 Good afternoon, dear colleagues, thank you so much for joining us today. My name is Beatriz Figueiredo, I am a young family doctor currently working in a family health unit in Lisbon, Portugal. Here with me today we have the pleasure to listen to Dr. Lawrence Dorman who is a family doctor working in a rural town in Northern Ireland called Kielke. She has been the RCGP in Northern Ireland strategic advocate for interface and communication since 2017 and assumes the role of chair of the RCGP NY in November 2019. Thank you Beatriz, good afternoon everybody, it's a pleasure to be with you. I am calling here from Northern Ireland and Market Hill which is near the border between Northern Ireland and the Republic of Ireland and it's a real honour to share this work that we did in Northern Ireland where we reached out to try and improve communications between hospital doctors and family medicine doctors. Good afternoon everybody, my name is Lawrence Dorman, I am the chair of the Royal College of GPs in Northern Ireland and I'm also a GP in Kielke, it's a pleasure to be with you here this afternoon and I'm sorry we can't be meeting in person but unfortunately due to infection control measures we have to meet virtually. I want to talk today about something which is apparently very simple but which can improve patient care and health systems in general. It can probably be reduced to two words, professional courtesy. This initiative came about for a number of reasons over a period of years where conventions of professional courtesy seem to be getting a little less friendly, a little gruff, a bit curt and maybe sometimes even a little rude. Of course we're all busy people and we want the best for our patients but over a period of time as clinicians working across primary and secondary care we seem to have lost the art of simple, friendly communication. Let me highlight some of the key issues in our health system and I'm sure many of you will recognise these in your own health systems. We had in Northern Ireland an ageing population, increasing multimorbidity and complexity which leads to an increasing need for generalists. We had risks of specialists focusing on only one aspect of our patient care and we had an increasing demand from our service from our patients some of which was quite overly optimistic. In Northern Ireland we had competition for resources between hospital specialties and between primary care and secondary care. Our hospital waiting times were getting quite long and our health care staff in Northern Ireland were not working as a team. Nobody seemed to be taking responsibility for test results with hospital test results being sent directly to general practice. Unfortunately none of this was facilitating the patient journey through our health and social care system. The mentality of your patient and my patient had become apparent between clinicians and there was frequently a misunderstanding of each other's rules and therefore unrealistic expectations about what either of us could do. With all of these issues in the background we discovered that language matters. It became clear that poor communication hinders patient care. A common theme from our discussions together was about the lack of appreciation or recognition of our respective workloads and the pressures of other clinicians. The use of language is very important. For example, when we refer a patient for an x-ray we often use the term order to request an x-ray but think of the word order. It is a command. We often use this term without thinking of the implications of a hierarchy with no consideration of another colleague's workload or pressures. In fact what we should be doing is requesting an x-ray. We're not ordering our colleagues to do anything. Our colleagues in mental health, for example, felt their workload was also undervalued and underestimated. They were never going to be seeing the volume of patients, a busy emergency department or family medicine clinic could. A mental health consultant could have the responsibility for two or three patients in one day which may take up the same workload as a busy day in an emergency department. Once we recognize that everybody's workload involves issues that we don't understand and when we force it ourselves to literally walk a day in another colleague's shoes, our behaviors will become amended and communications will be improved. Because of changes within our health care systems, the means of communications have changed over time, supposedly to deliver better efficiency. Where previously we might have simply picked up the telephone and talked to a consultant colleague, perhaps someone we trained with at university, or sent a referral letter to a specific specialist, our systems converted to centralized appointment systems, where a letter of referral will be dealt with by an anonymous central administration system, assigning patients to random consultants. Our messaging and our language changed in those referrals. We, all of us, both in primary and secondary care, lost the immediacy of our clinical relationships. We lost the easiness of our communication. We lost the safe space where we felt we were able to informally discuss complex case presentations, and at times the systems in place created real communication barriers while reducing our job satisfaction and efficiency. Using directive language does not endear us to our professional lives. Our body language changes when we are told to do something in a certain way, and so the easiness we might have known previously gets lost. Let me put our initiative into context. Northern Ireland is a small geographical area, a part of the United Kingdom on the island of Ireland. It is a mix of very rural and very urban areas with plenty of mountains and hills. I work as a GP in Gilkeale County Dine, which is highlighted in red on the map. Gilkeale is a small fishing town on the east coast of Northern Ireland. Gilkeale fishermen specialise in catching prawns or