Ciaran Healy, January 2014

Be the kind of doctor that you would want when you are sick

White coat ceremony key note speaker 31/1/14

Good afternoon Chancellor Modica, Ministers, Deans, incoming students to St Georges University Medical School, proud family members and guests. I would like to thank the Chair of the department of bioethics, Dr Cherly Cox MacPherson for bestowing the honour of inviting me to give the key note speech at this important occasion. Why I have been asked to do so I am not absolutely sure, though I suspect it is because I have survived to middle age in the challenging field of reconstructive plastic surgery in a large London teaching hospital. In doing so, I have followed my mentor’s advice to ensure that I concentrated on what he called the three A’s for the benefit of my patients. These being:
Availability
Affability
Ability

Availability includes all of the time you commit to your role as a doctor including training, clinical practice and increasingly time consuming administration. The induction of medical students into the profession through a formal process has come about since my medical school days and has gained increasing recognition as beneficial to both medical students and their future patients. While our understanding of human disease and its management has improved dramatically through the application of scientific process, as medical practitioners we must practice with the patient as a person in mind. Note I am already including you all as medical practitioners in my address, novices though you are. The process of learning as a doctor continues throughout your career, the rigid hierarchical structure of the profession is in place to manage us as a group, not to dictate when we have reached a point when we are replete with knowledge on which to base our clinical decisions. You will be educated by a dedicated faculty here in Grenada for your basic medical sciences for two years, followed by two years of clinical training in teaching hospitals in the USA, the UK and Canada. This will be followed by a range of specialist postgraduate programs, but through out your career your patients will teach you more than any lecturer.

Spending time with them will help you understand and remember their conditions and treatments more effectively than hours over dry textbooks. Occasionally you will meet a patient with an encyclopaedic knowledge of their condition such as I did at an ophthalmic outpatient clinic in my final medical school year. He had a rare neuro muscular autoimmune disease called myasthenia gravis, describing to me in detail its pathology, symptoms and signs, investigations and treatment. Some months later in my final medical clinical exam I was presented with a case of myasthenia gravis and was able to impress the examiners with my knowledge of this rare condition, helping me to pass my finals despite an abysmal performance with my clinical psychiatry case.

I congratulate the student body on your achievement in obtaining a coveted place in medical school, and those who have helped you to achieve this. The time and effort in doing so will be added to throughout medical school, postgraduate training and continuing medical education. To this will be added the time you will spend with your patients. This commitment is an aspect of availability. You need to be accessible to your patients when they are in need of you, be it in the emergency room at 3am or in your office at 3pm, at their hospital bedside or the operating room at 8am. This accessibility is an onerous aspect of the vocation you have entered and will likely persist throughout your career. It will impact on your domestic, romantic and extracurricular life. Even when you are not in direct contact with your patients they will occupy your thoughts, distracting you from the very activity with which you seek to escape this intrusion. Strangely, when occasions arise when you are not in constant demand it takes some adjustment, such as family vacation time which some busy doctors actually dislike. One of my bosses scheduled himself to be on call for emergencies whenever his mother in law was visiting his family.

Affability in a doctor needs to be tempered to avoid encroaching on the doctor patient relationship, particularly in matters of intimate behaviour. The balance of influence is so far in the doctor’s favour that it risks exploitation on their part. When interacting with your patient you will be in a social space which may be of varying degrees of familiarity to each of you. The norms of social interaction may appear distorted but the more you can create a relationship of trust and open communication with the patient the better will you be able to understand their needs and provide for them. Respecting cultural norms and clinical priorities will dictate whether you should, in addition to greeting the patient and their associates whilst introducing yourself and any team members present, also offer to shake their hands. With my female Muslim patients I ask first if this is appropriate for them, many decline but then co-operative fully with the clinical examination with an appropriate chaperone. I request chaperones for intimate examination of female patients to ensure both parties are comfortable. Identifying the patient’s needs through a structured interview, clinical examination and appropriate investigations is fundamental to the clinical process. Do not be misled by limitations in communication through age, intellectual or language barriers but always attempt to obtain information directly from the patient and those accompanying them. As a medical student I identified a young boy who had aspirated a peanut and was being treated for a persistent lung infection without the paediatric team’s knowledge of the underlying cause. By sitting down and actually talking to the child I was able to illicit what had initially occurred and then was able to bring it to the attention of the team. This had a beneficial effect on the treatment outcome when the peanut was removed endoscopicaly.

