Fall 2018 (Volume 28, Number 3)
Rheumatology Here and Away: Rheumatology in Ireland
By Paul MacMullan, MD, MRCPI
Ireland is a funny place. Like an errant sibling, I can complain
about it, but others can’t! It’s a mad country with a
crazy history of occupation and rebellion, with all sorts of
shenanigans and double-down back-stabbing, which serves
almost as the modus operandi for general political life.
That said, Ireland was home to me for some 40-odd
years; immigrating to Canada was a major life transformation.
Emigration was never the plan for me, my wife, and our
three boys, but became so when the Irish health service and
my so-called senior colleagues decided it was a good idea
to respond to the economic crisis by essentially halving the
salaries of new entrant consultants, while simultaneously
doubling their workload and barring them from private
practice, something I was never really interested in anyway.
Healthcare in Ireland is (I won’t say organized because it’s
anything but) let’s say “arranged” in a very curious manner.
Medical education is an export industry (there were more Canadians
in my med school class than Irish) and “residency” is
a never-ending saga of propping up a dysfunctional “system”
until somebody dies. There are poorly funded public hospitals
with long waiting lists and severe overcrowding that are
essentially staffed by residents and fellows. Meanwhile the
consultants who are supposedly full-time in the public hospitals
are running a glut of private facilities that over-investigate
the worried well and, once things get complicated, proceed
to dump them back onto the nearest public hospital. Similar
things happen in the National Health Service (NHS) in the
U.K. but are also not publicized due to the hierarchical nature
of the medical pyramid that exists in both countries. Having
done ten years of up all night in-house call with 36 hour shifts
once a week of unselected general internal medicine (GIM)
admissions in addition to daily rheumatology clinics, I have
the experience to say these things. . . and, experience, (as I tell
the residents who come through our clinics), is what you get
right after you just need it!
Anyway, I explored potential opportunities in other Commonwealth
countries and the U.S., but really focused on
Canada, as I had spent a summer in Vancouver many years
ago and really liked the egalitarian nature of the country and
the healthcare system. Fortunately, after some initial enquiries
and a subsequent site visit, I was offered an alternative
relationship plan (ARP) position at the University of Calgary
and haven’t looked back since. The licensing process was
cumbersome but relatively straightforward and, after four
years, I can now gladly say that my family and I have settled here. The work environment is challenging but rewarding
and services are extremely well integrated, in comparison to
what I was used to. Furthermore, not having to do GIM and
being able to focus on rheumatology has been liberating.
While I sometimes miss the “whodunit” of internal medicine
call, I don’t miss the constant hassle and, as rheumatologists,
we get enough GIM to keep us on our toes.
Alberta has been very forward thinking in developing
the province-wide data repository that is Netcare and,
along with the unique lifetime identifier (ULI), allows economies
of scale that were heretofore unimagined to blossom.
For example, our Division of Rheumatology has partnered
with the primary care network of family doctors to provide a
specialist link service for non-urgent telephone advice, and
a recent opportunity cost-analysis has demonstrated each
phone call, on average, saves the system almost $200, data
we will be presenting at the upcoming American College of
Rheumatology (ACR) meeting in Chicago. Such initiatives
are also great for patient care.
One thing I will say about the medical system here is
that, in my humble but experienced opinion, training is too
short, particularly for GPs. Two years ain’t enough, because
at that stage you don’t even know what you don’t know. That
said, there are other avenues such as special competency
certifications and special interest groups to build expertise
in certain areas, such as rheumatology.
So “to get right back to where we started from” (Maxine
Nightingale) I’m glad I listened to that Jean Chretien podcast
many years ago.
Paul MacMullan, MD, MRCPI
Clinical Associate Professor,
Cumming School of Medicine
University of Calgary