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.