our members at a time that is convenient to them, so they can also watch it, not just on Wednesday night at 5, but by the next day it is all online so they can access it at a time that suits their busy schedules. This is the way to go.

“We won’t be getting rid of other means of education — when we are allowed to, we will obviously meet again, because I think that face-to-face is important too, but I think it is nice to get that blended approach to education, and deliver it at a time that suits our members.”

RCPI’s premises on Kildare Street in Dublin plays host to many events, which in some cases are revenue-generating. Like many institutions, will the College have to examine other streams of income amid the crisis?

According to Prof Horgan, the College is “on a good footing” and has been “prudent” in its expenditure, but it will closely monitor finances.

“Thankfully, that is not an issue for us at the present time. And I have to say [this is achieved] working closely with our CEO Dr Terry McWade, who has been really good at working with us to ensure, like any other college, we are financially stable.”

Prof Horgan has resumed more clinical work in order to help on the frontline of the crisis.

She has been providing care to patients infected with Covid-19 alongside colleagues at CUH.

In an insightful piece for The Irish Times, Prof Horgan documented how she had “never seen a lung infection get worse so quickly in that small proportion of patients who need hospital care”. She highlighted the fear and uncertainty felt by patients and the compassionate care of healthcare professionals in trying physical circumstances.

Prof Horgan also offered words of hope in recollecting that when she trained in the 1990s, HIV/AIDS was the “big killer virus”, but now there were effective treatments and people with HIV infection could live normal lives.

Treatment

MI asked what kinds of regimens are initiated for hospitalised patients with Covid-19, given the current lack of any proven treatment.

“As you know, the only treatment we have for it really is supportive therapy with oxygen,” said Prof Horgan. “There is no medication that has been proven to be effective, so certainly, we have taken the approach at Cork University Hospital that any treatment should be in the context of a clinical trial.

“I have been appointed as Chair of the new national research ethics committee, which has the remit of ethical reviews of research proposals in a very expedited manner, and I acknowledge the Minister [for Health Simon Harris] for getting that up-and-running, which it is now, and I have got it together with my great committee members to look at exactly that — ensuring we have all the structures in place to promote research in the area, but in particular clinical trials… No medications have proven to be effective and the only way we can do that is [by conducting] big national and international studies.”

Is it likely an effective antiviral may precede a potential vaccine?

“That is the million dollar question. I just don’t know,” responded Prof Horgan. “I would say in a few months’ time we will have an idea if anything is effective, because there are a number of clinical trials going on, with hydroxychloroquine and many of the other drugs… in a few months, we will know if something does or doesn’t work, but really the ‘holy grail’ is a vaccine.”

Adopting new treatments in clinical trials activity is an established part of specialist medicine. But globally, this activity has moved at a much faster pace than usual, in a bid to help patients and put a halt on this destructive pandemic. Is there a sense of anxiety among clinicians about using drugs such as hydroxychloroquine, and remdesivir, in Covid-19?

“Every medication we give, we always weigh-up the pros and cons in each individual patient; that is essential, but I think that is best done when you have a lot of people on it, in a clinical trial. That is the safest setting for a patient.”

PPE

At CUH, Prof Horgan can report positively on the availability of personal protective equipment (PPE).

“The hospital management, in particular our Director of Nursing, she has been fantastic at being resourceful in getting PPE, not only from HSE central, but has negotiated with a lot of local manufacturers and we have not had an issue…

“They stock it up every few days but thankfully, so far, so good, I will put it that way. But that is because she has been organised, she has been engaged with companies who may not traditionally have made it but have adapted their factories to do so. That local investment has been really great because they see the local benefit of switching to manufacturing something for our health service. So we have been in a good place in Cork University Hospital.”

Doctor health and wellbeing has been high on the RCPI’s agenda in recent years. Prof Horgan indicated that she is determined this remains a key focus. The College was the first to develop a physician wellbeing department, which was officially launched in October 2019. The department is headed by Prof Gaye Cunnane and has a psychologist, Ms Hadas Levy.

“This [focus] is something I brought in as President. I felt it was very important that we support frontline staff. We are a training College, that is our remit, and I would see the health and wellbeing of our trainees being as important as the many other things we do. So certainly, while I am President, it will continue.”

On the clinical frontline, “we just continue to work hard and hopefully avoid any big second surge,” added Prof Horgan.

It is important to ensure the public understand that if and when some restrictions are lifted, the risk to health continues in the absence of a vaccine, “and I am not sure if that message gets out there or not”.

Prof Horgan said these are very difficult days for the population and the decisions ahead are tough ones.

“It is tricky because when do you lift [restrictions], what do you lift, how quickly do you lift them, how quickly do you re-institute them when you see increased activity again? It is a really hard task for anybody, for any Government, whether it is Ireland, the UK, or anywhere, because it is a fine line.”