Two Weeks on a Trolley

Quote of 2009

2009-12-20T16:27:00.002Z

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.

The antibiotic war.

2009-12-09T11:48:00.005Z

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.

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

2009-12-05T02:25:00.000Z

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.

2009-12-03T08:28:00.003Z

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.

A health-y appetite for the finer things in life.

2009-10-18T11:43:00.004+01:00

Posted by: Dr Thunder.

Two of the most important people in Irish health circles are Mary Harney, the Minister for Health, and Professor Brendan Drumm, the CEO of the Health Service Executive (HSE).

The HSE is, essntially, responsible for the say to day running of the health service. These are the head honchos. The buck stops with them.

For years, doctors and nurses in Ireland have felt anger at both these public figures. They have lectured us on cost cutting, and the need for increased efficiency. In fact, professor Drumm is one of the main reasons why I chose to continue working in Australia, rather than going home to Ireland. I was visiting my family around christmas two years ago, and he came on the radio at my parents' house. He was giving a rousing oration, where he told the public how the front line staff in the Irish Health Service need to look at themselves, and to work harder, and to work more efficiently.

This, to me, was a disgusting thing for a fellow doctor to say, while Irish doctors (including pregnant women) were still working shifts up to 48 hours long. I decided then that I would never work for a service with a man at the helm who was more concerned with populism and passing the buck than he was with the overworked demoralised staff doing their best in crappy conditions.

Here is a man who has lost touch with the grass roots.This is a man who gave up his job in the understaffed specialty of children's oncology to earn big money running the HSE.

Also, and this is VERY important.....professor Drumm spoke out criticising excessive bonus payments for senior HSE staff back in 2007/8. This fact will become important later.

Then there's Harney, our erstwhile Minister. She has achieved a degree of popularity recently by "taking on" the "professional elites" such as doctors, pharmacists and nurses. In fairness, I do owe her a degree of gratitude, as her treatment of junior doctors mean I no longer feel homesick in Australia, as there are as many Irish doctors working here than I've ever worked with at home.

One of Harney's favourite pastimes involves telling the public how healthcare workers are costing us too much.

So, here we have Professor Drumm telling us we're not doing enough for our money. And Harney tells us we get too much money.

Now, you would expect this pair of reformists to lead by example, if they're going to tell the workforce in a third world health system to tighten their belts and work harder.

However, in a shocking development, which will rock the very foundation of the state, it has emerged that both Harney and Drumm are.......

Talking out of their asses.

We all know that expenses and bonuses are part of both political and business life. I expect a servant of our country to be able to fly first class, so they can do their work on the plane. I expect them to stay in a hotel with a business centre when they're away. I even expect people running the health service to get a bonus when things are going well.

So, what do we know about Harney and Drumm's financial package?

Well, we know that Harney and her husand (!?!) ran up a bill of almost 70,000euro over 3 years in JUST hotel and limousine costs. That's about 23,000 euro per year. On hotels and limousines!!!!!! How often was she going away???

Then it emerges that she refuses to travel on commercial jets when going overseas. Instead, she insists on using the government jet. So, over the same period she ran up a ill of 750,000 euro on flights. That's a quarter of a million euro every year! This jet costs 7,000 euro per HOUR to run. This only the information that is available. The Freedom of Information Act in Ireland is so difficult to navigate that it is almost impossible to discover the full extent of the financial laxity within government and senior civil service ranks.

Sweet Jesus.

Now let's look at Brendam Drumm. He's just been awarded a 70,000 euro bonus for doing so well in navigating our country towards a world class health service. This is the man who gets 430,000 euro per years as a basic salary. This is a man who was critical of HSE bonuses before they were dangled under his nose. This is a man who has resided over a HSE which treats it's junior doctors as glorified slaves, and has closed children's services in our major kids hospital.

In Ireland, there are half a million people unemployed. The self employed who built the country get no social welfare when their business goes bust. Those lucky enough to get some government support are entitled to 204euros per week. There are little children who desperately need spinal surgery, and have been told we can't afford the service.

I don't know how these people sleep at night. But I guess the presidential suite at the Waldorf,or a flatbed sleeper on a government jet helps.

Dr. Thunder.

So, will that swine flu vaccine give my kid mumps or what?

2009-10-14T07:38:00.004+01:00

Posted by: Dr. Thunder.

I've just had my umpteenth conversation with a concerned parent about the swine flu vaccine. I'm starting to sound like a broken record now.

Parents have every right to ask questions, when we consider what's been in the media, regarding this jab. It's a minefield of information, and it's difficult enough for those of us who work in healthcare to get our heads around it.

