Tuesday, 24 February 2009

Spin Doctors are expensive!

The front pages of several papers today state that the HSE spent a staggering 51 million euros on SPIN DOCTORS!!!!

I hope they mean the band. They're not great or anything, I find that one song I do know very annoying, but quite frankly it would make more sense. And it would be marginally more entertaining.

So we're slashing frontline staff and services left right and centre-and paying spin doctors money to make it sound like it's all a good thing when if we didn't pay the spin doctors we wouldn't have to slash a lot of the services and this would actually in reality be a better thing and...and......I've gone cross eyed.

Just when you think you've seen it all. You, you know, see some more. And stuff.

Dr. Jane Doe

Friday, 13 February 2009

I believe the kids call it a "facepalm"

A facepalm, as pictured above, pretty accurately describes what I did when I heard the news last night.

Mary Harney, the Irish minister for health, has announced the formation of a committee to look at ways of reducing clinical mistakes in hospitals. This will be a panel of experts who will get together and publish a report in 18 months time, apparently.

Incidentally, there is also a "commission on patient safety" in existence in Ireland, whose role would appear to be the same as that given to this new committee. However, the commission recommended the setting up of this new panel back in July 2008. The minister announced it's formation yesterday. Indeed.

But this was what got me. Harney, in her distress at the interminable suffering over the practice of shoddy medicine by Irish hospital staff, admitted she had no figures for medical errors in Ireland. But she does know that "Medical claims were costing the state 60 million euro every year" and that the aim of the process was to "reduce adverse events in the health service, and to reduce litigation". So, eh.....seeing as you admit to not having any statistics for medical errors (despite setting up 2 expert panels to combat the "problem") how are you going to know if your new committee is having an effect, Ms Harney????

Now, Minister, I'm no economist. And I'm no risk analyst. But, and apologies for the bold capitals, I have a suggestion for you, if you want to reduce medical errors in hospitals..................


I'm glad I got that off my chest. I'll be here all week. I'm also available for Barmitzvas and public policy.

Dr. Thunder.

Wednesday, 11 February 2009

The Spin Doctors Against Doctors.

Posted by: Dr Jane Doe.

"If you, would like to call me lazy, just go ahead now. And if you, would like to call me greedy, just go ahead now."

The HSE is targeting the most vulnerable group in the health service for extreme cutbacks currently, and disproportionately compared to the cuts being proposed elsewhere.
Among the cuts being proposed are:

• Mandatory 1 hour unpaid meal break
• Suspension of Training Grant and PGMDB Allowance
• Discontinuation of Higher Degree and Diploma Allowance
• Attendance at in-house training no longer paid
• Discontinuation of Living Out Allowance
• Introduction of mandatory unpaid Pre call/Post call
• Overtime payment: Monday to Saturday
• First 9 hours paid at flat time
• Balance of hours T + ¼
• Sunday & Public Holidays T x 2

In addition the HSE is aiming to introduce the following measures:
• Rosters formulated 8am to 8pm
• Hospitals to examine and eliminate unnecessary layers of on-call
• Maximisation of on call off site where feasible
• Cross cover across different specialities to be maximised
• Full roll out of successfully concluded NIG pilots
• Interns employed on 48 hour week from 1 July 2009

In addition to these cuts specifically aimed at NCHDs, as public servants you will also be subject to the Government’s proposed pension levy which will result in between a 6.4% and 8.5% deduction from your overall salary. (I might add that, although the pension levy that NCHDs pay is based on their income PLUS overtime-ie if you make 60K a year you will pay the proportionate levy-the pension NCHDs will accrue is based only on their BASIC pay. Food for thought, no?)

Before the recession hit Ireland NCHDs (Non Consultant Hospital Doctors-ie; interns, Senior House Officers, registrars and Specialist registrars, often called junior doctors despite the fact that many of them are in their forties!) enjoyed wonderful working conditions. Ah the Celtic Tiger. Truly a golden age.


The Famous Overtime Pay!

