Second Opinion: Refreshing stint with team at the coalface of emergency care

A change, they say, is as good as a holiday. For those concerned with healthcare, this was certainly true of the recent Cabinet reshuffle. After one of the most shambolic performances in living memory, there has been a collective sigh of relief at the appearance of plain-speaking, realism, and an understanding that major change in a complex system requires calm deliberation and consensus-building.

Perhaps the major concern about the former minister for health’s tenure was the perception of being outmanoeuvred at budget decisions by wilier career politicians, as well as a failure to stem misconceptions that Irish healthcare was a basket-case not worth spending money on.

As for universal health insurance as presented, it looked like a sure-fire recipe for paying more, getting less, enriching insurance companies and producing a tangle of extra bodies.

One was reminded of Churchill’s retort when Brendan Bracken, his fiery Irish-born adviser and minister, was likened to a bull in a china shop. “The difference with Brendan,” he replied, “is that he is the only bull who carries his china shop with him.”

A worrying augury for the future, the Taoiseach’s remarks about the new direction suggested that, just as we have seen with the Catholic Church in relation to child abuse and the Garda in relation to penalty points, loyalty may be more important than getting it right.

On a brighter note, I had my own significant and refreshing change this month when I swapped my role as consultant geriatrician for a three-month stint in the acute medical assessment unit at Tallaght hospital.

Tallaght has been one of the leaders in this development, whereby patients with illnesses of a certain severity presenting to the emergency department during the day are directed to a specific unit with rapid assessment by a medical team and early investigation.

The approach has many benefits, ranging from faster assessment, earlier discharge and more effective use of resources to providing a focused approach that permits subspecialist teams to continue their specialist work during the day.

One of the good things about the Irish health system is that the HSE has accepted that a significant proportion of the physicians working in acute medical units should be geriatricians, given that older people are a key client group for medical services.

Opportunity

This is both an opportunity and a challenge. The opportunity arises from the input of specialist knowledge to deal with complexity and frailty, avoid unnecessary tests and interventions, and remediate disability to the greatest extent possible.

More challenging is the ability to keep the skills of geriatric medicine refreshed in a high turnover and short-stay setting. The work is also very intense, and it would be hard to envisage a full and unbroken working life in this manner.

For myself, although my usual work covers both geriatric and general medicine, including stroke medicine, it is a very helpful immersion in the more acute aspects of practice. Also, if geriatricians in Ireland wish to encourage junior colleagues into acute medical unit work, it is vital that they send a signal that they are willing to support them by just this sort of mix and matching.

So, as my colleague spends three months in the more traditional geriatric medicine settings of day hospital, rehabilitation, consultations and general medical take, I am now directing care for a different range of conditions, particularly chest pain, pneumonia, headache, falls, seizures and loss of consciousness.

The good news is that the acute medical unit has attracted a remarkable selection of nursing and associated staff and hugely enthusiastic trainees.

It is also a tribute to the consultant body and clinical directors in Tallaght that support from subspecialties for rapid consultation has been excellent, despite enormously strained resources and low consultant numbers for the large population served by the hospital.

As a geriatrician, I have always enjoyed engaging with people at the most complex and interesting stage of their lives. This acute aspect is also stimulating, if at times very revealing of gaps in our health services. However, they are still far from the “Third World service” description that all too often appears: a particularly insensitive term given the large numbers of staff from low and middle-income countries working in our health system.

Not everyone can change their working practice as readily, but if you can, I recommend grasping the opportunity with both hands.

Desmond O’Neill is a consultant physician in geriatric and stroke medicine and professor of medical gerontology at the Trinity Centre for Health Sciences at Tallaght hospital.