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

Posted by Dr. Thunder:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Highly recomment NZ as a working environment.

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

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

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

Dr. Thunder.

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.

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, essentially, responsible for the day 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 husband (!?!) 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 so critical of HSE bonuses before they were dangled under his nose. This is a man who has presided over a HSE which treats its 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?

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?

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.

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

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!

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.