Reinforcing our commitment to tackling inequalities

26 June 2020

I was a doubly lucky grandson! Not only did I know my grandfather as a child, but I was able to spend time with him as an adult and discuss work as a fellow professional.

My grandfather, Dr Eric Dorman, graduated from Trinity College, Dublin in 1935 and began working in Willowbank Surgery Keady a short time after until his retirement in 1985.

I loved visiting him when I was a medical student and listening to his stories on how he used to practice. The limited range of drugs available to him was frightening, compared to the 1600 pages of medications we enjoy in the latest edition of the British National Formulary (BNF).

History of obstetrics

My grandfather’s real skill was in obstetrics and he proudly told me the various home deliveries he attended, 365 days a year.

His insights were remarkable, and he claimed that of the approximate 2000 deliveries he performed during his career, he estimated 90% were forceps deliveries. This was, he explained, due to the necessity of speed, for pain relief.

"I hated administering pethidine," he told me. "It made the babies very flat."

Like all good GPs, he remembered individual cases, stories, and how they affected him.

He remembered delivering a baby boy at home in Keady, "But for whatever reason, I just could not get the child to take its first breath. He was a beautiful, perfect looking baby boy." He reminisced at his own father’s (my great grandfather's) antenatal skills and how his prized possession was a pair of forceps with mahogany handles.

The history of obstetric forceps, or Chamberlen forceps, reveals a murky world of discovery, secrets and money. The brothers Chamberlen who invented the device in the 1600s kept the design secret, which made them a lot of money, but undoubtedly put the lives of many women and new born children at risk

Forceps were not the only discovery, the widespread use of which was delayed in obstetrics, and in the 1970s a New Zealand obstetrician, Dr Mont Liggins, with his paediatric colleague, Dr Ross Howie, discovered that antenatal corticosteroids administered to pregnant women likely to deliver prematurely resulted in a 50% reduction in respiratory complications and a comparable decrease in perinatal mortality.

Despite repeated randomised trials throughout the 1970s and 1980s, and a systematic review of randomised trials in 1987 providing incontrovertible evidence in favour of antenatal corticosteroid therapy, its introduction was very slow.

The clinching evidence came from a systemic review by Crowley in 1990, which clearly showed the benefits of treatment.

It is a very recognisable forest plot, and was selected as the recognisable logo for the Cochrane Collaboration in 1996. 

These histories resonated with me this week with the announcement that, within months of the commencement of clinical trials, Dexamethasone has been recommended by all four chief medical officers in the hospital treatment of patients suffering from COVID-19.

Compare this to the delay in forceps design, and use of beclomethasone, and the importance of medical research and education comes to the fore.

General practice research and education is no less important, and RCPGNI has been highlighting and lobbying about this for some years now. We are in the process of supporting costed proposals to Department of Health and I will feed back when we hear about developments.

RCGP Council

RCGP Council met on Saturday, our first meeting using a virtual Zoom platform.

It was a full and packed agenda and I was struck by an emergency motion from North East London Faculty about the Black Lives Matter issue.

The ensuing debate highlighted the need for College to go further in reaching out to the Black and Asian and Minority Ethnic (BAME) community and to back this with actions. The College released a statement earlier today and you can read it now.

A consequence of our own Troubles meant that Northern Ireland has some of the most stringent equality employment law in Europe, but we must not be complacent in addressing this important issue. During the debate, discussion was had about Bystander Training

I have had a look at the website, and it does resonate with me. It is not good enough to simply "not be racist". We need to recognise our duty to stand up to behaviours which are not right.

I remember when working as a locum signing some prescriptions in a practice. A patient came to the desk and in a loud voice requested to see the "white doctor" as she claimed, "can’t understand that other foreign doctor." 

I am sure many of us have witnessed such behaviours, but I wonder how many of us have stood up to them?

The Bystander Training site has really good resources and it is worth reading some of the material and challenging ourselves to always strive for better.

