Saturday, 18 October 2008

Lazy golf-playing, arse scratching Irish docs costing the elderly their health.

Posted by: Dr. Thunder

I read this yesterday. It's a short article in the Irish independent:


The Tanaiste is putting pressure on doctors to reduce the amount of money they receive to provide healthcare for elderly medical card holders. Mary Coughlan has indicated that if GPs were prepared to take less money, the Government could readdress the abolition of universal medical cards for the over 70s. There has been uproar since the Government announced in the Budget on Tuesday that they would be scrapping the scheme, which automatically entitles every person over 70 to a medical card.The Minister for Health issued modifications to scheme last night.People on the State contributory pension will still qualify, and those over the threshold will receive either a GP-only card or a €400 annual payment, depending on their financial situation.

I think the Irish government are taking lessons in spin from the British government. When I was a paediatric SHO in the UK, all ills were blamed by the government on doctors. We were told we didn't work hard enough. We were told we weren't efficient enough. Patients were told not to let us hold them to ransom.
Then they went to town on the GPs. The Labour government said they were going to sort out those lazy bastards. They told GPs that they'd be paid ONLY for the work they were doing. They had made the assumption that GPs didn't work hard. Everyone working in the NHS knew that was a crock of balls. But I guess people in ivory towers in london don't really get the coal-face view.
Anyway, they paid the GPs for EXACTLY what they did. And it almost bakrupted them. The government soon found out just how productive British GPs are. So, they got paid a lot of money. Not the 250,000 pound salaries that the media talked about. But nonethless the GPs mostly got a payrise, as they were now being paid for work they previously did for free.

So, now the irish government are following suit. Our deputy prime minister (known as the Tanaiste in Ireland) is engaging in a bit of damage limitation. She has had to tell pensioners in Ireland that there's not enough money to provide primary healthcare for them.
But that's bad news. It doesn't look good for the health service when politicians have to make tough decisions that involve curtainling healthcare. That doesn't bode well for the next election.

So, they tell the public that the reason for their piss-poor healthcare provision is that GPs are over paid. They want them to take less money, to help the government out.
Now, I'm not a GP. But if I was, I'd be telling Mary Coughlan to take a jump.
The governement negotiated a contract with GPs, and now suddenly they want to change the terms of that agreement. They know no lawyer is going to be able to pull that off by force, through legitimate channels, so they use this disgusting spin.

"Old people can't get free healthcare because doctors are too greedy". Why are doctors the only group within the health service being asked to take a pay cut? Sure, they have to be paid, but so do lots of other people who are involved in the running of the medical card system. Admin staff, accounts staff, politicians and advisors are all taking a cut.

I would argue they're all less efficient parts of the equation than the GPs.

The Irish government tried this recently with the pharmacists. They decided they didn't like how much they were paying them, so they tried to bully the chemists into taking a big cut in their remuneration. That was equally as cynical, and it didn't work.

My advice to the health service executive is the look at the big picture. If you want doctors to work with you, and cut you some slack when they're senior enough to GPs....then stop treating them like crap when they're juniors.

Who is ever going to feel any loyalty to a health service that breaks them down to the point of emigration??

So, should GPs take a pay cut? Or are there other ways of making the health care system efficient enough to, well, provide healthcare?

Saturday, 11 October 2008

Please welcome our newest blogger, Dr. P

Hi guys,
Dr. Thunder here. Just posting Dr. P's blog entry while we sort him out with a password etc. Dr. P is a medical registrar working in Ireland. Here's his 1st post:

Few things to me seem as naturally paradoxical as locum work.

Condensation builds up on the windscreen of my pride and joy as the clock ambles particularly showly from 8.30 to 8.55. Here goes.
The sympathetic orchestra slowly climaxes in my small intestine as I click my car door shut in the shadow of my place of employment for the next few days.. (or at least the next few hours).
The fear and desire to take flight are in stark contrast with the determination and certainty that won me this short adventure in mercenary medicine in the first place.

I had to regularly update my CV. I had to provide proof that I was Hep B immune(again at least for the next few hours). And most importantly, I had to alert the agency that I would be available to stand in for one of my absent peers.
With lightening fast fingers, I dialed the agency. ‘Hi... Yes I’m available for the job in Portlaoise/Sligo General/St Lukes Hospital… Great… Thanks, talk to you then.’..

Some say locums get a raw deal. Not necessarily so. Suspicion is much more often bestowed on Medical Mercenaries than any significant level of responsibility. Locums usually carry out the work of juniors.

Studies somewhere would surely show that locums are at least twice as likely to be asked to perform the PR exam that the Reg forgot, roughly 30% more likely to be asked to take the peripheral blood culture that eluded the intern and four times more likely to be holding the SHO bleep for the less sought after portion of the night.
Thankfully, this contrasts with the inflated hourly wage of the Locum.
And the less advance notice the Locum recieves, the more hansomely rewarded he or she is.

But what I find most paradoxical however about my species is the fact that most locums are already overworked in their regular jobs.
Why am I doing this on my week off I think to myself as I walk into a ward I’ve never seen, a list of patients I’ve never met and a barrage of questions I’ll hear over and over again?
‘So where do you work normally?’
‘Do you not need your holiday?’
‘Are you saving for something?’
In a climate where we complain of the hours that we are forced to work, I’m choosing to work just a few more.. Why?
Why not? It’s 80 euros an hour. I’ll take a break on my next week off.

Dr. P

Saturday, 13 September 2008

The Dr. Scot Junior saga (2).....are these fuckers for real???

Posted by: Dr Thunder

So, a lot of people are aware of the "Dr. Scot Junior" saga. Jane Doe's post below outlines a lot of what the case is about. Essentially, a scottish junior surgeon was posting his views on the doctors-only password-protected website

On one of the mesage boards, he called Dame Carol Black "A shit". This is because Dame Black was heavily involved in the "rearrangement" of junior doctors training in the UK. This training revamp has pretty much destroyed the training of British doctors, and has had huge impacts on their personal life. Pretty much every British junior doctor thinks Carol Black is a shit. Her and her colleagues get called much worse in doctors' scabby tearooms across the country every day.

Anyway, Dame Black's mate, Professor Gillian Needham, up in Scotland, decided to ban Dr. Scot Junior from practising surgery there.

Now, I worked in Scotland for several years. Healthcare there is the pits. There are parts of Scotland where the life expectancy of males is 64. That means some Scottish males are expected to die before retirement!!!!!

The Scottish health service cannot afford to ban doctors. Not because they were a bit cheeky, anyway.

So, there were apologies. Dr Scot regretted his choice of words, and asked for his comments to be removed from the website. Professor Needham had no real choice but to reinstate him and allow him to continue practising. Especially as the Medical Council tells us that doctors should only be banned from working if their actions put patients at risk. There are no rules covering doctors who cause offence to your coffee-morning pals.

But she was pissed. This upstart has mocked her friend. Needham and Black have helped fuck up the lives of junior docs all over the country, by, for example, advocating a sytem which tells married couples with kids and mortgages that they have to move to opposite ends of the country to work until 2010, as part of the "training revamp" This is on top of making lots of doctors unemployed.

I left Scotland to go to Oz because of these gobshites. I will never go back. Scotland isn't exactly overflowing with paediatricians either.

As Prof Needham was angry, she decided she wasn't finished with Dr Scot Junior. So, she's suspended him again!!!!
The poor guy had only been reinstated 3 days!!!!

This time the reason is being kept private, but it relates to something he apparently did years ago, just after he qualified from medical school.

It didn't seem to be an issue before now, until he offended Needham's coffee buddy.

So, while the waiting lists in Scotland are out of control. Be safe in the knowledge that the medical hierarchy are looking after you and your loved ones by suspending the man who might cut out your colon cancer just before it spreads, or remove your appendix before it bursts. Be safe in the knowledge that no man who has the tenacity to call a superior "a shit" will be allowed anywhere near a scalpel in Scotland.

The NHS is in good hands.

Dr. Thunder

Tuesday, 2 September 2008

When do we stop? Should we stop?

Posted by: Dr. Thunder

It's 2pm, and the emergency pager goes off. "Emergency, ward 4" flashes up on the screen.

We all drop what we're doing and run to ward 4.

When the emergency team arrives we're greeted by a flurry of nurses running around little Dylan, a 6 year old boy with severe brain damage. Monitors are beeping loudly, there are tubes everywhere, and Dylan looks crap.

He has pneumonia. For the 6th or 7th time this year. This time it's really bad. This happens to him every few months without fail. Now that it's winter, he suffers a lot more than usual.

The problem this time seems to be that he has very severe pneumonia and is struggling to keep his oxygen levels up. After examining him, it becomes obvious that he's punctured one of his lungs now, and it looks like some of the bacteria in his lungs have made their way into is bloodstream, causing septicaemia.

He's a very sick boy.

So, we stick a tube into his lungs, through his chest wall, to drain out the excess air from his punctured lung. We give him a lot of fluids intravenously to help with his low blood pressure. We give him lots of oxygen. We pump some more antibiotics directly into his bloodstream.

This all helps, but it's not enough. Dylan is really struggling to breathe now, and he needs to go on a life support machine. This involves putting a tube into his mouth and pushing it into his lungs, allowing us to take over his breathing for him.

We managed to stabilise him where he is, and transfer him to intensive care. He stayed there for a number of days, and is now back in his old ward. He still has his pneumonia, and he's still very sick. He'll be in hospital for a while. When he goes home, he'll be back within 6 weeks.

