Ep13: Professor John McGrath on the ethos of medicine

What are 3 golden rules of clinical care? And what really drives Dr. John McGrath, who has received numerous awards, including the exclusive and prestigious Fothergill Gold medal by the London Medical Society? The answers might surprise you. This conversation also touches on the ethos of medicine. Dr. John McGrath is Head of Department, St John’s Institute of Dermatology. He is Professor of Molecular Dermatology and head of the Genetic Skin Disease Group. He qualified from Guy’s Hospital in 1985, having trained in dermatology and dermatopathology at St. John’s Institute of Dermatology in London. He is a recent President of the European Society for Dermatological Research, serves on the editorial board of 9 international journals, and is the section editor for genetics for the Journal of Investigative Dermatology. He has published over 400 manuscripts, including reports of mutations in Nature Genetics. His group discovered mutant genes in lipoid proteinosis, Kindler syndrome, AEC syndrome, OC syndrome and many others. Read more about Dr. McGrath at https://www.kcl.ac.uk/people/john-mcgrath. 

Transcript

[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I am very excited and honored to be able to speak to Professor John McGrath. Professor John McGrath is Head of Department at St. John's Institute of Dermatology. He is Professor of Molecular Dermatology and Head of the Genetic Skin Disease Group. He qualified from Guy's Hospital in 1985 having trained in dermatology and dermatology at St. John's Institute of Dermatology in London. He is a recent president of the European Society for Dermatological Research, serves on the editorial board of nine International journals, and is the Section Editor for Genetics for the Journal of Investigative Dermatology. He has published over 400 manuscripts, including reports of mutations in nature genetics. His group discovered mutant genes in lipoid proteinosis, Kindler syndrome, AEC syndrome, OC syndrome, and many others. Thank you so much to John for joining me. 

[00:00:50] John McGrath: Great. Pleasure to join you Christine. Thank you for the invitation. 

[00:00:53] Christine Ko: We were just speaking briefly right now before we started recording, and you mentioned how you come from a non-medical family. Do you mind telling everyone, listening in a little bit about that? 

[00:01:03] John McGrath: Definitely. Absolutely no one medical in my family, so I'm the very first person to embark on a career in medicine, so it's been very much uncharted territory. I didn't really know what to expect or how to behave or where the limits were in medicine. So I suppose in the 35 years or so that I've been a doctor, it's really been about setting my own boundaries, setting my own rules, trying to become a decent physician. And I hope that I'm starting to achieve that. When I teach students these days, I've come up with three golden rules that I think make good doctors, and this is based on being non-medical. As a background, my first rule to be a good doctor is to have clean fingernails. Most physicians don't realize that patients, particularly for dermatologists, look at your fingernails. So I always tell people have good, clean fingernails. Second one, in terms of these three rules is to always remember that God gave you two ears and one mouth.

[00:01:58] Therefore you should try to use those in that proportion. I don't think we always succeed. Me, especially, perhaps. And the final rule to try to be a good doctor, I think, is to try and manage every patient as if they're one of your own relatives. That's assuming you like your own relatives, but if you follow that sort of maxim of trying to treat each patient as a family member, then I think with clean nails and good ears, and a good sound ideal for managing the patient in the best way you can. You can be a reasonably good doctor. It's a sort of do as you would be done by philosophy, and that's been what's guided me over the last 35 years or so. 

[00:02:35] Christine Ko: I love your golden rules. One of the reasons that I wanted to get into conversations like this with highly experienced and respected individuals in the field of dermatology and dermatopathology like yourself is because of really my lack. I feel like a lack in, not to blame my education, but I really mainly focused on knowledge, the initial part of my career, not meaning to neglect that caring aspect or, you know what some people call the art of medicine. I didn't know. I'm also someone not from a doctor family, and just I was finding my way.

[00:03:05] John McGrath: I think you're right. We have in dermatology experience of looking at our peers and thinking, who is a good dermatologist? Who would we go to if we were sick? Would we actually turn to this doctor or that doctor? And I think it's very difficult to establish the rules because one of the things that we've learned in medicine is that there's not really a correlation between what a doctor thinks is a good consultation and what a patient thinks is a good consultation.

[00:03:30] We know of lots of famous old dermatologists that my Institute of St. John's in London, where the patients used to love them, but they were really just prescribing moisturizers and having a good conversation. Yet somehow their skin conditions were well managed and they did well in terms of their prognosis and outlook.