We worked anywhere from 60-120 hours per week. Our hourly rate was about ten euro less per hour than a primary school teacher. We did weekends “on call” which is a silly and grossly misunderstood euphemism for just plain old working, that lasted anywhere from 56 to 72 hours straight-with NO SLEEP BREAKS OR MEAL BREAKS SCHEDULED.
Our so called public service “job security” consisted of having to reapply for jobs and do interviews all around the country every six months to a year, indefinitely. We were shifted from hospital to hospital every three to six months, often in different parts of the country working with a whole new set of people and having to get used to a new hospital. We weren’t given so much as a day off to move house if we were rotated from say, Galway to Dublin, and many NCHDs moved themselves, their possessions and their families to new locations overnight and started a new job the next morning after pulling a change of clothes and their stethoscopes out of the boxes in the hall.

If we became sick while in the middle of a shift that could last anywhere from 32 to 72 hours then we had to keep working. If we were vomiting, had diarrhoea, had a high temperature, whatever. We had to keep working. If you became ill during the office hours of HR and management (9-5 Monday to Friday) then if you informed them they would often get angry with you, following which they would try and bully one of your colleagues to work the “on call” shift instead. Before even attempting to get a locum sometimes. The “on call” shift means that the person, who started work at 8 or 9 in the morning, has to stay on and keep working continuously all day, all night, and then resume their normal duties again the next day as though they hadn’t just been up all night working after working a full day too. 32 hour long shift-minimum. Usually it was more because one was so much slower at everything after already having done 24 hours straight with no sleep.

When we worked weekends, we worked all the next week too. In many hospitals around the country this meant that we came in on Saturday morning to work, and worked until Monday evening. No scheduled sleep break. No scheduled meal break. Even if you dared to have a shower you kept a nervous eye on your bleep. Often for most of this 72 hour shift we were continuously awake, and unfit to drive home on Monday evening. Following this marathon of insanity, we came back to work, bright and early, on Tuesday morning and continued working the week. Often there was another 32 shift ahead of us that week.

Yes, we were paid overtime at rates determined by the Labour Court. Time and a quarter for the first 15 hours after one went over 39 hours in the week, then time and a half thereafter. So after you had worked 39 hours, from hour 39 to hour 54 you were paid time and a quarter. From hour 54 onwards you were paid time and a half.
The Irish media has made quite the sensation of this. However, they forgot one teensy, weensy leetle detail.



The above working conditions have not changed and are still in practice all over the country.

There is currently, in Ireland, not one single NCHD who wouldn’t gladly take a pay cut in exchange for a reduction in working hours that would ensure adequate staffing and not compromise patient care. I for one would gladly never ever work another 32 hour shift with no sleep, if I could work a 40 hour week and be paid my basic wage. But, and this is the really big but, these OVERTIME HOURS ARE MANDATORY AND IT IS A BREACH OF CONTRACT TO REFUSE TO WORK THEM. We are contractually obligated to work an unspecified number (ie. however much they tell you to) of hours of overtime in addition to the normal 39 hour week. In addition, were we to all work only 48 hours a week, with the current staffing levels, patients would suffer and patient care would deteriorate drastically.

When the media runs these sensational headlines “Junior Doctor in Wherever Earns 100K in Overtime” they don’t seem to mention what the junior doctor was obligated to do to be paid that wage. This amount of overtime means that this doctor was working approx 120 hours a week, and was a registrar or an SpR. This means that he/she was doing 56-72 hour shifts with no sleep breaks at weekends and doing them every second or third weekend. This means that this doctor was chronically exhausted, never saw his/her family, drove a car and endangered their lives and the lives of others on the road while under the influence of severe fatigue. This means that the patients that he/she was treating were being treated by a medical professional who was so tired that their decision making abilities were akin to those of a person who was over the legal limit.

Personally, the unpaid days off pre and post call that the HSE are proposing sound almost humane to me. A 32-36 hour shift with no sleep or meal breaks will become a 16-24 hour shift instead. This is still insane, but more humane. And less dangerous. They will run into problems staffing the wards during the day, to be sure, if several people are off for two days because of a night on call. But overall, it will be preferable. For us.

The working conditions BEFORE the above proposals were already so bad that Irish trained doctors have been emigrating in the hundreds to Australia, New Zealand, the UK, USA and Canada. At earlier and earlier stages in their careers. Making the conditions worse is going to cause a torrential haemorrhage of doctors the like of which will not have been seen since the eighties.

