DrAndrewGreenland: 0:00

So, welcome back to Voices in Health and Wellness. This is the podcast where we explore the personal stories and professional insights of people redefining what care and wellness look like today. I'm really excited about today's conversation because our guest is Monica Monaghan, who works with the Western Health and Social Care Trust in Northern Ireland. Monica brings a wealth of experience in care delivery and community support, and she has a passion for seeing how health systems can evolve to meet modern challenges. I know she does lots of other things besides. Monica, it's wonderful to have you here on the show. So thank you very much for joining us this afternoon.

ProfessorMonicaMonaghan: 0:31

Thank you very much, Andrew. Delighted to be here and delighted to participate.

DrAndrewGreenland: 0:35

Wonderful. And are you calling from Northern Ireland now?

ProfessorMonicaMonaghan: 0:40

So I'm currently in the Southwest Acute Hospital, and that is in a town called Enniskillen in the southwest of Northern Ireland. Wonderful. And famous for the literary greats, and this is the town where Oscar Wilde and Samuel Beckett were educated.

DrAndrewGreenland: 1:02

Fantastic. I've just seen an Oscar Wilde play this very week, and I'm going to be seeing another one at the weekend, so I can relate to that connection with those famous playwrights. So maybe if we could start at the top, can you share a little bit about your role at Western Health and Social Care Trust and how this fits into the bigger picture of supporting communities?

ProfessorMonicaMonaghan: 1:21

Yes, so I'm a consultant cardiologist, sub-specialising in multimodality cardiac imaging. So everything from echocardiogram to CT, coronary angiogram, and cardiac MRI. So that's really the day job, job in cardiologist. And then I also hold a role in medical education, in the teaching of the medical students who rotate through the hospital. And we have three universities Queen's University in Belfast, Ulster Graduate Medical School, and then also the Royal College of Surgeons in Ireland. And then I also hold a role in the medical directorate, and so I'm clinical director for medicine, primary care and older people, and I sit at the associate medical director as well. So it's a varied uh job, no two days look the same. And that's uh and that's really what holds my interest. That's that's a great thing.

DrAndrewGreenland: 2:44

Amazing. I always admire people that hold multiple hats, and I just wonder how you fit all of that into your week. How does it how does your week pan out? How do you balance all these competing responsibilities and interests?

ProfessorMonicaMonaghan: 2:56

So we run a consultant of the week model. So when I'm the consultant in charge of the cardiac unit, then I'm very much the cardiologist, and around that, then I fit in the other duties and responsibilities. So it's an early start uh to the day. Um typically about 7 a.m. Um and in those couple of hours, I suppose, before we become clinically busy, I can uh get some of the other um roles done, the the paperwork, the endless emails, um preparation for meetings. So a lot of it is is just preparation, I suppose, the night before, um, in anticipation of what the next day might bring. But being in cardiology, that's often highly unpredictable. Um but the predictable and the schedule things, um, then I fit all the on-scheduled around that.

DrAndrewGreenland: 4:07

Got it. Yeah, well, anything in the acute care is uh, as you say, always unpredictable. As an emergency physician myself, I can completely relate to that and very difficult to plan for anything. But um, what um motivated you to pursue the kind of direction in health and social care from you know your sort of background in medicine.

ProfessorMonicaMonaghan: 4:27

Sorry, just repeat that.

DrAndrewGreenland: 4:28

I was just interested to know what motivated you to pursue the direction in uh social care and health.