The reason I bring up this incident is because there's a number of staff who don't think we should have resuscitated Dylan. This kind of thing happens to him several times a year, and he's always pulled back from the brink.

But in the interval, Dylan has really no functional capacity whatsoever. His mum think she can make out when he's trying to smile, but that's about is. He has no speech. He can roll his eyes around, but he's mostly blind. He gets fed through a tube in his stomach. He can move a bit, but not much. He has seizures most days, and they are almost impossible to control.

His mother remains very calm when he gets sick. She's been asked whether she wants all these intensive measures when he gets ill. She does. But there are a number of people who believe that this choice should be taken out of her hands.

They argue that, in the last few weeks, he's taken up a hospital bed for 4 weeks, and intensive care bed for 4 days, aswell as a stack of staff-hours and medication costs.

Personally, I don't like getting into the realms of deciding who's worthy of resusciation, and who's not. Dylan is a good example of how there are differing opinions. So, I just get on with it, and try not to think about it too much.

But I was just wondering what people thought. Should people like Dylan have a right to the same healthcare as the rest of us? Should the final decision rest with their parents? or does there come a time when the hospital should step in and call time?

Sunday, 31 August 2008

The Hours: (not the depressing film about Virginia Woolf, something different entirely. Still fairly depressing though...)

Posted by Dr. Jane Doe.

Out of hours. This phrase haunts my life. It’s in the papers, as in “GPs don’t provide out of hours cover properly due to golfing commitments”, or “Women doctors won’t work out of hours for fear of breaking nails” or “Out of hours access to such and such a service is shite” etc etc etc.
It’s not a phrase that is misunderstood very often though. Traditionally “out of hours” is taken to mean outside the hours of approx 9am to 5pm. Night work. Weekend work. That sort of thing. People have a fairly good understanding of what it means.

One phrase, however, that people outside medicine do NOT have any kind of understanding around is the phrase I think I hate more than any other phrase in the whole world. “On-Call”.

I didn’t really understand about “on-call” properly myself before I graduated and began working as a doctor. People often get really angry at me when I say this, for whatever reason. They say “Oh you expect us to believe you trained as a doctor without knowing about the working hours.” “You knew what you were getting into before you started so you can’t complain.” And of course, the single most oft trotted out “But you get paid overtime for those hours so you can’t say anything”.
You see, most lay people think that “on-call” is done from the end of a phone, from the comfort of your own home, or perhaps a nice doctors lounge. They think you get called once or twice a night, order some meds per phone, and generally sit around raking it in while doing nothing.

I don’t blame these people, because I didn’t understand about “on-call” before I DID it and I can see where they are coming from.

My very first day as an intern, we all drew straws to see who was doing the first night’s call. I and three other unfortunates ended up doing this. It was at this moment that I really understood that I had come to work at 8am, and would not go home that night, but stay in the hospital working. Not only that but I would be in the hospital starting a new days work at 8am the next day and would remain there until at least 5pm. 36 hours straight in the hospital, working, bleep on.
I felt sick, and most NCHDs will tell you that nauseous feeling of dread you get when you wake up the morning of a day you are rostered on a 36 hour shift, or “on-call” that night cannot be reproduced by any other set of circumstances.
It gets worse though. Oh, so much worse.

I also drew ANOTHER short straw, and that was to do the first weekend also. I asked the SHO what that entailed, and I still remember the shock I felt when I heard her reply.
“Oh”, she said, looking half regretful, half sympathetic. “It’s um, it’s not good here. They don’t split the weekends here. You come in Saturday morning and you go home Monday evening at 5pm”.

I felt the blood go from my face. “That can’t be right”, I said. “Don’t you even go home to sleep? That’s three days and two nights in a row!! Is that legal?”
She gave me a pitying but also amused look, “Probably not, but you can’t do anything about it if you’re a junior doctor.” She saw my face. “Look, at least you’ll get it out of the way, you won’t have another weekend for a while. And you’ll get double time on Sunday”.
I couldn’t have cared less if I got quintuple time on Sunday. And a foreign holiday thrown in. The first “on call” had been bad enough. I had slept for two hours from 4am to 6am, and gone on to work a full day the next day. I remember as I was getting dressed in the tiny hospital residence room saying to myself “I survived.” My eyes were burning all day long the next day. My muscles ached. I was constantly thirsty for some reason. I was emotionally labile-the slightest cross word (and in Irish hospitals junior docs will hear a lot of these) made me want to cry. And the fatigue made every single little job sound like an insurmountable hurdle.

The 56 hour weekends from Saturday to Monday are still happening in Irish hospitals all over the country. I can’t even describe how bad these are. You will have worked all week already, leaving work on Friday evening like everyone else. You then come in on Saturday morning (in some hospitals they make this Saturday at noon) and you pick up your cardiac arrest bleep and get to work. There are no scheduled meal breaks when one is “on-call. You eat when you can and you often have to leave your food to answer bleeps and attend to jobs. Even going to the bathroom is subject to when you can. You have no, I repeat, NO scheduled breaks.
You work all day Saturday doing whatever it is you do, if you’re an intern, doing scutwork and reviewing ward patients, if you’re an SHO, down in the A&E admitting or reviewing sicker patients on the wards, if you’re the registrar, also in A&E, or seeing consults on the wards, or reviewing the sickest people in the whole hospital and supervising the other two when you can. You work all night Saturday night and try to get to bed when/if you can. You may be lucky and get three or four hours total sleep, or you may get none, as is more often the case. You have a shower the next morning and get working again, and do the same all day Sunday, and all night Sunday night. At this stage you are incapable of safely driving a car. You are sick with fatigue. And here’s the killer-the next day, Monday, the start of a brand new week for everyone else-you have to do your day job EXACTLY the same as though you hadn’t just worked 48 hours straight with no sleep. No slip ups in performance will be tolerated. You’re so so slow to respond to anything or do anything at this stage that all your work takes you twice as long, and you usually get home later than you would on an average day.

So here’s where normal people say “Ah, sure at least you’ll have a day off now, yeah?”
WRONG. You’re back into work Tuesday morning, bright and early. You work all that week too. Making a twelve day week with a 56 hour weekend in the middle.

You see, the reason I didn’t really think this would happen before I started work as a doctor was that doctors are meant to be pretty smart people. It takes a lot of points in the Leaving Cert to get into medicine. It takes a lot of academic work and study to get your medical degree. It takes many post graduate exams and continuous courses and study afterwards to become a consultant. I couldn’t really fathom why these intelligent and motivated young people were all doing this. Within minutes given the total number of staff I could whip you out a rota where someone did a week of nights and had a few days off afterwards and spared everyone else this kind of horrific, dangerous and extremely stupid caper. In fact I did once or twice. But no-one will have any of it. And no-one will listen. Why?

A lot of people will say that it is better for “training” to work marathon shifts of 40-60 hours at one stretch. I will say this now-anything I have learned of any value that I remember was from a consultant or senior registrar during the DAY when they had time to teach me and I had any inclination to learn. The fact is that in Irish hospitals “on-call” you end up doing so much work that in any other developed Western country is performed by other staff (staff on shift work, not being paid overtime, which is CHEAPER, by the way) that you learn shag all. The antiquated idea that it “toughens you up” is illogical in the extreme. How? I’ve personally been forced to stay awake for 40 hours straight on average once or twice a week for a few years and all I got out of that was ill health and a vague feeling that I might have PTSD. I think it weakens people, if anything. It certainly makes them leave and go to the UK/Oz/NZ, that much I can attest to.

I wouldn’t want my relatives in the care of exhausted and suboptimally functioning junior doctors like these. I worry about a time, maybe years from now, maybe not so far away, when one of my parents or grandparents may need to be in hospital, and people in the depths of exhaustion, struggling just to live through their own extended shifts, are half heartedly treating them in the night where services are already at a minimum and any mistakes or problems tend to have much worse consequences then in daylight hours.

What’s so bad about doing a week of nights, people?

Here, down under, we still have what we think of as “on-call”. It is also known as “a long day”, from 08:00am to 23:00. You come in, do your days work, and then from 16:00 onwards you do whatever it is you are allocated to do until 22:30, where there is a scheduled supervised handover to the night team in a designated meeting room. Ah. Like a breath of fresh, common-sensical air. Better for training, patient care, and doctors wellbeing.


Shift work is BETTER for training than the Irish way. Not worse. Here’s why:

In my experience here, from doing acute medical “on-call”, the registrar and SHO admit on average about 15-20 patients from 08:00-22:30.

In Ireland, this would be unthinkably busy. Maybe A&E put in an IV line, maybe they didn’t bother. 15-20 IV lines, making up all those first dose IV meds and giving them and signing for them, taking any repeat bloods that need taking, doing ECGs, resiting the IV lines as they invariably fall out, the hassle and hell trying to organize even one CT scan “out of hours” not to mind getting it read.

Here, IV lines and bloods that need to be done will be done by the IV technicians who come on at 16:30. So will repeat bloods. Just write in the notes what time. ECGs and first doses ALL done by nursing staff. Basically your job is what a doctor’s job is supposed to be. You admit the patients, take histories, examine them, diagnose them, order investigations and follow up as needed. And you see more cases by 23:00 than you would have seen in your 36 hours constantly awake back home. And you aren’t exhausted so you remember them. And you have time to do procedures, and back up if you fail at doing them. Everyone back home has been in the situation of trying to get a lumbar puncture at 4:30 am and calling the reg, who blearily and exhaustedly says “just keep trying”. If people aren’t exhausted, they will do better jobs. Not rocket science.