I get asked a lot of questions about this vaccine. Some sensible. Some truly bizarre. I've had the crackpot conversations already, with the truly paranoid. We discussed mandatory vaccinations, and the big pharma conspiracies.

"This vaccine has been made to give us all swine flu"

"This vaccine has been made to stimulate the world economy"

"I've heard this virus was released accidentally from an American army lab, and they're trying to wipe it out, so unfriendly countries dn't get their hands on it".

These people must live truly terrifying lives, if they're so convinced that government is out to get them.

At the normal-ish end of the paranoid spectrum, I've had some unusual questions. But nothing prepared me yesterday for a previously sensible parent asking me, in hushed tones, whether I thought there was a risk of Anthrax from this vaccine!!!!!!!!

Jesus H Christ!

"It's just that I read it on a website".

I tried to keep it calm. But I'm sure my face cracked a little, as the laughter tried to escape. I reassured Harvey's dad, and he was accepting of my explanation.

Having said that, the concerns expressed to me have been, by and large, fairly reasonable. And those that are a bit crazy, have generally come from respectable looking websites, which are essentially conspiracy theory sites, or are peddling alternative meds. There is something ironic about these people claiming a big pharma conspiracy on hand, and trying to sell you expensive vitamin D "anti-flu" tablets at extortionate prices on the other

I feel I should put up a list of the common concerns here, and make an attempt to address them. Cleverer people than me might want to add some extra info too.

1) This vaccine was rushed through the safety checking process: There's no doubt that the swine flu vaccine was made quickly. If there was a new vaccine on the market. it would take years to reach the market. But the swine flu jab isn't really new.

Every year, we have different strains of flu circulating. We usually detect these many months in advance, and make a vaccine against them. The way we do this is by taking a vaccine mixture that is shown to be safe, and adding in the virus particle that is circulating this year. The virus particle is the bit that immunises you against a specific strain of flu. It is a part of the surface of the virus that your body will recognise. It is not live virus. This year one of the strains of flu is swine flu. We didn't know about it early enough to include it in the yearly flu vaccine, so we've had to make a new one. But it's almost identical to the seasonal flu vaccine that people get every year. It is very likely to be included in the normal flu vaccine next year.

2) I don't need it as I don't have an underlying medical illness: Depending on the country we look at, we're seeing 30-50% of swine flu deaths and admissions to ICU in groups with no risk factors. Plus, vaccines are not designed to protect individuals. They're designed to protect communities. If you don't catch it, you can't pass it onto a baby, or someone else who will be less able to fight it.

3) I read about it making people sick in 1976: There was swine flu in the USA in 1976, and there was a vaccination programme. About 40 million people were vaccinated, and 25 died from Guillain-Barre syndrome. This is true. But when you look closely at the figures, there were about 1 case per million people more than would have been expected in a normal year. That's still high, but it's not a huge risk. No cause has ever been found for these cases. But vaccines weren't as pure as they are now, and this is thought to have been a contributory factor.

Bear in mind, though, a good chunk of those people would survie today, as GBS is better treated. Also remember that influenza infection is a big cause of GBS.

4) This is only a mild disease: True. In most cases. 1 in 200 people who get swine flu end up in hospital. A third of these end up in ICU. Usually for about 2 weeks. 1 in 1000 patients die from it. Though in some countries this figure is much higher. If 1 million people catch swine flu in Ireland, that's 1,000 deaths we're facing, and about 5,000 hospitalisatoins. That will wreak havoc on an overstretched health service this winter.

Everyone has their own choice to make. It's not for me to tell anyone what to do. But, whatever your decision, make it based on facts. Speak to your doctor or nurse. Don't look at the quack websites.

I had mine the other day. Had a bit of nausea the next day. But otherwise I was fine.

Feel free to comment. Feel free to disagree. But please don't scaremonger.

Dr. Thunder.

Who are the trade unions kidding?

2009-10-10T09:45:00.002+01:00

Posted by: Dr Thunder.

I think most public servants are underpaid.

We all have the chance to work in the private sector, for more money and better conditions. We stayed with the public sector during the boom times, when all kinds of people were earning crazy money in the private sector.

We have had to listen to the private sector telling us we were fools for staying put, for the sake of our patients, when there was big money to be made elsewhere. Now we have to listen to them telling us that we're overpaid and that our perks are too lucrative.

I think, to an extent, the public sector have to suck it up. You take your risks in the private sector. When times are good, you earn big. But when things go bad, they go VERY bad.

I have to say, though, the Irish trade union, SIPTU, have left me speechless recently. This trade union represents various public sector healthcare workers. Mostly nurses and paramedics. Oviously, these two groups do a vital job. A job that most private sector workers wouldn't have touched during the boom years in Ireland. But they stick with it, loking after the most vulnerable memers of society, under very trying conditions.

