A presidential role

Bray GP Dr Rita Doyle was elected as President of the Medical Council last July. She speaks to Catherine Reilly about pressures on medical professionals, open disclosure, and doctors’ health

“It is tough for everybody out there, for patients and doctors, and not just doctors, but the whole health profession,” Medical Council President Dr Rita Doyle tells the Medical Independent (MI) during an interview in the Council’s offices in Dublin.

The Bray GP, who was elected as Council President in July 2018, mentions clearing up in the surgery before arriving at the Council that morning and working until 10.30pm the previous Tuesday “because I didn’t want to leave anything undealt with”. It’s a familiar story for many doctors.

Dr Doyle has worked for over 30 years in a specialty contending with demanding demographics, growing multimorbidities, poor access to public hospital care and, of course, FEMPI. This has all informed her role at the Council, where she is a vocal President and even political, in the broadest sense of the word.

Take as an example a tweet sent via her personal Twitter account in September. In response to a report about a 93-year-old woman waiting on a chair at the Mater Misericordiae University Hospital’s emergency department for over 20 hours, Dr Doyle wrote: “And at the same time,  just next door Mater Private are offering same-day or next-day consultant appointments — there is something rotten in the state of Ireland — prioritise sick and older people, not wealth.”

The need for doctors to advocate for fair division of funding and to prioritise “the sick, the old, the poor and the vulnerable” has also been highlighted by Dr Doyle in official speeches.

Transitional care

One of the issues Dr Doyle has expressed concern about is the communication breakdown between doctors at the interface of primary and hospital care. This vacuum has huge implications for patient safety, she believes.

“Transitional care, which is the journey of the patient from primary to secondary care, and from secondary care back to primary care, is the most dangerous journey for any patient. And if the communications on both sides are not right, the patient is going to suffer,” Dr Doyle tells MI.

“If my referral letter is not right and doesn’t give the hospital a list of the medications, a list of their past history, then that is poor. If I don’t get a discharge letter, if I don’t get a letter to know what happened to you while you were hospital, I am at a disadvantage but the patient is going to suffer.

‘I really felt that what was getting lost in the public image was the value of cervical screening’

“I think there needs to be more communications between the disciplines, between secondary and primary care. I suppose what we would say in primary care is we have all done hospital jobs, we know what it is like, very few of the hospital doctors have ever been out in general practice, they have no idea… whereas we have a good idea of what their job is like.

“If you ring and say that you are looking for something urgently and the young doctor says, ‘I am too busy’, actually, ‘you can’t be too busy’ is what I am saying, because you must prioritise. If this patient doesn’t get medication x that you have prescribed because I don’t know about it, or they don’t get a prescription, then the patient is going to suffer and that is still your responsibility.”

“It is absolutely vital,” continues Dr Doyle. “I think that journey needs to be studied really hard, the transitional care, because actually, it’s the most dangerous journey the patients ever make… currently, because both sides are overloaded with work, these are the things that will slip. I am not criticising them for not doing it, I am saying they seem to be too busy to do it because they don’t know the priority of it — and vice versa, sometimes they criticise GPs’ letters…

 “I think, maybe I am wrong, that in primary care we are more tuned-in to how important the referral letter is, and certainly with the trainees, it is part of what you teach them and they write really good referral letters.”

Does it warrant a complaint to the Council or the clinical director of the hospital?

“Yes, I think if you get no response,” says Dr Doyle. “I wrote a letter last week to a consultant; I needed to bypass the junior, because it was a waste of time. I wrote and I said, ‘I haven’t got a [discharge] letter’. I said, ‘please look into this because this is poor practice’. If I don’t get a response, my next line would be the clinical director; if you don’t get a response there, then you look at… I have no desire to be making complaints about doctors, but what I want them to realise is that this journey for patients is terribly, terribly dangerous and we need to put in all the supports we can to make it a safer journey.”

Council image

Dr Doyle has previously admitted the Council has a “poor” image among the profession, something she senses is changing. Some legislative changes may assist in this regard.

Proposed amendments to the Medical Practitioners Act 2007 seek to improve the complaints process, such that not all complaints will be assessed by the preliminary proceedings committee (PPC). Rather, the CEO and delegated officers/s will assess complaints initially and send to the PPC only those matters that warrant its attention. 

Dr Doyle believes this will hugely assist in sifting-out complaints that are not fitness to practise matters.

“I spent five years on the PPC, I know what the complaints are like. I think that is hugely sensible. I think that is something that could and should be sorted locally. It would save everybody, including the patient, a lot of hassle. I don’t think patients make complaints willy-nilly, but they feel frustrated and I know doctors are very distressed by complaints.”

Often, complaints relate to a remark the doctor has made, which they have forgotten but the patient has taken with them, according to Dr Doyle.

It seems a lot of responsibility and power to accord the CEO, however.

“The power is there, but really we are only interested in fitness to practise issues and not unavailability or the colour of the waiting room walls. You do see what you might call ‘minor’ issues. The CEO is not going to send back something that is a fitness to practise issue, and that is our job — fitness to practise.”

