Image from a talk at the Department of Health in Ireland. Access the full video here
“… a doctor that knows them, but more importantly… a doctor that they know.”
Professor Emeritus Trinity College Dublin, Tom O’Dowd was appointed Professor of General Practice in 1993 and continues as a practising GP in West Tallaght, Dublin.
After general practice vocational training in Ireland, Tom joined the University of Wales College of Medicine (1980 – 86) as a lecturer and subsequently the University of Nottingham (1986 – 1993 as a senior lecturer. He has been involved in curriculum change and design and postgraduate research supervision. He was Chairman of the Education Committee of the Medical Council that led to the current professionalisation of medical education in Ireland.
Watch the video of the interview below or on Youtube or listen to the podcast on Spotify and all the major platforms
Hello I’m Domhnall MacAuley and welcome to MedicsVoices.com where we talk to the key opinion leaders in health and medicine around the world. Today we are in Dublin and I’m talking to Tom O’Dowd, Emeritus Professor of General Practice at Trinity College, Dublin.
Tom, let’s take you back to the very beginning, where did you grow up, tell us about school, and what brought you into medicine?
Tom O’Dowd: I grew up in Roscommon, in the west of Ireland, and we had moved as a family from one part of rural Ireland to another. That’s a very big move because you leave all your support behind. So, we were a family that relied on ourselves and I think that has dictated a lot of my life- being an outsider and relying on our own resources. In the 1960s the government changed its policy on secondary school education and provided free education to children who otherwise wouldn’t have gone, and that included me. After that came opportunities to go to university. So I’m a success of that government policy in that it allowed me to get a good education and then go on to university.
The reason I did medicine…there weren’t any. I was the first in my family to go to university but I’ve counted 16 first cousins who went to university subsequently. It was something that was part of Ireland opening up at the time. I was always interested in helping people and, when I was growing up at that time in Ireland, the church was a very prominent part of our lives. Many young men like myself were getting an education and were expected to go on and become priests. I would have quite liked to have been a priest but there was one problem for me, I had lost my belief. I didn’t think that being a non-believing priest was the way to go. But I had that desire to, what I grandly called, help other people. And, at its simplest form, that has dictated my life. I think it was that kind of urge to be useful- nothing more grand than that- that took me to medical school.
DMacA: Tell us about medical school.
TO’D: It was dreary. It was awful. And I thought of giving it up many times. At that time there were Maoist groups around and I went to the Maoist groups to see if there was any excitement, and even they were dull, because there wasn’t that much establishment to be against. It’s funny that many years later, when I came back to Ireland in the 90s, I was asked to go on the Medical Council by Trinity, for whom I was working then. Eventually they insisted and I became Chair of Education. It was a five year stint and we reviewed medical education, which actually hadn’t changed a whole pile from when I was a student in the 70s.
During that five years we created a large number of changes and it was driven really by my own poor experience as a medical student.
DMacA: You did your GP training in Cork and then, like many of a generation, you took the boat across the water.
TO’D: I took the boat to Wales with my new wife and ended up in Cardiff on what would be called an overflow council estate. I had little experience of that kind of urbanization and I fell on my feet with wonderful group of people who were all salaried. Robert Harvard Davis was the professor at the time. And that was a very happy time for me and for the family. I went there because I intended to learn how to teach general practice. But I remember I got my first research grant, which was for 3,000 pounds sterling, and, I was able to do my MD on the on the back of that. I quite liked research, and I liked the esteem that it gave me, and the involvement with other people. I got in very early, as research wasn’t as professionalized then as it is now, but I did enjoy that. I found the teaching became a bit of a grind because the seminars were the same, one year after another, because you had to satisfy the curriculum. If one student was taught about breaking bad news, all 200 of them had to be taught about breaking bad news, and that became quite tiresome. Indeed, that’s the way a lot of teaching remains- teaching many students all the same thing- which is difficult. Clinical teaching in the practice was, of course, much more rewarding and interesting.
DMacA: You then went on to Nottingham where you continued your research career, and one of the things you researched was the ‘heart-sink patient’. How has that ‘heart-sink’ concept survived the decades of your professional life?
TO’D: At that time one could use the term but I don’t think you could get away with researching it now. I’m delighted to say it’s become part of a subculture, which is a much more interesting part of culture to be involved in. It did touch the core of general practice. It allowed GP’s permission to say that this patient makes my heart sink, or this family makes my heart sink. It’s been researched by others and it hasn’t changed. I remember one older GP telling me that he had a cure for heart sink patients. It was that – they moved out, the GP moved out, or the GP died. They were fairly radical solutions. Younger GP’s experienced it much more than older GP’s who, I suppose, had learned the ebb and flow of practice.
