Seamus O’Mahony spent 37 years as a consultant gastroenterologist, writing two critically-acclaimed books. Now retired, his third is a frank look at the absurdities, challenges and blind-spots of modern medicine. It tells a tale that is funny, touching, and infuriating, writes Emily Hourican
Over the course of two previous books, Seamus O’Mahony, recently retired consultant gastroenterologist at Cork University Hospital, has established himself as a clear-eyed and articulate commentator on modern medicine and healthcare systems.
He has written brilliantly about our expectations around life, death, disease and modern doctoring, debunking myths and challenging fallacies, including the notion that medicine can save us all.
Now, he has a new book, The Ministry of Bodies, that began as a kind of “year in the life of” a busy hospital.
A few months into that year – 2019 – O’Mahony, now 60, decided to retire.
“That changed the entire tone of the book,” he says. “I was coming to the end of a very long career, so inevitably I was looking back, at the good things and bad things.”
And so the book is both a series of reflections on the demanding, often absurd and tragically-comic happenings of everyday hospital life, along with broader reflections on the many changes that he has seen in the course of his 37-year career.
To read, it is funny, sad, infuriating, heartening and depressing, all in almost equal measure, although the over-arching theme is one of deep regret for what has been lost.
O’Mahony began his career as a junior doctor in the Cork hospital he refers to as The Ministry in July 1983. From there he moved to the UK, working for many years in the NHS, then came back to Cork with his wife and two children, and returned to CUH as one of just two consultants in the gastroenterology department, where he remained until last February.
“The timing of my departure was very strange,” he says. “My last day was the February 7 2020, and I think the word ‘Covid-19’ was coined by the WHO about four days later. A few days before I left, I ran into a microbiologist colleague and asked him, ‘what’s going on with this virus?’ and he said ‘f**k knows...’”
In mid-March, he offered to return to clinical duties but wasn’t called. Does he feel lucky to have left when he did?
“Yes, in some ways, but in other ways, I feel like a civilian for the first time in decades, and in a way I miss being there. I felt both relief and sadness. I had done it for so long. But I was weary and ready to go when I retired.
“I think working on through a pandemic might have been extremely difficult. And I know how many people in healthcare have found it difficult and demanding. I suspect we’ll deal with a tsunami of burnout and post-traumatic stress in nurses and doctors once this thing finally ends. People are holding it together very well, but I think there is an exhausted workforce. As if they weren’t exhausted already going into it.”
He points out: “just a few weeks before Covid arrived, on the first Monday of the New Year in 2020, we hit an all-time record for people on trolleys. The health service was in rag order when we went into Covid. We had a workforce that was already pushed very hard, and then this.”
How does he think the pandemic has been managed?
“I think the health service, given the fact that it was already buckling before this arrived, has done well,” he says. “Paradoxically, the fact that it was buckling may have helped. The Irish health service has been on a permanent war footing for years. That might have actually helped in the response – people working in it were used to being pushed to the limit.
“I think Nphet has done well. I think the advice has generally been good. I think the politicians have done well, for all we moan about them. And as a society, a citizenry, I think we’ve done OK.
“I wish the vaccine roll-out would be faster, but I understand the reasons for that; it’s ultimately down to supply.”
Does he believe the narrative that the pandemic will change how we see healthcare workers?
“I don’t, unfortunately. One of the more disturbing phenomena that arose during the pandemic, and one that surprised me, was that the Medical Protection Society did surveys in the UK and Ireland, and found that over a third of doctors in both jurisdictions had received either physical or verbal abuse during the pandemic.”
Sadly, that’s not a new story. At one stage in The Ministry, O’Mahony writes about the aggression and abuse he regularly encountered from patients and families on the wards, and wonders whether “all the time I had devoted as a trainee to research might have been more usefully spent shadowing a nightclub bouncer or a warder in a high-security prison.”
O’Mahony’s decision to retire gave him huge freedom in writing the book. And part of what he writes details the steady attrition of vital aspects of his profession.
“I’ve seen the best and I’ve seen the worst,” he says. “I started in a world that was almost Victorian in its degree of deference to authority figures.
“It was very male-dominated, some of these people behaved very badly indeed, because they had a degree of power. But others were brilliant doctors, kind to their patients, colleagues and students.
“Back then, you didn’t have the squalor and chaos that we now see in our health service. Many things have changed for the worst, many other things have changed for the better, and I saw them both.
“But I think we threw out a lot of good things: as I walked those same wards at the end of my career, I would look back to the beginning, from the horrors of the 21st century – of people abandoned on trollies in corridors of emergency departments.”
He describes trying to treat very sick people on a trolley in a corridor of an emergency department.
“That is unbelievably difficult for doctors, and goes against everything that you’ve been trained to do. It’s very difficult to take a proper history, impossible to have an intimate conversation, next to impossible to carry out a physical examination in that environment. Already you are at a huge disadvantage.”
To what does he attribute the crisis in the HSE?
“There are many causes. The first and biggest problem is that we lost beds in the 1980s and during the last recession that were never put back into the system.
“In the meantime, the population had not only grown, but it had become older and frailer. Not only that, we now have interventions and treatments and dilemmas that didn’t exist when I started 37 years ago. We simply have a hospital system that is way too small for the demand that is placed on it.”
