Shsshssh... Don't rock the boat!

Don't rock the boat! 

We are led to believe and indeed most are of the opinion that there are significant problems with the establishment of modern medicine as it exists today. In general terms there are two kinds of medicine in Ireland; community and hospital medicine, and each area has its own assortment of 'problems'. There is no shortage of solutions, and the usual form of a solution is the one that might afford the greatest benefit to the individual or group proposing the solution. What both the problems and the solutions lack is the ability to look at the Health Service from an entirely objective vantage, and to be prepared to accept that we ourselves (the potential problem-solvers) are as much a part of the problem as the entity at the end of the pointed finger.

In respect of General practice a significant portion of the 'blame' for our grossly inadequate system of community medicine lies fairly and squarely with the body responsible for training General Practitioners. As Bertrand Russell states of philosophy, the same can be said of an educative College, in that the highest compliment one can pay to a philosophy is to be brutally and objectively critical of it', for it is only out of a recognition of its short-comings that a philosophy or indeed a College can evolve and improve. However, what invariably gets in the way of philosophical criticism is that all too human mixture of dogma and ego.

At present there exists two medical systems in Ireland; community and hospital medicine, and most of the problems within one system are a consequence of the problems in the other. Waiting lists for procedures, overcrowded casualties, ill-affordability and lack of services in the community,  are all related by the simple reality that there is no clear distinction between hospital and community medicine. The dogs on the street are aware that an enormous portion of the 'treatment' that occurs in the hospital could easily be conducted in the community; here we are all in agreement.  Where the conflict and antagonism begins is when we attempt to discern why this should be so, and how it might be remedied.

Realistically we will never be capable of implementing community or hospital services unless we can arrive at a satisfactory answer to this question. I assert that the answer is twofold; GP's do not manage community medicine properly because in the first instance they are not trained or confident enough to do so, and secondly because they have not the time, are not inclined or incentivised to do so.

In the first instance the lack of training is the fault of the ICGP, the Medical Council, and the Medical Colleges, and the second part of the problem is the fault of; the State, the patients and the GP's themselves.

The Colleges.

After medical school and a one year internship at the hospital, What to you have to do to be a GP in Ireland? The answer quite surprisingly is Nothing! Any medical graduate on the General Register can hang a plaque on the wall and practice as a Private GP. He or she can work in the out of hours service (largely staffed by non specialist trained GP's), he or she can provide locum cover, or be employed at any GP practice in the state. Indeed were it not for the army of non specialist trained 'GP's working in the Irish system, community medicine would very likely collapse.

So what is the point or the purpose of specialist GP training in Ireland? In a fundamental and practical sense the only purpose of specialist training in Ireland is that a GP might be eligible for a 'medical card list' whenever such lists rarely become available. Non specialist GP's can see and treat medical card patients anywhere and at any time throughout the state, however to obtain formal 'ownership' of a list of such patients one must be a trained GP. It's an entirely Irish solution to an Irish problem, that has everything to do with money and nothing to do with medicine.

The actual end purpose of specialist training and the specialist register in the Context of General Practice exists solely to control who can access the lucrative medical card system. It is a means of reducing the numbers amongst whom the cream-pie must be divided. Once again it is reasonable to reiterate that the only difference between a member of the Irish College and a non-member is the ability to own a list of medical card patients.  In practical medical terms both are fully licensed to practice in the exact same manner and see exactly the same patients. The difference is one of ownership, possession, contracts and quite simply, money.

In practical terms if the end result of General Practice training amounts to little more than entitlement to the lion's share of the community health budget, we should not be surprised to discover that General Practice training in Ireland is entirely lacking, and to a great extent irrelevant to the actual practice of community medicine. For example a significant majority of presentations in General practice have a psychological or psycho-social component, whilst General Practice training in Ireland includes merely the 'option' of a six month psychiatric post. Dermatology waiting lists in Ireland (mostly in the hope of a simple biopsy) are quite possibly the longest on the planet, and not surprisingly one could complete formal general practice training in Ireland without ever once having picked up a scalpel.