langoustine, herring and bucky whelks which are exported all around the world. Gilkeale is surrounded by the beautiful Morn Mountains on the sea, which you may recognise as they are famous as being part of the film location for the Game of Thrones series. The mountains of Morn provide a neat semi-circle, making it a neat geographical location, and because of this geography as a rural GP, it makes us dependent on our hospital and secondary care services. The efficient and effective use of hospital and secondary care for services is reliant on having good levels of communication between primary and secondary care services. My story in general practice starts a long time ago. I am the fourth generation GP in my family. My great-grandfather found at his clinic back in 1894. I entered medical school in Queens University in 1993. I loved my university years and I made many friends and enjoyed studying medicine there. Unfortunately, most of my clinical learning took place in hospitals. My mentors were hospital consultants and while they were skilled and dedicated professionals, their view was possibly understandably that hospital medicine was intellectually superior to general practice and that hospital medicine was the most desirable career. But despite being close friends with my fellow students, a gulf emerged once we graduated and embarked on our own medical careers. When we undertook research amongst our peers during this initiative, it became clear that we had lost that easiness of communication. Despite being good friends of students, we were too busy or too involved in our careers to maintain the friendships and the natural way of communicating. For those of us who were successful in undertaking postgraduate general practice or family medicine residency training programs, we felt that our choice of career was undervalued, dismissed as a specialty of failure or that it indicated that we are of lower ability and couldn't get into hospital specialty training programs. A them and us mentality grew between primary and secondary care colleagues and old friends. It might be useful to point out here that in the United Kingdom, the terms GP and family doctor are interchangeable. I know in some countries, a GP needs to have no further qualifications than their initial medical degree. In the United Kingdom, we are required to undertake a three-year residency training program to gain our professional qualification. When I left Queen's University and trained to be a GP, I was saddened at how our specialties, general practice and hospital medicine, had become less of a team. There was something about falling into different camps with family doctors in the community having little or no contact with their previous friends who worked in hospitals. GPs were frequently portrayed as less academic. Hospital colleagues were deemed by us to be out of touch and having poor communication skills. Speaking to my friends, I realised a gulf had emerged. All my colleagues in university class were intelligent, compassionate and committed to patient care. We could have chosen any specialty we wanted. Unfortunately, due to the negative modelling of our teachers, the undermining of general practice became prevalent. Our wider health and social care system has many different specialties and teams requiring collaboration between them. Unfortunately, in Northern Ireland, these natural interfaces had started to become barriers. An important report by Professor Val Was, many of you who know, was published in November 2016. By choice, not chance, highlights that general practice is a career choice for many and those who embark to do so do it by choice, not by chance. Professor Was highlighted that general practice needs to be celebrated and that medical generalism is a specialty in its own right. The report also highlighted the importance of medical students having experience in and exposure to general practice in the community at the earliest possibility in their medical education and how we value this vital profession. Family medicine should be integral to every health system in the world and while it is not the case everywhere yet, I am hopeful that in working towards the achievement of the Global Sustainable Development Goals and the promises made by every nation in the world at the Astana Declaration that family medicine was still integral to each and every health care system around the world. So, we need to get our communication right and to recognize how good communications between primary and secondary care can improve patient care and that of each of our health systems. The experience of my colleagues indicated that the communication between primary and secondary care was breaking down. This was not the exclusive experience of my generation. The relationships between primary and secondary care colleagues had been eroding over a number of generations. Underfunded and unresourced work was being assigned from secondary care to primary care with no consideration of workload or workforce capacity. Similarly, secondary care doctors were also frustrated. GP referral letters for secondary care assessment or opinion were frequently inadequate with per information or clear asks. The language used was also not very collegial, more of an instruction. There was no obvious breakpoint in communication but there were definitely fractured and as I mentioned previously there were a number of interconnected factors which had gradually eroded that easiness of communication. Over time, they developed a real them and us mentality between primary and secondary care and we needed to address it before our communications collapsed. Our patients were caught in the middle of this situation with a slowing referral system managed centrally with neither the patient's GP nor the hospital consulting knowing what the patient's referral trajectory would look like. The only solution to these issues was to work together. In 2018, the Royal College of GPs in Northern Ireland took the lead