They don't get a Christmas bonus. There was no free staff night out at Christmas for them. there is no health insurance.

So, now their trade union has asked for a 3.5% pay rise for these workers.

For those of you reading this from overseas, Ireland is in trouble. I mean BIG trouble. Think Iceland-Lite. I know there's a global recession. But Ireland is suffering a global recession, plus a national recession. There's just no money left. I wrote recently about how children's surgical services are being closed down because the piggy bank is empty. Unemployment is skyrocketing, and hundreds of thousands of familes are trying to survive on their weekly 204Euro social welfare payment, in one of the most expensive countries in the world.

The people are fed up. They've seen politicians spend crazy money on lavish expenses, and they've seen the bankers bailed out with huge financial packages, while the self-employed don't even qualify for the dole when their businesses fold.

The dole office is so busy, it's taking 3 months for applications to be processed.

This is not the time to be asking for a pay rise.

Healthcare workers continuously come out top of public opinion trustworthiness polls. There's a good reason for this. Healthcare workers are supposed to care more about the people than about money. I think that still holds true. But I think the trade union are trying to play hardball with the government.

But how can we expect the public to have any respect for us if we're demanding pay rises in the current climate? The cost of everything is going down, so it's difficult to justify on the basis of inflation.

For a nurse on 35k per annum, a 3.5 pay rise works out at about 20 euro per week extra, before tax. That is not worth alienating the public for.

I hope common sense prevails. I hope our nurses and paramedics are rewarded when the economy turns a corner. I, and they, know that won't happen, though.

But, in the run up to a very lean Christmas for most of the country, it's time to put the begging bowl away for now.

Dr. Thunder.

The Spin Doctors Against Doctors.

2009-02-11T17:21:00.004Z

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.

NOT.

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.

IT IS ILLEGAL TO WORK OVER 56 HOURS PER WEEK IN THE EU ACCORDING TO THE EWTD.

IT IS ILLEGAL NOT TO HAVE A SCHEDULED REST AFTER ELEVEN CONTINUOUS HOURS ON DUTY.

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.

EU may have finally smelled the Irish coffee.

2009-03-13T09:37:00.006Z

Posted by Dr Jane Doe.

This article is taken from today's Examiner. It is truly remarkable that this issue has taken so long to come to anyone's attention.

"Friday, March 13, 2009

EU to take up issue of junior doctors’ hours
by Ann Cahill, Europe Correspondent

THE European Commission is to take up the issue of punishing hours worked by junior hospital doctors with the Government.

Doctors in training should not work more than 56 hours a week under current EU rules, but a report in December, by the Department of Health, found the 4,800 junior doctors regularly exceeding this, working shifts of 36 hours or longer and no hospital was fully complied with the law.

Dublin Labour MEP Proinsias De Rossa referred this to the EU commission, whose job is to ensure states implement the laws.

The commission responded that they "viewed with concern the report and intend to make contact with the national authorities".

Mr De Rossa said: "This is a very significant development. It is the first indication that the Health Minister Mary Harney is facing the prospect of legal action at EU level, and ultimately EU fines, for refusing to abide by the EU health and safety rules on working time. Incredibly, there are still reports of junior doctors on duty for 36 hour shifts, and sometimes longer."

Dr John Morris, vice president of the Irish Medical Organisation, said non-consultant hospital doctors were the only grade in the health service that work on temporary contracts into their 40s and work shifts of 24, 56 and 72 hours without appropriate breaks. Hours are due to fall to 48 a week from the end of July.

Junior doctors are already in dispute with the HSE having voted overwhelmingly for action over proposed cuts in overtime and allowances. Talks in the Labour Relations Commission broke down when the HSE walked out yesterday."

I would like to draw attention to this particular phrase, which sort of cracks me up a bit. "Incredibly, there are still reports of junior doctors on duty for 36 hour shifts, and sometimes longer."

There are STILL reports of this, huh? Wow. That's weird. Considering that EVERY SINGLE HOSPITAL IN IRELAND OPERATES ON THE 32-36 HOUR SHIFT BASIS AS A MEANS OF STAFFING THEIR POORLY MANAGED SERVICES!

There is, currently, not ONE hospital in Ireland where this isn't the accepted and normal way of working for NCHDs. Weekends can be split into 26-30 hour shifts between two people IF management sanction this, or they can be a 56 hour straight marathon with no sleep and no scheduled meal breaks. Some even do from Friday morning to Monday morning working, an incredible 72 hour shift. Not week. SHIFT.