” For the profession, it was almost as if the stone that the builders rejected has become the cornerstone. And we have very much become the cornerstone of health care.”
DMacA: Then you came back to Dublin, to Trinity, which was a fantastic step. You followed in the footsteps of James McCormick and of course, his sidekick, the inimitable Petr Skrabanek. That must have been an enormous challenge.
TO’D: I got to know James McCormick much better and he became a much sought after speaker at meetings. And, of course, he articulated views that challenged a lot of the dogmas that we all believed strongly in. When poor Petr Skrabanek got his final diagnosis, I looked after Petr and provided palliative care for him at home, which was a great honour and I got to know his family well. And again, I could relate to Petr very much because they were a very self-reliant family. When the tanks moved into Czechoslovakia, Petr and Vera were on holidays in West Cork. They had nothing, and people rallied around them. He received an updated medical education in Dublin and he remained grateful for that. But he was very much his own man, and right to the end. I remember giving him a medication to help his bone pain, and he asked me for the patient information leaflets so that he could read up the side effects. He was a scientist to the end even though he could, perhaps, be seen as anti-science.
DMacA: James and Petr were pretty much pioneers. But, in a sense, you too were a pioneer because, at that stage, academic general practice was a bit of a desert.
TO’D: Yes. It was. Even though the Irish College of General Practitioners and the Royal College of General Practitioners were both present on the island, you could have described it as a cold house for general practice. Our specialist colleagues expected very little of us. And, the thing I found most difficult was to hear my much loved colleagues being patronized quietly behind their backs. I found that very difficult. But we stood at it. Finally, I remember, we set up a policy group to discuss the role of primary care that was acceptable to the government. It became evident to me that GP’s didn’t have the language of policy and didn’t have the language of government. They got very frustrated and would become short tempered and would fulfil the preconceptions- that you can’t work with them anyway.
We now have that language and are much more successful as a result. We have learned the language of policy, we’ve learned the language of government, and we’ve been able to bring that ‘listening to patients’ to the table. We were very short of data about what went on in practice. I remember attending meetings where the professor of surgery, the professor of medicine, or the professor of whatever would be able to say how many patients they’d seen, how many of them were very ill, how many of them were quite ill, how many were waiting whereas we, who were doing the bulk of the work, had no data on that. That has changed now. We now have information about how much work we do. Covid, and it sounds terrible to say it, was a wonderful gift for general practice, because when it came down to it, we were in the patient’s corner. There was nobody else in the patient’s corner. It was almost as if the best kept secret was out. When it came to the diagnosis, when it came to vaccinations, we were there. And of course, the Irish College of GP’s realized that handling the media was very important because the subspecialists voice on the media, on Covid in particular, was absolutely alarming and it frightened people. GPs like Mary Favier and Nuala O Connor, were that reassuring voice saying- Yes. We know. This is the way things are but if you do this, this, and this, you’ll have a better chance of avoiding it. And people couldn’t get enough of that. It was during that period that general practice led the news cycle in a way I’d never heard before. We availed of opportunities that were out there, and I think we’re now there. For the profession, it was almost as if the stone that the builders rejected has become the cornerstone. And we have very much become the cornerstone of health care.
“All those things came out of that five year period, and it was a big achievement in bringing a conservative country and a quite conservative profession into that area.”
DMacA: In becoming a cornerstone you played your part through your leadership roles, you were on the Medical Council and you were President of the ICGP. Tell us about those experiences.
TO’D: I was very reluctant to go onto the Medical Council because it was so time consuming at a time I was trying to build a department and one thing and another, but it turned out to be one of the high points of my career. I worked with Gerry Bury, who was my opposite number at the other university, UCD. He was another driven character and, between the two of us, we influenced medical education both at the undergraduate and postgraduate level. And that was very important. It led, for example, to the establishment of what we called the Fottrell Commission, which led to the establishment of the University of Limerick, which is a different style of medical education. All those things came out of that five year period, and it was a big achievement in bringing a conservative country and a quite conservative profession into that area. Being President of the ICGP, I characterized myself as an e-President because it was largely during Covid. I worked out a way of communicating with people through the College Journal ‘Forum“, where Niall Hunter afforded me a regular slot. He would ask- what is your view about this, that, or the other? And one of the things I can do is write. So I was able to write a piece and stay in touch. And, of course, people read everything. I don’t think they read anything I’d written previously, but they read what I wrote during Covid. It was a great way of staying in touch with the profession and, indeed, with patients as well.
Growing up in Ireland. Access the website here
Budget holding: A step into the unknown. An article written by Professor John Bain after a visit to Tom’s practice in Nottingham. It was published in the BMJ in 1991
DMacA: When you reflect back on your own individual achievements through your academic career, what are the things that stand out for you?
