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?