CONTINUITY OF CARE : As for continuity of care-that is another weak excuse for dangerous working hours and workloads. Unless the same doctor is on the premises 24-7, 365 days a year, there IS no continuity of care. In this day and age, with increasing complexity in medicine and increasing caseload, what is of paramount importance is continuity of information. Formal handovers at designated times and places, supervised by senior staff and co-ordinated by a team co-ordinator minimize anyone “falling through the cracks”. By the way-there are NO formal handovers that I know of for doctors in Ireland. Some may conduct their own informal ones if they are worried about someone.

Also-if your team are on acute medical take here, the patients remain under your team. You know the 15-20 you admitted. Maybe 9 more overnight, nights tend to be less busy. They will have been admitted and thoroughly assessed by a well rested doctor and all you really have to do is read the notes and go see the patient yourself. So what if you didn’t admit them, you can familiarize yourself with them fairly quickly, you are supposed to be able to do that with any patient if you are any kind of a doctor at all, and they will be your patient from now until discharge. Put a well organized summary in the notes for the night/weekend teams and continuity of information and hence preservation of good care are maintained.

In Ireland it is not usual for the registrar and the house officer of the same team to be “on call” on the same night for their own consultant. Some services in good hospitals do try to arrange it like that, but with differing numbers of every grade of staff and rotas made out by management, it is not usually the norm. Hence the pretence of continuity of care being preserved by extended shifts of 40 hours is farcical anyway. You’re on call admitting for a different consultant, and the reg from a different team is also on call for a consultant not their own. What’s so continuous about that?

Surgical services appear to be different, and need more exposure to time in theatre necessitating longer hours than most other services. However, they still go home and sleep for 7 or 8 hours here, and surgical outcomes appear to be just as good as at home.

One final point, (speaking of “hours”, it’s going to take anyone “hours” to read this longwinded post), I feel I must correct anyone who thinks that we should suck it up as it’s only for one or two years and then we’ll be registrars.
You see, a lot of people, I have discovered, think registrars are NOT junior doctors! Even some nurses think this.
Registrars are NCHDs, that is Non Consultant Hospital Doctors, same as SHOs, same as interns. They are required and forced to work the same hours and often more than SHOs or interns. It’s true, they’re not junior in the sense of the word, but their working conditions and entitlements are, and this is all the more shameful. Hence the years spent working dangerous extended shifts can be as long as ten or fifteen years.

I hope this has shed a little light on the antiquated reality of the archaic working practices of the junior medical workforce in a first world Western developed country. It’s embarrassing, frankly. Far from being tough, we are simply not adapting to suit the times and the needs of patients and doctors. And it needs to change.

Sunday, 24 August 2008

A Different Way of Doing Things

Posted by Dr. Jane Doe.

I’ve been pondering the way in which healthcare is delivered here and looking at why it seems to work so well here in comparison to Ireland. I am gradually getting used to the way things are done here, and hence the differences are not always apparent to me anymore the way they were when I first arrived to the Antipodes. However, the recent influx of Irish junior doctors fleeing the system back home have reminded me of ways of doing things and procedures in place back home that I had forgotten about. And one of the things that I had almost forgotten was the difference in the general attitudes and perceptions surrounding hospital delivered healthcare at home. This sounds like it might be a woolly, subjective thing, but actually it is not. The attitudes and perceptions that people have influence them to shape systems and procedures accordingly.

One of those things that struck me here was the attitude of both doctors and patients towards the delivery of healthcare. The perception in Oz/NZ is very much “We will fix the problem you came to us with. The other things must be dealt with in due course, through the proper channels, unless they have direct influence on the outcome of the problem you came to us with.” The doctors make no secret of this, if you are admitted to hospital with pneumonia, we will treat and cure your pneumonia. The gastro oesophageal reflux symptoms you have been having you will need to see your GP for. If he/she thinks it is appropriate, they will prescribe you something and/or refer you for a gastroscopy, at their discretion. The high blood pressure that is somewhat inadequately controlled you should mention to your GP while you are there, and they should adjust your antihypertensives accordingly. We will cure your pneumonia, and then you will go home. We will not see you in clinic in 4 weeks time to check on your chest, make sure you have had a gastroscopy, and check your blood pressure. Your GP can comfortably manage all of those things. If they have a query about anything they are welcome to contact us.

Hospital consultants in both countries, for the most part are specialists who usually participate in acute medical “take” in the interest of service provision ie. they have general medical patients with non-specialist requiring problems admitted under them every few days or so on a rota that they share with other specialists medical consultants. This is essentially how acute hospital based medical care is delivered.

If you employ the attitude above, the “We will fix only what you came to us with” attitude, what you DON’T get is Outpatient Clinics with 50+ people in them every day, waiting and stewing because they have to wait, and getting all upset because they were seen by a junior due to sheer workload and also because they are a return patient with no serious problems. Because the above patient and others like them can be followed up perfectly well by their GP. Indeed, they SHOULD be followed up by their GP for these things-ultimately the GP is going to need to be the most familiar with all of these problems and manage them accordingly.
In addition, the specialist consultant, say, an Immunologist who does medical take, is not seeing return patients with heartburn and high blood pressure in their clinics-they are seeing the people that need to be seen with rare T-cell deficiencies, severe combined immunodeficiency, people with atopic conditions, treatment refractory asthma, etc etc. Hence not too much of a wait for the specialist appointment if you really need one.

In Ireland, usually, most patients that come in under any consultant are booked for follow up appointments in Outpatients to check, basically, that they’re ok post discharge. The attitude among patients and staff is that the patient is going to have an NCT while they’re in hospital. There are a few reasons for this. (For those of you not from Ireland an NCT is a type of car servicing that sorts out the whole car so it can stay on the road-a roadworthiness check)

Every doctor is acutely aware of the waiting times in Ireland for procedures due to understaffing and stretched resources.

Your patient has been having heartburn for the past few months. They’ve lost a little weight but they think that’s maybe because they’re not eating so much because they have heartburn but they’re not too sure really. You ask have they tried anything for it-ah sure they got tablets from the doctor but they’re not really sure, maybe they were for the chest infection.

Hmm. The pneumonia’s gone. Patient is well, and should go home. But there’s the heartburn and the possible weight loss. Their haemoglobin is fine and it sure ain’t urgent. But they’ll be waiting for months and months on the outpatient scope list, so might as well sort it while they’re here as you never know, it could be something. It’ll mean a couple of days more in hospital as the inpatient scope list is pretty busy and your patient is pretty non-urgent but better to keep them in. More nights in a hospital bed that costs 600 euro a night. Their blood pressure’s high too. You’d better tinker around with their meds. Might add in an ACE inhibitor, they’re on all the other stuff already. Now you need to be monitoring their U&Es while they’re in hospital for the next few days.
Well they got their scope after three or four days, and now they’re on their way home. Seeing as how you ordered the scope, know the story, and also tinkered with their antihypertensives, they will need to be seen by your team in Outpatients really. The GP could follow up this stuff, but if there’s anything on the scope they will need a referral to a gastroenterologist or a surgeon, and again, this will happen faster if they are in the hospital system. And this happens to almost all your patients, and hence outpatient clinic lists grow ever longer.

In Oz/NZ if their pneumonia is gone you send them home and send a detailed letter to their GP. The GP makes an appointment for the patient to have an endoscopy which is done in a couple of weeks. There is no real indication for doing it sooner. They adjust the antihypertensives and check the renal function. The patient does not have to return to hospital for an outpatient clinic visit and wait a couple hours. All the stuff that should get done, gets done, in a timely manner. The scope lists aren’t clogged with not so urgent inpatients who need to be sorted before discharge otherwise they will be waiting weeks/months, and paradoxically, this means there is a little less total waiting time for scopes.

I can see why we did things the way we did in Ireland. The waiting lists for things are so long, we try to find ways around them, each one of us, for our own patients. But is this behaviour influencing the length of the lists and having a boomerang effect for us? I don’t honestly know, but thinking about it like that, I fear it might be.

But patients as well as doctors think differently in Ireland too. A large proportion will not be satisfied with you simply curing their pneumonia. I have been called out of clinic or away from ED because they want their antidepressants adjusted or maybe changed before going home. I explain that it’s not really appropriate for me to do that as I am not the doctor that is managing their depression (usually their GP or occasionally a psychiatrist). They become VERY unhappy with me as do their families and I end up having to get a psychiatric consult before they go home. Again-not so urgent-so maybe waiting another night in hospital before they see the psychiatrist. You can’t force someone out of the hospital if they really don’t want to go.

This simply does not happen here. I don’t know why. Patients seem to understand how the health service works here much better, and they tend to understand that certain things are more appropriately followed up by their GPs. But it is also pretty easy to see your GP here. They’re not very expensive, and there are a lot of them and it is really easy to get an appointment as they are not all snowed under. I walked in to a random surgery here one day for a check-up. I was waiting about ten minutes and they apologized for the wait! I’m quite used to waiting myself up to two hours at times back home, and usually bring a book and a drink, or my IPod. It’s expensive to see your GP at home if you don’t have a medical card, and access can be an issue as they are very, very busy.

Here in the Antipodes there is a fair amount of revenue spent on educating the public. There was my personal favourite, the “1-2-3 Where should I be?” campaign a few months ago that explained in an easy to understand, logical and unpatronising manner the difference between your GP surgery, the 24 hours acute care walk in services, and the Emergency department, and gave examples of conditions appropriate to each one as well as numbers to call if unsure. It was on billboards, TV, bus stops- everywhere. I thought again and again how we could do with that back home. How could you always know if you are not a medical person and you are in pain, where you are better off being?