I intend to pursue this issue further this year and would be grateful if any members who would like to be involved could get in touch with me.

Joint injections

I am receiving many more request from patients who have joint pains and require intra-articular corticosteroid injections.

Like many of you, I perform many joint injections during my working week and take pride in the benefit this has for my patients.

During the height of the pandemic we stopped joint injections, but for the past week I have restarted doing them cautiously in practice with full consent for patients and the risks associated with COVID-19.

RCGP has good joint guidelines on this issue.

Celebrating our ST3s

It was great to congratulate our ST3 doctors on Thursday on their achievements at a Zoom celebration arranged by the Northern Ireland Medical and Dental Training Agency (NIMDTA).

The celebration highlighted a book of stories reflecting their experiences. From amazing painting, poems and patient reflections, I was really humbled at the talent and commitment of our students.

Like my grandfather recounted, stories are what makes our job rewarding and Professor Trish Greenhalgh edited a great book: Narrative Based Medicine: Dialogue and Discourse in Clinical Practice (ISBN 0-7279-1223-2).

Our former RCGP Chair, Dr Clare Gerada attended the event and gave some wise advice on how the new generation of GPs must not put their own health at risk and to remember to look after themselves.

My own practice just started teaching in the past year and it has been very rewarding.

There are huge challenges to face in medical education if we are to continue social distancing and face a second surge.

Work has commenced to apply to enhance our sub-deanery education which would help ensure there is local flexibility enabling the optimum use of teaching practices.

Please consider being a teaching practice, no matter in how small a role. I hope to be able to guide you to your local Federation Support Unit (FSU) if these applications can be progressed.

COVID-19 assessment centres

During the week, myself and Alan Stout, Chair of Northern Ireland General Practitioners Committee (NICPC) met with over 70 GPs who have significant concerns about COVID-19 Assessment Centres.

I thank all those who gave up their time to feedback their views and experiences.

It is easy to look back now and feel COVID-19 Centres were an overreaction, but it is worth remembering the horrific images appearing from Italy and our projected death toll of 15,000 patients in the beginning of March.

Currently, patients were inadvertently entering our surgeries and mid-consultation revealing a cough or high temperature.

This necessitated consulting rooms being closed for industrial cleaning (which we had very little official experience of) and as symptomatic patients are much, much more likely to harbour COVID-19, it heightened the risk of infection to GPs and our staff.

It could also have ground our services to a halt and the success of COVID-19 Centres is that they allowed GPs to continue to see traditional General Medical Services (GMS) work.

Hospital services were stopped but we kept going. With the worst of the pandemic over and the centres still running at a much-reduced staffing rate, I understand your concerns both about the current centres and what happens in the future.

We know that COVID-19 transmission still exists, so we have a duty to protect our staff and practices.

A consequence of the pandemic, though, is that our health service will look different in the future.

It is right that we do not go back to the long waiting lists and poor service of the past and we will represent GP concerns and challenges at discussions to ensure our patients’ care needs are met and our workforce is protected, doing the essential job of a GP in the right place - their community surgeries.

Please feedback to me any issues you want to discuss, and to all our ST3 doctors who are finishing their training, congratulations and we look forward to welcoming you to our practices soon.

Post written by

Dr Laurence Dorman, Chair of RCGP Northern Ireland

Dr Laurence Dorman took office in November 2019 after three years as Deputy Chair of Policy for RCGPNI. A GP principal in Mourne Family Surgery, Kilkeel, Co Down, since 2007, he is the fourth generation of GPs in his family. He was also, until recently, the Chair of Newry and District GP Federation. 

Laurence has particular interests in new ways of working in primary care, cancer care, and inspiring the next generation of GPs. He set up the successful 'Dear Colleague' initiative to improve the interface between primary and secondary care and has been a strategic advocate for interface and communication since September 2017.

During his time as Chair, he wants to support College members to ensure that the future of GP services is protected, supported and sustainable.

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