Escaping a broken health system

Trinity medics outline their reasons for emigrating and react to talk of plans to make them stay.

indepthBANNERA recent NUI Galway study of medical students in Ireland found that 88% of respondents were considering pursuing their professional career overseas following graduation. Of course, soon after the study was published, the headline “9 in 10 medical students may leave Ireland” quickly squeezed its way into the national press, prompting a new question of Ireland’s old problem: how do you tackle emigration when some of the brightest, and frankly most employable graduates are choosing to leave?

A closer look at NUIG’s study reveals that the situation is not quite as ominous as the headline might first suggest.  Slightly over 2,000 students across Ireland’s six medical schools were surveyed, however, 1,519 of these were Irish. It’s fair to assume that the quarter who are not Irish are more likely to practice outside of Ireland when they graduate. Nevertheless, even if foreign students are discounted, Irish medics still make up many of the 34% who said they definitely plan to emigrate, and make up the majority of the 54% who said they are considering emigration. It may not quite be 9 out of 10, but the significant majority of Irish medical students are considering emigration.

Push factors

The question is what is pushing them away from Ireland, or indeed pulling them towards Australia, Canada, and the United States. Irish medics typically train for five years, and then complete an intern year in Ireland. Traditionally, they have been encouraged to then go abroad and gain practical experience, and the assumption has always been that one day they will return. Now there is real worry within the medical community that they won’t. The NUIG study put the most popular reasons for this under three broad categories: career opportunities, working conditions and lifestyle.

Dairé Rothwell, a final-year medic in Trinity, does plan to emigrate after his intern year. He says, “[This] is the case for most of my class I would imagine.” However, he sees himself returning to Ireland in the long term. For him, the “allure of travel” is the impetus behind his intention to emigrate temporarily. “It’s not as if for most of us we feel driven away by an arduous system.” However, Rothwell does concede, “Certainly after intern level there’s still a perception of very long working hours and limited training opportunities.”

Eoin Murphy, a second-year medical student also in Trinity, does not believe the tide is turning fast enough. He describes his shock when he heard of doctors in Irish hospitals campaigning for a 24-hour maximum shift to be implemented nationwide: “The prospect of working longer than this frightens me, as I would have reservations about my ability to care for patients – the raison d’etre of the medical profession.” This is one of the main reasons why Murphy is himself seriously considering emigrating. “It seems balancing the rota is more important than ensuring optimal care for people, and I’m not sure if this is a system I would be comfortable working in. The HSE has ignored, and continues to ignore, the 13-hour EU shift limit. This is the law and covers doctors’ (and other healthcare professionals’) rights as workers. The bare minimum of a system would be to respect these rights.”

Indeed, the subject of Murphy’s criticism has not been ignored by the EU. The advocate general of the European Court of Justice, in an opinion published on the 19th March, said that Ireland was in breach of its working time directive, and as a result the Irish Medical Organisation has said the government may face fines of up to €100 million. The European Court has yet to announce its verdict, however, in almost all cases it upholds the opinion of the Advocate General. Speaking to The Irish Times,Eric Young, assistant director of industrial relations at the Irish Medical Organisation, claimed that 33% of non-consultant hospital doctors were routinely required to work in excess of the legal 48-hour limit.

Plugging the shortage

Unsurprisingly, these claims are indicative of a shortage of doctors and a culture of emigration. Moreover, this culture seems to have spread to medical students, even though they themselves often have had little exposure to professional working shifts. With Irish doctors increasingly relocating abroad and those in training planning to follow suit, Ireland is attempting to plug to shortage with doctors trained overseas. 34% of doctors currently practicing in Ireland were not trained here. This is one of the highest proportions within the OECD nations and the trend is increasing.

However, this fact often makes the professional lives of doctors even more difficult. Those trained outside of the EU face significant challenges in pursuing their careers in Ireland, which are not encountered by those trained in Ireland or Europe. To qualify for trainee positions, non-EU medical graduates must first pass a pre-registration examination, but also possess a “certificate of experience”. This certificate is effectively proof that the doctor in question has completed an internship equivalent to what an intern in an Irish hospital would complete. Yet, crucially, the Medical Council only considers graduates from New Zealand, Australia, Pakistan, South Africa, Sudan and Malaysia to have a Certificate of Experience equivalent in standard to one issued in Ireland. This means that non-EU doctors not trained in these six countries cannot apply to trainee positions in Ireland, even if they have a number of years’ experience working in Irish hospitals. Not only does this damage the careers prospects of doctors whom this country is reliant on, but also provides a disincentive for doctors to travel and work in Ireland, where in fact they are in high demand.

