They take your bloods, deliver your babies, stitch your wounds and insert your stents. They are growing in number and the Irish health system could not survive without them.
Yet overseas doctors are some of the invisible workhorses of the Irish health system, rarely heard from until one ends up before the Medical Council on a disciplinary matter, or – as occurred this week – they become embroiled in a pay dispute.
Even when they are pitched into the centre of events – as during this week’s protest by locum doctors over a pay cut – they tend to keep their heads down. Widely reported as a “wildcat strike”, the action taken by the doctors, almost all from outside the EU, was in fact a withdrawal of services by contractors engaged by agencies.
Their action, which put emergency departments under severe strain, was as much about a lack of training and career opportunities as pay, a group of the doctors told The Irish Times.
Ireland is more dependent on overseas doctors than almost any other country in the world, though their concerns are seldom aired in public discussion.
For many who come here, Ireland turns out to be a career cul-de-sac where the most attractive promotional opportunities are effectively out of bounds.
“It amounts to systemic discrimination. You have the same hospital, the same work – yet one guy gets a place on a training scheme and the other, from overseas, does not,” says Dr Altaf Naqvi, founder of Overseas Medics of Ireland. “With no training qualifications, you cannot move on to senior posts in other countries.”
“The current system is so entangled that it has become impossible for young doctors from Pakistan to get on a training programme,” says one senior consultant, who arrived in Ireland more than 20 years ago.
This consultant, who does not wish to be identified, successfully trained as a consultant with the assistance of the RCSI.
Since then, changes in arrangements for training consultants have made it more difficult for many non-Irish-educated doctors to become consultants. He says the system is not set up to support people who have trained outside Ireland and tends to favour the “locals”.
He contrasts the Irish system with the US, where “if you’re good enough, you’ll get in”, or the UK, which has more interim grades.
Here, non-nationals struggle to get training places because they don’t have an EU passport.
As a result, he says, many overseas doctors live a transient lifestyle, moving from one locum job to another. Their families settle in one place while they move from hospital to hospital on short-term contracts.
“The money is often good – they work long hours – but there is no future for them as a consultant,” he says.
The general term “overseas doctor” refers to medics trained outside the EU. Four out of every 10 doctors in the Irish health service belongs to the category, and their number is rising fast.
Overseas doctors are registering with the Medical Council at a rate 16 times higher than for Irish medical graduates, a recent study found. They come from 101 different countries, at the last count, but the vast majority hail from a handful of populous non-EU countries: Pakistan, India, Sudan, South Africa and Romania.
One-quarter of Irish medical graduates are registered in the general (non-specialist) division, compared with two-thirds of international medical graduates. Four out of every five junior doctors occupying a non-training post is an international graduate.
Due to staff shortages, they sometimes fulfil the role of consultants but are vulnerable where permanent appointments are made. Ironically, some have been here long enough to see their Irish-born children grow up and study medicine here without any such hindrance.
More than one-third of doctors working in Ireland were trained overseas, but their internship qualification is not recognised here unless they come from Australia, New Zealand, Malaysia, Sudan, South Africa or Pakistan.
Despite their unhappiness with the current set-up, many overseas doctors are afraid to speak out. Dr Naqvi, who retired two years ago, speaks for OMI because colleagues working in the system are afraid they will be targeted for going public, he says.
“It doesn’t say much for what is supposed to be a free, democratic country. Overseas doctors recognise that Ireland is a small country with a limited number of consultant posts. It is not that they want to take these posts; more that they want to be able to move on and get posts in other countries with the learning they have received here.”
I really don't think anybody bats for these guys either in medicine or in public life. Ireland's treatment of them is quite shameful
Keeping your head down is an ingrained habit with many of Ireland’s overseas doctors, but there is one area where this may not be an option.
Foreign-trained doctors are over-represented among those brought before fitness to practise hearings at the Medical Council, and the headlines generated by some of these cases have served to tarnish the reputation of all overseas doctors.
Lost and bewildered
Some cases have raised genuine issues about standards and competence, but on other occasions the young doctors appearing before disciplinary hearings have seemed lost and bewildered at the unfamiliar surroundings.
“I feel terrible about the way Ireland treats its overseas doctors,” says GP and medical columnist Maurice Gueret, who like many Irish doctors worked with staff from around the world during his training.
“I found them wonderful colleagues. They were fantastically adaptable in what was a chaotic and dysfunctional health service.”
Just as with Irish graduates, and those from everywhere else, standards among migrant graduates vary, he points out.
“It really galls me to see an endless procession of these guys hauled up in front of TV news cameras for misidentifying X-rays, misinterpreting instructions or whatever.
“Yet those who recruited, interviewed, trained, hired, licensed them etc get to do a Pontius Pilate, washing away any grubby whiff of responsibility from their hands.
“I really don’t think anybody bats for these guys either in medicine or in public life. Ireland’s treatment of them is quite shameful. They are entirely expendable, their faults cherry-picked for entertainment on TV news in the evening.