It looks like more staff and resources again are at least one of the answers. The city I live in currently, I swear there are at least three medical centres on every street. GP access-SO not a problem. When I phone to make an appointment for an inpatient I’m given whatever day or time they want, instantly. There are one or two MASSIVE 24 hour GP acute care facilities and they too are easily accessible and uncrowded. If they refer you for a scope, chances are good you will get it in a couple weeks, because there are more resources and staff per capita than at home. Hence uncomplicated hospital discharges stay just that. Specialists don’t have to be hospital based GPs for at least half their clinics. People who need specialist appointments get them faster because specialists aren’t being hospital based GPs for at least half their clinics.

The next answer is more controversial. We need free access to primary care for all our citizens. Cost is a limiting factor in a LOT of people’s unwillingness to attend the GP in Ireland. I am not an economist. I don’t have a lot of ideas how this can be achieved. Practically, I think we may have to accept that we will have to ultimately pay more taxes, but I don’t really know. But it needs to happen.

Public education is another thing we need. Most Ozzies/Kiwis will tell you the names of their tablets, inhalers etc, and can often tell you doses as well. A LOT of Irish patients can’t. Because the time has not been spent telling them. The time, and the staff, often simply aren’t there, or are too busy. I have never seen posters telling people the most appropriate ways to use the public health services available to them back home.

All of the above, unfortunately, cost money. A LOT of money. More staff, more resources, more public health involvement in educating the public, more media campaigns to do so. This isn’t a post on how to save money for once, but a post on how things would perhaps be if there was more money to spend. And I don’t have the answers to that one.
Dr. Jane Doe

Sunday, 10 August 2008

Rageing mums

Posted by Dr. Thunder

There's something in the water over the last week, I've always said that the Aussies are a bit more aggressive than the Brits and Irish, who used to keep a "stiff upper lip" about things. If they had a gripe, they'd complain to their friends and family, rather than to me. That's not neccesarily a good thing by any means, but that's the way it was.

Here in Australia, it's very different. People complain. A lot.

It's one of the few things about life as a doctor over here that's tougher than being a doc in Ireland or the UK. I've definitely been hollered at more (by staff and my patients' parents) here than I ever was in Europe. In some ways it's a good thing. You usually know if people aren't happy with the care you're giving their kids, and you can explain the reasoning behind it. So, in some ways it's actually conducive to a better working relationship.

But in other ways it's just a pain in the arse. Like this week

Parent 1 went to see the paediatric orthopaedic surgeons about an infected wound. The surgeons had put it in a cast, for some reason best known to themselves, and told the kiddy to come back for review in 3 days. At the follow up appointment, the cast was removed, and the wound was still infected. So, they rang the paediatric registrar

"Hi Dr. Thunder. Its Dr. Bone from orthopaedics........blah blah blah.......we think this it's cellulitis., that will require IV antibiotics. Can you come and review?".

"OK", I said "But limb celulitis is something you guys can manage, so can you start the IV antibiotics? I'm stuck in the emergency department with quite a few sick kiddies, so it's going to be about 2 hours before I get there".

"OK, no problem".

2 hours goes by and I ramble onto the ward to see this kid. I walk over to the bed and say "Hi, I'm Dr. Thunder, how are we all doing?".

The torrent of abuse was unforgettable. It's also unrepeatable here. I was lambasted by this indignant mum for taking "2 WHOLE HOURS" to come and see her sick child.

I explained that there were 3 very sick babies in the emergency department, and I simply had to prioritise. Most people can see that kind of logic. But not this lady......"But we've been waiting TWO WHOLE HOURS" she repeated.

So, then I changed tact. I told them that the diagnosis of cellulitis had been made and that the antibiotics had been started, so any delay on my behalf wouldn't affect the outcome, as I was just here for a second opionion (In relaity I had no idea what I was there for, but I'm known in the hospital as someone who rarely refuses a referral for a consult. I'm a soft touch).

"The fucking antibiotics haven't been started yet. That's YOUR fucking job".

She was right. Nobody had bothered their arses starting antibiotics on this kid.

So, I sat there for a few minutes listening to some abuse, while writing in the notes. I have no idea what she said to me. She was screaming at the top of her voice about how I'm lazy and incompetent and the whole hospital should be shut down etc etc.

I walked off without saying a word. I paged the othopaedic surgeon with the following message "I can't believe you sent me into the jaws of hell without warning. Revenge will be mine. And don't think I'm cannlating that kid for you either!".

Parent number 2 rang me directly. She convinced switchboard to put her through to the on-call paediatric registrar. I answered the phone..."Hello Dr. Thunder, paediatrics".

"I want a prescription for Omeprazole 20mg twice daily, salbutamol 2 puffs as required....are you writing this down??.

"Eh, can I ask who's calling?".

"Mrs Smith....I also need some lamotrigine......".

"Hang on just one second. WHO ARE YOU?? Why are you ringing me up to write you a prescription?"

She sighed loudly, and started to speak very slowly and condascendingly."My son is a patient of the hospital. He gets these drugs. He's run out, so you need to write him a prescription".

Fine. I can do that. It's his own doctor's job, but if he's run out, then fair enough. So, I took his name and patient number so I could get his notes. I told his mum I'd prescribe whatever is in his notes. She said "OK, I'll be in at 11am tomorrow. Bye".

She hung up.

At 11, the pharmacy rang me. "Eh, this crazy lady is ranting and raving because you've prescribed the wrong drugs".

So, I went dowstairs to see her. Apparently her GP had changed a few doses since their last visit to the hospital, and she wanted them prescribed. I told her that I'd have to check with her GP first. At this point she went flipper. "Are you saying I'm lying?? I've been waiting half an hour for a simple prescription. This is outrageous. I'm going to write to the hospital about this".

So, I lost it. I shouldn't have, but I did.

"Listen. I don't know your son. I've never met him. I don't know him or you. I don't know if you're trying to scam drugs out of me, or if his GP did prescribe them for him. But I can tell you this'll either wait for me to check with his GP, or you'll get someone else to write this prescription for you. I'm doing YOU a favour, and I won't be spoken to like this.

I was quite proud of myself.

"But I've been waiting half an hour and it's just a prescription".

Oh sweet jesus.

I phoned the GP. Her story checked out. I wrote the new prescription. I brought it out to her. She just grabbed it out of my hand, and stormed off, as though she'd just dealt with some faceless, obstructive beauraucrat.

You can't win 'em all, I guess. But It would be nice to win once in a while :P

I've posted this not to have a go at anyone. I guess it was merely to point out that it's not all rosey in the garden of Australian healthcare. It's a damn sight better than what you deal with in Ireland and the UK, but we still have a way to go before we have a totally contented bunch of junior doctors.

Dr Thunder

Saturday, 9 August 2008

Lets All Hold Hands and Dance

I'm constantly apologising when I write to this blog, mainly because I never post as much as I want to. In truth thats down to two things........1) I've been so horrendously busy lately with the new job and 2) the Ain't No Angel wedding 2008 is quickly approaching and any free time I have gets taken up by that!

So bear with me folks,

I'm sure you've all been very happy though with the new addition to the team, Dr Jane Doe. Her posts thus far have been insightful and reasoned, much better than the tripe from that old hack Dr Thunder........:)

Joking aside though, its great to have her aboard, may she be the first of many more new team members!

So now for the bit you've been waiting for.....the Ain't No Angel trademarked rant.........

You might be wondering why I've posted a picture of Fernando and Robbie, looking happy and joyous above. Well apart from the fact that signing Robbie is an inspired decision on the part of the GodMan Rafa, I'm using it as a visual illustration of a concept sadly missing from the Irish Health Care System.

Let me explain........

Liverpool football club have many great players, but what we really missed last season was a player to play with Torres to link the midfield genius of Steven Gerrard/Alonso/Mascherano with the blonde excellence of Torres. Sure from time to time Stevie G stepped up to the plate and performed excellenetly, but it was never consistent enough for my liking, and ultimately we relied on Torres to produce a special moment far too much. This is were Robbie comes in, not only can he score many a fine goal himself, but as a player who sits back a little, works hard and links up the play he is one of the best around.

The Irish Health service is very similar. No.....we don't have long haird Spanish goalscoring machines performing colectomies, or emptying bedpans,but what we do have is this.......

All in all our hospitals are pretty damn good. When I say this, I mean from a clinical point of view. Our nurses, doctors and other professionals are well educated bright people. The standard of care once you get into a hosptial bed is good. Sure, there are resource issues etc but taken in isolation our medical care is comparable to anywhere else in the developed world.

When you look at the community setting, things are always so rosey, but certainly improving. Schemes like Hospice in the Home, which allows those patients on the last rung of the ladder, to die in their own home, with dignity and family support, are certainly excellent. I could name more.......the Diabetes Watch Scheme in the North-East, the countless local community day centres and community units.....and not to forget the army of Public Health Nurses covering huge areas of the country on a daily basis. Again, resources are an issue, but if all these things disapeared in the morning, chaos would ensue. I'd go so far as to say that those in the community are most definitely keeping the wolves from the door and playing a very large part in keeping the whole health service afloat.

Anyone see the anaology here.........

