Dr Conor Loftus

From UCD to the Mayo Clinic - An Interview with Dr Conor Loftus

By Siân Roberts-Walsh

Conor Loftus - 150 x 180Dr Conor Loftus graduated from UCD in 1996. After initial postgraduate training in the Mater Misericordiae University Hospital, he relocated to the USA where he undertook a residency in internal medicine and a fellowship in gastroenterology at the Mayo Clinic in Rochester, Minnesota.

Dr Loftus is currently a gastroenterologist, Chair of the Mayo Clinic Midwest Outpatient Practice Subcommittee and a member of the Outpatient Practice Optimization Group. The Student Medical Journal (SMJ) spoke to Dr Loftus about his life as a gastroenterologist, training and working in the USA, and the challenges facing medicine in the future.

What was your original reason for deciding to become a doctor?

I grew up in rural Ireland, a place called Ballingarry, Co. Limerick. My father was a veterinary surgeon with a practice dealing with large animals.  So I spent my childhood interacting with farmers, giving them medicine for the animals’ ailments and I liked it.  I liked thinking about the problems as I travelled around in the car with my Dad.  I learned a lot about veterinary medicine to start off with, treated lots of conditions, saw lots of surgery with him.  I liked all of what I was seeing there. However, the farming environment was a bit too messy and disorganised for my personality, so I said, well, let’s go into caring but in the hospital and office environment.

I attended the Cistercian College in Roscrea from age 12 to age 17.  It was a great School and I had an excellent biology teacher.  When studying for Leaving Cert, I was reading outside of the curriculum and was really interested in the digestive tract.  So I was differentiating towards the gastrointestinal tract (GI) even before I went to medical school. It’s funny how you gravitate towards these things. Investigating why a person you know has symptoms also contributes to that. I had a strong biology teacher, I had a clinical background and that’s why I pursued medicine.

What were your initial impressions of UCD Medicine?

I did my Leaving Cert in 1990 and started off in Med School at UCD in September of 1990.  It was a very exciting time.  Socially that first year in UCD was phenomenal. I had a great group of friends, a lot of country folk, some city folk also. It was a really, really good social environment.  I have good memories from that time, cycling around Dublin, from Earlsfort Terrace around the city, when we got into the hospital rotations in 1994, going from the Mater over to UCD Belfield. It was a good time. We worked hard and played hard. I was very studious, I worked hard during the week but definitely on Friday and Saturday night, I enjoyed socialising too. I was very focused on getting the job done and I wanted to get on well and be as good a professional as I could be at the end of the day. It was a fun time.

Tell us about your career path towards gastroenterology

We had all our lectures in Earlsfort Terrace. I remember the anatomy labs there, and physiology. In our first year we had chemistry, physics, social and behavioural science lectures out in Belfield. 1st Med, 2nd Med, 3rd Med was all in Earlsfort Terrace. Then in April of the 3rd Med year, you elected to go to Vincent’s or the Mater and that’s when we started in the Mater in April of 1994. 

My very first rotation in April 1994 was on GI in the medical rotation. I worked with Dr John Lennon, Dr John Crowe and Dr Padraic MacMathúna. Dr Padraic MacMathúna had just returned to the Mater from doing an advanced fellowship in endoscopy in Boston. These were key interactions on that first rotation. Also the GI registrar at that time was a guy called Dr Ray Merriman. I remember working with Ray on that very first rotation. Greg Leonard was my colleague on these rotations and Greg is now a medical oncologist in Galway, a great friend, a great colleague.

I remember we had a patient with advanced liver disease, decompensated with ascites. We were doing a paracentesis and going through the analysis of the fluid and it was really, really cool. And then the next case came in and I remember it being a variceal bleed and being down in the endoscopy centre and seeing the colleagues treating variceal bleeding and I thought that was really cool as well. These were all very impressionable moments, and first impressions last. Given my vague interest in gastroenterology beforehand, this was further consolidation that this was going to be pretty high up on my list of career pathways.

In the GI profession you’re hands-on, you’re doing procedures, you’re doing endoscopies, colonoscopies. I spend a lot of time in the office seeing patients, I do procedures, I do hospital service consults, I do lots of different things. There is good variety in it. The procedural side of the practice is something that attracts all people who go into that speciality. You spend some of your time seeing patients and figuring things out and some of your time fixing things. It’s that nice balance which attracts people.

I will tell you in medicine, no matter what area of medicine you’re in, just like any job, variety in a person’s work day is key to sustainability and long-term satisfaction. I still like it as much now as when I went into it. My career has changed a little bit though.

