I recently spent a week in Ireland, taking in the sights and spirits sometimes even together (see Dublin Literary Pub Crawl and the view from the top of the Guiness Factory). I was actually there for work too – visiting the University College of Dublin and the Mater Miserecordia Hospital – or the original Mercy Hospital as they refer to it. As the future of primary care, residency work hours, and the healthcare insurance system continue to cause angst in the US, we often find ourselves referencing what our European colleagues do. Well, there’s nothing like asking the people and observing for yourself. For example, the first time I heard the word “bleep”, I thought they were politely avoiding colorful language in front of me. But in fact, to page someone is to bleep them and you’re always afraid your bleeper will go off. While this is a small difference, there are quite a few substantial differences in their medical education system.
- Residency work hours? I was expecting that the European Working Time Directive was in effect, where all workers are to work only a maximum of 48 hours. What I learned is that each country has determined its own ‘solution’ and really ‘style’ in managing this constraint. In Ireland, to preserve some aspect of continuity, they have in effect argued for dividing educational hours from ‘service hours.’ Therefore, all junior doctors can work 48 hours of ‘service’ and have an additional 12 hours of ‘education’ for a total of 60 hours per week. The residents do still have a culture of staying until the work is done. But, they are on the cusp of change since this years interns are now limited to 24hour shift maximums creating some concern that they will not have the same experience and learning as the seniors before them got.
- Supervision? The team model of inpatient care was in full effect but with slightly shuffled roles. Interns did mostly cross cover for large numbers of patients. Admitting was done predominantly by residents (aka Senior House Officers or SHO). Also in house is a registrar, who is a physician who has completed at least 3 years of post graduate training and is available for supervision for the intern and senior house officer and is spending another 4 to 6 years in training in a clinical subspecialty at this level. Consultants (aka attendings) come by for rounds less frequently since the registrar is quite capable having in fact completed their training.
- Cost of medical school? Indeed, medical school in Ireland is free for EU citizens, but only if you continue to pass so there is a strong incentive to pass. Entry into medical school can be from high school but also can occur as a graduate of the college. In fact, there is quite a diverse generation of students that are all in training together simultaneously. Moreover, the tuition from foreign students (non EU that is) is what the medical schools thrive on, which was similar to my experience in China. The foreign students come from all over, but quite a few come from Malaysia.
- Access to care? While healthcare disparities are not focused as much on race as they are on income. Those that are rich are able to buy private insurance and ‘jump the cue’ so to speak to get a consultation with a specialist. If you don’t have private insurance, you’re relegated to the public insurance system where it could take several months at least to see a rheumatologist or orthopedic surgeon. Seeing a general practitioner (primary care doctor) also costs quite a bit of money so people don’t visit the doctor unless they have to. Interestingly, in Northern Ireland, which is still under British rule, citizens can see their GP for free. In certain rural areas of Ireland, Gaelic may be exclusively spoken by patients so doctors in those areas need to have a strong command of the native language of Ireland.
- Competitive specialties? While I explained to my colleagues what the ROAD was, they speculated it would be the O’s for them– Opthalmology, Orthopedics and OB/GYN. While the first 2 are understandable, I had to ask about OB. Obstetric care is insured in Ireland guaranteeing a decent salary (they also don’t face the high malpractice premiums). Also, primary care is not devalued since Irish docs actually enjoy becoming GP’s since they get more autonomy and entry into specialty training is heavily restricted by the number of positions and is tied to the hospital limiting jobs, since a ‘consultant’ post at a hospital may or may not be available upon completion of specialty training. Workforce planning seemed to be a hot topic while I was there, as there were commissions that were deciding the future of the numbers of training posts in Ireland.
Thanks especially to all my wonderful hosts at the University College of Dublin and Mater Misericordia Hospital for their generous hospitality and putting up with all my questions!
-Vineet Arora MD