The hospital setting ( some world class staff in a system that needs some more basic funding and management)


Liverpools midfield ( some world class players, in a team that needs some more basic funding and improvement)

The community setting ( over-relied upon, over-worked even though they rarely complain and just get on with the jobs that they have to do)


Fernando Torres ( over-relied upon, over-worked even, rarely complains and just get on with the job that he hasto do)

So who is the Health Services Robbie Keane in this long winded and possibily confusuing analogy.......any guesses???

Well that would be a second level, a level between the acute hospitals and the non-acute community setting. A level for those people not quite sick enough for say a bed in St Vincents Hospital but not quite well enough to be home alone go and get sorted. A level where GP's have access to x-rays, scopes and even CT's allowing quick diagnosis and treatment. A level that would speed up the discharge of patient out of the acute sector, preventing the blocking of beds (that happens by no fault of the patient) and cutting the waiting lists and emptying the A&E Departments around the country, as people don't feel that the only place to go when the they feel sick is the local A&E.

In the new job, I'm spending a lot of time following my patients from admission through to their eventual discharge and treatment in the community, and my God it can get complicated! Every region does things differently, the right hand doesn't always know what the left hand is doing and the red tape can be frustrating! In contrast, when I deal with the private health insurers with many of the same aims in mind, its sooooooo easy, efficient and simple.

Spot the difference??

Wednesday, 6 August 2008

Doctor, heal thyself. And hurry up, for f*$k sake, there’s plenty of work to be done. Posted by Dr. Jane Doe.

I had intended to continue on with my cost cutting theme and bang out another simple idea for saving money within the health service. However, I’m angry about something and I think I’ll share:

I’m feeling a bit under the weather today. It’s nothing serious, but I am too unwell to work today as I am feverish, my glands are swollen, and I’m fairly miserable. It’s definitely contagious.

Now do I,

A) Suck it up, get my ass into work anyway and work anything from 8 to 36 hours straight with no designated break or sleep taking care of critically ill patients and making important decisions regarding their treatment and diagnosis while feeling terrible myself, unable to concentrate, almost unable to keep going, not to mind give them my full attention, such as it is at the moment? And almost certainly pass on my lovely virus to them? Being old and frail and already ill it might even be the straw that broke the camel’s back. And drive home afterwards in an impaired state and possibly endanger fellow road travelers as well as myself.


B) Recognise that my performance and decision making ability as a doctor is very likely to be seriously impaired today in addition to the fact that I have a responsibility to both patients and other health service staff members not to be at work when I may pass on a contagious illness and affect their health adversely and potentially cost the health service more in sick leave for others. If I become sick while at work, then after notifying my line manager who arranges cover I am expected to get a taxi home at the hospital’s expense if I cannot arrange for someone to pick me up.

I have done both. A) is the course of action you are expected to follow in one of the countries I have worked in. B) is the course of action you are expected to follow in another. In both cases the expectations are those of management as well as your seniors and even colleagues at your own level and you are obligated to follow them to the letter, and if you make the wrong decision, the consequences will be on your head.

Which do you think is the right attitude to have towards your job and responsibilities?
Which do you think is the right attitude to have towards the public service employees you are responsible for? Which do you think is the right attitude to have towards your juniors or colleagues? Which is the right attitude to have regarding patient care?

There is a climate of fear in one of the places, and often if you are so unwell that you physically cannot come to work and you do notify management, they will become angry with you, particularly if you are rostered for a 36 hour shift that day. In some places they make another of your colleagues pick up the shift, and then when you are back at work you have to pay them back in addition to doing all of your own extended shifts that week, rather than attempting to get a locum in. Working a 110+ hour week when you are convalescing is a real picnic, let me tell you.
You notify your colleagues, and you can get a mixed response, but usually they are disappointed and more than a bit angry with you. This is because they are going to have a bloody AWFUL day trying to pick up your work along with their own, and everyone is already stretched to over capacity. They too, feel the absence of a locum keenly as they stay on late that evening trying desperately just to make sure the patients are safely looked after, and stable. They won’t thank you for taking time out. I have heard of doctors working when their temperatures are so high that they are actually hallucinating, and still no-one stops them or makes them go home (or admits them to hospital, at least until they collapse!)
The doctors cannot stand up for themselves. There is no support from any quarter. In many cases there is nothing much they can do at all, and they soldier on. But they suffer and patient care suffers too. And no-one does anything about it at all.

In another of the places there is a climate of honesty, openness and taking responsibility for your actions. You are expected to recognize when your performance may be suboptimal, for any reason, including stress, and take appropriate action and notify the appropriate person when relevant. There are ample provisions in place for the inevitable event of staff members becoming ill, or needing maternity leave, or bereavement leave or even a holiday. A pool of medical and nursing staff employed specifically to cover absence are available in the hospital at all times and are allocated on a priority basis according to the activity levels of the services requiring cover. In the unlikely event of all the pool staff being utilised on the same day, a universal bleep goes out to all other similarly qualified staff in the hospital offering extra money and/or time off in exchange for covering the gap at short notice. This almost always works, and averts the need to attempt to find a locum.

I must emphasise I am not referring in the above post to any specific recognised policies or procedures in place at any specific location. Many countries share the type A) mindset with the place I worked, and many countries share the type B) mindset. Both are a way of thinking put into practice. One works well, and one doesn’t. In the end, one ends up saving more money than the other. The thing is, the one that sounds initially more expensive is the one that in the long run works out much cheaper, and I’m not talking about anything other than money here.

Anyone have any thoughts about which one is cheaper, and why?

Thursday, 31 July 2008

The HSE and Cost Cutting Part 2) Getting a blood test done: Posted by Dr. Jane Doe

“A penny saved is a penny earned.”
“Take care of the pennies and the pounds will take care of themselves.”
“Waste not, want not.”

My grandfather was quite thrifty. He used to love those old chestnuts above. He was a great one for shopping around, and finding a bargain, and loved budgeting etc. Unsurprisingly he was a financial advisor for a large corporation and they loved all the money he saved for them. He grew up in the post WWII days when people were careful with money and businesses kept a hawk eye on the books.

The thing is, even small savings add up over time. Another example that struck me when I first came here was request forms for blood tests. Again, selfishly, I only noticed it because it made my life easier at first, but then I realized how efficient it was and how it must surely be saving money for the system.

In Ireland, every blood test you want to carry out on someone has a different request form. And different hospitals have different forms for the same tests. In Ireland, if you are on a ward round and your consultant asks you to get urea and electrolytes, coagulation screen and a full blood count on someone (this is pretty much a standard admission profile), then in some/most hospitals this requires three different forms. In the first hospital I worked in, the urea and electrolytes went on a blue form, the coagulation on a red form and the haematology on a purple form. There was a green form for miscellaneous things and microbiology requests went on that and sometimes inflammatory markers depending on what ward you were on.

You also had to write in the name of the test you want done, for example if you wanted a thrombophilia screen in a lot of hospitals you had to write in “Anticardiolipin antibodies, antithrombin III, lupus anticoagulant, Protein C, Protein S etc etc” and of course there was one you always forgot to write in.

Sometimes the nurse or occasionally irate phlebotomist would tell you the glycoslyated haemoglobin (HbA1C) went on a miscellaneous form, then the lab wouldn’t accept it because it was supposed to go on a haematology form (the red one). You would be called out of clinic or away from a patient to come and retake the blood yourself and put it on the correct form. “Which one would that be?” you’d ask. Invariably this would take up to half an hour because you’d end up having to run it over to the lab yourself as well as taking it.
Sometimes the ward would have run out of the haematology forms and you could only fill in the biochem forms. You’d have to make time to get one another ward and drop it over later. If you don’t get one in time, the phlebotomist will have come and gone, and you’ll have to take the blood yourself, and run it over to the lab while your bleep goes mad with other “Just to let you know so and so hasn’t had their potassium checked today because you didn’t put out a form” notifications. “Sure I’ll come up as soon as I can. By the way, there weren’t any biochem forms left on the ward today. Would someone be able to order some more please?” Don’t ever say this-the inevitable response will be “That’s not my job.” “I’m not the ward clerk” etc etc. You will get your ass handed to you.

In the second hospital I worked in, haematology requests and coagulation requests were on the same red form. I loved this. So efficient! Now just to fill in the yellow form for the urea and electrolytes. I need to do FSH and LH levels too though, this person looks like they have PCOS. Yellow form? Is that the one? No-it’s the blue form but we don’t keep those here. You’ll have to request one from the lab. The porter won’t get those so you have to run over and grab one yourself and then come back to take the blood because the phlebotomist’s already been and then drop it back over to the lab again.

Hey-this person had a rectal bleed. We should probably do a Group and Hold on him (send a sample for crossmatch and blood typing to the lab in case he needs a transfusion later on). You have to do that yourself. Phlebotomists don’t do those. And you have to drop it down to reception yourself-only a doctor is “covered” to transport those.

AAARRGGHH!!! Anyone remember Michael Douglas in Falling Down? “I’m-having-a-bad-day”.

Down Under, there is one form for all blood tests bar blood bank requests. Want to check glucose levels, urea and electrolytes, FBC, Coagulation, D-dimers (did these go on the red one or the purple one at home? I can barely remember!) and thyroid function tests?

Pick up one of the blood forms. No writing, except for your name and the date. Tick the boxes next to the name of the tests you want. Put it in the box. There are four phlebotomy rounds a day, at 07:30, 11:30, 13:30 and 15:30. The next one will get his bloods done. You check them at noon. His Hb is a bit low, he might need a transfusion. Fill out a group and hold form and stick that in the box. The next phlebotomy round at 13:30 will get it done. He can start his transfusion at 15:00 if he needs it. You haven’t left the ward. No time wasted. All the patients have been seen and blood tested and results checked and acted on appropriately.