NCHDs have no choice in the matter as the overtime is MANDATORY, and it is worded that way in their poxy 6 month contracts that they remain on for years and years on end. When I was an intern I did 56 hour shifts at weekends. Once I was so ill with fatigue by the Monday that, alarmed at the state of me, they decided I should maybe not treat patients, and I was sent instead to do photocopying for the day.

End this madness. And give the patients a safe health service, and the doctors a health service they can provide care in, as opposed to exhausted and half hearted troubleshooting.

Official stement from the Kim Jong-IL school of public relations.

2009-06-27T12:35:00.004+01:00

Posted by: Dr Thunder.

Now, I've never been a big fan of the HSE. The Health Service Executive is essentially the arm of the Irish department of health that runs our pretty shoddy health service.

In Ireland, despite having recently had over a decade of unprecedented economic growth, we still have a third world health service.

Expensively trained Irish healthcare professionals can be found all over the world, as they make their escape from an environment which is one of the most demoralising in the developed world in which to work.

Patients still languish on trolleys in emergency departments, as they wait for one of the precious beds in our understaffed, filthy, crowded wards.

As a doctor it's frustrating to see healthcare being run into the ground by people who have lost touch with what it's like at the coalface. Talk to people who have worked in emergency departments when there's a ministerial or departmental visit. Patients who have been lying on trolleys for days are suddenly found beds. Exhausted staff are kept out of the way. The sycophants are wheeled out for a meet and greet.

Against a background of spectacular cockups, it wasn't a huge surprise when I heard the HSE will be closing down a part of their spinal surgery services in Our Lady's Hospital, Dublin. This is one of the finest children’s hospitals in the country, and provides essential services for children with scoliosis in Ireland.

Scoliosis is a curvature of the spine. Its effects can be devastating. It leads, in many cases, to significant disfigurement. The curving spine can also impinge on vital internal organs, such as the kidneys, to stop them from functioning properly.

However, we are in the fortunate situation, whereby scoliosis can be treated, or at least managed. Sometimes surgery is the answer. Sometimes a cast is fitted to help the spine grow back straight.

Time is of the essence in these case. Because as the child grows, the curvature gets worse if not treated.

Because of the economic crisis, the HSE need to save money. They need to cut back on wages. So, they had a look around at potential targets.

Admin people? No.

Political advisors? No.

Government trips overseas for St Patrick's day? No

"Hey, what about the only people looking after kids with scoliosis in Ireland?". Great idea.

So, operations have been cancelled, and appointments have been binned. Casts won't be applied. Operations won't be performed. Curvatures will get worse, and these children will go from being able to live a normal life, to being a burden on the state.

Unsurprisingly, the weary Irish public have asked the HSE to explain this decision. So, they did. Oh, sweet Jesus, they did. The statement released to the press said:

"The incidence of children with scoliosis in Ireland is different to other countries, as termination of pregnancies that have a prenatal diagnosis of spina bifida, or other conditions that may develop spinal curvature, is not legal in Ireland".

Christ on a bike!

Why oh why oh why would they say this??? There is a technical point of some sort being made here. But what is it? Are they saying these children should never have been born?

Will they say to all the parents of disabled ex-premature babies "Sorry. If it wasn't for the fact that our doctors are obliged under law to treat your sick kids, then we wouldn't have these problems to deal with. So, we'll be withdrawing all future cerebral palsy care".

There some things that may be technically true, but imply a judgment of sorts. In this case, it's hard to read the statement as saying anything other than "You really shouldn't have had these kids".

There's a lot of offended parents out there.

I've seen too much of this type if nonsense to be surprised.

The HSE are thought to be better at PR than actually managing the health service. If that's the case, we're all screwed.

Dr. Thunder.

Don't worry, doc. I've brought a load of people to have a look at your sick kid. I can get more if you need them!

2009-06-12T14:58:00.005+01:00

Posted by: Dr. Thunder.

I find it ironic that, nowadays, when I see someone keeling over, it often makes me want to go in the opposite direction. Very fast. Especially when I'm already busy as hell. But, it's fair to say that's not the case for 99% of the general public.

People love a good old collapse. Nothing draws the crowds like a wham-bam-outa-nowhere-keeling over. It's one of my pet hates. If someone is unfortunate to become unwell in a public place, they can be guaranteed one thing.....that a lot of people will have a good look.

The people I always feel sorriest for are those who have seizures in public. Imagine it. You drop suddenly. Next thing you're waking up on the main street in on a saturday afternoon in your urine soaked trousers, with blood gushing from your bitten tongue, confused and just wanting to sleep. But that can't happen, as someone ALWAYS takes it upon themselves to make sure you don't fall asleep. Like in the movies, where if you let an injured person fall asleep they die. In about 50% of cases, the misery of the unfortunate "seizee" is compounded by someone ramming a spoon in their gob. Gotta make sure they don't swallow that tongue! Swallowing a spoon, or tooth fragments is fine. But keep that tongue firmly in their mouth, at all costs.

