Irish healthcare workers feeling the recession blues.

There's a recession in Ireland.

A really BAD recession.

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

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

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

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

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

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

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

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

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

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

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

Please enelighten me.

Dr. Thunder.

Quote of 2009

Posted by Dr. Thunder.

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

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

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

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

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

Dr. Thunder.

The antibiotic war.

Posted by: Dr. Thunder.

What are we doing wrong?

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

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

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

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

"Really? And why is that?".

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

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

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

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

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

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

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

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

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

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

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

The thing is, I suspect they may have.

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

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

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

Dr. Thunder.

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.