Wednesday, 30 December 2009

Time to outlaw the smacking of children. Seriously.

Posted by: Dr. Thunder.

Today I was in "The Square", a large shopping centre in Dublin. A young mother wheeled her trolley past me, and a small child was sitting in it. He was about 18 months old, and mum had let him play with a plastic bottle of milk that she was going to buy. As tiny curious people do, he threw it out of the trolley to see what would happen.

Unsurprisingly, milk exploded all over the floor. Mum was very embarrassed. So, what was the first thing she did? Put the trolley over the spill to stop people slipping in it? Go and get a staff member to tell them?


She slapped this tiny child across the face.

I saw red. I was so angry. If she did that tme, a large male, she wold be arrested and charged. But it's OK to do it to a small toddler.

I wanted to ring the police and tell the security guard. But there was no point. This behaviour is COMPLETELY LEGAL in Ireland.

The baby looked stunned, and cried for a minute. But this obviously wasn't the first time it has happened to him. Will it stop him doing it again? No. He isn't old enough to know why he was hit. He isn't even old enough to know that it's wrong to throw a bottle of milk out of a trolley.

I've been a staunch opponent of corporal punishment for as long as I can remember. I've heard all the arguments. I'm sick of "A smack never did me any harm". Well, smoking didn't do my 90 year old neighbour any harm, but anecdote shouldn't form the basis of policy. Plus some of the people who say it hasn't done them any harm are the most maladjusted individuals I know.

I'm sick of the "I just tap him if he's bold" argument. Firstly a "tap" from a 20 stone man is probably quite painful to a child. And surely a "tap" that doesn't hurt won't have the desired effect.

Aside from the fact that it's wrong for be to be allowed to hit a lid, when it's illegal for me to hit an adult, it's also not effective.

Virtually all of the scientific studies and all of the paediatric bodies come to the conclusion that corporal punishent is the least effective form of punishment, and it can lead to problems in itself. I used to work in a paediatric behavioural clinic, and more problems are caused by smacking children than are solved by them. In fact, getting parents to stop hitting children is one of the first steps in improving behaviour.

Smacking a child tells them A) Violence is an acceptable way t0 solve a problem and B) That their parents are not in control of the situation.

A child who believes either of the above has the potential to be a disciplinary nightmare.

I respect no-one who hits children. I know it's harsh. But I lose all respect for someone when they tell me they hit their kids. It's always followed by a nonsense excuse. But it's still assault in my eyes.

The UK have gone some ways towards protecting their children. And special praise must go to New Zealand where they have banned the smacking of children in all settings.

Sadly, Australia and Ireland (as always) are lagging behind. The Irish in particular have most to be embarrassed about, considering it's still legal to slap kids in reidential settings (though virtually all of these institutions have guidlines for staff advising against it).

Both Ireland and Australia have a pretty shameful history of failing to protect the most vulnerable people in their societies. Outlawing corporal punishent would be a step in showing that we're beginning to take the welfare of our children seriously after all these years.

Dr. Thunder.

Saturday, 26 December 2009

Irish healthcare workers feeling the recession blues.

There's a recession in Ireland.

A really BAD recession.

We've had to stop buying new BMWs and 500,000 euro houses while earning 30k per year. That's no bad thing, it has to be said. But it's meant a pretty lean Christmas for a lot of Irish folk.

So, a budget was called recently, to sort out this mess. This PR (and I mean that in the non medical way) exercise had, and will continue to have, signifcant repercussions for healthcare staff working in our beleagured public service. It was aimed at punishing those with a weak voice (with social welfare cuts) and placating those who tend to vote in greatest numbers (The private sector workers and pensioners).

The public wanted public sector heads to roll, because they were angry at giving up their BMWs and 500,000 euro houses that they bought on credit. There was a bizarre thought process that permeated the private sector regarding the payment of all public sector workers. The logic was that "we've all taken pay cuts, so now it's your turn".

The public sector is too expensive, went the argument, so the public sector workers have to pay to keep it running.

We have hospitals that cost millions to run every month. We can't afford it, so we need money. Fair enough. The whole country uses these hospitals. So, how do we get the money? We take it from those people WORKING in the hospitals. A friend argued that he had already taken a 6% paycut while working for a large accounting firm, so he shouldn't have to pay for the hospitals and the police service and the fire service to keep operating. Only in Ireland.

I'm just back from Australia for a holiday, so I thought I'd missed something. "But you've taken a pay cut so your boss's company can survive. That's exclusively for your company's benefit. But the public sector is used by everyone, so why do only the 1/6th of the workforce who work in it have to pay to save it?"