Printing off all those different forms and shipping them all off to different hospitals must cost a LOT of money. Three or four different forms for a couple of common blood tests! And all the problems that can cause. All the wasted doctor time, time that you as a patient have to spend sitting in A&E, or Outpatients, or the ward, waiting to be reviewed by a doctor who can’t come review you because they are acting as a phlebotomist despite the fact that we are PAYING phlebotomists so other people won’t have to leave their work to come and take bloods! All the overtime we pay to that doctor who stays late reviewing people who have had to wait all day because of this inefficiency in getting routine things done.

All we need to improve the above situation is:

1) One standardized form for all blood tests in all hospitals all over the Republic of Ireland. Understood by all laboratory staff, and all doctors and all phlebotomists.

2) Several phlebotomy round in a day. Phlebotomists to take all blood tests, Group and Hold samples too. This is not a special God given skill bestowed upon doctors on graduation. You can train anyone to take a blood sample and label it.

Time saved. Happier doctors. Happier patients. Money saved. Over a year or two, maybe quite a LOT of money saved. Enough to pay for at least an extra phlebotomist or two, I’d imagine.

Dr. Jane Doe

Saturday, 26 July 2008

HSE cost cutting

Posted by: Dr. Jane Doe

I'm hearing an an awful lot these days about how the HSE is woefully hard up for cash and needs to cut costs as a matter of urgency. People get very angry about this, as it will, no matter what, affect patient care.

Staff are not being hired, existing staff are being "redeployed" or their positions done away with, and new units and departments are not being opened as there is not the money to do so nor to staff them appropriately. Having worked as a doctor in Ireland for three years before emigrating Down Under for a better life, I can see a lot of ways the Irish health service could improve things for their patients and their staff that would also be very cost effective.

While I was working in the morass of chaos and hostility that is every day as an NCHD in Ireland, I was generally too busy trying to stay awake through 36 hour shifts and just trying to drag myself through the days to really see where the problems lay. Yes, we all had a sense of utter dissatisfaction and knew vaguely that things weren't working well, but qualifying how this was so was often difficult to do. After working Down Under for almost a year now, time and time again it has struck me how efficient the system is. How organized and streamlined. And by extension, how cost effective.

At first, in sheer relief at being away from the Irish health service, all I noticed was how easy it was for ME, to get my work done and done well and how stress free my days were. How I wasn't exhausted and depressed. However, looking closer at the whole picture, the system is designed to be easy for everyone. Other staff, but ultimately and most importantly, for patients. Patients here get fantastic care, from doctors and nurses who are looked after themselves and feel happy in their jobs as well as able to provide a good service in their jobs.

Recently there has been a mass exodus of junior doctors from Ireland, mimicking the 80's almost. In the past month a fair few have come from Ireland to where I'm working now, and I have usually been asked to show them around and orient them. Talking to them, and hearing their shocking stories about the way Irish hospitals continue to run, it makes me furious that no-one is doing anything about it still, after all this time. It used to be that Irish docs, on completing their intern year, did the obligatory rite-of-passage thing and went to Australia for a year, had a blast, went bungee jumping, snogged a surfer or two, and then returned to Ireland to get onto a GP training scheme or medical scheme etc and settle down to get their MRCPs and become a specialist registrar. This has changed even since I graduated. Now they are leaving, and not going back. All the NCHDs I have talked to in the past few days that escaped Ireland have no immediate plans to ever return. Many are expending their studious efforts on getting exams that will allow them to train as consultants in other countries-their USMLEs, Canadian boards, Australasian exams or even MRCP UK. Even many of the GP trainees are leaving Ireland and training over here-and staying. For the first time ever this year, the medical scheme in a certain part of Ireland had to advertise twice-still could not get staff and had to advertise in the UK. The chickens are finally coming home to roost.

I will illustrate example by example over the next few posts how inefficient, disorganized and downright unpleasant it is to work in the Irish health system compared with working in a well run system such as the one down here. What I'll do is give an example of a certain simple task, for example, obtaining and reviewing an Xray, that forms a daily part of any doctor's job. I will illustrate what it takes to do this in Ireland, and what it takes to do this here.

Example number 1) Obtaining and reviewing a chest xray. Scenario: You've decided a patient needs an x-ray, say, of their chest. You think they might have a pneumonia but they're elderly and not spiking a temperature, and have a history of congestive cardiac failure, and you need to differentiate so you can treat them appropriately.

Obtaining and reviewing an Xray in Ireland:

Find an Xray form. You could put it in the outbox to go down to the radiology department after letting the patient's nurse know they are for an xray. The problem with this is you don't really know if it will be collected and dropped down, this varies from hospital to hospital, from ward to ward. Some places have times that porters/orderlies come and collect these things. Some don't. Some require the nurse to bleep the porter to collect it and drop it down. Some porters won't come and some nurses won't bleep.

So it's really better in a lot of cases to run down to the department yourself with the form. This takes about 10-15 mins if you factor in walking down (quickly), after first making sure it's ok with your consultant or registrar if you leave the ward round to do so. This in itself will result in further problems and disruptions during the day-the consultant will order tests you won't know about and in general you won't know what happened with anyone they saw on the round while you were gone, which means you'll get bleeped a lot about things you don't know about until you manage to make time to go up and review the charts of anyone they saw while you were gone. No-one will be understanding about the fact you missed what happened, they in fact will be angry with you.

Anyway: You get down to Radiology and go up to the desk. The girl there tells you that after you register the xray at the desk you have to take it around yourself to the xray department. You do this. Another 10 mins or more, depending on whether anyone is available to talk to you and take the form. (Note: If it is something like an ultrasound, you may need approx another 15 minutes to try and justify to a unimpressed sonographer why your patient should have an ultrasound. They may refuse and you will have to do some more tests on your patient to strengthen your case, and return to them at a later time/date.)

Anyway. You return to the ward round and later during the day you have to check the xray. You go down to the Xray department. You look first in the Xray dept in a box that they keep some of the most recent Xrays in. It's not there. At this point it has been moved to somewhere in the department in some pile and only people who work in the radiology dept could really know where it is. You spend the next twenty minutes looking through piles of Xrays and checking the names on them and asking around and generally getting underfoot. Assuming you eventually find it, you cannot take it out of the department to let anyone else look at it, so if you are unsure about something you see on it-is that a pneumothorax in the left upper zone?? you have to take it to a radiologist to get a verbal report.

This is where you start sweating and feeling nauseous. Radiologists want you dead. They do not want to give you a verbal. They want you out of the dept and out of their lives. This is because they are much too busy and their workload is too great. Any mistakes they make are immortalized in film. The consequences of making a mistake are too great for them, the media typically does not let serious issues like a dangerous workload get in the way of a good old witch hunt when a doctor is involved. So they are weary, and not happy to see you, most of the time. This is where you have to justify why you need a verbal. You had better know ALL of that patient's history off by heart, blood results, everything, because if they ask, and you don't know, it will not bode well for you.

Assuming you get through that part ok, 15-20 mins later, and arrive back up to the ward having a diagnosis of Congestive Cardiac Failure (CCF), you can now treat your patient. You wrote the Xray form at 11 am. It's now 15:30. You think they should have some IV Frusemide to treat their CCF. You chart it. Nurses in Ireland do not give IV medications in the first instance, they only can give them "as per protocol" ie. after the doctor has given the first dose. There is no evidence based reason for this practice, and it is not safer or better for the patient, it just is. Frustrating for doctors AND nurses. So you go to the drug room. The IV press is locked. You ask around for about ten minutes till you get the key. You draw up your frusemide, go and give it and then go to sign for it. Someone has taken the medication chart. You should have remembered to keep it locked tightly under your arm or sign for it before you actually gave it but you forgot because you were drawing up the frusemide. You look all over the ward. Someone has it but you can't find it and your bleep is going mad. You leave and a while later you get a bleep to come up give the Frusemide because the nurse can't give a first dose IV. You explain you've given it but someone took the medication chart and you were called away and couldn't sign for it. You are told to come up and sign for it. You do so. It's now 16:15.

Obtaining an Xray and reviewing it Down Under:

Find an Xray form. Fill in the details. Go to one of the fax machines on the ward (there are several so people don't have to wait). Fax it down to the Xray department. Approximately 30 mins later you see, as you continue on the ward round, your patient being wheeled off by a porter that xray sent up to get them.

Approximately 20 minutes later you check the PACS system on one of the ward computers to look at the xray. You haven't left the ward. You think there might be a pneumothorax in the left upper zone, so you turn to ask your reg who is still on the ward with you finishing the round. They tell you there isn't one, and spend a few minutes discussing chest xrays with you and you learn what bronchial cuffing looks like and commit to memory.

You go to chart the IV Frusemide and let the patient's nurse know you have charted a stat dose of something. They thank you for letting them know and you say thank you back. You continue on the ward round. After about half an hour you bump into the same nurse who says how much easier your patient is breathing after all that fluid was diuresed off of their lungs. You are glad the problem was easily solved and that your patient is now comfortable. You thank her/him for letting you know. You bump into the family as they are visiting and update them on the patient's progress for a few minutes before continuing to see the rest of your patients. You faxed the form at 11am. It's now noon. However, you never left the ward.