Many Irish GP's simply “do not suture” and GP's who work at the out of hours service in Dublin are specifically asked not to suture. Not because of hygiene or the usual palaver about infection control, but rather so as “not to set a precedent” .  Undoubtedly most of the GP Members at the out of hours service are also Members of the ICGP and yet, how one could maintain ones membership of a college, fulfil the various requirements for continued education, and still remain unable or unwilling to close a simple flesh wound, is beyond incredulous, and speaks volumes in respect of our health service.

The disparity between training and the actual practice of Community Medicine is not only a product of the non-clinical and entirely financial endpoint of the process, but is highlighted by the fact that so many General Practitioners provide an exemplary level of care to their patients (including suturing) without any formal training in General Practice.

Unless General practice training becomes focused upon the task of producing community practitioners capable and competent in the provision of relevant community health services, we will continue to burden the hospital with that which could easily be managed in the community.

The Patient

Not being eligible for a Medical Card list, my practice is entirely private. I have in excess of 1500 patients and at most I see between 5-10 patients per day (from whom I extort the relatively modest fee of €50 a visit). I have worked for many years at practices with a significantly smaller number of medical card patients and yet I would see 20-30 medical card patients per day.

We don't like to talk about this reality because we are not fond of truths in Irish medicine, however the simple reality is that medical card holders present more often to the GP simply because the service is entirely and completely free, and when something has no price it has no value. Therefore if much of the practice time is spent entertaining frivolous free-consultations, there is little time to actually treat people. This reality is complicated by the fact that many practices are entirely dependent upon their Medical Card incomes, and as such will scarcely rock the boat upon which they sit, regardless of the fact that it might be full of holes and sinking fast.

How community medicine will cope, or whether it will survive the Minister's promise to turn every patient in the country into a medical card patient is beyond comprehension, but in traditional Irish style, it sounds great, and is a clever evolution of the Haughey (Ha Ha) era...'vote for me and I'll buy you a pint' or in this case “free” GP's visits.

The state

The state is probably the most significant contributor to the problems of Irish medicine, however this reality is at once complicated by the fact that the state is a product of we the people, of vested interests such as the medical establishment, the HSE, and of the gullibility of the people to swallow empty promises and accept quangos and bureaucracy as the end result of those same promises.

Unfortunately the state lacks the courage to draw an appropriate distinction between; the nursing home, the hospital and General Practice, and as such it allows the most expensive component of the trio... (the hospitals) to function in the capacity of providing care on all three levels.  Not only are the hospitals incapable of doing this, but they must also expend stretched resource upon the education of fee paying medical students. Incidentally the fees being paid by almost a thousand medical students at Beaumont hospital are in excess of 35,000 per anum, all of which is paid to the registered charity that is the RCSI.

In short the State presides over a medical system where General Practice does not fulfil the needs of the community, the hospital cannot supply hospital services, and the state will notprovide a distinction between the two.

The GP's

No problems here, we are all perfect?

Marcus de Brun

North Dublin GP

Why I Rip My Patients Off!

Dr Marcus De Brun explores a hypothetical rationale behind the current financial structures in general practice (IMN)



Mary works part time at a local supermarket. She has a three-year-old daughter, Annie. Mary’s husband, Ben, is a bus driver. Mary and her family are just outside the eligibility threshold for a medical card. Mary has had diarrhoea for four days and cannot go to work. Annie has also picked up the ‘bug’ and has diarrhoea.
Mary needs a letter for work and she is worried about Annie. Ben is also unwell, but he goes to work as ‘someone has to hold the fort’.
Mary and Annie come to my surgery in Dublin. I confirm that Mary has gastritis and a yeast infection. Annie also has gastritis and is a little dehydrated. Mary needs a note for work, some medicine and ideally someone to help her look after Annie. She gets the note for work and the medicine… we do not live in an ideal world.