Other issues are “a cult of managerialism, where meeting targets is more important than treating patients,” and “a parting of the ways in the relationship between doctors and nurses over my professional lifetime”.
“When I started, there was a justifiable feeling among nurses that there was too much deference towards doctors, and that they were professionals of equal worth. But that gradually morphed into two professions that stopped working together in the way that they used to.
“And that I think is one of the great regrets of my career – that that close co-operation has become frayed and tattered.”
O’Mahony writes very openly about his own errors, bucking the trend for doctors to present themselves as infallible. Did he think twice before admitting to anything less than super-human ability?
“I think it was important for me to write about and openly admit that I have made errors over the course of a long career. I think I wouldn’t be human if I didn’t. The doctor who hasn’t made a mistake, is either a liar, or doesn’t do enough medicine.
“And yet, publicly we’re very slow to admit these truths. We’re slow to admit that medicine is messy, imprecise, uncertain. Slow to admit that we’re human, we’re frail, and we will inevitably make mistakes.”
Pretence at infallibility feeds into another area O’Mahony writes brilliantly about: having “the conversation” with patients who are not going to get better.
“As a profession, we have consciously or unconsciously given our patients the idea that we can fix just about everything,” he says. “And so we avoid having these conversations, and we don’t have them at the right time.
“Most people now die in old age and of diseases they’ve usually had for quite a long time – cancer, dementia, organ failure. And yet, too often, doctors are having The Difficult Conversation at a time of acute crisis, in the worst possible environment, possibly on a trolley in a corridor of the emergency department.
“What we should be doing is initiating these conversations when the person first develops one of these life-limiting diseases.”
Among the changes O’Mahony has seen in the course of his career is a rise in self-diagnosing. Does that make the job more difficult?
“It does,” he says. “There is an ever-widening gap between the doctor’s knowledge and the patients’ belief in what is wrong with them. Food intolerance is now thought to be the cause of all sorts of disease and chronic conditions, which it isn’t.
“I’m not dismissing food intolerance and allergy – they are real, but much less common than people think.”
It is, he continues, “incredibly difficult for the doctor, because if a person arrives with a very fixed view of the cause of their symptoms, and an expectation that you’re going to carry out food intolerance tests which either don’t exist, or doing them would be a waste of resources – this can lead to a stand-off between a patient and a doctor.”
These patients have what O’Mahony calls a “consumerist approach to healthcare,” pointing out that “you can’t apply the rules and ethos of consumerism to healthcare. Patients must respect doctors as much as doctors respect patients.”
Does he miss the days when no one knew anything?
“There’s a middle path. You don’t want to be dealing with a patient population who are kept entirely ignorant — but on the other hand, most doctors will admit that the heart does sink when the person comes into the consulting room with a huge pile of print-offs.”
This kind of “consumerist approach” isn’t a victimless crime in a system where resources are finite.
“I spent far more time discussing the dietary concerns of people with irritable bowel syndrome than I did attending to my dying patients on the ward. I think sometimes the ‘worried well’ have the habit of elbowing the sick and the dying aside,” he says. “And I would say that is cognitively and even spiritually difficult for the doctor. Professionalism is all about taking the concerns of everyone seriously.”
And where there is no physical cause to be discovered for the symptoms some patients complain of, there is usually a great reluctance to accept that the cause may be psychological.
“My experience was that no matter how hard you tried to nudge people towards acceptance of a psychological explanation, many remained resistant to it, insulted even by the suggestion.”
Why does he think this is?
“Whatever we say now about destigmatising psychological distress and psychiatric disease, there remains a huge stigma around what used to be called psychosomatic symptoms. It’s much more comforting for the individual to believe that their chronic fatigue or IBS is caused by a food intolerance than by a psychological factor.
There are many parts of The Ministry of Bodies that had me laughing out loud — the weekly motivational emails from “the head of health and well-being” recommending mindfulness, some of the more hilarious patient encounters — and O’Mahony has a very keen eye for the absurd.
But much of it made me wince too: the reflexive cruelty of institutions, the patients who couldn’t be persuaded to make the changes that might save them, the unhappy, lonely, frail and old who had nowhere except hospital to go to.
And indeed the moral conviction of the book is unwavering, to the point where O’Mahony talks, in the context of his retirement, of his “apostasy” (defined as the formal renunciation of a religion) and how this was making his job increasingly untenable.
“When I used the word ‘apostasy,’” he says now, “I meant that I could no longer accept, or believe in many of the protocols and guidelines that dictate what doctors do in hospitals. I was not an apostate when it came to the core functions of a doctor. These guidelines and protocols took away your ability as a doctor to treat patients in the way that you saw best.”
When does he anticipate a return to ‘normality’?
“Not until 2022, and then who knows?” he says, stressing that “my opinion on anything to do with Covid is no better than any reasonably-informed lay person; a gastroenterologist would have no special expertise.
“One of the more amusing phenomena of the pandemic has been the emergence of self-appointed experts who do not really have relevant expertise. Clever scientists commonly suffer from the delusion that because they are clever, and because they are scientists, they can talk knowledgeably about any scientific topic. I will listen only to a very limited number of people on Covid.”
‘The Ministry of Bodies’ by Seamus O’Mahony is published by Head of Zeus, €14.99, and is available online now from bookshops