You know what's happening with all your patients as you were on the round. You were taught several things on the round by your consultant and now you are a little less ignorant. See what I mean? Patient was treated more quickly, less overtime was paid to a doctor, less people were left waiting while the above shenanigans took place which results in quicker and better care for those patients also. Less money wasted. Better outcome. If the HSE wanted to cut costs, all they have to do is attempt to provide an efficient sensible service. It's not hard.

Next week I'll give another example of a simple task and compare its execution in both systems, then compare how caring for patients well is actually cost efficient, something I feel the HSE does not understand.

Dr. Jane Doe

Friday, 25 July 2008

DNUK making me mad!!!

Posted by: Dr Thunder

I use email a lot. Especially right now. I'm emailing a few people back and forward about registrar jobs for next year. For roughly the last 8 years, I've used the email services at for everything.

I went to log in today, as I was expecting some important messages. As I typed in my password I was greeted with the following message...."Your account requires security clearance, please ring our helpdesk".

WTF? I thought. So I rang them. They explained to me how they realised today that I wasn't registered with the General Medical Council of the UK any more. Therefore they were cancelling my account. "But I work in Australia, I haven't been registered with the GMC in about a year" says I.

Them's the rules I was told. But don't worry, we can hook you up with our sister site http://www.ausdoctor/ or something like that. They'll even transfer my emails over for me.

That's not the end of the world I figure. So I ask when this will happen.

"Tuesday", they tell me. Tuesday in the UK will be wednesday over here. That's a lot of potentially important emails to miss. I ask can they reinstate me on their UK site until tuesday, then.


They're the rules.


My parents arrive in Oz on sunday for a holiday. They're spending a couple of days up north before meeting me. Their phone won't work here. It's ok, Thunder junior, we'll email you on sunday and arrange everything that way. It's just totally unneccesary. I'm spitting mad here thinking about it.

So, on tuesday (wednesday my time) they'll allow me acces to the oz equivalant of and then they expect me to stay with them????

I'll be forwarding all my old emails to whoever my new provider is, and saying goodbye to them.

So, onto the real reason I posted this blog entry.....can anyone reccomend a good email provider in Oz. I've been with the same guys for 8 years, so I'm a bit out of touch!

Thanks in advance,

Dr. Thunder

How are there ANY doctors left in the UK?

Posted by: Dr. Thunder

So, I'm back from my outback junket.

I'm back practising medicine in a hospital that has actual equipment and specialist staff. It's nice not having to say to any more patients "You need to see a neurologist. There's one visiting from the city in 6 months time. I'll see if there's s space on his list, if there isn't, of you can't make that appointment, he'll be back about 8 months after that", or "Yes, your child needs to se an Ear, nose and throat specialist. There isn't one here. And none visit either. I'll just have to refer you to a general surgeon. He'll probably know something about tonsils".

As I've had no real regular internet access for the last few months, I've been catching up on the world of medical blogging this week. There seems to be one recurring theme coming from the UK. That is This has managed to annoy the medical fraternity in Great Britain like nothing since the government told them they would be making thousands of junior doctors unemployed "But patient care won't suffer".

So, I had to investigate further. Iwantgreatcare is the brainchild of Dr. Neil Bacon. He's a doctor who set up the excellent website

Spurred on by the success of that particular endeavour he has now embarked on this new project, which aims to let patients judge their doctors online. So, you go to, find your doctor's name, and give your opinion of him/her. Simple and quick to do, and increasing transparency and accountability. This is what Neil Bacon says anyhow. Obviously, the patient isn't identified. there is no way to verify if they are a patient and there is no right to reply for the doctor.

I have grave concerns about this. It sounds condescending and paternalistic, but patients aren't always the best judge of a doctor's performance. This week a particularly aggressive mum demanded I give her toddler antibiotics for a snotty nose. I refused. I tried to reason with her, but she went home in a huff. I believe I did the right thing. If Iwantgreatcare had a section dedicated to "Irish doctors in Australia", she would no doubt have told the world that I was a crappy doctor who doesn't even know how to treat a runny nose.

Similarly, the lady who went potty at me in the emergency department 3 weeks ago would likely be another customer of Dr Bacon's. Her child had a mild viral rash. The emergency department doctor tried to send her home with reassurance, but she wouldn't go anywhere without seeing a paediatrician. I was called about this very well child while I was stabilising a newborn that I had just resuscitated in the neonatal unit. I said I was going to be a while. I was. It took me about 2 hours before I got to see this rash. The child's mum went crazy. She said she was going to write a letter to the hospital. She may have done, I don't know. I told her that, as the only paediatrician in the hospital, I had to prioritise. A very sick newborn takes priority over a well toddler in the play area with a rash. Two hours was the best I could do. It wasn't good enough, apparently.

She would love Iwantgreatcare. So would many of my patients' parents.

I have an excellent rapport with most of the familes I interact with in work. I don't imagine, though, that they'd go home and look up a website to tell the world that I'm amazing. But those who have a gripe will. Just like the patient on that same website who says his doctor "put his wanger in my ear"!!! Or the doctor who was described as being "like David Brent".

But it's only a hair brained scheme, and it will likely die out soon as no-one in their right mind will regard something like this as being the way forward in assessing doctors. Surely anyone with half a brain will realise that allowing anonymous comments by anyone on the web about any random doctor, without any verification process whatsoever, is not sensible?



Apparently, senior members so the General Medical Council (The body that regulates medical standards in the UK) and the government support this idea, and are giving this website their backing.

I despair, I really do. We can give patients what they want, or we can use our judgment. I know what i'd rather my doctor did.

May I remind any doctors in the UK who despair at being reapeatedly humped from all sides by a crappy union, an ineffective regulatory body and a shamefully spin-driven government, that it's 27 degrees here, and it's mid winter :D

I look forward to seeing more of you guys out here soon. I'd also be very interested in comments about how we should regulate doctors' standards in a sensible way. Maybe you think IS the sensible way.

Share your thoughts below.

Dr. Thunder

Saturday, 5 July 2008

It's access to health care, stupid.

Posted by: Dr. Thunder

Hi all. Sorry about the lengthy absence. I've been sent up to a hospital in "rural Australia" to cover staff shortages for a few weeks, so I've not had regular internet access. I shall blog about my outback experience when I'm back to civilisation next week, and have a functioning laptop at my disposal.

But Ain't No Angel's post below inspired me to haul my ass out of bed between 24 hour shifts and put finger to keyboard this morning.

It seems he's been poached away from the coalface by the private sector, like so many good nurses before him. Good luck to him. Given the right opportunity, I'd jump ship too. I wish him all the best. Sadly, the hospital system has lost yet another bright young mind to disillusionment and poor management.

But does it really need to be like this. We have nurses tempted away from the coalface, not by unimaginable sums of money, not by improved status, not by glamour and not by less work. I don't know the details of Ain't No Angel's contract, but it seems he was won over by......."normality".

What I mean is that... what the private sector could offer him, that the public sector can't, is the chance to have a normal life, and human working conditions. In the new job he's well respected, he's properly and promptly trained for the tasks he's expected to perform, and he is allowed make decisions. He also, presumably, has opportunities for promotion, too. OK he gets a pay increase. He also gets a company car, but it's an "on the road" kinda job, by the sounds of things.

My point is that a company car and an extra few quid wouldn't be enough to pry our nurses away from doing the job they were trained for if they had the other things that Ain't No Angel talks about....autonomy, respect, proper training, career progression, reasonable working hours and freedom from bureaucracy.

I have said it time and time again...whatever savings the HSE think they're making in the short time by shafting patients and staff in Irish hospitals is costing them in the long term.

How many agency staff will be employed to cover Ain't No Angel's work? how much will that cost? How much did we spend to train Ain't no Angel? Now the private sector will reap the benefits of our investment. How many nursing students will miss out on his mentoring skills, and how many patients will be worse off for not benefiting from his care?

But then again, this government has never cared about the long term. They can't see past the next election.

Which brings me onto.....well, healthcare in Ireland actually! More specifically access to healthcare in ireland.

This week I have gotten 2 text messages from friends in Ireland asking for medical advice about their ailments. This, I must say, has been a quiet week for the Dr. Thunder health advice line.

Why would an adult risk their health by taking advice via text message from a paediatrician who's in a different hemisphere?

Well, let's look at what you need to do to get a non emergency medical problem dealt with in Ireland.

Step 1: Go to your GP. Take time off work. possibly loose money for it. Then you pay 60 euros for the privilege.

Step 2: Try conservative management first, then come back for a review. Another 60 euro.

Step 3: After an indeterminate amount of GP reviews, you might be referred to a specialist. Waiting list in Ireland are up to 2 years.

Step 4: Specialist sees you, and tries first line treatment. Can't bring you back to evaluate treatment for another 6 months due to lack of appointments.

And so on.
3 years later, you're well on the road to getting an appointment to start the process of recovery!

In fairness, I'd take my chances with a "I have a lump on my head, wot is it plz?" text message, too.

Free access to GP services is what I believe needs to happen. Then, and only then, will those on low incomes be able to take control of their health. Sure, it'll cost a hell of a lot of money. But if people could afford to go to their GP to get their cholesterol checked, to have their blood pressure measured, to talk about giving up the fags, then we could potentially claw back a significant amount of the money, while at the same time improving the nation's health.

But when you have the choice between paying 60 euro to have your BMI measured, or buy the tin of baby formula that your nipper needs, I know which most people would choose.

But what do we expect of a government that has so little regard for public health that it refuses to allow public health consultants to use the title "consultant", and pays them less than half of what their clinical colleagues earn?

Pay peanuts.......and everyone will emigrate to Australia :D

Dr. Thunder.