Pharmacy mark-up
Mary must pay €80 (€55 for herself and €25 for Annie) for the privilege of seeing me. When she gets to the pharmacy, she must pay €30 for her medicine (including the pharmacy mark- up of 100 per cent). Mary’s supermarket does not pay sick pay for part timers and the crèche gives no discounts for non-attendees.
Mary is silently stunned and confused when she gets home and looks at what remains in her purse after she has paid €110 for a pack of Imodium and 20 minutes at the doctor’s. The groceries will just about be paid this week, but the crèche will have to be put on the long finger.

Fair deal
As a doctor, I feel comfortable ripping Mary off, because I am highly qualified and far better educated. I understand relativity. And I should be rewarded with an income ten times higher than both Mary and her husband combined. Besides, look at the bankers and Pat Kenny at RTÉ, at solicitors and accountants and the financial regulator etc, ad infinitum. Compared to any number of patently inferior social contributors, I make a mere pittance.
For my 900 medical card patients I receive €130,000 per annum from the HSE. I receive another €50,000 per annum for cervical smears, pregnancy care, blood tests, childhood vaccinations, insurance claims and contract commitments.
From my private patients, I receive between €100,000 and €150,000 per annum. My surgery opens for 30 hours per week, but much of the work I do is behind its closed doors.
Fortunately, I receive a grant from the HSE  for a practice nurse and practice manager, in addition to free courier services, free clinical waste collection and a grant to invest in ‘improving my practice’ with computers and equipment, if and when I need it.
Fortunately, I also receive holiday pay, study leave, sick leave, a grant for living in the country and, thanks to the vigilance of the IMO, a reasonable pension.
My indemnity insurance and college fees are also paid for me, my out-of-hours is paid for by D-Doc and it pays me €90 per hour if I choose to do my rostered shifts. All of this reduces the stress… just a little.

Fortunately, I do not have to worry about competition from any other doctor. My medical card patients belong to me; they are my property, my chattel. Should another GP try to move into my town, my medical card patients have no choice but to stay at my practice, unless that other doctor enjoys the special relationship I enjoy with the HSE.
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Unless that doctor has a GMS number, he can be as qualified and as nice as he likes, but he is of no competition to me. Fortunately for me, if another doctor wants a GMS number, he must buy one from the College of General practice.   Or,  he/she  can buy into my practice, agree to work for me as an indentured labourer for a number of years, after which I might make him my partner and give him a share in my herd.

Still, my salary is only half of Pat Kenny’s, and a Dublin barrister or government advisor would hardly get out of bed for it.

On the bread line
Recently, I have been thinking on how unfair the system is, of how Einstein’s relativity has me almost on the bread line. Therefore I have decided to take a stand. I will employ a doctor to mind my patients (a foreign doctor would be best, as these are often a little cheaper).
I will devote some of my relatively paltry income to my election campaign. If I make it as a TD, that will bring my gross income from €500,000 to €600,000 per annum, and if I manage to get a ministerial post, that will bring my income to almost €700,000 per anum and at last I might just be able to get by.

Of course, I will still be well short of what Pat makes, but I will be close enough, and at least I will have conquered the moral high ground. I will have taken a stand for what is right and fair.
I will have made a difference.

Our Sick Health Service

The hypocritical oath. 

There are few occasions in my career when I feel compelled to ask myself whether medicine was the right choice for me. No doubt many in the College and the Council would concur.  Today was one such day, one where I not only question myself as a member of the Medical Profession, but also as a citizen of Ireland.

Tom is a 40yr old office worker, he and his wife Kate are the kind of soft spoken, gentle, introspective people who make General Practice a meaningful place to work. Three weeks ago Tom came to see me complaining of a tingling sensation down his left arm with occasional stiffness in the wrist.  The immediate suspicion of carpal tunnel syndrome was somewhat borne out during the exam and Tom was referred for physio and given a short course of anti-inflammatories. Tom saw the physiotherapist for two sessions during the week.. however matters came to a head during the following weekend when Tom noticed that his speech was becoming a little slurred.