CervicalCheck

The Medical Council’s purpose is to “protect the public by promoting and better ensuring high standards of professional conduct and professional education, training and competence among doctors”.

Last August, the Council took the unusual step of issuing a statement on the eroding public confidence in the CervicalCheck screening programme, a matter it typically would have seen as broadly outside its parameters (notwithstanding the fact that Dr Gabriel Scally’s scoping inquiry into the CervicalCheck programme, published in September, identified specific matters for the Council to address).

This statement, which was issued on August bank holiday Monday, outlined Dr Doyle’s concern “at the levels of inaccurate information that is in the public domain as a result of the recent CervicalCheck difficulties”.

‘There is almost this shame among doctors — “I should never be sick, I should be perfect, I should never make a mistake”. These are huge burdens to carry’

“The fact is, cancer screening saves lives every week, however screening is not a diagnostic exercise and there is an acceptable norm of false-negative and indeed false-positive results,” Dr Doyle said in the press release.

“The CervicalCheck programme has decreased the mortality rate by 7 per cent year-on-year since its inception, thus reducing the number of women who die from cervical cancer.”

Dr Doyle recalls her growing anger over commentary that could dissuade women from participating in potentially life-saving screening.

Was the statement something the regulator was receptive to her doing?

“Absolutely, very supportive of me doing it, and very supportive of having a public say about things like that,” replies Dr Doyle. “I really felt that what was getting lost in the public image was the value of cervical screening.”

Screening was “haphazard” before the programme’s inception. “As a woman, I would have been avidly screening patients but you were screening the ‘worried well’. It is the people in areas of poverty and deprivation who weren’t being screened, and CervicalCheck pulled all of that in as much as it could… Each year, it has saved lives, so as a Council we need to say ‘look, this is really good for patients’.”

The CervicalCheck crisis emerged because of a failed attempt to disclose the results of a retrospective audit of screening results to a large group of women who had developed cervical cancer. The decision of patient advocate Ms Vicky Phelan to share her own experiences ensured the matter came to light.

Dr Scally’s report noted women’s concerns about paternalism in healthcare, arising from their experiences of certain attitudes and lack of openness by doctors involved in the disclosure (or non-disclosure) process. Most of the disclosure letters were sent to colposcopists as ‘treating clinician’ and these contained little advice on disclosure, the Scally report also pointed out. The majority of disclosures occurred only after Ms Phelan spoke out, and many were handled badly.

Speaking at a conference in January, Ms Phelan said her campaigning had led to “dirty looks” from some doctors. She said she encouraged people to ask questions “and they (doctors) hate that”.

The suggestion that doctors resent questions is not something Dr Doyle recognises in her own work or that of many colleagues.

She strongly credits Ms Phelan and fellow advocates like Ms Lorraine Walsh, Mr Stephen Teap and the late Ms Laura Brennan as having “done more for healthcare in this year than lots of doctors have ever done in their lives…

“I mean, Laura has probably saved more lives than I ever have; there might have been one or two occasions in my whole life as a doctor that I thought I might have saved someone’s life. By her actions, she has saved more lives than any doctor ever did.”

Some of the poor communications by doctors related to them breaking difficult news that hadn’t “anything to do with them”, remarks Dr Doyle.

“So you are given bad news to break; not just bad news, but difficult news. I don’t think anyone briefed them on how to do it. Some doctors are wonderful at breaking bad news, some doctors are lousy — there is no good way, but there are better ways. If it highlighted anything, it highlighted that communications are vital within the medical profession.”

According to Dr Doyle, “I accept everything that Gabriel Scally said. But I also think that was a really tough job and it could have been done better… We have to learn from these things and make sure it doesn’t happen like that again.”

Doctors must be aware of patients’ vulnerability, underlines Dr Doyle, who believes a patient’s medical results always belong to the patient.

The Bray GP sees about 30-to-35 patients a day at her practice. Consultations are routine for her “but I have to remember that it is not routine for the patient, and to stop between each consultation and to ground myself.

“Say, you have had a very sad consultation — not to carry that into the next consultation. Doctors’ jobs are difficult, I don’t underestimate that, but patients are vulnerable and you have to be so careful how you handle.

“I think probably — and the rest of the profession won’t like this — but nobody will survive in general practice unless they are a good communicator; they just won’t. And yet you don’t want a surgeon who does very meticulous work to be a ‘softie-softie’. So the communication skills that they need are different to the communication skills that I need. It has to be tailored to your discipline in the profession… ”

Ethical guide

Dr Scally found the section on open disclosure in the Council’s ethical guide as orientated towards doctors’ feelings rather than patients. Furthermore, the guide was not definitive in terms of a duty to practice open disclosure.

“We are reviewing the ethical guide and we are looking at that passage and it could do with some improvements; I would absolutely agree that it needs to be improved,” says Dr Doyle.

