Hidden reality of medicine's cheap labour


NON consultant hospital doctors - also known as junior doctors - are going to be paid somewhat better by the State and will have more flexible hours, so as to have time to study. A welcome improvement. But the structure of medicine as a profession still leaves the onlooker gaping.

You may have noticed, for instance, that recently the hospital consultants - the senior doctors - asked for more money. The pay out to these consultants through the VHI alone has risen to about £75 million. There are only about 1,200 consultants, as far as I know.

You may also have noticed a recent article in this paper by Alison O'Connor, which reminded us that non consultant hospital doctors are still working well nigh unbelievably long hours. On average they work 70 hours and the one who spoke to Alison - presumably not untypical - had just worked a shattering 103 hour week.

"Most people doing this are interested in training to be consultants," that doctor said, "but there are very, very few consultant positions." There are indeed not nearly as many consultant positions as there might be, and that is why so many private consultants are (a) very, very busy and (b) very, very wealthy. In Dublin they are, anyway.

Why are junior doctors trained the way they are? Why are we blandly put at risk by doctors zombie like with tiredness? And, I'd like to ask, is the money situation at the top of the medical tree connected with the rather harsh conditions down at its roots?

I don't mean that top consultants have always kept their ranks small out of a - completely unconscious - desire to protect their own wealth and power. Rather, does the medical profession, more clearly than other professions, offer the possibility of great rewards as the quid pro quo for a long and exhausting training?

Please don't reach for pious explanations about vocations to heal the sick. The spiritual element does not inhibit hardball pay struggles. If the money didn't matter there would be doctors out there, barefoot, among the peasantry.

The consultants are looking for ways to put pressure on the Minister for Health in pursuit of a claim for a 30 per cent increase in the public part of their income. I'm sure they feel justified. I have never yet met anyone, however rich, who didn't feel righteously entitled to more. Or rather, I did.

I was talking to one of our most distinguished senior counsel the other day and he deliberately annoyed me by saying that he'd been down the country doing High Court personal injuries sessions, a favourite with him because he can fit so many into a day that he makes even more money than in a day in Dublin. I admire this as a preemptive strategy. I also like the way one can talk frankly now to lawyers abut their burning interest in money.

With doctors you still have to pretend that they're saints, who only incidentally get paid for knowing the things they know.

If we had just arrived from Mars and were proceeding to design a health service, is the one we have the one we'd want? For instance, why are young doctors allowed by older doctors to endure such brutalising conditions? The small improvements accepted by the IMO last week do not make training for the medical profession notably more pro human, more allowing of personal relationships, or more open to combining training with child rearing.

Why is the structure of the profession so pyramidal? The Department of Health didn't make it like that. It was shaped by the profession itself.

Last week's extracts from a history of the Garda Siochana, in this paper, described the awe inspiring mixture of idealism and common sense that went into the transformation of law enforcement to serve the new Ireland. But read Ruth Barrington's book, Health, Medicine and Politics 1900-1970. In 1913 medical benefit was rejected, "to the private satisfaction of the more affluent private practitioners".

THAT never changed. The Mother and Child crisis "marked the end of the initiatives begun in the mid-1940s to provide a first class health service for the whole population."

By 1970 the medical profession "were reconciled to working in a publicly financed and planned health service" in return for "commitments on the perpetuation of private practice and the maintenance of high incomes, the independence of voluntary hospitals and professional involvement at all levels in the administration of the health services."

Today "the boom in private medicine has encouraged the appearance of separate private hospitals and clinics, independent of any public hospital or having little connection with a public hospital. What is not generally understood is the extent to which this trend has been encouraged by public subsidies and policies."

The Department of Health is the paymaster. But the profession has most jealously guarded its internal arrangements. In spite of the many magnificent examples of individual goodness and selflessness, at all times in our modern history, and no less strikingly today, the medical profession is a private profit service dependent on the use of young doctors as cheap labour at the bottom of the career ladder.

All this has been shrouded in mystique, of course. If you ask a medical personage at the top of the profession why his junior colleagues must accept working conditions that would disgrace a Victorian sweat shop, he's inclined to say, well, he and his peers did, and they owe everything they are to that same harsh system. As if, by the way, what they are is the pinnacle of some evolutionary process. And as if there's a value in continuity for its own sake.

The 103 hour doctor said that it was difficult for junior doctors to speak out if they feel they are not being treated fairly. "They often feel they would be discriminated against, or endanger their career."

That's a very sad remark, isn't it? What value is being upheld here? Deference? Self sacrifice? Hierarchy?

Before their decision to enter negotiations this weekend, the consultants were threatening to go on strike or otherwise pressurise the Department of Health on the issue of money. But would they go on strike about the hours the younger people in their profession are obliged to work? Well, can we do anything about those hours?

Risks to the public are in general being more and more keenly eradicated. You couldn't get into an unlicensed ferry boat. You couldn't buy a grubby hot dog. Fire doors are cut in beautiful 18th century walls so you couldn't be at risk from smoke.

Yet you can go into hospital and the profession accepts that you may be seen by a person who may have been working for days and days with no sleep. Is that the best we can do? If not, who is in a position to change it?