Forced contracts set the precedent that the state wants to see purely an economic return on its investment, rather than appreciate the social benefits of a cohesive medical profession, enabled to provide care.

The emigration of Irish doctors is not only an Irish problem. Despite the barriers they face, many foreign educated doctors travel to Ireland in search of higher salaries. The faster Irish educated doctors emigrate, the greater the demand to fill the gap. Dr. Diarmuid O’Donovan, a lecturer who supervised the NUIG study, has picked up on this phenomenon: “Not only is this a problem for Irish recruitment, but we need to be mindful of World Health Organisation guidelines on international recruitment and taking skilled personnel away from countries that have medical staff shortages.”

Although Ireland does have its own problems with a lack of healthcare professionals, the situation is even more acute in other EU nations. The Polish city of Radom has one of the fastest shrinking populations in the country, and what has been termed “Euro-orphans” is a serious problem there and across other areas of Europe. Many parents are leaving their children in the care of grandparents so they can work abroad where they can command a higher salary and send home money. Speaking to the Observer, the director of the local job centre in Radom, Jozef Bakula, said, “The city is 10 GPs short. The situation is paradoxical because we have absorbed the cost of their education and training and often their upkeep, and then they go abroad and we’re no longer the beneficiary of their skills or the GDP they’re creating.”

Return on investment

Dealing with the problem of emigration from Ireland then, may also decelerate the rate skilled workers are leaving other countries. The question of how to deal with it has frustrated governments, industry and service sectors, and families for years. However, increasingly there is a sense that emigrating doctors should be held to a higher standard than other Irish graduates. Proponents of this view make a similar argument to Bakula. The UCD economist Cormac Ó Gráda has argued that because the cost of educating every doctor is so high relative to many other graduates (he estimates €300,000), the state should be entitled to a return on its investment. The argument is that medical students should feel obliged to care for those people whose taxes have contributed to their education. The idea being floated is that Irish graduates should be required to practice medicine in Ireland, at least until they have offset the cost off their third level education.

This approach is one that Rothwell and Murphy are equally critical of. “With regard to the argument we should feel shackled to the Irish health service, frankly I find that concept offensive,” Rothwell says. “Especially when one considers we will virtually all at least do our internship here and many, if not most of us, will go abroad and gain experience that we will later come back with.”

Murphy agrees with Rothwell that it is unfair to single out medics: “Plenty of people from all walks of life emigrate from Ireland. Many graduates who benefitted from taxpayer-funded third level education have studied dentistry, mathematics, engineering and commerce.” He also makes the wider point: “There are graduate and foreign students who pay fees and it would be remiss to bind them in a contract.” His argument is particularly applicable to EU students. While non-EU students meet the €32,000 cost of their tuition fees, students from all over the EU pay the same student contribution as Irish medical students. Ó’Gráda’s argument would therefore imply that EU students are also obliged to practice in Ireland and reimburse the taxpayer.

“Also,” Murphy continues, “the notion of paying back our economic cost to the state sends a disturbing message. Is the value of having motivated compassionate doctors solely an economic one? Forced contracts set the precedent that the state wants to see purely an economic return on its investment, rather than appreciate the social benefits of a cohesive medical profession, enabled to provide care.”

Other critics of Ó’Gráda’s proposal have similar objections, arguing that to halt the emigration of doctors we should try to engineer a healthcare system they want to work in, rather than chaining them to the current one. In a letter to The Irish Timeson March 14th, Eoin Feeny, a consultant physician in infectious diseases at St. Vincent’s Hospital, wrote: “Proposals to charge people more for medical training or stop them from leaving would be extremely counter-productive. Instead may I suggest an attempt to deliver better working and training conditions, and an improvement in relationships with health service management?”

Murphy puts it this way: “When you have invested in somebody (financially or emotionally), I would hope the reaction to their leaving would be to ask why they are upset, not how can I stop them.”

Illustration: Mubashir Sultan