ProfessorMonicaMonaghan: 4:35

So I have a background in in research um and in molecular biology. So my whole interest in in medicine was driven by evidence um guidelines, and then I took up the post here in the Western Trust in 2016 as a consultant. The population is is largely rural, um, and with that comes its own challenges and opportunities, and very much, of course, as well an aging population, and with that, there's a recognition that while we're specialists in cardiology or in imaging, I think there's a responsibility when we meet a patient or meet the patient with their family, that there needs to be a holistic assessment, and that's what I enjoy most. Of all the roles, I think the best is still sitting down either with a patient in clinic or a patient at the bedside and listening and understanding their story and giving them that time and space. I realize that we don't sit in isolation, so I might be able to organize for an aortic valve replacement or send somebody for a heart transplant. That's only a very small part of their journey and of where they sit, and the holistic care, and this is what whenever I'm teaching medical students or on ward rounds, trying to understand that holistic care of within the whole community setting and social care is so important as clinicians, and understanding way beyond just heart health, and that's I think where we can make huge impact as doctors and as part of a larger team, so less siloed working and more, I think, joined up thinking, and more integration between hospital and community, and that's I suppose where my my passion sits working as part of a team, working with the patient, working with their family, and then that has led to some projects where we have gone outside the hospital and have worked in communities, in local communities, to talk about heart health, about exercise, about frailty, um, about type 2 diabetes, and those have been very, very enjoyable because we're meeting people outside of their pajamas, if you like, um, in their own communities, and what's important to them.

DrAndrewGreenland: 7:50

Amazing, and I completely resonate with this. I my um interest in functional medicine, which is taking a very holistic approach to disease prevention, disease management, totally get where you're coming from. I just wondered how this fits into a kind of stretched health model. Obviously, it's slightly different for you in Northern Ireland versus the UK. But how does how does this fit in? Do you have a challenge in trying to do this really important work in the confines of a stretched system?

ProfessorMonicaMonaghan: 8:18

Yeah, and I think it's important to recognise that one individual can't do everything, but two individuals working closely together can can be do more, and three can be exponential. And it's really doing the very basics right, and that might just be simply starting off with communication, meeting um GP colleagues who, of course, are integral in rural communities. We still very much have the family doctor model here, where the general practitioner has treated maybe the third generation, and with that comes so much institutional medical memory, and me coming in, building relationships with general practice, with pharmacy, suddenly you start to develop a momentum, and I have that good relationship with a number of key individuals in the community, family doctors who are really striving within the confines of the human resource and the financial resource to still deliver really excellent care and the ideal, which is upstream care, managing chronic disease before the patient comes to my cardiac unit with their event. So I have great relationships, excellent colleagues, and there's a real willingness to recognise that change is needed and that together we can do so much more. So, for example, tonight I'll be going to uh a meeting in another local town in our next county called OMA, where myself and one of my excellent GP colleagues will be giving a talk to a host of healthcare professionals on the role of upstream medicine, the role of the healthy heart, the role of chronic disease management, the role of exercise, um, and a host of other issues which is passionate to me, which I'm passionate about, which is um sort of know your numbers, and and that's the other thing that I think is very important. We look after patients, but we forget that we ourselves one day will become a patient. And how does that look like? And what can we do to, I suppose, prevent that happening for as long as possible and getting that into our psyche? Um, and that's really part of the know your numbers campaign, which we're actively promoting within the trust as well.

DrAndrewGreenland: 11:30

Thank you. You mentioned know your numbers, and in terms of how do you measure the impact of what you do? I mean, for what do those numbers look like? And I guess you must have made a significant difference, but how do you measure the impact of the things that you do in this realm?

ProfessorMonicaMonaghan: 11:46

So, just to give you the context, maybe it's because I've almost been in post-10 years, and therefore my peers are starting to get that getting into that age bracket as well, where disease starts to manifest itself. But in the last couple of years, I've treated a bigger than expected number of healthcare professionals and doctors with cardiac disease and with myocardial infarction and angina. And I think the the overall understanding was we are we could look after ourselves better. So many of us do not know what our our simple parametrics are. So, our blood pressure, for example, what is what is the expected normal blood pressure for a 50-year-old or a 60-year-old? And there's new guidelines out last year where we really should be trying to get to 120 over 80. Then what's our HBA1C? So many have undiagnosed type 2 diabetes, and breaking down and talking about understanding cholesterol, so the good, the bad, and how can we improve that, and just having taking the time as healthcare professionals, taking the time out to get those things measured and to have a think about what I can do differently as a doctor so that I can continue to function well and deliver care well, and that's really where the thinking around know your numbers came from because of the disease profile that I'm seeing in colleagues.