and instigated and led on a collaborative piece of work with the full range of specialties being represented by the retrospective Royal Colleges. Through organised discussions both formal and informal we determined that we needed to decide on a common goal of re-establishing successful communication between primary and secondary care which, if we achieved it would lead to better patient safety better clinical outcomes for patients with much improved job satisfaction for all of us and improved recruitment and retention of clinicians in each specialty. Getting to that early stage of deciding on a common goal required a series of things to be in place and it took time. The practicalities of meeting together when we were all under immense job pressure was difficult. But we held a series of round table discussions where every voice had equal weight where every person representing their specialty was considered unequal. Everyone was encouraged to listen and to be open and honest about their experiences of communicating with fellow clinicians. We openly recognised and tried to resolve and acknowledged that if there was a problem it was up to us to address it. That helped us to own it and want to resolve it. Let's face it, as clinicians we like to resolve problems. This time the problem was with us and how we communicated with each other. Together we formulated 10 communication principles. There could have been more but we got them down to what we thought was a manageable number. All 14 medical royal colleges working within the Northern Ireland health care system were involved in the discussions and the development of the principles. I know that getting secondary care specialists to work together with primary care specialists it's almost unheard of in some countries and it had become difficult in Northern Ireland but we managed to do it. All medical royal colleges agreed on these 10 principles which contained issues that were pertinent to individual different specialties. They agreed principles recognised that the old way of doing things were no longer effective and that we needed to adopt and embrace values which subsequently influence our behaviours. Only by embracing these values did we feel that general practitioners and hospital consultants could move forward together to a common purpose. As you will see 10 principles are based around mutual respect, collaborative and professional courtesy. They were also focused on influencing our new and future generations of medical students and how these doctors as well in specialist training and we all equally recognised that for these principles to work and be seen to work that we needed to lead by example. That was easier said than done. To launch the 10 principles we publicised them heavily using social media, college chairs blogs and by word of mouth. The document was given a long title which explains what it contains. We called it professional behaviours and communication principles for working across primary and secondary care interfaces in Northern Ireland. I know it's not the catchiest of titles. We launched the professional behaviours and communication principle document in 2018. It is jointly owned by all 14 medical royal colleges listed at the base of the document. It is not a GP document. It is owned by all of us. GPs can access it on the Royal College of GPs website under the Northern Ireland section. It was also subsequently adopted by the Academy of Medical Royal Colleges which represents all medical royal colleges in the UK. And you can access it using the links that we have shown. We launched a much shorter title for Twitter which we used to publicise the document and it has lasted. Our hashtag Dear Colleg title is the one that we most often use now. We launched a positive week-long campaign in March 2018 where we encouraged all GPs to start their refer letters to their hospital consultants with the greeting Dear Colleg. At the same time, we encouraged hospital consultants to write to their discharge letters to GPs also using the same greeting The purpose of this was to re-establish that professional courtesy and mutual respect which are the key values we wanted to embed in our work. It seems really simple but it did have the effect of making each of us stop and think what we were doing, what we were going to write how we were going to phrase the letter and importantly what language we were going to use. The document used 10s principles. They are intended to influence medical education and training to highlight the importance of leading by examples and of the modelling of behaviours of senior clinicians. We established early in our discussions that the need for a common goal was important to both parties. Patient safety was paramount and issues such as job satisfaction, retention and recruitment were similar to both primary and secondary care specialties. The first three of the 10 principles are on the slide. We are keen that the first three words of the first principle should be the most important and the most impactful. They read leading by example. We felt that a senior clinicians behaviour was so important to highlight the attitudes and the development of behaviours of junior staff. It needs highlighting for both GPs and hospital consultants though. It is vital that our language is courteous, respectful and professional when we talk about and talk to other colleagues. We debated at length about the importance of communication when there are changes in treatment plans or in a patient's condition. We were also keen to ensure that the principles document was a practical document and this is reflected in each principle. We were not explicit about ensuring that these communications were done face to face or telephone and we acknowledged that there was frequently different places and different ways that this was best done. In principle 4 we highlighted the importance of communication when transferring the care of a patient to another colleague or seeking an