The Mathematics of Overtime:

It often surprises me that people would become incensed by the thought of someone working 100 hours a week and getting paid for them. The fact remains that if ANYONE worked 100 hours a week doing whatever it is that they do and was paid for them, they would make a lot of money. Hell, if you were paid minimum wage, 8.65 per hour, and worked a 110 hour week like a surgical registrar on some crappy rota somewhere with no locum cover who never gets to see his/her family, you would make 951.50 that week. That’s 4281.75 per month. So if you make 20 euro an hour, then you come out with 9900 per month before tax. This is taxed at the high rate, so I don’t know, you probably get a lot less after, but still.

You see my point. If this junior doc with his 100k worked a 40 hour week instead of a 100 hour one, his salary would be nothing to write home about. If my buddy the primary teacher worked 110 hours a week, they would make 3630 per week gross as they’re on a higher hourly rate than an NCHD.

When NCHDs work a 40 hour week and get 100k, then that will be newsworthy. When they work 100 plus hours a week and get 100k that’s called basic mathematics. (If they worked 100 hours a week and got 40k this would also be newsworthy, as it would mean that registrar doctors in Ireland were paid approx 7 euro per hour, and this would be gross exploitation).

I’m not sure how the HSE thought that this spin was going to get the public on their side. Only an idiot would not be able to do the math here. (I used the calculator on my phone, but you take my point!) No matter how many stories they run about NCHDs working illegal unsafe hours being paid for those hours, they aren’t fooling anyone anymore. Maybe they should hire more doctors and divide our hours equally. Hmmm?

The Training Grant-and by extension, the training:

Being an NCHD in Ireland is an expensive business. One pays the Medical Council about 400-500 euro per year to stay on the register. The training grant does not cover this. Medical Indemnity insurance costs another couple of hundred euro, again out of your own pocket.

Things that the grant will cover:

To register your GPT-that is your General Professional Training, now changed to BST (Basic Specialist Training) which everyone has to register in order for their training to be accredited, it costs 2000 euro PER YEAR currently.

To register and pay for you training on the Surgical SHO scheme is currently 3200 per year. The scheme is two years long totalling 6400 euro just to do the scheme. This doesn’t pay for your exams.

The ACLS (Advanced Cardiac Life Support) course is mandatory for all medics working in an Irish hospital and must be redone every two years by every doctor. This course teaches basics like effective CPR, intubation and ventilation skills, defibrillation, and recognising abnormal cardiac rhythms and how to treat them. It costs 550 euro currently.

The equivalent for paediatric doctors is the PALS course (or APLS I believe it’s called elsewhere). Again, 550 euro, and an absolute requirement for work.

ATLS (Advanced Trauma Life Support) aimed at Accident and Emergency doctors-this one may even be more expensive than the ACLS or PALS as it takes longer.

Basic Surgical Skills courses can run from 500 upwards and teach trainee surgeons basics like suturing and operating skills.

The Royal College Membership exams (MRCPs) for General Medicine, Pathology, Psychiatry, Obstetrics and Paediatrics are requirements, respectively, for entry to specialist training schemes to train up the consultants of the future. The memberships have three parts, and each part costs 590 euro currently. So 1770euro to get these exams assuming you pass them all the first time. Which no-one does, believe me.

Prep courses for the membership exams cost 1000-2000 each sometimes. Particularly for the practical parts of the exams, they are vital.

The ACLS and PALS etc, are always on weekends, and hence one must often use one of the only weekends one is not on call in a month to do these courses.

Axing the training grant is, um, not such a hot idea. Doctors who don’t have the ACLS are probably not going to resuscitate you or your relatives properly. Or if the A&E doc didn’t do the ATLS, then all those RTAs wheeled in after hours are in serious trouble. Lack of doctors progressing through the ranks having obtained their membership exams means less staff at senior registrar and SpR level, and these are the most senior doctors in the hospital after hours, and the most knowledgeable.
Deskilling of the steadily decreasing pool of frontline medical staff is about as intelligent as raising taxes and decreasing incomes during a recession. Oh wait, it’s the same crowd as what done the recession in the first place.