Of an anxious disposition Tom presented to a nearby 'Swift' clinic, and after being examined he was informed that he may have had a “slight stroke” he was advised to go to A/e and given a letter. Whilst driving himself to A/E his nervous disposition evolved into anxiety proper and with Olympian self control he endured the six and a half hour wait in Beaumont casualty, to have a blood test, be examined and ultimately reassured that it was unlikely that he was having a stroke and allowed to drive himself home.

On Monday Tom presented to my practice once again, with an unexplained and unresolved slurring of speech and persistent neurological symptoms in the arm. Fortunately Tom has VHI, this was unfortunately of no use at the Swift clinic, but we will come to the financial costs in a moment. I referred Tom to a Neurologist at a private Dublin hospital. The following week Tom went to see the neurologist, who organised an MRI scan and after examining Tom recommended that he have some bloods done “there and then”. Tom was asked to pay 350 euros for his 20-30 minute consultation with the Doctor.  He was then informed that his blood tests would be an additional 300 euros. When informed the receptionist that the cost was 'a bit too much' and that he would rather have them done at his GP's he was informed that one of the tests was a 'special test', that could not be done at the GP's.  When he asked if he could have just the 'special' test done and have the remainder at his GP's, he was informed that this might be possible?  But that he would have to 'go through the public system to get the remainder his results ' and that this would greatly complicate things. Tom acquiesced and left the rooms of the neurologist after paying out some 650.00 euros for a 30minute consultation and some bloods. Although it is pure here say upon Tom's part he described his encounter with his consultant as being very formal and not at all friendly.. of course we only have Tom's word for that. 

This was on Tuesday morning, on Thursday he had his MRI scan. On Friday Tom's wife called to say that Tom was quite unwell, and that she was very distressed and worried on his behalf. It is important to reiterate here that Tom and his wife have been my patients for quite some time that they are very nice people, who don't complain and don't present to the Doctor's unless there is something wrong, and have a resolute faith in the medical profession.  I advise Kate to bring Tom to my surgery.

Once again this time on a Friday evening at 5pm Tom and Kate are in my office. On this occasion Kate is in tears, Tom has a hard time holding back his own tears, and I myself am emotionally shaken by the presentation. Tom has an envelope with his MRI films inside, he is pale upset, clearly hasn't been eating, drinking enough or sleeping well since he saw the Neurologist. After I examine him he asks me to look at his MRI scan which I do, whilst warning him that I am neither a radiologist nor a neurologist.

I do the decent thing and lie, I say that I can see nothing wrong with the MRI scan but that we will have to wait on the formal report and in the meantime we should try to deal with the other 'elephant in the room' which is our collective anxiety. I ring the private hospital on the off chance that the MRI might have been reported but of course the world of private medicine has gone home for the weekend.

I give Tom the only remaining tool in my arsenal of impotence in the form of a letter to A/E should his speech become worse over the weekend. I also give him my mobile number my refusal to take a consultation fee has the apparent effect of deepening Tom's anxiety, for which I gve him a short term script for some anxiety pills.

Now for the Bills: First presentation to me  50, two visits to the physio 80, visit to VHI 125, return visit to me 30, visit to the consultant 650. Grand total 925 euros. Tom has been out of work for three weeks, if we count the cost of his medication and the fees I have waived Tom's symptoms have cost him almost one thousand euros.  He must return to the Neurologist next week and was reassured before he departed that his next consultation would not be as expensive!  This will undoubtedly bring the grand total to some 1200 euros of which he is entitled to a 60 euro refund from his VHI.

Tom and his wife will spend the weekend worrying, awaiting the diagnosis which they most fear; a cancer a brain tumour, multiple sclerosis. The professionals, like myself who have treated Tom will sleep quite soundly this weekend, oblivious to the pain Tom and Kate will endure, oblivious to their fears and the financial burden that has been placed upon them. This is modern medicine in Ireland, this is the predatory nature of the relation between the 'system' and decent honest hard working good natured people.

It is a good thing that the Hippocratic oath has been dispensed with, else we might add cynicism to the growing vices of our profession.