Just picture yourself waking up in that situation. Number one rule when dealing with a sick person in public...make sure they have some privacy.

I'm writing about this as I was in a similar situation about 2 weeks ago. I was doing an outpatients clinic, so I definitely wasn't in "emergency mode". I was strolling towards my little room, eating a hearty breakfast of one slighly over-ripe banana enroute. The only thing on my mind was whether it's dangerous to eat a banana that's more black than yellow.

And then then it happened. The 11 year old girl walking ahead of me just dropped. Her mum started shouting for help, and I looked around hoping some nice person was going to sort this kid out. Then I had that "oh yeah...I'M the doctor" moment that every medic will have had at some stage in their career.

Anyway, I made my way over to the girl an her mum, and worked out reasonably quickly that she'd just had a faint. I was on my knees beside her, just talking quietly to her, reassuring her that she was going to be fine. I didn't really notice what was going on around me. Until I turned around to see if I couild find someone who could call the emergency team.

I was looking for one person. There were at least 15. Whoa!!! All these people just having a look at the poor kid.

They were staring at her. She was staring at them. She looked horrified. They looked fascinated.

So, I said "OK, guys, we're fine here, thanks". No-one budged. "Eh, could we please have some privacy here, please?".

Two, maybe three or four, people walked away. The rest just kept staring. This girl looked so embarrassed, and I couldn't blame her. So, I became more forceful, and stood up. I literally forced these grown adults away from her, and into the foyer. The emergency team came with a trolley, picked her up, and took her away. All was well with the world again.

So, why do people do this? I can understand the odd punter offering you their phone if you need to get help, or their first aid skills. But why just stand there and gawk? It's embarrassing for the patient, and it SHOULD be embarrassing for the person watcing.

I remember once looking after a guy in a burger king, who'd keeled over. The problem was so bad, that the excellent and ballsy security guard just decided to empty the store. He just threw every single solitary person out of the restaurant, and shut the big glass doors. When the incident was over, there was still a massive crowd, faces pushed up against the glass, desperate for a glance at this poor guy on the ground.

Has anyone else experienced this phenomenon? It's more of a concrete legs than a rubber neck situation, I think.

As someone who has been part of the mob of medical students turning up unannounced to the bedside of sick patients hundreds of times, I shall continue to take the high moral ground on this issue :D

Apologies for the lack of blogging lately. I'm exceptionally busy in work and real life at the moment, and am likely to be for the next few months. So, please bear with me.

And thanks for the emails reminding me how slack I've been. You're an unforgiving people :D

Dr. Thunder.

Inefficiencies in the Irish Health Service: The "First Dose".

2009-03-14T18:13:00.006Z

Posted by Dr. Jane Doe

The ongoing campaign against NCHDs in the Irish health service has recently accused us of "inefficient work practices". Over the next few posts I am going to illustrate some major ineffiencies in the way the health service runs in relation to our job, and the effect this has on patient care. These inefficiencies are not of our making, and are usually stupid, irritating and inefficient ways of doing things that make our job difficult, the nurses job difficult, and the patient's life difficult.

So today, boys and girls, I'm going to talk about a very inefficient and stupid work practice that occurs in every hospital in Ireland, and as far as I am aware, nowhere else in the world.

The First Dose:

In Ireland, for some reason that no-one knows, the first dose of any intravenous medication is required to be given by a doctor. Usually this falls to the intern, or occasionally the SHO. There is no evidence base for this practice. Nowhere else in the Western world has this practice. I have no idea why it exists, nor does anyone else. People stumblingly explain when asked by the frustrated patient waiting for hours that this is "in case you have a reaction" but this is bollocks, as I'll explain in a little bit.

Now, the "first dose" is not limited to antibiotics. Oh no. It can mean first dose intravenous corticosteroids, IV vitamins (such as Pabrinex to treat alcohol withdrawal), IV vitamin K, first dose IV morphine, anything.

And get this. This'll really crack you up. This is just beautiful. Even if the patient has had IV Augmentin 1000 times before on previous admissions, if they get readmitted, the "first dose" principle applies all over again, and only a medic can administer it!

Ah. The flawless logic of our health system astounds me yet again.

So deconstructing this tower of imbecility, I will explain why the "In case you have a reaction" explanation is bogus in extremis. If a patient has an honest to God anaphylactic reaction when I give them an IV medication, what the hell am I going to do? I'm going to put out an emergency call so that the anaesthetist will come and be ready to intubate, and I'm going to give IV antihistamines, IV hydrocortisone, and administer subcutaneous epinephrine,which should be done first, readily available in the form of an EpiPen, or whichever one the hospital has in stock.