I've asked this question several times, and have been told the following:

A) The public sector are useless and "bloated". As this is a medical blog, I guess we should be focussing on whether that's true in healthcare. And healthcare workers took the same large cuts that everyone else did. In my experience in Ireland, EVERY SINGLE hospital department I've ever been in has been grossly understaffed. Pregnant doctors have been working 48 hour shifts. It's common to work 24 hours every 4th day. Now THAT is value for money!
My sister used to work in medical records, and came home a shell of herself each evening. Another sister worked at a reception desk in a large hospital, until she got a much more sedate, and much better paid job in the private sector.

B) The public sector are overpaid: This is more difficult to fathom. There are various reports that support this claim. But they compare averages. In the private sector, some people are on pheomenal money, but some people get left to the dogs with appalingly low wages. Averages work best when there's a normal distribution. The private sector has been quick to throw the crumbs to it's lower skilled workers for donkey's years. I don't think that should be applauded. My private sector friends have been almost boasting about how there are people in their offices doing long hours for a pittance while angrily frothing at the mouth thinking about public sector workers earning a fair wage.
Then the comparisons with the UK start getting made (particularly in relation to doctors and nurses) and my eyes start to roll.
People in Ireland look at the NHS as a utopia where fatcat doctors and nurses get paid a smaller wage than they do in ireland. It's probably true. But the morale of the doctors in Britain is unbelievably low (and not just because of their pay). It's probably true that junior docs in the UK DO get less money than their Irish counterparts. But the UK docs don't have to cope with 24-72 hour straight shifts on a very regular basis. Plus the cost of living is much higher in ireland. I get paid less in oz than in Ireland, but I get a MUCh better stanbdard of living for my money (and I live in a big city). Same when I worked in the UK. I used to own a lovely apartment in the posh part of town, but wouldn't have been able to afford a cardboard box on that wage in Ireland. So, there's a context to wages.
I'm just not sure why Irish docs have to be benchmarked against British doctors, when both are treated like dirt by their employers. The only difference is that the Irish docs have been a bit more successful at getting remunerated for it.

Also,and I realise I'm being controversial, getting a place in nursing school in the UK is a LOT easier than getting a place in ireland. Irish nurses TEND to be better qualified in my experience, and to adopt the private sector mantra, we should reward excellence. I have a good friend in the UK who is a qualified nurse who tells me he never learned ANY pharmacology at nursing school!!

But I guess the real purpose of this post is to ask whether anyone can explain to me why public sector workers in Ireland have to pay more for the upkeep of these PUBLIC sectors than anyone else? Are, Irish healthcare workers now more entitled to a hospital bed? or a quicker police response?

Please enelighten me.

Dr. Thunder.

Sunday, 20 December 2009

Quote of 2009

Posted by Dr. Thunder.

I'm just on hoilidays at the minute, in the North of England. Last week I was walking down the street, and noticed a small frail nun standing outside a parish hall, just before their weekly saturday night service began.

Another little old lady, who looked like she's in her 80s, was hurrying home, when the nun waved to her. "Hello Carmel" said the nun.

"Oh hello, sister" she replied in a thick northern accent. "Sorry I haven't been to church recently. But the X-factor finishes tonight, so I'll be able to make it from next week".

And they say it's just kids who've got the X-factor bug!!!

PS...lots of "leaks" on the net tonight suggesting Rage Against the Machine have secured the Christmas number one. If this is true, it will make my Christmas :D

Dr. Thunder.

Wednesday, 9 December 2009

The antibiotic war.

Posted by: Dr. Thunder.

What are we doing wrong?

Why have we not got the message out there about antibiotics?

How come we struggle to get parents to give their kids life-saving vaccines, but we've convinced them to to demand an antibiotic for their little ones, at the first sign of a sniffle.

I saw a 5 year old boy, Thomas, a few days ago in the emergency department. Thomas had a mildly elevated temperature, a runny nose, a sore throat, and a pain in the side of his head.

"We're here because we can't trust our GP any more".

"Really? And why is that?".

"He told us Thomas IS sick, but he won't give us an antibiotic", mum answered.

As Thomas sat there on the trolley-bed watching his portable DVD player, and laughing loudly at the cartoon on his screen, I began to suspect that A) He did not have a bacterial infection and B) This consultation was not going to end well.

I gave him a good look over, and concluded that he had an improving, self-limiting viral infection. Red ear, red throat, runny nose and a bit of a temperature. He was eating and drinking normally again, and seemed to be on the road to recovery.

I sat down with Thomas' parents, and explained the difference between viral and bacterial infections. I told them that this infection seemed viral to me, and reassured them that their GP had made the right decision.

"Look, can we stop all the side stepping here? Are you telling us he's not going to get an antibiotic?".