Mandatory Unpaid One Hour Long Lunchbreaks:

HAHAHAHAHAHA! NCHDs getting LUNCH BREAKS? Okay. When did we EVER get LUNCH BREAKS? What planet are these people on? I know they probably think this would be awesome spin fodder, eg: “Fatcat overpaid junior doctors paid to just sit around eating”, but the public aren’t that stupid for heaven’s sake. There’s just no spin value to get out of this one, lads. Sorr-ree.

NCHDs carry their bleeps at all times and are available to work at all times when on duty. If you are called you have to go. None of us sit down to a nice lunch and coffee every day, or even ANY day. In addition, you can’t leave hospital grounds. Others can go to the bank or post office at lunch. Not us.

I remember many times eating a Snickers going down the hall and this served as my lunch and kept me until about 10pm when I might get a sandwich out of a vending machine and eat it with one hand while writing up an admission with the other.
I guess what they must want is for us to hand our bleeps en masse in to reception and head off downtown for lunch or for a nice hot meal in the hospital cafeteria. Cool! I’m down with that. As long as whoever has the bleep can handle the situations they are bleeped for. But wait! If all the NCHDs are on their (snigger) lunch break, then who will take care of the patients. Or are we not caring about that anymore because there’s a recession?

I suppose there could be staggered lunch breaks, but if they’re staggered then they sure can’t be a whole hour long. Otherwise you will have people going on their (chortle) lunch breaks at 4 and 5pm and such.

If the HSE would bother to engage with NCHDs and try to compromise then they might find that we are willing to help them devise rosters that decrease hours and consequently, overtime and still ensure enough staff are on at any given time to keep patients safe. They might find that we might be willing to limit the training grant to course fees and exam fees only, and forgo the one off laptop and equipment grant. They might even find that we might be willing to agree to a pay freeze. There are lots of ways we could help them to make savings, if we were to work together. In fact, if all health workers came together and we reorganised things a bit, we could still have a reasonable health service. Or maybe I’ve watched one too many Disney films.

But I suppose unilateral imposition of drastic alterations to our contracts without discussion and with lots of spin to try and further their cause is so much more effective. And industrial action and emigration on an EPIC scale of NCHDs trained at the taxpayers’ expense is a much better solution than us all working together to try and make the best of things.

Saturday, 7 February 2009

The idiot's guide to "slashing overtime"

So, I was listening to Mary Harney on the radio the other day. She's the Irish minster for health, and I liked what I heard. That surprised me greatly.

She said she was going to "slash overtime" for junior doctors. Great. Our Juniors in Ireland work shifts that are up to 72 hours long, with no guaranteed breaks, and no guaranteed sleep.

There's also a shortage of junior doctors in Ireland, which means they can work a lot of overtime.

Now, Mary Harney said she wanted to reduce overtime in order to save money, so her motives weren't pure. But that's fine,a s long as she was committed to cutting their hours.

How shocked was I, then, when I heard that when she says she wants to "slash overtime", she actually means "not paying overtime rates". 

Essentially, what used to happen is that juniors would be paid time and a quarter for their first 9 hours of overtime every week. But the new policy will mean they just get paid normal rates paid to them for their overtime.

That's how she wants to slash the overtime bill. I guess it's likely to achieve it's aims.
The alternative would have been to realise a decade ago that we were short of docs, and train enough of them!

Not content with dropping the morale of doctors by making them work overtime at normal rates, she's also slashed the training budgets.

Basically doctors get a subsidy from the government for courses and education each year. The amount is variable depending on the doctor's seniority, but it can be a few thousand euros per annum

Out of this, the doctor is expected to pay for courses in emergency resucitation, and to attend conferences and surgical skills courses etc. These things cost money, but we should be teaching our doctors how to resuscitate people,and we should be teaching our junior surgeons their basic skills. Not any more. No money for it. 

Of course, Harney knows that young doctors won't be able to progress up the ladder without dong these courses, so they'll pay for them out of their own pocket, and will do them on their own holiday time. Everyone's a winner.