Now nurses are allowed to administer subcutaneous meds, and they usually know how to put out the emergency/arrest call faster than the intern/SHO would as they are the ones that usually do it. So the two first, and most important steps, namely 1)calling for help and 2)administering subcut epinephrine do not necessitate a medic at all. Now, if someone other than a doctor was able to administer the IV hydrocortisone and IV antihistamines, say, one of the ward nurses on receipt of a verbal order, then before the emergency team ever got to the patient, most of the treatment would have been instigated and the anaesthetist could then assess the airway etc. and the medic can manage as appropriate thereafter. So the patient would actually get FASTER treatment, and faster is usually better in emergencies.

If a reaction occurs that is NOT anaphylaxis, then the doctor can be bleeped and review the patient as appropriate.

The whole concept of the first dose is mind-bogglingly stupid anyway. The first dose will likely sensitise you to the drug. The next dose might be the one that gets you, if it is going to, in all probability. Or maybe the third. Or fourth. In fact, you have as much chance of having a reaction every time.
Also, the number of cases of reactions to IV medications on the first administration is exceedingly rare. I have never seen one. Nor has any other doc I know. We have occasionally seen angioedema, and very, very rarely anaphylactic shock, but never after a first dose IV med.

In addition, medics are required to make up the first dose IV med before they give it. Now this is where it starts getting dangerous. You see, as it's not really a doctor's job to do this, we obviously don't receive any kind of instruction on it ever. Some drugs are incompatible with normal saline, some are incompatible with dextrose. Some have to be diluted a certain way, some made up under aseptic technique, some vials have to shaken after the solvent is added, some cannot be shaken or the compound will be ineffective.
Some have to be diluted to a certain volume, so that a certain amount can be administered over a certain time. Nurses receive ample training on this. We are not even shown how to put the connecting tube into the bag, or put it through the infusing machine, let alone set it. Occasionally a kind hearted nurse will show you, but the machines change all the time, are different in different hospitals, and in different wards.

Pharmacists know all this stuff. Nurses know all this stuff. Doctors don't have a frigging clue. The majority of this stuff is usually done by the interns, who, having completed 5-6 years of training to know how to prescribe these meds, the indications for doing so, the intended effects, the potential side effects, and long term complications of therapy, now get to use none of that taxpayer funded training as they instead do a job that they were never trained to do and are unfamiliar with.

You tax dollars at good work, people. Once,as an intern, I was called to do anti-TNF alpha infusions. I had never done one before. There was no-one around to show me, so I made it up with the water for injections which the nurse had thoughtfully left out for me. It wasn't dissolving, so I gave it a good firm shaking. As I was doing so, the nurse came in, and turned pale. "STOP SHAKING IT! NEVER shake it! That's about 800euro worth of Remicade gone!"
Shite.

Also, doctors are not based on one ward. Or even one floor. We have to go everywhere, all the time. Routine administration of IV medications is a bit down the list most of the time, as it is relatively non-urgent. So patients are waiting. Waiting for antibiotics to start to treat their pneumonia. Waiting for IV frusemide to ease their breathing and decrease the swelling in their legs. Waiting for IV hydrocortisone to stop their wheezing. Waiting for IV antiemetics to stop their nausea and vomiting.
They wait, and get uncomfortable and frustrated. So do their families. They get mad, usually at the nurses, whose hands are tied, and they in turn get mad at us for not being there-but we have to be eight other places and what can we do? Nurses hate the first dose malarkey as much as we do, they will, after all, be giving all the other doses, and it does not say much for confidence in their professional training either.

So the above practice has the following implications:

1) Causes unneccessary waiting for patients and resultant discomfort, frustration and suffering.
2) Is a completely inefficient use of a trained doctors' time and contributes to further delays in other patients' treatment. The reason the docs aren't reviewing your new onset pain may well be because they are tied up giving 15 first doses.
3)Is potentially dangerous as the person reconstituting and administering the intravenous medication is not formally trained to do so and is often unfamiliar with the ward equipment.
4)Is not based on logic or evidence, and thus is a completely useless and inefficient hindrance to patient care that should be eliminated without delay.

But will it? Is efficiency and good value for money in the public sector really what we're aiming for? It never seems like it.......

I need to form an opinion. Can anyone help?

2009-03-05T11:36:00.006Z

Posted by Dr. Thunder.

There's controversy brewing in Ireland. Like many countries, it was decided a while ago to introduce a programme of vaccinations for Irish girls, to help protect against cervical cancer. As most of you will know, there's a jab available that has been shown to be very effective in protecting against the viruses that cause most cases of this disease.