opinion. That colleague needs all the information in a clear and concise format ideally outlining a specific aim or objective. This was an issue raised by our physician colleagues who were frequently receiving refer letters from GPs with poor information or an unclear request or specific aim. In principle 5 we were keen to bring in the views of our patients. We had discussions with the patient group in the Royal College of GPs where they emphasized the importance of having clear and concise information about what trajectory or referral or course of treatment would have. We were keen that our patients did not attend any service with unrealistic expectations. In principle 6 we tried not to commit any other team or individual to a particular action without checking that it was reasonable or practical. This came back to the original value we discussed about walking a day in another colleague's shoes. In principle 7 we urged colleagues not to hand over work to another clinical team unless we were sure that this could be done safely. It highlighted the need to instigate practical and basic tests and plans but the ethos was that we should not hand over work to another colleague or teams if we cannot do it ourselves but we should check first to make sure the handover team can take on the patient and the workload involved. In principle 8 is an acknowledgement of a problem raised by GPs. GPs were finding that investigations such as blood tests or X-rays which have been requested by secondary care colleagues were then forwarded to GPs in a statement plan or suggested follow-up activity. Our GPs may have been asked to take responsibility for all tests and investigations without knowing the context in which the decisions are taken. So it was important that this issue was recognised and that the requesting doctor or clinical team who initiated tests also reviewed the results of those tests and took the appropriate action. Principle 9 is the complications of this when big teams in hospitals such as an emergency department were unable to do this work. Principle 9 recognises that this is sometimes not possible as individual but it urges a courteous sharing of information with direct communication ideally by telephone to resolve any issues. The last principle highlighted the need to respond quickly when our colleagues try to contact us. It embodies the professional courtesy offered in professional communication. Unfortunately resources did not allow us to instigate specific pieces of work or to take its project as far as we would have liked in Northern Ireland. Despite that, there have been many examples we have witnessed but without categorised evidence of its success. For example, in 2018 a proposal was made to close the emergency department in DZ Hospital in Urean County, Dine. This is a district hospital covering a very broad geographical area with 150 beds. It has provided secondary care services since 1841. The threat of the closure of this hospital caused a public outcry and concern both from the public and from GPs. We were going to eluse established patient pathways and community facing diagnostic services. The Pathfinder Group which offered a much appreciated direct assessment unit as a service after extensive discussion with local stakeholders. This unit was truly providing joined up primary care. GPs could telephone the service for same day assessment providing diagnostics and initial treatment of care for many conditions which could not have been managed in primary care clinics. This included ultrasound scans for suspected deep-famed thrombosis and intravenous antibiotics for potentially early sepsis. However, the principles document was never mentioned or cited as the reason for this more joined up thinking but it is hoped that the ethos of this document of what it tried to initiate was the success. We would really like to systemically assess the success of incorporating the ten principles of communication into our clinical lives. Another example is that of the diagnosis of bowel cancer which can be difficult for GPs in the community. Traditional Bicola-cult-blood testing had become not sensitive or specific enough compared to the modern symptomatic qualitative Bicola-immunochemical testing QFIT which is now currently recommended as the gold standard practice. Colleagues in colorectal surgery were struggling to meet with the demand of the number of colonoscopies required by GPs. GPs wanted reassurance that their patients didn't have bowel cancer and so we had joint goals where we all wanted our patients who had colorectal cancer to be diagnosed early and we only wanted patients who really required it to undergo colonoscopy. Considerable time and effort were taken by the Northern Ireland Cancer Research Network or NICAN for consultant surgeons and GPs to discuss a new way of working. The Cancer Research Network set up series of interactive lunchtime talks where participating clinicians could ask questions, seek advice which led to better clinical care pathways being agreed by both primary and secondary clinicians. During the lunchtime sessions there was ample opportunity for questions to be asked for clinical issues to be raised with the service designed to resolve those questions and answers. Once again this is a good example of success of applying the 10 basic principles based on professional courtesy and mutual respect. The most powerful example of the success of the Dear Colleague Initiative was through the establishment of the GP Society in Queen's University in 2018. The GP Society is for undergraduates in our medical school for them to learn and celebrate family medicine. This organisation has gone from strength to strength and they run a series of educational podcasts providing direct links between medical students and general practice. The GP Society highlights what a varied, academic and stimulating career general practice can be and the group provides practical help with ASCII practice exam practice exposure to GPs