Fall 2018 (Volume 28, Number 3)

Rheumatology Here and Away: Rheumatology in Ireland

By Paul MacMullan, MD, MRCPI

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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
Calgary, Alberta

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