After I finished at UCD, I did a year of internship in the Mater. On my first rotation I had a fantastic time working with Prof Hugh Brady, who had just returned from the United States as a Nephrologist and was a Professor of Medicine in UCD at the time. Again, myself and Colm O’Donnell who is now a neonatologist in Dublin, were the first interns for Prof Brady since his return. He spoke so highly of the United States – again another major impression made!

I then worked with the endocrinology service. I spent 3 months in colorectal surgery with Prof Ronan O’Connell and he had spent time at the Mayo Clinic in the 1980s. Listening to Prof O’Connell speaking, I was beginning to set my eyes on travel and the United States. I had also worked with Professor John Fitzpatrick in the Mater and other colleagues who spoke highly of travel and further education.

I applied to the SHO scheme which rotated me to the Mayo Clinic, so I came out [to Rochester, Minnesota] for 6 months in 1997 and just loved it. I loved Rochester.  The level of organisation and education! Things happen – bang, bang, bang – everything flows very quickly.  It suited my personality. It is a phenomenal establishment to work in, but you are still in a rural setting. Going back to my rural setting in Ballingarry, it suited me perfectly. I could be out in the countryside in 5 minutes and yet working at one of the foremost medical establishments in the world. It was very exciting.

I spent 6 months [at the Mayo Clinic] in 1997 and went back to the Mater for an additional year in 1998. I then rotated out to Dundalk for 6 months, where I worked with Dr Tom O’Callaghan who was an internal medicine-trained gastroenterologist also. This was another major influence in my career pathway. Dr O’Callaghan had gastroenterology training in the Mater. He had a procedure clinic up in Dundalk every Wednesday afternoon and he taught me to do my first upper endoscopy and flexible sigmoidoscopy. That experience cemented my desire to do gastroenterology, so when I returned to the United States and returned to the Mayo Clinic in 1999 it was with the fixed intention of doing 2 years of internal medicine residency and then going into gastroenterology.

I came back [to the Mayo Clinic] and did 2 more years of internal medicine in Rochester, and then came into a fellowship in gastroenterology. The benefit of doing the 2 years of internal medicine residency is that you can become board certified and this gives you a greater foothold going forward.

What were the main differences between Rochester and Dublin?

When you moved to Rochester did you find culturally there was a difference between working there and working in the Mater?

It took about 5 years to get used to living over here, to be honest with you. Firstly, you have the whole culture and society. [In Dublin] we used to go out on a Friday night and enjoy ourselves and or go to the rugby matches on a Saturday or watch Premiership soccer.  I definitely missed all of that activity when I moved over.

In the work environment, we had a nice schedule in the Mater, it was a little bit more relaxed. We weren’t up and in there at the crack of dawn. Here [in Rochester] you came over, you pre-rounded on all the patients early in the morning, you saw the patients before the ward round, then you had a structured teaching session at 8am. So, there was more involvement with the patients, there was more teaching, it was a longer day but at that point in my evolution I was more willing to put in the time, I was willing to put in the effort here because this is the final pathway to my career as a gastroenterologist - becoming a consultant. So it was very different both socially and in a work environment.

The Mater was great, don’t get me wrong. I learned a tonne there and when I rotated out to Dundalk, particularly in that setting where you have less support. It’s different. In the Irish setting 20 years ago it was a lot of learning on the spot doing the work and treating the patient.

When I came to the United States and came to the Mayo Clinic it was a little bit heavy around the formal didactic sessions, teaching sessions - teaching sessions in the morning, on ward rounds, after ward rounds. There was more structure – I suspect there is probably more structure in the training schemes at home now also. Somewhere in between is probably the right balance. Here [in the USA] maybe there is too much structure and too much focus on regulating work hours and so on. In Ireland maybe there was too little.

Another difference between the training schemes is that [in the USA] in their 1st and 2nd year, the medical students are already deciding their specialty. Part of [it] is typically they come out of high school at 18, they do an undergraduate degree for 4 years until 22 and then they go into medical school between ages 22 and 26 – so they are further along in their maturation. They think about their career early. Here they are differentiating earlier in their training schemes than at home. At home people take a little bit more time. I had an inkling that I was going to go into gastroenterology, but it wasn’t firmly decided until I worked with Dr O’Callaghan in Dundalk in the first 6 months of 1999 when I was in the second year SHO. 

There are certain things that go with your personality also. I remember being in the operating room with Ronan O’Connell, who is fantastic, now Prof of Surgery in Vincent’s – you ask yourself- is this me standing in the operating room for hours on end. You have to identify your personality, identify your strengths and play to your strengths.

What is the Mayo Clinic philosophy?