Affability is a useful habit to cultivate with your patients as it tends to override the cynicism that can easily overcome you when you are in the midst of a heavy workload. During my junior residency in the busy emergency room, despite the urge to curtail a patient who sought my advice as she suspected that she was going mad, I methodically went through her symptoms of a recurring vague illness which had defied diagnoses by her family doctor and internists. The wave like pattern of her symptoms brought the term undulant fever to my mind, this is a bacterial infection otherwise known as brucellosis which can be contracted from animals. On further questioning she gave a history of assisting her father in his vetenarian practice particularly with difficult animal births. My tentative diagnosis of brucellosis was confirmed with appropriate laboratory tests and the patient was then referred to have treatment by our medical department. This tendency for the diagnoses to be within the doctors grasp once a detailed history is obtained is particularly relevant in my current practice of skin cancer surgery. Many of the patients whom I have treated for advanced melanoma had their diagnoses delayed by doctors who reassured them that the skin lesion that concerned them on earlier presentation did not require removal for analysis. It is only by carrying out such laboratory analysis that the true nature of the skin lesions of concern can be ascertained at the present time, though none invasive diagnostic devices are being developed. The majority of suspicious skin lesions prove not to be dangerous when removed for analysis and the patient must be informed of this and reminded of the inevitable scar that follows.

The process of developing trusting relationships with your patients is not without moments of sadness.
One of the first cases I helped manage as an intern was a middle aged man with advanced lung cancer. On asking him if he smoked he replied no, further questioning however elicited heavy tobacco consumption throughout his adult life, ceasing the day his lung cancer was diagnosed. I administered his chemotherapy regime to him, always taking the time to talk to him of his thoughts and concerns whilst doing so. Moving on to my next role as the emergency room doctor in the same hospital, I was touched when he made regular visits to me there to keep me appraised of his progress. When my son was born I returned to work the next day to be told that the patient’s condition had deteriorated in my absence and that he wished to see me. Struggling to talk to me despite his advanced cancer, he wished me the best as a new father and presented me with a beautiful blanket for my newborn son. Such experiences whilst emotionally painful should not deter you from forming appropriate relationships of endearment with your patients as it is to their benefit when they feel that they are important to you.

Affability with the full spectrum of your work colleagues is essential. Placing the patient at the centre of the decision making process leads to the development of super specialist, multidisciplinary team management for many conditions particularly cancer. For whatever disease process we are managing, the input of medical practitioners with complimentary specialist skills, nursing staff with defined supporting roles of clinical care and pathway management, therapists with specific clinical skills and administrative support staff are all brought together in such teams. As a doctor, it is important to ensure that you understand and fulfil your role in the process, without loosing site of your patient’s essential humanity and your responsibility to them. You should also participate in defining and updating the management protocols guiding the team and ensuring your patient progresses smoothly along their treatment pathway.

Question the dogma of such protocols, always insisting on continuous improvement in the process for all your patients. As a resident I challenged the assumption that all melanoma patients requiring reconstruction following surgical excision should have a split skin graft. Combining traditional plastic surgical flap design with modern concepts of the blood supply of the skin, I developed an improvement in the reconstruction of melanoma defects avoiding disfiguring split skin grafts. Whilst this approached was challenged by long established surgeons, it was subsequently published in a peer review journal and skin flap reconstruction for melanoma is now widely practiced.