with specialist interests and they have wide ranging discussions. I so wish I had a GP Society when I was a medical student. These students have run seminars and a variety of topics including highlighting portfolio career opportunities within general practice. Their most impressive series of talks were entitled the Dear Colleague series. These talks celebrate interprofessional working across specialties which the students recognise will improve whole patient care. These talks involved a variety of healthcare professionals from primary care, secondary care and pre-involuntary sectors and highlighted important topics such as domestic abuse, alcohol addiction, Parkinson's disease and perinatal mental health. Our students have embraced the Dear Colleague values and recognised the importance of working collaboratively with other healthcare professionals for the benefits of patients. In 2019 Health Education England published its report on the Doctor Programme. We see this as one of the legacies of the hashtag Dear Colleague initiative where the report highlighted the need for the doctors of the future to be generalists. Our view is that we need communication pathways to be as effective as possible. Embedding the core values of professional courtesy and mutual respect would ensure the interfaces between professions will never again become barriers. Thank you for listening today. Please do follow up about the Dear Colleague initiative and maybe you could introduce it into your own locality. If you do, I'm sure it will lead to better relationships between us as GPs and our secondary care colleagues. But more important than that, it could lead to better patient care and better clinical outcomes. Thank you. Thank you so much, Dr. Dorman. I find this topic of communication between primary and second care extremely important. In my daily practice I make about one to two referrals each day. We have an online platform where we write our referral but it's very often one sided. The colleague has the chance to write back to us after the first appointment at the hospital, but usually they don't have the time to do so. I imagine that your referral is by letter or do you also use an online platform? We do it through an online platform which is essentially the same as a letter. I imagine it as a similar system. In Northern Ireland after we refer a patient, we still accept clinical responsibility for that patient. We have a clinical risk lying with the family doctor with the GP. Because in Northern Ireland we have long waiting lists that means that even though I have referred a patient for assessment we still hold the clinical responsibility so it is very difficult. There are things that we could do better that would maybe make that system a little bit quicker, a little bit more professional and sometimes the assessment we request is more sort of quick advice of improving communication. Maybe we could do some more that could help that patient be managed in the community such as a telephone conversation an online conversation a suggestion of an initiation of a treatment or potentially even a medication. That would be an advantage for our patient that ultimate is our main goal to provide better care. We are waiting for the audience and our dear colleagues to place some questions for Dr. Dorman. Please, please do some questions. I was wondering if you because it's inevitable that we talk about the pandemic era, do you find that this communication changed during the pandemic and if it did for the better or for the worse? Yes, no it definitely did. So I think we definitely recognise that we had to do things very differently because the traditional methods of writing a letter or an online letter had become clunky and slow so we reached out a little bit more through telephone through email advice and again that clinical face-to-face professional method of communication has seen us the best. There have been some alternatives to the traditional way of referring so one of the methods now is instead of a formal referral for an outpatient's appointment we're seeing a referral for an advice, online advice which is really helpful and it's particularly been helpful for specialties such as nephrology so renal medicine where a lot of that is done through figures and numbers through blood tests and so on so it can be quite helpful through that so if a patient's renal function is deteriorating that online advice system works quite well because some of the advice can be related to lab data but other specialties such as surgical or maybe a bowel assessment is necessary is less amenable to online advice forms but there's still plenty of scope. Another one that we're discovering as well is about dermatology so dermatology for skin lesions so historically in the north of Northern Ireland up towards the Giants Cosway our GP colleagues have found out a big waiting list of skin lesions created to assess by the hospital the waiting list got very big so they met together with their colleagues and said how can we make this better how can we improve the system so the simple way was through photo dermatology assessment where we take a photograph of the skin lesion and we were able to email that photograph into a central system and then the dermatologist using his computer can zoom up the screen so that has dramatically improved waiting counts taking that communication, that joint purpose where we meet together to improve our patient's experience Yeah, that's very true. We also use the teledermatologic referral with a picture with the proper consent of the patient of course and we often resolve things in primary care after our colleague in hospital tells us what to do or what is the best procedure for our patient I don't know, we are still waiting for the audience. I think maybe they are shy so Dr. Dorman, I imagine that you maybe thought about continuing this dear colleague initiative and would it be interesting or useful for GPs in Northern Ireland to expand this