"I'm sorry. I'm not going to prescribe an antibiotic because....."

"OK, can we get a second opinion. He gets these infections several times a year, and ALWAYS needs an antibiotic".

I told them I'd happily get the consultant involved, but that this would take some time.

They agreed to wait, and Thomas loaded another DVD to watch.
After about 20 minutes they started to complain loudly to each other, as people do when they're trying to get your attention.

"I told you we should have brought him to the other hospital", dad said to mum, VERY loudly. "At least THEY know what they're doing".
This went on and on, and I ignored them.

20 minutes later, they got up to leave. On the way out, they told random nurses and patients int he corridoor that they were going to find a private doctor "Who bloody knows what he's doing".

The thing is, I suspect they may have.

These parents are very likely to have found a doctor who agreed to give Thomas some Amoxicillin. Then Thomas will have continued to get better, except for his antibiotic-induced upset tummy. In two more days he'll be right as rain, and they'll tell all their friends that the antibiotics cured them, and that the pillock paediatricians at the local hospital haven't a CLUE what they're doing.

It has bewildered me for so long that we give out so many antibiotics without any justification. It's hard not to, and when I was a bit more junior I did so, when I couldn't stomach the fight. I don#'t resent the doctors who prescribe them easily. But I really wish they wouldn't.

Anyone got any thoughts on what percentage of antibiotics given for acute respiratory illness actually result in improvement? I've no idea, but I'm sure it's very low.

Dr. Thunder.

Saturday, 5 December 2009

To work in Ireland, the UK, Australia or New Zealand?..the choice facing thousands of junior doctors

Posted by Dr. Thunder:

As a registrar, who has worked in Ireland, the UK, Australia and New Zealand, I thought it might be useful to share my experiences here, in the hope of helping other doctors decide whether they want to trek halfway across the world in order to ply their trade.

I've included my thoughts on each of the countries below, and what they're like to practice medicine in:

Ireland: Oh Jesus. Juniors are still working shifts up to 48 hours. The European Working Time Directive will be implemented shortly, which will reduce the working week of doctors to 48 hours. In order to maintain a service, while halving the hours of medical staff, the Health Service Executive have decided they will simply ask the overworked juniors to work twice as hard while they're on the job. Simple.

They will also be docking 30 mins per day from the wages of junior doctors for their lunch break. Just ask any junior doc if they get a lunchbreak. Even if they do, they're not allowed leave the hospital, and they still have to carry their pager. It's a total joke.
Another disadvantage of being a junior doctor in Ireland is that the media, and consequently the public, think you're overpaid and lazy.

The standard of medical care in Ireland is also likely to fall, as the universities adopt GAMSAT and PBL with gusto. It used to be very difficult to get a place at medical school in Ireland. Now, about 1 in 3 of those sitting GAMSAT get offered a place. Call it elitist if you like, but when I'm old and have a complex medical condition, I want someone who works hard and is brainy as hell treating me. To stop these GAMSAT graduates doing too much damage, nurse prescribing is also being introduced, which required the nurse to do about 6 weeks training to convert themselves into a doctor. Good times.

Patients also routinely wait several days in the emergency department corridors on trolleys for treatment, as there are not enough beds.

In the "pro" column, my family and oldest friends are in Ireland. So, I'll probably end up returning someday. But I'm doing postgrad qualifications so I can hopefully get a post in a university, or be based in Ireland whilw working for an aid agency.

The UK: Also not a great life for a junior. Here you will find an imaginary 48 hour working week. In fact, they monitor you to make sure you're not working extra hours, by getting you to fill out an "hours diary". Essentially, you are expected to lie on this form, so your employer can ignore the fact that you work an extra 10-20 hours per week for free.

My biggest peeve about working in the UK, was the famous "4 hour waiting time". This is possibly the greatest con in the history of medical politics. Essentially, what happened was the labour party government got tired of people complaining that they had to wait 12 hours in an emergency department to get treated. So, they announced

"From this day fortwith, no man, women, child nor beast shall wait more than 4 hours in an emergency department".

WOW, we all thought. That's going to require a hell of a lot of investment into acute services. Right?....Eh, yea,...sure.
Obviously there was minimal extra invgestment. So, what happens is....the patient turns up to a crowded A+E department, and is seen about 3 hours later. So, they have some blood tests taken, which won't be back until 4 hours are long gone. You'd like to get a specialist down to see the patient in A+E, but they won't be able to make it before their 4 hours is up.