Friday, 27 June 2008

Was he pushed or did he jump.......

I'm back........from my imposed sabbatical as a blogger, and I've got news!

As any regular reader will know I can be quite a grumpy sod but all in all I love being a nurse-boy. I do however have major issues with how the health system in this fair isle of ours is run and the stupid situations we clinical peeps have to put up with day in day out. So a few months ago I started looking around for something new...........


I left ward nursing and all the hospital bollocks for a job as a clinical specialist/advisor/rep for a rather large, nice, progressive company. Thus, you may now understand my enforced absence from the Internet is general.......(Sorry Dr T, i should have told ya!)

My day now consists of trotting around in my car, speaking to nurses, dr's and anyone else who will listen. Educating about medical conditions, nutrition, co-morbidities and what I can do to help. I teach public health nurses best practice and how to get the best outcomes for patients, reassuring people with toes hanging off, that we'll do our best, and looking super freaking sexy in an array of suits.

Did I also mention I've had a pretty decent increase in pay, an expense account and a company car! All for kinda just being a nurse.

What a difference a capitalist sell out can make!

All in all, I'm pretty damn happy I made the move. I get to see some mad shit......burns, cardio, plastics, GI, Colo-rectal you name it. I'm seeing the best and the worst. I'm learning stuff each and every day ( a cardio-thoraic consultant taught me how to read ECG's the other day) and finally feel like the 4 years I spent in college getting a degree is paying off, and getting quite a lot of respect for the knowledge and advice I'm giving. I'm allowed to be pretty autonomous in how I do things, and am trusted to get on with my read back and see the sort of things I used to write on here...........big change methinks.

If nothing else, this gives me another string to my bow, and maybe I'll go back to hospital work in a few years, armed with a bit more knowledge aboout how the bigger badder world can and does operate. But maybe like hundreds of other RGN's, I won't......and thats the shame of it all really. The health service in both Ireland and the UK is hemorrhaging nurses quicker than an arterial bleed on a stab victim.......and what do they do to stop this.........sweet fuck all other than do their best to piss us all off even more!

Don't worry, I'll still post here, tell anyone who wants to listen about the crazy stuff I've been seeing and stuff, but as a final note.......and just in case anyone form the god old Dept of Health down in Hawkins House is reading, take this as a learning point. I've worked hard and well for you guys for a while now. I was pretty decent at my job, and gave you more loyalty and time than you deserved. But I did it for any of the patients that I was looking after. But you fucked it up, you pissed me off so much that I felt I couldn't work or give you anymore. SORT IT OUT lads, and maybe you'll eventually get the good nurses, Docs, physios, OT's etc etc etc etc etc etc etc etc etc etc back again, and give people the health service that they deserve!


Ain't No Angel

Friday, 30 May 2008

The mental health lucky dip

Posted by Dr. Thunder:

I'm struggling a bit lately. I help run this "Child and adolescent behaviour clinic" once a week at my new hospital. As I've said before on previous posts, I've no real training in this kind of thing. Adults with mental health problems get seen by psychiatrsists (well, they're supposed to), but kids here get seen by the paediatrician for pretty much every ailment under the sun (medical, surgical, psychiatric). It's fine. I'll get used to it. But at the moment, I'm a little out of my depth.

I saw a kid today. A 7 year old girl with Attention Deficit Hyperactivity Disorder. She's got it BAD, to the point where she is pretty dysfunctional. Her brother has mild autism. Both her parents are disbled, and on disability allowances.

So, the little autistic boy goes to a special school, and is in a tiny class, with an individual carer. Quite right, too. The health authority seems to regard autism as an "important" illness. He does well at school, and functions relatively well in her day to day life,within pretty strict parameters.

His sister with ADHD obviosly hasn't got an important enough mental health problem. She has to go to the local state school, which is a very good school. But there's 26 other kids in her class. There's no individual teaching assistant. There is no one-to-one time.

To my mind, the child with ADHD has a better chance of managing to get what we in the mainstream would call "a good education" than her autistic brother. The autistic child is likely to require care for the rest of his life. That is not the case with his sister.

So, Nicola (with the ADHD) is doing badly at school. Her lovely parents are very worried. They came to me with an agenda today. They informed me that if Nicola was diagnosed as being on the autistic spectrum, she would get the financing for a classroom assistant.

Nicola's parents can't afford an form of extra tuition.

They looked at me, hopefully. They wanted me to diagnose Nicola with autism. I couldn't do it. It's not ethical. But it's tempting. I told the parents this. They're sensible people. They understood. But it didn't stop me feeling like crap for the rest of the day,a s I sent Nicola away with an increased dose of Ritalin.

I shall see her again in 2 months, when her school reports have deteriorated further. I have asked ther social worker to look into their situation, but she didn't hold out much hope.

I see Nicola becoming a pretty unproductive member of society when she leaves school, due to what is likely to a huge educational deficiency. We'll complain about how much benefits the state will have to pay her for many many years. Sadly, the savings would be enormous if we could just give her the money she needs to get some help at school.

Roll on next week's clinic!

Sunday, 11 May 2008

Psychiatry services making me crazy!!

It's been a long week. Nothing too out of the ordinary, but there's a lot of sick kids kicking about in my neck of the woods right now.

One in particular is "sick", but not in the way in which we think of sick kids. Sarah has a psychiatric illness. I think. I'm no psychiatrist, but when you're on-call for paediatrics, all kinds of things come your way.

So, earlier this week i took a call from a worried GP. He had just seen Sarah*, who's in her early teens, and had been brought to him by her mother. Mum was worried as Sarah has been becoming more withdrawn over the last few years, and is now at the stage where she hardly speaks. She also suffers from delusions and paranoia.

So, the GP sent her to me as he was having difficulty finding the psychiatrist on-call, plus he reckoned a kids ward would be a more friendly "waiting room" than either A+E or the psych department. I agreed entirely, and told him to send her straight to me.

When I met sarah, 2 things struck me.

1) She has a LOT of issues, and needs psychiatric assessment, and likely psychiatric treatment.

2) She has been neglecting her own healthcare. Sarah has other quite serious medical problems, and is required to take medication every day. Mum reckons she never takes her medicine. In fact, mum is SURE she never takes her medicine.

I had a chat to both of them. I told them that I'll phone the psychiatrist and get him to have a chat. They agreed. Mum was amazed that sarah was open to the idea of psychiatric input, as previously she wouldn't even go to her GP. We had to ride thinsd wave and take the opportunity to get her help while she was willing to be helped.

You could see they were both relieved that something was going to happen.

I phoned switchboard and asked them to put me through to the psychiatrist on-call. "No problem, doctor, one moment".
The phone rings, and a very pleasant lady answers.

I say "Hello, this is Dr. Thunder from paediatrics, are you the on-call psychiatrist?".

"Well, I'm on-call FOR psychiatry".

"Ok, well, I need a psychiatric evaluation of a patient. I'm not sure if she's psychotic. She's a teenage girl who has a 2 year history of ......."

"Can I stop you there, doctor?".


"I can't assess your patient, i'm a social worker".

"Oh, OK, not to worry, can you put me through to the psychiatrist, then , please".

"No, I'm on call for psychiatry".

"But you're a social worker".


Oh fuck.

After a few minutes of trying in vain to explain my situation, I was put through to "our clinician".

Thank christ.

"So, are you the psychiatrist on-call?"

"Well, I'm on-call FOR psychiatry"

"Are you a psychiatrist?"

"No, I'm a psychologist"

Sweet baby jesus on a motorbike.

Better than nothing, i suppose, and definitely better than me! After finding out that there are psychiatrists around, but none of them are on-call. I asked the psychologist to come and have a chat to Sarah and her mum.

"I can only get involved in conjunction with the psychiatrist".

"OK, can we get the psychiatrists involved then?".

"They're not around today"

I hung up.

So, the question is...what in the name of good is a social worker doing "on-call" for psychiatry??? Is their doctor sitting in the social work office helping people with their housing applications?? It beggars belief.

I let sarah and her mum go home. I spent half a day trying to get them psych input. They really need it. But instead they are coming back to see me at the general paediatrics outpatient clinic next week. I've slotted them in at the end of the day. So, I will try to get them a psych review at 4.40pm next thursday. I don't hold out much hope.

When you're a sick kid, and you have a "trendy" illness, the whole world wants to know. If you have no hair, and a tube in your nose, then you are worthy of sympathy at the highest levels. Actors and sports stars come and see you in hospital. there is huge govenment funding for new buildings, and no drug is too expensive. Quite rightly, too. these are some of the most vulnerable people in society, and that's who we should be doing everything in our power to help.But, if you're an adolescent with a psychiatric illness, you are also vulnerable. Probably as vulnerable as anyone else in society. But there are very few hospital visits by the rich and famous, and you might not even have access to a doctor. Imagine theheadlines if a child with cancer couldn't get access to a doctor in a developed country.

On a lighter note, I bumped into one of my cardiology colleagues yesterday. It had been a rough day for both of us, as we both chatted in ED. I'd just admitted a septic baby, and a diabetic ketoacidosis. He'd been involved with some clot-busting shenanigans that I don't really understand anymore. It was 2am. We had both been in work since 8.30 that morning.

So, exhaustedly, he says...."I really wish i'd done a specialty like paediatrics instead of cardiology. I'd love to just play with kids all day. I mean, you wouldn't believe how sick people get on my ward".

Indeed. At that point I left to go and deal with the 3 year old having uncontrolled seizures in cubicle 3..............

*As always, I have used a false name.