Many would think that the Mayo Clinic is all about technology – absolutely not. Certainly personally my philosophy is, if you think of rugby, the New Zealand All Blacks do things very well, but they do the basics very well – take the history, listen to the patient, examine the patient– when you do the basics well that’s a great foundation to build from.

The Mayo Clinic model of care is a combination of having the time to examine the patient, listen to the patient, combine that with access to technology and testing and also access to consultant colleagues who are very ready, willing and able to be involved in multi-disciplinary team care. It’s through that teamwork that we deliver very high level and high value care. It’s combining talent with teamwork that is key to delivering good care in medicine.

In Minnesota, we’ve got the entirety of our downtown campus interconnected by a subway system so when the patients are seen in the clinic building they basically just go into the subway and they are connected all internally into the hotels, they are connected to the labs, all the places we do the testing. It’s all indoors. You could be indoors here at the clinic for days, weeks on end and not have to go outside. The infrastructure has accommodated to the environment [and the long winter season] also.

We have also the Mayo Clinic Health System which is 27 hospitals in the surrounding large area, probably encompassing a geographic area the size of Ireland. We also have Mayo Clinic in Florida, which was opened in 1986 and Mayo Clinic in Arizona which was opened in 1989. We have a fairly significant footprint. We call the whole operation the Mayo Clinic Enterprise. All of these operate under the Mayo Clinic Model of Care: that is the needs of the patient comes first and that is our primary vision. Everything is integrated under an umbrella of our 3 shields; 1 representing clinical practice, the other 2 representing research and education. The very same model of care, the very same infrastructure, the very same structure of practice is seen at Mayo Clinic Florida, Arizona, Rochester and Mayo Clinic Health Systems and that is where we as an enterprise have moved forward in a very unified manor with many areas of standardised practice across the entire system. If a patient is seen for a particular diagnosis at one site, the approach is going to be very similar across the sites.

Can people rotate between the sites?

Absolutely, I as a practising gastroenterologist can rotate down to Florida, do a couple of weeks of gastroenterology in Florida or Arizona in the wintertime if I so wish, while my colleagues from Florida and Arizona can rotate up here. In actual fact our divisions and departments are integrated. We have speciality counsels. The gastroenterology speciality counsel represents the practicing gastroenterologists in Rochester, in our Mayo Clinic Health System, in Florida and in Arizona such that we are conversing across enterprises with our colleagues on a regular basis. Practice is very much integrated.

If we have a patient who calls into Mayo Clinic Rochester from New York and they have a particular type of tumour for example, and we decide the best person to see them is in Florida or Arizona we’ll schedule the patient at one of those sites. (However, we have specialists in almost everything in Mayo Clinic Rochester because it’s homebase). Likewise if we have a patient coming from South America, for example, and they call Florida or Arizona first, but they should be seen in Rochester, then they’ll be scheduled in Rochester. It’s a very unified system aimed at bringing the optimal care to the patient. That’s the  centre of every discussion - what is the best care that can be delivered and what is the best way of delivering that care to the patient.

Describe your current role at Mayo Clinic Rochester

You are chair for Outpatient Practice across Mayo Clinic Rochester, Mayo Clinic Health System, Mayo Clinic Florida and Arizona. What does this involve?

When I became a consultant here I was interested in gastroenterology and I was also interested in being a teacher. My natural passion is to teach so I spent a lot of time teaching the internal medicine residents and fellows in gastroenterology and I won teacher of the year for 5 or 6 consecutive years. I started to take roles about 10 years ago helping to manage the practice. I started off with managing the hospital side of our practice in gastroenterology, then I started to manage the outpatient practice in gastroenterology, so the whole practice. Then I started to manage our community practice so our gastroenterology practice across Mayo Clinic Health Systems. Then I started to help managing the department of medicine – so that’s all the medical specialities rolled up into a department. I became the practice chair for the department of medicine. Then I became the practice chair for Mayo Clinic in the Midwest – so that’s Rochester and all of the Mayo Clinic Health System.

In the past year I’ve become the Chair for Outpatient Practice across the whole enterprise.  What does this entail? Well, as an enterprise we want to deliver care to as many patients as possible but at the end of the day it has to be a sustainable operation. We have to plan out year upon year upon year how many patients we’re going to be able to see and how many surgical procedures we’re going to do. We then take all those numbers and divide them out by division and department and speciality. Those of us who are involved in the administration of the practice ensure that all of those areas are able to see the volume of patients that they need to see, that they are able to do the surgeries that the need to do, the procedures that they need to do. A lot of it is practice productivity, a lot of it is standardisation of practice, ensuring the highest quality is achieved, the safest care is delivered, and the highest value is delivered to every patient that is seen at Mayo Clinic.