DrAndrewGreenland: 13:46

Got it. So, what um I was gonna say, I mean, you've been doing this work for a little while now. How has it evolved with time since you first started at the trust?

ProfessorMonicaMonaghan: 13:57

So I suppose we all develop at different speeds, and and uh it takes some time to get embedded into a job to build relationships, to become equipped to deal with more than just uh the the job that we're trained for in medical school, which is of course very much the anatomy and physiology and the application of that, and yet what we do every day goes way beyond uh anatomy and physiology, and my role has evolved from clinician to I suppose a leadership type role in the clinical director, and then one of the other roles which I enjoy very much is the is the teaching and nurturing and fostering of our resident doctors or non-resident doctors and our medical students, and trying to share the experience and going a little bit beyond just what their curriculum might ask of us to deliver. Um we meet every Friday, for example, with the our FY1 tier doctors, and that's a protected hour where we have the opportunity and a safe space to share experience, to talk about communication challenges, conflicts. And that's I think my impression is that's probably as useful as maybe spending an hour teaching them on diabetic ketoacidosis, which they will get as well, and they will see, but it's that opportunity, and that's what I enjoy about the last 10 years. Probably that's only started to develop more in the last few years, and we all have to develop the confidence to be able to share our feelings and where we have learned and where we could do better, and then cascade that on to our colleagues as well who are coming through to understand that it's okay to say, A, I could have done that better, and or B, actually, I'm not in a great place. Could you give me some signposts to get to a better place?

DrAndrewGreenland: 16:45

Do you think that's something that's been neglected over time? I mean, obviously, you're picking up on it now, but do you think that's something that has been neglected in sort of conventional training? We're kind of leaving these people behind to fend for themselves and not having these conversations.

ProfessorMonicaMonaghan: 16:58

Yeah, I do. I think despite the best will, very often we do get caught up in the day-to-day runnings of an organization and the running of a busy ward or in a busy emergency department, and we become accustomed to dealing with life and death situations, and it can be easy to forget that there maybe were other people as part of that resus team, for example, um, who would really like to have five or ten minutes to have a conversation or a debrief, and that might be a week later or a month later, because we do we all carry those cases with us, and I do think that in the delivery of a curriculum very much focused on disease and illness, and that we can forget about our psychological wellness and well-being, and and how do we cope and manage that in a healthy way, or how do we even recognize it at an early stage because it might not manifest itself in a traditional way? Um, and that's something that we do here in the organization is try to have a focus on mental and psychological well-being as well as physical well-being. We'll talk about healthy management strategies. We talk about movement and exercise or music or chess, and when our new doctors come through in rotation, I'll have a presentation, for example, on advanced life support. But what I much prefer is just sit down and hear what I ask them what is one interest you have that is nothing to do with medicine, and that's really me trying to get an understanding. Do they have an interest? Do they have a support network? Because I recognize that we are in a rural area. We many of our doctors could be two hours from maybe their families, and it's important about building that network of support for them when they're here as well on the hospital site, and knowing that there's an open door policy.

DrAndrewGreenland: 19:49

I think it really is so important, and you're right, if we don't recognise this and it ends up with being burnout some years down the line. So I think what you do and the way you treat and look after and listen to your juniors is absolutely key for the rest of us to take from. Also, from your perspective, what are the major shifts that you're um seeing in the health and social care realm right now?