This would be given for free to girls in their early teens.

All was well, and public health/preventative health was back on the agenda.

But then the tough times came along. A load of bankers loaned a load of cash to people with no money, and we were all snookered.

So, as is historically the way of the politician, money was taken away from the population health strategy. They must have already syphoned off their quota from mental health services for the year.

The long and short of all this is that Irish girls were told they wouldn't be getting the vaccine. Well, they wouldn't be getting it for free. So, the rich would still get it.

But the type of people who are really at risk of cervical cancer would be less likely to be able to afford it.

There was a big fuss about this initially. But, like most public health initiatives, the fallout from the funding cut was short lived.

However, now a group of doctors have announced that they will be administering the vaccine for free to 300 12-year old girls in Dublin this week. Local businessmen have paid for the vaccine itself, and the doctors won't be charging for their time.

Word on the street is that the administration of the vaccine would have been outsourced to China if the GPs had asked for payment.

This all looks very noble. Fair play to the local businessmen, and fair play to the GPs.

But is it that simple? Possibly not. One of the GPs is a member of the Irish opposition. Dr James Reilly is not just a member of the Fine Gael political party, but he's their health spokesman.

He claims this isn't a political stunt. But in the same breath he says:

"The fact that the local community, 19 schools, parents associations, teachers, parents, doctors, nurses, and 300 children have indicated their demand for this vaccine should send a loud message to the Minister and this Government and the Minister should take up the baton and continue this programme throughout the country,".

My dilemma lies herein. On the surface, I like this idea. Private business funds overseas aid all the time, so why not give something to Irish people who may not have been able to afford this vaccine.

On the other hand, I'm uneasy because:

A) A politician, and a doctor, seem to be using their patients to make a political point.

B) Let's face it, we are seeing these vaccines being given out because this is a popular cause. It has, and will continue to, attract media attention. Do 12 year old girls need a cervical vaccine right now?? probably not. Could it wait a year or 2 until the country is financially more stable? Yes.

Could we use more counselling/psychotherapy services for the mentally ill? Absoloutely. Would this attract a lot of media attention? Absoloutely not.

Like I said, I'm a fan of this idea on a superficial level. But I also have deep misgivings about it in the context of an overall health startegy.

So, I have decided that, for once in my life, I don't have an opinion that's set in stone. Yet.

Can anyone help me out?

The full story is available at:

http://www.irishtimes.com/newspaper/breaking/2009/0302/breaking43.htm

Dr. Thunder

Pink eye for the homeopath guy

2009-03-01T06:37:00.003Z

Posted by: Dr Thunder

Little Timmy is 7.

He's from a middle class family, and goes to a good school. But he's been ill a few times lately. Mum reports that he's been getting "pink eye" recurrently over the last few months.

Their GP has given them antibacterial eyedrops each time, and has showed them proper "eye toileting", which have cleared it up. But timmy's mother reckons their GP isn't treating the problem properly, because it keeps coming back. I had my doubts, as this GP is known locally as being very reliable. But that's why they ended up in the paediatric emergency department this time. They wanted a "proper opinion" from a paediatrics registrar.

Ironically, their GP used to be a paediatric emergency registrar in our department.

Anyway, I examined the eye, and it looked like pretty straightforward conjunctivitis. So, I took a swab to see if there were any bacteria growing, and sent him off with some antibacterial drops in the meantime.

I phoned Dr. Taylor, their family GP a couple of days later, to tell him that Timmy's swab didn't grow a bacteria. We were talking about the recurrent conjunctivitis, when the GP told me what was actually happening.

One kid in Timmy's class has had conjunctivitis for the last few months. It's an easily treatable condition. But it's HIGHLY contagious. This child's mum doesn't like conventional western medicine. So, she's been bringing him to see a variety of herbalists, and lately he's been going to a homeopath.

Meanwhile, he still has pink eye, and keeps giving it to his classmates. it's just going round in circles.

Dr Taylor is seeing his classmates on a regular basis, and has been giving the correct treatment and advice. But conjunctivitis is difficult to prevent when the "index case" is being treated with magic water.

His mum has told one of the other parents that she's using a homeopathic remedy called "Argentum Nitricum". I cannot find any studies that suggest it works. But, ya know, you don't have to bother with that kind of legwork if it's "alternative" medicine.

The GP is going to talk to the teacher, and ask her to try to persuade them to get the kid to a doctor, as I'm little unsure about the long term effects of untreated conjunctivitis. All this really needs is good cleaning, as it appears to be viral in nature. I've suggested the school ask parents to keep children with conjunctivitis at home.