TO’D: My early days in research, where I never expected to be a researcher, were very enjoyable. It was in-practice research. The large database research really didn’t do it for me, even though I spent ten years on a ‘Growing up in Ireland’ project. And this will divide your audience…My time as a fundholding GP was very formative. I think it brought out my inner barrow boy in that, I can remember doing deals with the ophthalmologists and orthopaedic surgeons to clear our waiting lists. And that social entrepreneurship has been very much part of what I have developed. I’ve developed an academic primary care centre, together with the private sector, where I work in southwest Dublin. I don’t mind who comes along as long as we can develop it. And that has been a hugely successful theme in my life. My Medical Council time again was a very successful period. And the fact that while I had a busy academic career, I was able to be a GP for a deprived population and get to know them and be respected by them. Being accepted by them has been an achievement for me, which I value greatly.
“I had a sense at that time that general practice was changing and that we were moving fairly quickly from single handed general practice into larger, more professionalized multi partner, multi doctor, general practice.”
An image of Tom from this remarkable exhibition of photographs by Fionn McCann
Read a full description of this exhibition in the Irish Medical Times
Cover of the History of Irish General Practice, with an image from the exhibition.
DMacA: We’ve spoken about your academic and your political achievements. But you did something else which really struck a note with me in terms of the heritage of general practice through your photography project.
TO’D: That was very influenced by John Berger’s book, “The Fortunate Man.” That was about ten years ago now and I had a sense at that time that general practice was changing and that we were moving fairly quickly from single handed general practice into larger, more professionalized multi partner, multi doctor, general practice. I engaged a photographer to go around practices with me. One was on an island off the northwest coast of Ireland, one was in County Clare, an urban practice in Mallow, in County Cork and two practices here in Dublin and, we then had a public exhibition. Getting the ethics approval for all this was tricky but we managed to do it and had a public exhibition called ‘General Practice’. I used to go down and stand in the exhibition centre and there were always people coming in and out, and it was amazing to overhear the conversations with people saying- “that’s just like my GP”. It captured the authenticity of general practice.
Its travelled to other centres in Ireland. People wanted to show it. And some of the photographs are now on permanent exhibition in Trinity College and in the Irish College of General Practitioners. So, it did capture that authenticity of general practice.
DMacA: We started off introducing you as the Emeritus Professor, as you’ve retired from your academic post but, you are still in practice. That’s very different to many academics who stop general practice but continue their research. You did it differently. Tell us about that experience.
TO’D: I’m now retired nine years and I’ve just recently stepped down as a partner in the practice. I still have the energy. I think a lot of it goes down to your biology. I’ve had my medical problems, of course, like every older male, but I still have the energy and the interest to do it. I just love the fact that the practice I’ve seen grow and develop is now thriving, responsive, and high tech. We have access to all the investigations, investigative modalities, and also the drugs and medications and that I’m now able to provide for patients. I was very much involved in providing the policy document for the introduction of chronic disease monitoring in Ireland which was taken up by the government and is now funded. It has yet to be evaluated, of course, but it’s been a hugely successful engagement with general practice. So, I suppose, I want to sit there and enjoy what’s going on at the moment. I’ve got my colleagues in the practice who are 25 years younger than me and are amazingly committed people who bought into the values of looking after a deprived population, worry about them, don’t make judgments on them, all those things are very precious to me.
DMacA: I heard you give a lovely introduction to the book of the History of Irish General Practice. So, my final question is, what is the future of Irish general practice?
TO’D: I think the future of general practice is always guarded. Having been around watching the NHS after the Second World War when general practice looked like it wasn’t going to survive, and then seeing it prosper and now seeing it struggle as we are prospering, it takes us to be vigilant. I think we have reached a good point at this stage but we have to be vigilant. There other models out there where colleagues in some of the other specialties have become complacent and have, dare I say, become avaricious. I think we have to retain the humility that will shape our future.
Our future will be shaped by, as Bill Shannon used to say- “working with people in their times of difficulty”. I think we need to remember that’s what we do, because we can, with the bigger practices, become remote. The idea of personal doctoring, and we’ve had a very strong tradition of personal doctoring here in Ireland, may suffer. There are segments of the population who consult online, consult doctors who provide primary care on-line, but we’ve always got to be vigilant about the kind of bread and butter general practice. We have to sort out how we can have that personal care and I think that’s a big challenge for us as we get bigger. People want to come to a doctor that knows them, but more importantly, they want to come to a doctor that they know.
DMacA: A doctor that they know and a doctor that knows them. A great end to the conversation. Tom O’Dowd, thank you very much. It’s been a pleasure.
“…we have spent 25 years restoring and developing a derelict cottage in rural County Wicklow. We have bee friendly gardens with native flowers and a marsh with wild irises, willow and rushes (sedge). and a tree house for the grandchildren.”
