The decision by the State's non-consultant hospital doctors (NCHDs) to go ahead with a day-long, allout strike on May 17th comes as no surprise.
This much put-upon group of junior doctors are, in theory, undergoing training. The problem for hospitals is that they are service-providers without whom the system would collapse overnight.
Medicine is still a hierarchal profession. Junior doctors are the non-commissioned officers who report to generals in the form of hospital consultants. The system has its roots in a time when young doctors lived in hospital residences in circumstances which were really an extension of undergraduate life. You were apprenticed to a house surgeon or house physician and you received training which was based on the master-apprentice model.
Circumstances have now changed to the point where the system is no longer compatible with either the demands of modern medicine or the lifestyles of young doctors. Being "on call" has changed to being "on duty".
Whereas in the past the young apprentice could reasonably expect to be called to the wards once or twice at night, the reality of 21st-century medicine is that he or she does not get to bed at all. This means working from 9 a.m. to 5 p.m. the following day without adequate rest, 32 hours of continuous responsibility for the health and lives of others.
Junior doctors have the full support of their consultants in taking industrial action. Whereas 20 years ago senior doctors might have wrinkled their noses and commented: "We worked long hours, why can't they?", this is not a view you will find today. They see the huge cracks in the system and will testify to the negative impact on both patient care and doctors' health.
There is a substantial body of evidence to show that the inhuman demands of the "on call" system affect young doctors' well-being. Rates of depression, suicide, alcohol and drug abuse and marital breakdown are higher than in other professions.
As an intern 15 years ago, I fell asleep at the wheel of my car when driving home one Monday evening. I had reported for work at 9 a.m. on the previous Saturday and worked until 5 p.m. on Monday, 56 hours of continuous duty.
Luckily, I avoided serious injury, but it was a salutary reminder of the exhaustion induced by a busy weekend on call in one of Dublin's teaching hospitals. Others have not been so fortunate. Sadly, in the last few years a number of young doctors have committed suicide such is the dehumanising effect of a clearly outdated system.
PATIENTS suffer, too. An exhausted doctor can quite easily and unintentionally misplace a decimal point when writing a prescription for a seriously ill patient during his 38th hour of continuous work.
Is it right to expect a doctor who is sleep-deprived to think clearly and logically when faced with a patient whose condition has deteriorated rapidly and in whom an accurate diagnosis is essential? Can we really ask doctors to carry out highly technical procedures the day after they have been up all night without a break?
The recent Irish Medical Organisation conference heard how pilots deal with the demands of out-of-hours work. Capt Neil Johnston, an Aer Lingus pilot and safety expert, suggested that junior doctors insist on defined rest periods. The International Air Line Pilots' Association guidelines ensure duty periods do not exceed 50 hours in any seven consecutive days. A pilot cannot operate for longer than 16 hours at a stretch. By this yardstick, junior doctors are part of a dangerous system.
Two statements in particular stood out from Capt Johnston's paper. "The work and rest-time limitations, being essential to safety, should be considered to be minimum requirements and should be given the force of law" was one. The second, and for junior doctors even more sobering, statement was the "Aviation Bottom Line":
"If you do not consider yourself fit for duty, you should not report for duty." The implication of such a bottom line in medicine would render the present "on call" system unworkable overnight.
From a hospital manager's perspective, not alone is he/she getting away with staffing levels that are Victorian, but the financial attractions of so much doctor overtime are considerable also.
NCHD overtime rates are equivalent to the hourly earnings of an entry-level employee in the service industry. Due to a complex system, hours worked over a certain level actually attract rates equivalent to half-pay. Clearly, there is no financial incentive for the hospital administrators to change.
This may go some way to explain the extraordinary intransigence of the Health Service Employers' Agency in this dispute. Six months into negotiations and the best the employers' group can muster is to suggest a review group. Has the HSEA learned nothing from the national nurses' strike of 1999? It badly needs to take ownership and manage the hospital system in a manner appropriate to the times.
To quote one of the junior doctors' representatives, Dr Ronan Collins, of Tallaght Hospital: "The HSEA needs to get its act together." He was supported in this call by Mr Liam Doran, of the Irish Nurses' Organisation, who suggested the repeated disputes in the health service were a reflection of mismanagement and the existence of a "sick service".
The ICTU has come out in clear support of the NCHD strike and, in a key contribution, has said that meeting the doctors' demands will not jeopardise the Programme for Prosperity and Fairness.
The public and junior doctors are rightly asking: why has this dispute not been settled? Over to you, Mr Martin.