“The system’s failures carry on, as do the mutilated careers of those that we deem entirely fit one day and completely unfit the next.”
The motivation of doctors coming to Ireland is changing.
“A decade ago, lots of overseas doctors were coming here for the money,” says Dr Kevin Moore, clinical director of Naas General Hospital.
“They would work up to 80 hours a week. They were making decent money, while supporting families at home.”
Then the European Working Time Directive capped long working hours of doctors, with a weekly ceiling of 48 hours. “Overnight, Ireland wasn’t a place you came to make a large amount of money. With their income cut by over one-third, many went to more lucrative shores,” he says.
“Recruitment tailed off, to the extent that three years ago we had to go overseas and bring in doctors directly. Like other hospitals, Naas experienced a significant shortage of doctors.”
While Ireland’s appetite for overseas doctors appears insatiable, the popularity of this country as a work destination ebbs and flows. Things have turned around again, and Dr Moore thinks Brexit and Donald Trump might be factors.
“What we’re seeing is that doctors are now more cautious about going to the UK, given the potential impact of Brexit. Meanwhile, Mr Trump has made America seem a less attractive venue for a lot of international medical graduates.
“However, the doctors who are coming now want real training opportunities and these are frequently lacking in the Irish system. Lots of doctors are not getting the qualifications they want because they are in non-training posts. They should be able to get a qualification that is of value to them when they go home.”
Dr Moore detects a touch of hypocrisy operating in relation to the training of doctors. “We seem to be reluctant to train the doctors who come to Ireland, yet every Irish graduate who comes back as a consultant after spells in the US or the UK has received the best training in the world.
“We need to ensure Ireland is one of the best places in which to train a doctor, so our own doctors stay and the overseas graduates coming here are of the highest calibre.”
‘Every system is struggling’
Overseas doctors working in Ireland have a global view that enables them to assess our system objectively. Some aspects of it impress them; others do not. “From the day I did my internship I had an aspiration, like most people in Pakistan, to go abroad for the international experience,” says Arslan Ali Sohail, a doctor at Naas General Hospital.
“There are things we would lack at home, and to fill those gaps we need to get exposure to other health systems.
“My preference was for an English-speaking country. I also had a friend who was already here and who was able to tell me about the conditions. I liked what I heard, so I came.”
That was in 2013. Unfortunately, due to a change in regulations shortly before he arrived, his internship training in Pakistan was not recognised in the Irish system, thereby barring his access to higher specialist training.
Despite this limitation, Dr Sohail feels he has learned a lot working in stroke medicine in a range of Irish hospitals.
“I’m a very different doctor from when I came here. I know that a lot of things are said about not being able to train. I would say there is a lot to be gained here still, through being supervised by a consultant. A major part of training is experience, that’s part of the picture.”
I never came to Ireland for the money, I came for the training. The problem is that I can't access any formal training here
He is unfazed by the overcrowding and other problems that plague the system. “Working here has been an absolute pleasure. Every system is struggling, the NHS too, with the challenge of treating increasing numbers of older patients.”
Pramod Kumar Agarwal, an Indian colleague in Naas who specialises in nephrology, has a similar view. “Every system has its own problems. I’m not an outspoken person but we do get good training and you are well supported.”
Dr Agarwal says he has no personal experience of the bullying referred to in confidential surveys by a substantial number of junior doctors. He says he is “not sure” if he will stay in Ireland, though two of his children were born here.
“It’s a nice place to work and be trained. Eventually, if I get a consultant position, I may stay.”
“I never came to Ireland for the money, I came for the training,” says another Indian doctor, adding that he could make “much more” at home where the health system is largely private.
“The problem is that I can’t access any formal training here,” he says, echoing a point made by many overseas doctors based in Ireland. “I will move to the UK once an opportunity there opens up.”
This doctor, who declined to be identified, says there are many good things about the Irish health system, particularly the level of care afforded to patients.
What gets to him is the level of red tape, and the lack of support he feels he gets from some colleagues.
“Doctors don’t have the power to make decisions anymore. It’s the bureaucracy – this regulator, that regulator.”
In many ways, his grievances are of the kind any doctor would make, not just one from outside Ireland. “If you ask a porter to do something, they don’t see it as their responsibility. If they even answer the phone, they’ll walk down to you, regardless of the urgency.
“Everyone feels it’s not their responsibility because, at the end of the day, responsibility comes to the doctor.”
Many overseas doctors come to Ireland with the intention of maximising their earning to support family at home or to plan for an eventual return home. However, the attractiveness of the Irish system has waned since the European Working Time Directive curbed long shifts and long working weeks.
“When people are earning money they are happy, but now that they aren’t they are leaving.”
He can’t understand why the Irish health service pays doctors the same no matter where they are working, even though living costs are higher in Dublin.
“In India, you are paid a living-out allowance that varies according to the cost of the city where you live. Here, they want people to work in Dublin but they don’t want to pay them enough to cover costs.”
Ultimately, with the path to consultant training blocked, he sees his long-term future in the UK.