Part of the problem regarding open disclosure is “we are, I think, the second-most litigious country in the world and doctors are afraid of that. All of the studies show that all that patients really want is information and that if you give them the information, that is enough… None of us is perfect and that is the problem — it is human to err, everybody makes mistakes, minor ones, and sometimes there are major mistakes.

“The real thing is to learn from that; the critical incident analysis — you sit down and you include the patient in your discussions and you discuss what went wrong, why it went wrong, how you can prevent it going wrong in future. And you support the doctors because when doctors make mistakes, they feel awful. I know times when I felt absolutely awful and thought ‘if I had done that’.”

Does she view as positive proposed legislation providing for mandatory disclosure of serious incidents?

“As long as it’s done properly and professionally, I think yes. But there needs to be protections for both sides on it… It is serious stuff for everybody. As I said, we are all patients.”

Medical register

Dr Doyle describes the Council as the custodian of the medical register. However, this resource has increasingly been misused by employers, including the HSE, as a measure of quality assurance. Is this a concern?

“We maintain the register, and that is a very important role of the Council and it is meticulously done. We have a whole department that deals with it and we have 23,000 doctors on the register.

“Now, recruitment and registration are two different issues and all the information that is available to recruitment agencies is that they are registered… on whatever division.”

One of the problems around registration, according to Dr Doyle, is that the Council is required to automatically recognise a doctor who has qualified in an EU country, where they present the relevant qualification.  These graduates may have a different training system to that of Ireland (for example, some graduates are deemed fully qualified without undertaking a clinical internship). These issues were the subject of a HSE circular in March.

Given Dr Doyle’s proactive approach, one wonders if the Council could have better highlighted these matters publicly for the benefit of patients. This would include the fact that some doctors in consultant posts are on the general register (which was noted in the Council’s medical workforce report in 2016).

Dr Doyle believes the Council has been proactive, although as she points out, it was the President of the High Court Mr Justice Peter Kelly who highlighted the issue publicly.

Doctors’ health

Dr Doyle is a particularly strong advocate for doctors’ health and continues to chair the Council’s Health Committee.

“I asked Council to let me stay with it because I wanted to develop it… it is the nicest committee in Council because it is completely supportive of the doctor,” says Dr Doyle.

Doctors can self-refer to the Health Committee and “nobody in the Medical Council, bar myself and the Health Committee, know about it.

“We treat them absolutely confidentially; they are seen after-hours… we do not have a therapeutic role, we are not treating them, we are supporting them to either keep them on the register or get them back on the register if they have come off the register.

“Doctors are patients; like everybody else, they get sick, but it is almost like, in medicine, it is a shame to be sick, it is an embarrassment, and I have used these statistics from New Zealand recently, similar country, similar population — in their health committee they have at least five times more doctors than we have.”

The Council has a memorandum of understanding with the independent Practitioner Health Matters Programme. However, “between us, we haven’t even got the tip of the iceberg. Either we have a very healthy population, or there are a lot of sick doctors out there who could do really well with support. And that is what we are there for. I suppose there’s a fear of the Medical Council… but no doctor need fear for their health in this Council and we will do our best to support them, get them back working and on the register.”

A wide spectrum of physical and mental health illnesses are experienced by doctors attending the committee, Dr Doyle points out. 

“There is no shame in being sick… there is almost this shame among doctors — ‘I should never be sick, I should be perfect, I should never make a mistake’. These are huge burdens to carry. It is okay to make a mistake, as long as you are honest about it. It is okay to be sick, because you are human. It is human to err. It is almost that they think they can’t be human… ”

Self-care is a professional obligation, according to Dr Doyle.

“If you don’t look after yourself, you can’t look after your patients, or your spouse or your family, so you have to prioritise your own health, then you can look after the others. I get a bit passionate about that, don’t I? It comes across. I suppose I didn’t myself,” adds Dr Doyle, explaining that it took a serious health issue for her to take a step back and give this proper recognition.  

Does she think it would be beneficial if more senior doctors spoke out on this issue?

“Yes I do, but I see the pressures on senior doctors, they have hardly time to get through their day’s work. That is the problem at the moment.”

Meanwhile, the Council is nearly finished its revision of the ethical guide in the context of the new termination of pregnancy law. The issue of conscientious objection remains hugely contentious among pro-life and pro-choice doctors. The current guide states that if a doctor holds a conscientious objection to a treatment, they must inform the patient that they have a right to seek treatment from another doctor and give the patient enough information to enable them to transfer to another doctor.

Does Dr Doyle foresee that revisions will satisfy the profession?

“It is a very divisive issue; nothing will satisfy everybody. It has gone the furthest it can to support all angles and that is as much as I can say about it. It has been very seriously considered; hours have been spent with lots of experts and it is almost ready. I think it’s in its penultimate stage and hopefully launched [by the end of this month]. But there is no way you can satisfy the whole of the profession… it has been a very divisive issue, not just for the profession, but the whole country.”