One major initiative that I am involved with and chairing at this point in time is the incorporation of the unified EHR, which has been a monumental task for us in practice administration. With the introduction of the EHR in a unified manner we are looking at the roles and responsibilities of all care team members. From consultants to nursing staff who work with us, to scheduling staff who work with us, to clinical assistant staff who work with us, we are asking what each person is doing and how can they best help the provider provide the best care to the patient. These are the type of things that I am working at on behalf of our provider to deliver the highest value care to the patients. I spend a good chunk of my time working on that type of thing and the remainder of my time is spent doing procedures, hospital-based deliveries in gastroenterology and outpatient-based deliveries of gastroenterology. Lots of things going on!

If you’re involved in practice leadership, you cannot lead a practice without being involved in the practice. When I’m in clinic seeing patients with my colleagues, I understand the challenges that are presented in a practice and it’s going forward and solving those challenges and making the care that we deliver best value care for the patient and easiest care to deliver for the provider [that is important]. We are always looking for ways to improve our care in terms of delivery to make sure we are delivering the highest value care, the highest quality care and the safest care with the patient at the centre of all discussions.

About the Mayo Clinic Care Network

Would a lot of your patients travel long distances to come to the Mayo Clinic?

Yes, so we are based in the Upper Midwest geographically. Minnesota borders on Canada to the North and we are surrounded by North Dakota, South Dakota, Iowa, Wisconsin, Illinois. 90% of our patients come from the state of Minnesota and the surrounding 4 or 5 states. Then you have a cohort of patients, somewhere in the 5-10% range, that are national patients from the United States. Only about 2-3% of our patients are international patients at this point in time. We have significant interest in growing the international component of our practice. We have, over the last 10 years or so, evolved what is called the Mayo Clinic Care Network so we have relationships based with many hospitals across the United States who reach out to us to help administer the business side of their practices but also healthcare virtually through electronic consultation. We are now extending that network across the continents. We have a large number of patients who come from the Middle East, we are expanding into China and many different countries through our Mayo Clinic Care Network including the delivery of medicine electronically and virtually through the digital space.

I think the days of all patients travelling long distances to see a doctor are dwindling. We need to connect with patients in their home environment even, perhaps their hospital environment on their terms. The consumer is changing. We at the Mayo Clinic wanted to allow patients to self-schedule. Patients may not be available to call our scheduling office between 8am and 5pm. They may want to schedule their appointments after hours when it works for them, so we have to be able to evolve to consumer demand not only among our local patients, our national patients but also our international patients.

What changes do you expect in medicine over the next 10 years?

What major changes do think will occur in your speciality, or in medicine in general, in the next 10 years and what do you think will be the biggest challenges for healthcare in that time?

I think in the United States, one of the major challenges facing healthcare is the cost of healthcare. 13% of GDP of the United States is spent on healthcare at this point in time and this is not sustainable, particularly with an ageing population. Driving down the cost of healthcare and the cost of delivering healthcare is a huge opportunity and challenge and for those that can deliver high value care. We at Mayo Clinic like to do that, to focus on cost and improve cost and value.

The second thing is the evolution of medicine in the electronic and digital age. Whether it be a patient travelling across Minnesota or across Ireland to receive care, it is difficult I am sure for patients in rural Donegal to travel to Dublin when they need to see a doctor or a specialist. We need to involve the electronic platform so that that patient may not need to travel to Dublin. We need to try to deliver that care virtually to their local doctors, or to the patient even, in their home environment. 

We have a large group of people who work in what we call connected care. We do many thousands of consults every day, every week - electronically. Whether that’s for a patient here in Rochester or not, in the United States or internationally we do thousands of e-consults every year in the electronic environment. That will grow. We deliver care electronically when we can. When we need to we bring the patients to Rochester or Florida or Arizona. I think the growth of electronic medicine will be very important going forward.  As my Grandmother says, ‘The world changes, we’ve got to change with it’. We have to keep evolving.

Acknowledgements

Dr Conor Loftus:

“My career has been supported and facilitated by wonderful parents (Bea and Bill Loftus, Ballingarry, Co. Limerick), many friends, our patients, and all of the fantastic professional colleagues and care team members I have had the pleasure of working with over the years”.

The author would like to thank Dr Conor Loftus for being so generous with his time.

The author would like to acknowledge the assistance of Dr Peter Holloway of UCD School of Medicine in organising this interview.

This article has been edited throughout to allow it be reproduced here.