initiative to other healthcare workers, I imagine nurse practitioners physiotherapists Yes, of course, yeah. When we did the work on it, we could only do it with the doctors because otherwise the project was becoming too big so we limited the doctors at the start but absolutely the values and the ethos of this it works right across all multidisciplinary teams and you can see our students have grasped that, they recognise that the future of healthcare throughout the world will be multidisciplinary care so they recognise that we have to respect each other's professions on each other's skills and work together as a good team. Have we a question there? Yes, so that's a good question here from Larry Green, how have financial arrangements in general practice and hospital services enabled or impeded working together as dear colleagues? That's an excellent question Larry, and in Northern Ireland financial arrangements are weighted very heavily towards hospitals in the United Kingdom general practice does 95% of the clinical contacts but we only get 6 to 8% of the overall health budget, we get a fraction of the health budget and quite frequently it's very difficult to compete against big hospitals or trusts whenever we have a small workforce and so we're unable to do a lot of the workload. The principles document or the dear colleague document it's about setting ethos and values it's important, it's impossible for us to put in every eventuality or every scenario into that document because there are literally so many in clinical medicine and so if we can get that embedded values about how we respect each other, about how we walk another day in another person's shoes I think that definitely services would improve. So we have another question from Professor Evelyn Van Wielpangart thank you for the inspiring presentation, you encourage others to try to do the same in their own context can you provide us with advice from lessons you have learned about how to approach specialities efficiently? Effectively yes. So frequently I find is the best way is to speak to people on the telephone ideally because whenever a request comes in on paper whether it's a dear doctor please check the CCG or cheese please check the blood results sometimes the context can be lost and also the impact on our services can be lost so a hospital colleague a long time ago requested me to organise the results or to deal with the results of a patient's CT brain but it was possible for me to do that instead of me pinging back with another angry letter it was better to resolve that so the easiest way was to pick up the telephone and together we discussed the best way of resolving that issue and what was going to work best for that patient so although it's impossible to put in every eventuality I find working together collaboratively on the telephone or face to face is frequently the best way. So now we have Dr. Garth Manning asking do you think that Queen's University GP society could be developed in other medical schools maybe through the International Federation of Medical School Association Absolutely so we have been blown away by our Queen's University GP society that throughout the pandemic our medical students became an integral part of our workforce they were amazing they stepped up and worked alongside us in Covid assessment centres through vaccination centres and they really developed a real sense of leadership and pride and they were fantastic and so this GP society I would recommend for every country around the world it enables medical students to have a flavour of general practice about the complexity of our work and the importance of our work and ideally obviously we would love them to become GPs in the future even if they don't become GPs in the future I think it's very important that the future doctor has generous skills I think we need more doctors who have a generous skills and who have an understanding of community health care so if a doctor is working in a special day in a hospital setting at least they will understand the constraints of community and what sort of things they have a role in I think every university should have a GP society and again I'm very happy for people to get in touch with me we can get them in touch with our own GP society and on the basis of the success of our GP society we've developed an all island GP society where all the medical schools in Ireland collaborate together we have joint competitions we have essay competitions we have case presentation competitions and we hope after the pandemic students will be able to meet up with each other and see each other's universities it's very interesting we have another question from Dr. Shakira Karol good morning excellent presentation Dr. Dorman and thank you, I agree with Dr. Figures that our secondary colleagues rarely respond in writing if at all like the ideas of dear colleague, hashtag dear colleague as well as the round table hopefully at least to start with complex patients seeing multiple services then hopefully faster, better communication thank you Shakira, that's very important and again in Northern Ireland as well we were seeing multiple specialties on the lack of generalism the document sort of encourages that we collaborate better together to improve our patient communication definitely we need more generalist training so one more question from Dr. Karol Habal thank you for the interesting talk I am wondering how were you able to get the buy into this initiative from the hospital specialist so thank you Dr. Habal yes it was interesting so it was and one of the big things we had to acknowledge is that we had to acknowledge there was fault with GPs as well as with hospitals and I think when we all came to the table and there was no egos and we said sometimes our referral letters are not as good as they should be and sometimes yours to us are not as good so I think once everybody acknowledged and we were able to move forward okay so I don't think we have any more