This is likely to be the only thing that will make the index case's mum get proper medical treatment, as having a kid at home with pink eye is likely to affect her coffee morning attendance abilities.

Cases like this make me mad. People have a right to shun conventional medicine. But surely seeing half the class walking around with inflammed eyes would guilt any reasonable person into getting proper treatment.

I need to go and calm down I think. Now where did I put that herbal tea?........

Dr Thunder.

Spin Doctors are expensive!

2009-02-24T13:46:00.005Z

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

I believe the kids call it a "facepalm"

2009-02-13T17:48:00.008Z

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..................

STOP MAKING YOUR JUNIOR DOCTORS WORK ILLEGALLY LONG HOURS, AND REVERSE YOUR INSANE PLAN TO TAKE AWAY THE BUDGET FOR THEIR TRAINING IN RESUSCITATION AND BASIC SURGICAL SKILLS.

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.

The idiot's guide to "slashing overtime"

2009-02-07T01:33:00.007Z

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.

A Different Way of Doing Things

2008-08-24T06:24:00.005+01:00

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

HSE cost cutting

2008-07-26T05:12:00.006+01:00

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

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

2008-07-31T02:49:00.003+01:00

“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

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

2008-08-06T00:05:00.002+01:00

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.

OR

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?

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

2008-08-31T02:20:00.005+01:00

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.

TRAINING:

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.

Doctors. Their hours. The ten year lag.

2009-02-05T03:24:00.006Z

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

Dr Thunder: The Lazarus Project

2009-01-25T02:32:00.004Z

Posted by: Dr. Thunder

May I take this opportunity to wish you all:

A) A happy halloween

B) Happy Christmas

C) A happy new year.

Retrospectively, of coure.

I haven't been blogging since late October. Not because nothing has happened. Not even because I'm lazy.

I've just been tired, grumpy, overworked, and unmotivated.

We've recently gone through a very busy period in the paediatric department. We were really snowed under, and everyone was pretty miserable. This had the effect of causing 2 of our doctors to resign.

As a result, the rest of us were even more overworked...and grump.....and unmotivated.

I started working every day of the week, with the occasional weekday off. I worked pretty much every weekend, and all my shifts were long and unsociable hours.

So, I guess the blogging suffered because I was miserable in my job, and just didn't want to talk about it.

But things are better now. I'm getting 2 days off a week, and I have some wekeends off, plus we have more staff.

That has had the effect of improving my demeanour somewhat, which is lucky. Lucky because Mrs Wiley turned up with her toddler today. Mrs Wiley is a "heartsink mum". That means that as soon as she walks in the door, everyone looks the other way, and nobody wants to deal with her.

She brought her toddler, James, in to see us, as she has done every couple of weeks since he was very young.

Mrs Wiley is extremely worried about high temperatures in her son. Someone once told her that high temperatures in a little person suggest meningitis until proven otherwise.

So, she takes his temperature every morning and night.

If it creeps above 37.5 degrees, she comes straight to hospital.

So, the consultation usually involved a happy,playful toddler with a temperature of 37.8 degrees, a rageing mum who's angry at having to wait 3 hours with her meningitic son, and a bemused doctor. The key here is that, while the temperatures tend to be just above 37.5 degrees, they're not signiciantly elevated.

I've seen James a few times. Initially consultants got involved, in order to allay mum's fears. We also wrote to her GP, and arranged health visitors. Nothing worked.So now we've given up, and we just see the kid each time.

Yesterday he looked as well as he usually does. I think he's geting to know me, as he offered me a rusk when I was listening to his chest. I politely declined, and continued the examination.

I told his mum that he looked fine, and gave the standard advice about temperatures to her. She wasn't happy. I had a chat to her, and explained the symptoms of serious illnesses, such as meningitis, and explained why i didn't think james was unwell.

She was unhappy because we "never do blood tests". This, to her mind, meant we weren't taking her seriously.

I don't know what else to say. I tell her I'm not going to do blood tests. We argue. She goes away unhappy, and says she's going straight to her GP. I think that's a good thing actually, as I think she could use some help.

It's a difficult situation, and an akward one. But what do I do? Investigating this well child is a waste of resources, and it will just foster the culture of dependence even more.

I rang the GP and told him that James was on his way. Social services are involved in a superficial way, and he's going to broach the subject of counselling.

I hope it works. I hope mum gets some help. But I suspect we'll be seeing alot more of James and Mrs Wiley in the future.

*all names used in this blog are fictional.

Dr. Thunder

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

2008-10-18T12:28:00.002+01:00

Posted by: Dr. Thunder

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

Source: http://www.independent.ie/breaking-n...s-1502090.html

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

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

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

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

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

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

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

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

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

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