ProfessorMonicaMonaghan: 20:08

So I'll answer on a number of levels. As a cardiologist, uh, one of the most exciting, and I think one of the biggest impactful things that we're doing now is the investigation of angina using CT coronary angiography, and that is in all the hospitals in our trust, and we have a number of skilled cardiologists delivering this. So we've moved away from the treadmill for the investigation of chest pain, and we've moved towards where we can actually visualize the coronary arteries and we can predict the health of the arteries, and that guides us on prevention strategies. So we might know that there's disease there and there's athlosclerosis, but the goal then in a shared care model of discussion is around the prevention of the event, so the event being the infarct, which then could lead to heart failure. So that's that's one big, and that's endorsed by NICE, which is which is excellent, and and I would love to see more investment in CT coronary angiography across the region. And I think that's aligned with our health minister, um, who is also very keen on this shift left move upstream. Other things that have come, I suppose, through my own practice is the ageing population, the and where there are deficiencies in social care in the community, leading to lengthy hospital stays, and people who want to be back in their own homes, independent, contributing to the community, having to remain in hospital because we don't have that social package available, and that's I know a lot of focuses on that, and we know that lengthy stays in hospital will lead to increased frailty and sarcopenia and reduced psychological well-being, and it's so frustrating for patients, for their families, and it's a detriment to the community because they're not there contributing and being active in the community. So that's one area that is frustrating, but I think that by getting educational programs out earlier to our population, maybe in their 50s, their 60s, their 70s, about keeping active, doing small things can have big differences. So even if you're walking 20 minutes, 30 minutes, that will have a big impact on bone health, for example, uh, in the decades going forward. And that's what we're trying to get across in messaging about women's health. Traditionally, cardiology, we spoke about, we recognized that the typical features of angina, for example, in our in our men, the classical, typical, but now there is a movement and it's growing worldwide by a number of key individuals, which is wonderful to see, and that's percolating now down through all the societies, down into our small communities, about the recognition of heart disease in women. And we have we have got the bikini medicine, as it's called, so good. So the bikini medicine is the breast cancer, the gynee cancers, and we're so good at that, and yet in cardiology we have let that slide. So there's a movement now called Beyond the Bikini, and it's really about motivating and educating women in the communities and also cardiologists and doctors about recognising heart health in women, and that we are not many men, we are not smaller men, that we present and can present in different ways. And just because we might also have the vasomotor symptoms of menopause, or we might also have anxiety, or we might also have palpitations, we're also allowed to have dual pathology, and we might actually be presenting with angina or an underlying heart disease. I think there is a recognition out there that sometimes we have, as clinicians, been dismissive to some degree, but that's changing, and that is, I think, a very healthy place to be right now as a woman having menopause.

DrAndrewGreenland: 25:44

Thank you. What about um patient expectations or even generational differences? What are you seeing from patients in and how is that affecting the way you deliver care?

ProfessorMonicaMonaghan: 25:56

Patients are, I think, more empowered. They are they have the access now to the internet, they will have looked up and read about their symptoms before they attend, and that I think, in general, is a good thing because they will come with questions, and it's an opportunity then for us to guide, listen first, and listen where are they coming from? What is this story? They might chat GPT may have advised them on what this might be. Um, and I don't think any of us should feel threatened by that. I think it's an opportunity to sit down, listen, um, learn, and um, and then just talk through. Well, here is what I'm thinking, um, based on what you're telling me. And I might need to do another test to prove that, I might not, but the real basic, Andrew, is still back to his really good history and examination and spending that time listening. So I think expectation and demand, if that's the right word, not sure it is, but that has gone, that has increased, but that's not necessarily a bad thing, and moving away from the paternalistic um doctor-patient relationship is also a good thing. There's more shared care, there is the onus on us to be honest, open, and transparent, and also it's okay to say, you know, we work in diagnostic uncertainty, and we might not have all the answers, but I might be able to talk to somebody or signpost you to somebody who might give us more information and restore you to better health, and I suppose we're funded to do some things really well, so treat heart attacks, treat valve disease, treating heart failure, but all of the things that go around living with a chronic disease, we don't necessarily maybe have the time and resources to do that, and that's why I'm so grateful to organisations like Northern Ireland Chest Heart and Stroke and other voluntary organisations who do provide that wraparound care when we maybe can't, as clinicians, give the time that's absolutely essential, or the funding to areas like psychology or physiotherapy and things like that. So I have to say, I do encourage patients to bring along their questions. I always tell them you will forget. So when I come to see you on the wardround tomorrow, write everything down or bring somebody with you to clinic because four years is better than two.