open questions would you like to add anything else Dr. Derman no I just encourage people if they would like to my details are again on the end of the slide there please get in touch we have more than happy to take any further questions or highlight it's important to remember this is a long process it's about culture and ethos and only by embedding that culture and ethos then do we improve our communications and our relationships with each other maybe we see if we start this communication during university would be much easier for our future generation of GPs yeah I think so and I think embedding it as part of students education I think is really important we did reach out to our students as you can hear our students have taken the initiative on one of them we took it to speciality training as well so we took it to postgraduate you know specialty training for those GPs for potential surgeons and so on and tried to embed it in their training sessions as well so I think the more that we hear about it the more that we practice it it just makes us all better communicators do you still work in this table around with a lot of specialties do you think do you still do this meeting so we don't I know so the that device doesn't meet anymore but we still as a result of colleagues and friends who I was involved with and for possible way we do try and keep that sense of collaboration and mutual respect going it's also very important I mean as chair of the Royal College of GPs I have a public profile with Twitter and so on and so we try to keep cross-border as a complementary as possible and if there are disagreements and so on we try and keep them all fair and try to resolve as simply as possible as any more questions I ask the audience if our colleagues want to make any more questions one of the big reasons for doing the document was was higher medical school teaching was done whenever I was in Queen's University where general practice hadn't been valued as a specialty and that's very important and again we saw from Professor Valois's report that general practice is a career choice by many it's not just a career that people took because they couldn't become a hospital specialist so we thought that was very important to highlight and that has become recognised now in Northern Ireland I think there's better lines of communication okay now that with the pandemic we've done a lot of learning with Zoom and we've done a lot more educational sessions together and one of the things that our hospital colleagues are learning about is performing outpatient clinics through Zoom or through digital and remote methods and actually TPs are starting to teach some of our hospital specialties how to do more remote consultations so it's unusual in Northern Ireland for TPs or family doctors to teach hospital doctors any new skills normally the flow of information has come the other way so it's nice to be able to do the teaching the other way and I find that sometimes when the hospital doctors want to provide us with the lecture they often tell us the very theoretical lecture and not really focussed for our practice sometimes I use to say that it's what they think that we need to know but it's not actually what we need to know to provide very care yes and again we frequently have to remind them about people and how interventions act people so you may be an expert in heart failure medicines but if you're prescribing lots and lots of diuretics and a patient maybe has got mobility issues that the specialist isn't aware of that might be causing problems with them in their own home so there has to be an element of a generalist doctor or a doctor in the community who needs a patient in their own home and who recognises that while we can have theoretical tablets and so on sometimes the practical realities have to be seen exactly I find that the table rounds when we present clinical cases are much more useful for our team of GPs than the lectures that are only chosen by the secondary care doctors yeah it's very important so we still have I think 10-1 minutes it's okay we're always keen to hear from our specialist our hospital informally if there's ways that they can help support us in the community one of the problems we have at the moment is dying cancer as well and how we can make early cancer diagnosis and we can have better access to tests and how much access general practice has to those tests and whether they can support us in doing the tests GPs in Northern Ireland we have some access to CT scanning but we need support to do that because modern scanners pick up sometimes little lumps that are not significant we need assistance with that so it's a difficult one but we need the support of our colleagues yeah that happens a lot we have a lot of people here in Portugal as well we also have a four-year residency program so our career is definitely by choice it's our own program it's very competitive excellent ours is three years in the United Kingdom but we would like it to be four we think it needs to be longer three years it's very fast yeah it's very short yeah we have between university and residency program we have one year general yeah we spend some time in each speciality and often we spend three months in a primary care setting okay so we have something similar I think ours was extended from one year to two years so it's something similar but I'm jealous of your four years yeah I think it's more organized this way we have a lot of we have time to spend at the hospital with our speciality and then we spend some time in the family health unit okay so I think if we don't have any more questions from the audience we can finish the session so thank you everybody please get in touch with us we will be there at the end and I'm very happy to take further discussions about this topic later on thank you thank you Dr. Darman thank you so much for everyone who has joined us today and I hope we will see each other very soon and preferably face to face next time