A modern family doctor based in a 10-GP practice, located at a purpose-built primary care centre, the Carlton Clinic, in Co Wicklow Dr Mairead Cassidy was a worthy winner of the GP of the Year prize, which was this year sponsored by Medisec Ireland, at the Irish Healthcare Awards 2019, hosted by Irish Medical Times.

Teen health and the children’s hospice are among major interests she has developed in recent years, following her arrival into general practice back in 2006.

Dr Cassidy entered general practice after some initial years in anaesthesiology. While she thoroughly enjoyed working in the specialty, the inflexible lifestyle and hours attached to the work were less to her liking.

Uncertain of which path to take away from anaesthesiology, a stint with a family friend who was a GP, led her to apply to the Royal College of Surgeons in Ireland (RCSI)/Dublin North East General Practice Training Scheme. Ultimately, when they asked Dr Cassidy to stay on, she was to make her career as a GP with her training practice in Bray, Co Wicklow.

Appreciation of variety
What drew Dr Cassidy to switch to general practice was an appreciation of the variety of seeing “a little bit of everything”, the level of independence and to some extent control, offered by general practice around life decisions such as where, and how you worked.

While she sees there can be two sides to the coin for certain aspects of practice, at this point in her career, she said: “It is lovely to get to know people over time, and you don’t realise that until time goes on. As the years go by, you enjoy that part of it more.”

Gaining an understanding
With general practice, one of the benefits was that you got to know not only patients but their families. “Over time, you began to recognise connections that you did not know existed,” Dr Cassidy said.
While GPs may not look forward to some routine duties, such as house calls, she believed they allowed GPs to gain an understanding and insight into why a patient might be struggling.

“You can learn how you might work with that person. “Sometimes, you might feel as a GP you are not making any progress, but you have got to change your definition of progress. A success for one person may not be success for another.

“You see another side of life that nobody else sees. People who have huge burdens in their lives that nobody knows about but – despite that – they keep going. You see the resilience of people, and how amazing some people are living normal lives, how they keep going despite huge adversity.”

Large group practice
Dr Cassidy was positive about the benefits of working in their large group practice of 10 GPs, which covers anything up to 20,000 patients. Added to which, their practice had just moved out of their old premises at the beginning of last month. They were now enjoying the space and facilities of a new dedicated primary care centre that was wheelchair accessible with dedicated parking available for older patients.

Pandemic
Reflecting on the Covid-19 pandemic, if her practice could have predicted what was to happen, they would have put two waiting rooms in place for infection control.

Teen health services
Outside of day-to-day practice, Dr Cassidy has been involved in efforts to provide teen health services.

She said the statistics showed the least likely person to attend a doctor was a 14-year-old boy. Overall, the majority of teenagers were healthy they did not – in general – need physical healthcare.

But access to information and healthcare was limited for teenagers and, she added, more so for private patients. At least in the case of a teenager with a medical card, they could attend their GP themselves. For a teenager who was a private patient, and wanted advice, information, the pill, or anything like that, they would be unable to attend independently and without a medical card were very much at a disadvantage. She felt it was an area “that is very lacking. They are very much disadvantaged and are in that awful grey area, they have outgrown paediatrics, they need an element of independence and an element of support.”

Her own involvement in providing services began under a team project with the Irish College of General Practitioners. The experience has provided an insight into what teen health needed to look like.

Nationwide coordinated system
Her experience in delivering services in teen health prompted Dr Cassidy to recommend that an integrated nationwide coordinated system for teen healthcare should be put in place, possibly in school settings to reach teenagers in their own settings. As teenagers vary so widely, mentally, and physically, the information needed to be tailored to the groups being targeted.

Research had shown if any barrier were put up to teenagers attending health services they would give up. “When they do feel they need help, they feel they need it immediately and any delay will deter them. If the receptionist is rude, they give up and will not come back,” said Dr Cassidy.

Another obstacle she highlighted was their failure to grasp the concept of confidentiality, fearing that a GP might discuss what they said with others.

While her practice had run a teen clinic for a period of time, initially aiming to target the teenagers who would have been vulnerable, it was accessed in the main by teenagers with parents, “which is great” but it was not their real aim, and they discontinued the clinics.

Dedicated clinics
With the advent of the pandemic, she anticipated they may have to run dedicated clinics for different age groups for infection control and, as a result, they might look again at the teen health clinics.

“I don’t think we can have our full waiting rooms anymore. We are going to have to look at doing it a bit differently. But we are adapting. There is good and bad in it. I think these full waiting rooms where people just sat until they were seen were also awful.