DrAndrewGreenland: 29:24

I I smile in jest because um I've had those patients that bring their referrals from Dr. Google and Dr. ChatGPT pages and pages and pages. So I smile in jest, but I completely get your point. It's important people come with all of their concerns and questions and have them all answered properly by a clinician who can take a good history and examine and do all the things that the electronic things that you mentioned can't do. With all the improvements that you've mentioned and the early intervention and preventative medicine, what are the challenges or bottlenecks that are still most impactful in the work that you do right now?

ProfessorMonicaMonaghan: 30:00

Challenges, waiting lists. Would love to get patients their echocardiogram, which is you know such a such a fundamental front door mobile test, and how wonderful would it be with all the advances to be able to bring that point of care ultrasound into the communities. So I suppose there is a frustration around what it could look like and what it does look like, and then sometimes the bureaucracy around making a good idea, or at least what I might think is a good idea, happens. And that's certainly a challenge. I think the human resource there is a willingness there, and there's a drive, there's a keenness to explore AI and artificial intelligence, but I still think we still have to get the actual intelligence right in order to get the artificial intelligence right. And other frustrations, the timing, um just not enough time sometimes to do everything, and feel that I could have done that better when you reflect. But I suppose that's part of the learning, um, and that we're still continuing to evolve as healthcare providers. So I still think get the basics right and everything else will follow, but it is it's it's seeing that increase in chronic disease in the community and where there might have been opportunities to intervene earlier, and we can only see that with the benefit of the helicopter view when they present into cardiology with their event. And in fact, one of the things that I'll be speaking about tonight with my colleague Dr. Emer Darcy is about the role of Q risk and that this has been adopted uh through NICE, and yet I can see it when I scan so many so many people in their 50s and their 60s, and we're so good at measuring things that we can see that they've had their LDL measured innumerable times. We can see it climbing, and there were opportunities there to intervene on this disease, and there was a reassuring cure risk, and yet the patient still presents then with the event or with an advanced form of the disease. I know that there is a movement out there as well of like-minded individuals who would love to move beyond these scoring systems, which are really just guidelines, and maybe move towards a more aggressive preventative strategy with all the things that we have now that we can offer people that we didn't really have 30 years ago.

DrAndrewGreenland: 33:38

Thank you. Finally, um, looking back, if you were to start, if you were starting in your various roles again fresh tomorrow, what would you approach differently if you had your time again?

ProfessorMonicaMonaghan: 33:49

So great question. Um I would I think it would tell my younger self to maybe take life a little bit less seriously. I I do do a lot of exercise, um, which I love. Um I would maybe take more time to consider. Um we're all inclined to maybe try to please and say yes to roles, and sometimes it's also okay to say no, thank you. Um, that's just not for me at the moment. Um I'm even thinking through training, how many family things that I I missed because of the training programme and the delivery of service. And looking back now as an older person, um there is some regret there, and and that's part of what I teach our resident doctors too, that that life is important and that life outside of medicine is important.

DrAndrewGreenland: 35:13

Monica, thank you so much for your time this afternoon and sharing these insights. It's been such an honest and inspiring conversation, and I'm sure our listeners are going to derive enormous value from listening to this podcast. So, really many thanks to you and your time this afternoon.

ProfessorMonicaMonaghan: 35:29

Pleasure, thank you, Andrew.