This week, Minister for Health James Reilly warned that hospitals will not be able to hire enough junior doctors by July 11. Here a junior doctor working in an Irish hospital, who wishes to remain anonymous, describes the situation on the wards.
JULY 11 IS QUICKLY becoming the doomsday of Irish healthcare. The changeover – when new doctors arrive, ex-interns flee to the new world, and emergency departments throughout the country finally crumble beneath the sheer weight of patients on trolleys.
The reality is that we will struggle on, as we have for so many years – understaffed, overworked, denied overtime payments in some institutions. It is the junior doctor who will bear the shortcomings of our health system in the months and years to come. Who would want to stay in an environment so destined for failure?
Understaffing is a hot topic, but not a complex one. When you don’t have enough doctors to do the job, the doctors who are there work longer and harder. They work more hours and more nights on call – a rota where you were on call one in every six nights might becomes one in three. The European Working Time Directive (EWTD) dictates by law that no doctor should work longer than 12 hours without a rest period. But this just isn’t possible if, after a night on call, there aren’t enough doctors to staff the facility.
You stay for the next day, and you can’t really argue with it. You could enter the hospital at 8am on a Thursday and leave at 8pm on Friday night, with two hours’ sleep. This is a reality in many hospitals where the EWTD simply cannot exist because of understaffing. The situation will worsen on 11 July.
Where the EWTD is in practice, junior doctors face different problems, again due to understaffing. If you work a week of nights, for instance, sleeping during the day after working the night (how selfish) – your regular team of five junior doctors, or non-consultant hospital doctors (NCHDs), are reduced to four. If two doctors are rostered for nights, or if someone is on leave, it becomes trickier still. But you just work harder and longer to fill the gaps, and get on with it.
Every junior doctor has a horror story. I once worked an 80-hour shift with about six hours sleep in total. I was a hero for half a day and then someone else stole the limelight. But on the whole, it’s not that bad. It can be a difficult lifestyle, but we knew this before we entered the profession. It does of course depend on where you work – some hospitals are notorious for long hours and ridiculous on-call rotas, features of an understaffed department.
‘The patient is more likely to die’
But is it just hard work, or is it dangerous work? Understaffing can be genuinely negligent in some cases. For example, cardiac arrest is a situation where understaffing simply isn’t an option.
Or so you would think.
Let me re-tell a worrying anecdote from one particular hospital. Staff are often moved around depending on where they are needed the most. Junior doctors working nights may be moved from less busy, more remote areas of the hospital to the emergency department. But if there is a cardiac arrest in that remote area, they are absent. The anaesthetist, too – who usually leads a cardiac arrest team – could be absent if working in the operating theatre. This can leave only two people to run a resuscitation – not enough, particularly when one of them will be an intern who may just be starting out on the job. The patient is more likely to die, thanks to substandard resuscitation.
A friend of mine had a horror story. She had just started on an oncology (cancer care) rotation as a new intern. This was a rotation that was notorious among the senior house officers (SHOs) for being incredibly difficult – so it was always a post that was hard to fill. While my friend was an intern with oncology, they were short an SHO all the time. She was often left alone on the wards, and described nightmarish days running from ward to ward dealing with acutely unwell cancer patients, some of whom were critically ill. Patient care no doubt suffered.
Training is another issue. As NCHDs we’re supposed to be part of an ongoing medical education programme, with formal structured teaching. This is not possible if doctors are stretched to fill a couple of positions at once. You may not be able to attend teaching because of commitments to ward jobs. You may be after a night on call – do you stay for teaching, or go home and sleep? Or if you are part of an EWTD setup, you may have fled the hospital for your ‘rest period’. If you sleep, you miss out on training.
Poor training is bad for us professionally and in terms of our confidence as medics. It’s also bad for patients who may be exposed to substandard doctors. Training also requires us to pass professional exams. Understaffing simply doesn’t equate with successful study – longer hours, more on-call, more tired, and less chance of getting a week of study leave. Ultimately, most junior doctors want good training – this will trump everything at the end of the day. But more often than not, Irish training programmes are too unstructured to compete with international standards.
So it is with this uncertain future that many of us will battle on. But suppose you’re hit with that woeful hospital – there is no teaching programme, you’re too busy with menial tasks to actually learn anything clinical, and you might not even get paid for your overtime. Typically these are severely underfunded peripheral hospitals with Third World facilities. But it is actually the huge Dublin hospitals where junior doctors are the worst affected, as their catchment areas far surpass the facilities and staff available. It’s really only word of mouth that you can rely on to help you avoid these hospitals. I feel sorry for the unsuspecting foreign doctors who are landed with a nightmare job.
It’s no surprise, then, that I’m emigrating – soon to become a statistic, an enemy of the state because I am leaving emergency departments in tatters. But do I feel bad about it? Not really. I’ll be back at some stage with good training and some idea of how a functioning health system works – two things that I may not get if I stay in Ireland.