“They were unpleasant for patients sitting for 40 minutes, looking at their watches, and stressful for us with a queue outside the door, and constantly trying to catch up,” she said.

Looking ahead, she suggested there may be improvements. “Maybe going forward, patients will have to change and accept that we do a children’s clinic in the morning, we do a diabetic clinic in the afternoon, so that we try to separate people out as much as we can.”

Children’s hospice
Another significant commitment for Dr Cassidy as a GP has been working with LauraLynn, the children’s hospice on Dublin’s southside. Originally, she started working with the adults living there in residential care at the time in the Sunshine Home in 2009.

When the children’s hospice opened in 2011, she started working there and, as the hospice had expanded, so too did her commitment. At the moment, LauraLynn provides hospice services to children from all counties, providing choice and support for parents, short breaks and respite care, “but if you live in Donegal accessing our services is much more difficult than if you live in Dublin”.

A lot of things were being looked at and, over time, they may be able to expand and set up hubs, or there may be more outreach nurses.

“Children’s hospices are different from adult hospices, most of our work is not end-of-life care. These would be children with life-limiting conditions but not necessarily life ending.

“Some would come in and out for many, many years, and some for all of childhood. “You get to know children and families. The complicated cases can have a lot of medication and a lot of symptoms. We would be involved with their paediatrician for symptom control, trying to make them more comfortable, and make life a little bit easier for them.

“The other part would be the end-of-life care. It allows parents’ choice. Ideally, a lot of parents want to bring their child home, and when they are in the home, there is an outreach service. Some families couldn’t manage at home and some will come to the hospice.”

Dr Cassidy works with a consultant paediatrician at LauraLynn and said the two disciplines complemented one another, adding “General practice goes well with palliative care, you do it with your patients anyway as part of your normal patient community.”

“There is an element of continuity of care and dealing with uncertainty, you don’t have blood tests, you don’t have x-rays, you are very much dealing with the patient in front of you,” she added.

Irish Healthcare Awards 2020
The Irish Healthcare Awards 2020, which highlight innovation and excellence across the Irish medical sector, are now in their 19th year.

Brought to you by Irish Medical Times, this year’s competition has introduced five additional entry categories: Best Response to COVID-19, Mental Health Initiative of the Year, Surgical Advancement of the Year, International Project of the Year, and Hospital Manager of the Year.

For further details and to enter please visit https://www.irishhealthcareawards.ie/IHCAs2020/en/page/home.

Entries close on August 14.

valerie.ryan@imt.ie

Pre-existing small airways disease is not a risk factor for acute changes in lung function following initiation of lumacaftor/ivacaftor (LUM/IVA) in children with cystic fibrosis (CF), a study is reporting.

The researchers, who all work at the Children’s University Hospital, Temple Street, Dublin, said their results suggested that a LUM/IVA-related decline in lung function was more significant in CF children with higher baseline forced expiratory volume (FEV1).

Writing in the May 2020 edition of the Irish Medical Journal (IMJ), Finnegan, O’Grady, Smyth, Ryan, and Williamson, said the aim of the study explored risk factors for acute changes in lung function following initiation of LUM/IVA in children diagnosed with CF. They noted a transient decrease in FEV1 in 14 out of 15 children; this decline has been attributed to bronchoconstriction.

“Cystic Fibrosis conductance Transmembrane Regulator (CFTR) modulators represent a major breakthrough in the pharmacological management of cystic fibrosis,” they wrote.

“Clinical trials have shown significant improvements in lung function, nutritional status and rates of pulmonary exacerbations. Subsequent studies, however, reported acute lung function changes following administration of LUM/IVA.”

Noting that the benefits of LUM/IVA have been well-established and initiation was generally well-tolerated, they said that the mechanism of drug-induced decline in per cent predicted forced expiratory volume (ppFEV1) following initiation, however, was not known and caution may be required, particularly in patients with end-stage lung disease.

“Identifying risk factors for this decline could improve individual patient management during initiation and help understand the mechanisms involved,” they continued.

The researchers retrospectively reviewed all children commenced on LUM/IVA treatment over a one-year period and reviewed CT thorax images for evidence of air trapping using the Brody score.

A transient decline in ppFEV1 was observed after initiation of LUM/IVA in 93 per cent (n=14) of patients with an absolute mean decline of -10.8 per cent, they added.

Furthermore, the results also showed there was a statistically significant inverse relationship between ΔFEV1 and baseline ppFEV1, while there was no relationship between air trapping score and ΔFEV1 (p=0.41).

IMJ; Vol 113; No. 5; P70