[00:03:46] The art of medicine is really ill defined, and I guess we just have to care enough to look after our patients and then hopefully those invisibles, those intangibles, that doctor patient relationship will go to a new level. And most importantly, we can help our patients. Although of course it does help if we know a little bit of dermatology as well.

[00:04:06] Christine Ko: Such a balance, and I think that balance is just what sometimes I find still so hard to achieve, especially with shorter and shorter visits sometimes the way the healthcare system is going and just so many competing interests... Just meaning just even in the room, the electronic medical record and with Covid all the cleaning that needs to go on and things like that.

[00:04:27] John McGrath: I think, so for me, I think I'm rather fortunate in that most of my practice is for patients with genetic skin diseases. And it's a tertiary center, so people have been referred and if I can't give the patient what they want or what they need, then I'm not sure where the patient goes after they've been to see me. And so most of my consultations, I have the luxury of having longer consultations to be able to engage in really deep consultations and also to have good conversations with patients about their condition and to build a sort of relationship. So maybe I'm fortunate in having a special type of circumstance that enables me to have that more holistic approach to looking after patients, but you are right. We do have to manage our time and we have to manage our expectations. But it's fundamentally about caring and about trying to help patients. And for those patients with genetic skin diseases, the ones who I look after, that's really the goal, the ambition that we strive for.

[00:05:27] Christine Ko: One of the reasons I really enjoyed the lecture that you gave recently To my department is because the amount that you care, the depth of that caring really came through to me. Since you are at a tertiary care center and you really may be that, one of the last stops for patient or patient family that's searching for a diagnosis, how do you come to that diagnosis and do you think you use your gut versus analysis or both? Or, how do you think at this point in your career with all your experience, how you might encapsulate that?

[00:05:58] John McGrath: It's quite challenging to make diagnoses. Sometimes we have cases where we diagnose very quickly. I had a case not so long ago where only I got, for some reason I only got half of the referral letter, but I'd already decided by the end of the third line of the text that this was probably a case of Schopf-Schulz-Passarge syndrome with biallelic loss of function mutations in WNT-10A. So three lines of text and not even having seen the patient. I felt I was at the diagnosis, but there are many other patients where it's work in progress. You don't always make the diagnosis in the first consultation, and I think for many young doctors, that's sometimes feels like a sense of frustration or a sense of failure if you can't get to the diagnosis instantly. Sometimes diagnoses evolve. They take time, and particularly for genetic patients. As we moved into this era of next generation sequencing and analyzing DNA variants and trying to make sense of those in the context of somebody's illness, you have to be patient. Sometimes it is like a good detective story where you pick up the clues, you filter them, and you try and reach the answer. And of course, there are still many cases where we can't yet establish an accurate diagnosis. So we are managing expectations both for the patients and ourselves.

[00:07:19] But of course we always do get a personal buzz when we diagnose something very quickly through familiarity and having seen lots of similar cases and discuss them with our colleagues. So there's a mixture of approaches, but it's understanding and accepting the reality of the process. 

[00:07:37] You can't be brilliant all the time. 

[00:07:39] Sometimes it does take a little while to unfold. It's like a good book. Sometimes you need to get to chapter 13 before you think, Aha, I know where we're going here. 

[00:07:49] Christine Ko: I'm an impatient person. I have to admit that I know that's one of my faults or weaknesses. So how do you prevent diagnostic error? Or maybe I think you were touching on premature closure or diagnostic momentum where I just decide too soon what something is and I really shouldn't have.

[00:08:05] John McGrath: Yes, that is, that can be a challenge sometimes when you just decide what it is and then suddenly later on you think, Oh no, we've got this wrong. Fortunately, for a lot of genetic skin diseases, we don't tend to have that circumstances. We tend to have a question mark left in the diagnosis rather than a wrong diagnosis. Sometimes we do revise diagnosis, so for example, a subtype of EB, epidermolysis bullosa, might get changed from one variant to another, but that feels like a refinement of diagnosis rather than a correction of diagnosis. But you're right, there is a feeling that sometimes we do want to just get to the answer, but I think in genetics and in genetic skin disease, getting to the answer isn't always the solution because you can get to a disease, you can give somebody a label, maybe it has a nice autonomous title or an acronym or something, but then the patient can always come back to you and say, So what? What do we actually do? How is establishing this diagnosis going to change my life? So you focus on symptoms, you focus on helping the whole patient.