Ability as a doctor involves accurate diagnoses of the patient’s condition, formulation of an appropriate treatment plan and its efficient delivery. Success as a doctor depends on your mastery of the scientific knowledge upon which clinical practice is based and on your application of this in a practical way to the optimal benefit of your patient. The knowledge and skills you acquire throughout your career progression may come together in ways which are not predictable to you from the out set. When thrown into the role of lead clinician in the emergency room early in my career as an attending following a terrorist bombing, I used my training in advanced trauma and life support to guide my assessment and management of over thirty severely injured patients. Using triage to select them in terms of priority, I directed their care by other clinicians as they arrived to lend assistance. Despite the predicted mortality of five of the patients, all survived, partly as a result of the tough decisions I made to amputate a total of five limbs that night.

Similarly my current super specialist role in reconstruction of the nose following cancer excision is greatly enhanced by my training and experience in cosmetic surgery. Many of these cases require a series of operations to achieve optimal results and it requires time on my part with the patient to explain the need for such protracted treatment and to gain their trust prior to them making such a commitment. The restoration of appearance and function is a team effort which includes the patient.

Scientific research has yielded enormous advances in the treatment of diseases and promises to deliver much more throughout your careers. My research has always involved clinical subjects and it is extremely important to have a relationship with them that is based on mutual trust and support. Interrupting my residency to undertake laboratory based research on the recovery of function following injury to skin nerves lead to the award of a doctoral thesis. While I was collecting data from my clinical subjects my research supervisor questioned my submission of the restaurant bills I paid when taking them to lunch at a nearby modest Italian restaurant. She relented when I explained that the day long experiments required a lunch break where I accompanied the clinical subjects, being worried that they may not return for the afternoon component of the study which involved application of painful stimuli to assess recovery of pain perception.

It is important to retain curiosity throughout your career, trying where possible to advance the understanding and care of your patient’s problems. Whilst participating in the surgical care of a victim of the mass bombings in London in 2005, I was made aware of the need to conserve our dwindling stock of blood for transfusion. I used fibrin glue obtained from human blood to seal the patient’s split skin graft donor site as studies had shown that it reduced the requirement for blood transfusion. The following day we asked the patient how the normally painful split skin graft donor felt and were surprised when she told us she was not even aware that she had a donor site, let alone a painful on. Curious as to whether this was an anomaly my team carried out a pilot study of split skin graft donor site pain prevention through fibrin glue application. The result encouraged us to proceed to a randomised controlled trial which confirmed that sealing a split skin graft donor site with fibrin glue significantly reduces pain.

I would like to conclude with some crystal ball gazing. The recent changes in medical insurance coverage in the US will most likely lead to additional physicians being required to care for the up to 40 million additional patients. Your generation are at the threshold of the most dramatic expansion and transition of health care ever, I have no doubt that you will rise to the challenge. In doing so, be aware of those who do not have such opportunities. Over thirty years ago, while on my medical student overseas elective, I met St Georges University vice provost and professor of parasitology Dr Calum Macpherson, when he was collecting specimens of infected human tissue for his research into neglected tropical diseases. We travelled with the flying doctors to the inaccessible Turkana district of Northern Kenya where I assisted the surgeons in removing hydatid cysts from infected pastoralists. Dr Macpherson used these specimens to carry out the first laboratory cultivation of the responsible echinococcosis parasite and its strain identification. He continues his important research into neglected tropical diseases as director of Windref, the internationally renowned Windward Islands Research and Education Foundation, here at St George’s University’s beautiful True Blue campus. Immediately north of Turkana lies the newly established country of South Sudan from where a group of thirteen prospective medical students have come to Grenada, supported by their government, St Georges University and Windref. The students have been selected on their academic achievement under extreme adversity and their commitment to return home on graduation to help build much needed medical services. They have the opportunity to be trained at this internationally diverse medical school, housed in a modern purpose built campus with a committed well informed faculty and administration. No doubt they will receive encouragement in achieving their goals and humanitarian support from you, their fellow medical students at St Georges University, renowned for friendly hospitality and cultural awareness. It is hoped that when they have completed their medical school training and graduated that they will return to South Sudan and establish medical services for their people. No doubt some of you will assist them in this when you are established in your careers by spending time with them in a voluntary educational role.

I would like to conclude my speech by emphasising the humanitarian core of medical practice which will reward you as well as your patients.

Thank you for listening and best wishes to all of you.