Of course, many young doctors won't have the time, or the finances to do all the courses they need, so they'll skim. They'll do what they can, but training will suffer in a MAJOR way. I'm concerned that the public don't understand the implications of making no provision for the training of medical staff after the graduate from university. Just think of the difference between a newly qualified intern, and a consultant. The difference isn't simply the result of experience. It's a result of training, too. 

Many of my Irish colleagues feel that this will result in the worst post graduate training in Europe. I agree. These will be the doctors looking after you when you're old. That is, if they stay in the country. Many are planning to follow those of us who've been tempted overseas.

There have been other cuts proposed, but the most laughable has to be the announcement of "a mandatory one hour lunchbreak each day". I had to do a double take when I read this. Every doctor in the country knows that most days a junior doc doesn't get a lunch break. They most certainly don't get an hour. A quick rushed sandwich in the canteen is considered a success, as they still have to carry their pagers while on a break. No-one has suggested that someone else will be covering these duties at lunchtime, so they'll still be carrying emergency pagers. They'll still be on-call.

When the one doctor who's working in intensive care gets paged at 1.30pm to tell him Mr. O'Malley in bed 3 is having severe chest pain, is he going to say "sorry, I've a half an hour of lunch still to take"? Of course he's not. He's going to forsake the rest of his break and deal with the patient.

The government know this, and they don't give  a hoot.

It would have been more honest for them just to say "we don't care about you. We know your consultants won't kick up a fuss to defend you, and we know you're desperate to climb the ladder. So, we know you'll pay for courses yourselves, and you will go without breaks, and you won't complain. We know you're an easy touch".

But somehow we all know this will turn into greedy doctor propaganda if anyone dares speak out.

Thank goodness for the welcoming Australian healthcare system, I reckon. I suspect I'll be hearing  a few more Irish accents on the wards over the coming year.

Thursday, 5 February 2009

Doctors. Their hours. The ten year lag.

Posted by Dr. Thunder

So, this week the Department of Health in the UK announced that they won't be implementing the European Working Time Directive (EWTD) for junior doctors anytime in the next few years.

The EWTD is a piece of European legislation that seeks to offer employees protection from overwork and exhaustion. The aim was to have no person being required to work more than 48 hours per week.

Now, the UK department of health has asked for a FURTHER extentsion (doctors have already been way behind the rest of the workforce in terms fo their entitlements for years). Despite having a decade to prepare for the implementation of this legislation, the department say that they can't meet the requirement.

With the farcical new method of selecting doctors in britain, many have moved overseas to get better training. In the same breath, the authorities have made it extremely difficult for overseas doctors to come and work in the UK.

And they wonder why there's a problem,?

The interesting thing is that both the Royal College of Surgeons and the Royal College of Physicians (doctors' representative groups) have supported the delay in it's implementation. Bizzarre. I think this is because a lot of the old school doctors who run these organisations believe that the juniors SHOULD spend most of their best years working.

I call shenanigans on that. I think medicine is a job. It's a privileged job, but it's a job nonetheless. More importantly, it's a job where cockups are not acceptable. It's difficult to reconcile this with the long hours culture that exists within our ranks.

I think we should treat our young doctors like we treat our pilots. Pilots have a limited number of hours they can work in a year. 

When I get older, I'll be much happier when the guy about to cardiovert me has had his full 8 hours sleep, and statutory lunch break!

In Ireland, things are worse, as per usual. Though the Health Service Executive (HSE), who are responsible for the "running" of the irish health system, are clinging to the hope that their junior docs will be working a 48 hour week by june 2009.

Now, we all know this is either a crock of balls, or they have something up their sleeve that will allow them to fudge the figures, much like they do in the UK.

The HSE are talking about getting around the law by not counting "inactive" hours as "work" when a  doctor is on-call. If anyone thinks this will reduce the official hours tally, then they clearly have NEVER done an on-call shift in an acute specialty.

I don't kow what the solution is right now. I know that the Irish and UK authorities and unions have had about 10 years notice of these changes, but they've not prepared themselves.

I know it won't be the people responsible for this mess who'll be working the extra hours, and spending less time with their families because of it, though.

Dr. Thunder