The head nurse hassles the junior A+E doc to get this person home or onto a ward. "But I need to get the bloods to see what's going on". Doesn't matter. They cannot be here longer than 4 hours, or the whore-child of Satan shall rise and engulf the hospital in his flames of jizm.
So, you have to send them home and hope to God their bloods/xrays etc don't show anything untoward. Or that the pain doesn't return when the pain killers wear off after they go home. Or you hassle the admitting doctor on the ward to take them, even though you've no clue what's wrong with them.

So, the patient usually ends up getting admitted at 4 hours. Nothing serious wrong with them. But they now have to stay overnight because they've been "admitted".
Every doc who's worked in acute care in the UK will have had a nurse coming in to see them while they're seeing a genuinely unwell patient to remind them that there's someone much less sick outside who needs to be seen NOW as they're going to "breech" the 4 hour target. It's not the nurses' fault. They get it in the neck if these people wait more than 4 hours. Some units improvise, by removing the wheels from the patient's trolley. So, they're no longer "waiting on a trolley" in A+E, they're admitted in a "bed". It's genuinely soul destroying.

What's also soul destroying is the way jobs are allocated to juniors. I still don't fully understand it either. All I know is some amazing doctors are unemployed because of it, and some real muppets are doing well because they can tick the right boxes in their "self assesment portfolio" or whatever it's called. It seems juniors in the UK are rewarded for being good at paperwork, rather than being good at medicine.
Oh, and everyone in the NHS is now a "consultant" of some sort. Everyone is taking on a doctor's role on the cheap, and healthcare is going down the pan.

Most consultants are not interested in the plight of juniors, so it's a lost cause.

It breaks my heart to write the above, as the principles upon which the NHS is based should make anyone proud to live in a country where free good quality healthcare for all used to be a reality.

New Zealand: Lovely place to live. Lovely place to work. My experience was in a hospital that was off the beaten track. But the consultants would come in and help immediately if you have any dramas. Colleagues were supportive, and standard of living was good. Managers actually spoke to us, and consultants backed you up.
I ended up looking after some pretty sick people who should have been moved somewhere else, but they were too unstable to go the long distance. This is a recurring problem in this part of the world, because of the geography. I saw it as an opportunity to improve my critical care skills, and, as mentioned earlier, consultants were generally very supportive, so I never felt out of my depth

Highly recomment NZ as a working environment.

Australia: Great place to work, by and large. If you stay for any length of time, you'll probably end up working in an understaffed remote hospital with minimal senior support. But working in a city is well worth it. Great hospitals. Reasonable workload. Supportive consultants, by and large. Nice atmosphere too. Generally first name terms with your seniors. Hours are not too onerous, unless you work remotely, when you can end up doing 24 hour on-calls.
I usually got a l;unch break in oz, and when I finished late I got paid for it.
On the downside, their politicians tend to use health as a political pawn, as is the case in most countries. For example, the recent swine flu response was 50% medicall driven, and 50% political, which was disheartening.
But, while Ozzie politicians are the same as any others, I'd still recommend it as a place to work.

Major downside is that the universities recruit a LOT of GAMSAT students. IN my opnion, and it's only an opinion, these students are simply not that good. MANY og my colleagues share this view. But it's a quicker way to train, so it will be a case of standards being sacrificed to save money.

Hope that helps. feel free to add your own opinions in the comments box.

Dr. Thunder.

Thursday, 3 December 2009

Posted by Dr. Thunder.

Well, they said it couldn't be done......

A conference without drug company sponsorship.

It was a small gathering, but I was there. Last week I went to my first ever "pharma-free" conference. It wasn't big. It wasn't fancy. There was no breakfast provided. Lunch was a few sandwiches and a slice of cake. There was a dinner afterwards, which you could attend at your own cost.

The experts were mostly local. Nobody was flown halfway round the world on a first-class flight and put up in a penthouse suite.

But the information presented was pretty much as good as that presented at any other conference I've ever been to. The meeting was based in a large capital, so there's plenty of research going on locally to present. A couple of times, research was discussed that hadn't been conducted by the presenter, in a "new developments in....." format.

It was great. Nobody was trying to sell anything. Nobody was trying to con us into presecribing their new decidedly average wonder drug. The cost of attending hardly ate into our budget at all.

It was just doctors talking about the best science. I loved it.

I have real problems with the pharmaceutical industry. I have no problems with them developing lifesaving drugs. Let's be honest, we'd have much worse outcomes without the pharmaceutical advances of the last 10 or 20 years.

But the way they try and peddle their drugs, regardless of how effective they are, gets very tiring, and ultimately erodes any trust in them.

This was a small conference, though, and only a small step in the right direction. As things stand, there's a world of work to do in order to limit the interface opportunities between drug reps and healthcare professionals.

BUt this was one step that was supposed to be impossible. BUt it' wasn't.

Dr. Thunder.