[00:09:15] Of course, understanding the precise disease can take you into lots of other studies, understanding pathomechanisms, and maybe then thinking about drug repurposing or clinical trials and so on to help them. But I think it's up to us to accept our limitations, but always thinking in the next sentence. What can I do for the patient now if I have a diagnosis? If I don't have a diagnosis, let me be a better clinician. Let me help the patient. And that's the motivation. So I think in short, establishing a diagnosis isn't really a source of much satisfaction or frustration for me. If I can't make it, I just need to engage with the patient and we'll get there sooner or later, I'm sure we will.

[00:09:58] Christine Ko: Yeah, that's a really good point, and I think that was one of the lessons that I took away from your recent lecture because I think that's really true. It's fun. It is fun for me, especially since I do dermatopathology and I'm writing out these diagnosis lines. Those words often are quite meaningless to the patient, as you just touched on. It's really what do we do about it? How does this, how? How then can my life be better? What are the actual practical steps? 

[00:10:21] John McGrath: One of the interesting things patients, of course, is one equates diagnosis with some journey towards a cure. But that's not actually what patients with genetic diseases are really wanting these days. Doctors may think that's what the patient has, but patients are having their expectations changed into more real world. And for example, if you have patients with epidermolysis bullosa, sure, maybe they'd like gene therapy to correct and get rid of their condition, but they've come to the realization that's not really going to happen.

[00:10:55] And so what they want are things that will change their lives, improve the quality of their life. So for example, patients with fragile skin, they want better wound healing. They want reduced pain. They want you to help them with their itch. These are the priorities rather than cure. And so somehow this process of diagnosis is filtered into clinical expectation and reality as well.

[00:11:21] So trying to appreciate what's going on. Setting a scene for you then to be able to intervene on levels that the patient thinks are useful to them, and I guess that sort of dilutes the meaningfulness of making an accurate diagnosis. But one is always trying to help the entire patient. And I guess that's the ethos that drives genetic skin diseases and many other aspects of trying to be a good clinician.

[00:11:48] Christine Ko: I really enjoyed this so far. Do you have any final thoughts? 

[00:11:52] John McGrath: Just in terms of genetic patients and trying to think about the future, there's always this feeling that when we sit with our patients, we need to promise them something now. And one of my challenges as a doctor is being able to manage my own frustration in terms of the clock. Just yesterday I was sitting with a patient with ichthyosis, and I was thinking, what can I do for the patient right now? And I'm not thinking about the clock, with the outpatient clinic ticking around to five o'clock, I'm thinking about the patient's life because I can talk to the patient about how great it would be to try some biologics or how great it would be to have this new form of protein therapy.

[00:12:31] But I know the patient, when they leave the consultation, their life is going to be exactly the same as it was before they came into the room. And so this clock of life that's ticking all the time is a very much a driver for me. I really want to be able to try and make a difference for patients. One of the very strongest motivations for me is that one of my predecessors, my mentor, the late Professor Robin Eady, I trained with him in epidermolysis bullosa research and clinical care.

[00:13:01] And I went with him on his last ward round about 10 years ago. And we came out of a room where an inpatient with epidermolysis bullosa, and he said, I've looked after this patient for the last 20 years and I'm really wondering whether I've ever actually been able to do anything for her. And of course, I was slightly shocked by that because he's done amazing things for her in terms of organizing clinical care.

[00:13:27] But there is this reality that the clock had been ticking over 20 years. We'd only been able to do incremental benefit for this particular patient. And so I have this same feeling that the clock is ticking and when it comes round to my final ward round, am I going to have that same sense of, I dunno whether it would be disappointment, but frustration in not being able to deliver better care for these patients that we dearly care for.

[00:13:53] And so that maybe is one of the final thoughts for me is. Trying to achieve something in the finite amount of time we have as physicians, and the finite amount of time that we have to look after our patients. And knowing at that same time, the other lesson I learned, of course, from Robin is that some of our therapeutic care, we can't do everything ourselves, and so we need to have a system in life where it's a little bit like a relay race where we carry the baton.

[00:14:21] Robin carried the baton for patients with EB and he handed it over to me. And I'm looking to train up a few others to carry on that baton as well, because we really need to complete the lap and do something for patients like this and really try to make a difference. And that motivation I know will stay with me forever.

[00:14:40] Christine Ko: That's so inspiring. Thank you so much for all of your insights and your time today. It was truly a pleasure to be able to speak with you in this format. 

[00:14:51] John McGrath: Likewise, Christine. It's been wonderful chatting with you.