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Minister for Health Simon Harris appears to have bought into the dogma of acute medical care in Ireland, namely that the health system is good once you are inside it. The Minister evidently fails to grasp that any system serving fewer than five million people that has more than 500,000 people awaiting outpatient review, has record numbers on trolleys and loses 40 per cent of its medical graduates to emigration requires fundamental reform rather than the tinkering we have witnessed over the last three decades.
Over the past decade there has been an 11 per cent increase in public, non-capital health expenditure in Ireland, together with a 27 per cent increase in consultant numbers. Despite this substantial increase in resources, access to the system remains appalling.
One area worthy of more scrutiny is the way medical patients are managed in our acute hospitals. Specifically, the central role played by the consultants within the acute medical system.
In terms of emergency-department delays and trolley counts it is consultant general physicians, as opposed to surgical, anaesthetic or obstetric consultants, who are the key clinicians within the hospital system. The role of general physicians in Irish hospitals is where one should look for pointers to the cause of the dysfunction in Irish hospitals.
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Hybrid role
The most relevant aspect of general physicians’ role is its hybrid nature. Most Irish hospital general physicians are also part-time subspecialists, not to mention also being part-time sole traders, ie private-practice operators.
This means that should you require acute hospital admission you will be managed by a part-time general physician. They will spend a significant amount of their time attending to their subspeciality, such as cardiology, undertaking endoscopy lists, subspeciality outpatient clinics and perhaps some research, That is before they head off to their private subspeciality clinic, or “rooms”.
Your physician may also head off to Dublin or Cork or Galway to examine either undergraduates or postgraduates. Participation on national committees and overseas attendance at educational symposia are two further reasons for absence from the hospital wards.
Similarly, given the above, you shouldn’t be too surprised that you are one of 500,000 waiting on an outpatient list for subspecialist care. This part-time general physician, part-time subspecialist physician structure goes a long way to explain the poor figures for prompt public access.
While this model (“two for the price of one”) was perhaps suitable in the cash-strapped 1960s and 1970s, the exponential growth in medical knowledge, together with the public’s expectations, mean it is no longer satisfactory.
What is needed now is full-time general physicians and full-time specialists. This change has already occurred in the United States, where the full-time generalists are now termed "hospitalists". These physicians are responsible for the management of patients admitted through the emergency department. Their other commitments are greatly reduced, allowing them to focus solely on patients admitted acutely.
The benefit of separating physicians into either a hospitalist or a specialist cuts both ways. The specialists, no longer managing those admitted via emergency departments, can provide 100 per cent specialist care, including greater numbers of outpatient clinics, endoscopy lists, etc.
Other obvious benefits include a better quality of care, given the removal of major competing distractions. Patients therefore receive not just quicker care but also better care.
Training time
One crucial benefit of this model is the much shorter time needed to train as a hospitalist/general physician. Currently consultant training is about eight years in duration, roughly four years of general training and four years’ subspeciality training. Obviously, subspeciality training is not needed in the case of the hospitalist discipline, postgraduate training being reduced to four years in total (currently three years in US). The option of the generic (and flexible) hospitalist career would greatly increase the attractiveness for doctors to both remain and return to Irish hospital medicine.
Of benefit to both doctors and hospitals, the flexible nature of the hospitalist allows both doctors and hospitals to both match their requirements and other commitments.
The separation of hospitalist from subspecialist also addresses the crisis in consultant physician recruitment, increasing as it does the number of potential candidates for a hospitalist post, in addition to increasing the attractiveness of specialist posts.
In summary, the job of consultant physicians in the Irish hospital system is fundamentally flawed. They are neither fish nor fowl when it comes to the patients they treat. The separation of this current hybrid job into either hospitalist or specialists is the key structural change needed if Irish hospital medicine is to come off life support and prosper in the future. The introduction of this discipline with its shortened training period, and flexibility potential, has the potential to greatly reduce the emigration of Irish medical graduates and improve consultant recruitment in Irish hospitals.
Cathal O’Sullivan is a consultant microbiolgist at Midland Regional Hospital