Anaesthesia Ireland – present tense, future – bright but scary

Run through training at last – this will guarantee a bright future for our specialty and correct the wrongs of a previous generation. But some questions must be asked. This process may open a Pandora’s box regarding anaesthesia staffing around the country and may ultimately hasten the implementation of a sub consultant grade.

In the late 1990s the Specialist Registrar System (SRP) was introduced – and it ambushed the Department of Health. They could not distinguish SPR from senior registrar (SR) with the result that trainees essentially went from SHO ┬áto SR salaries, they received SR contracts and started looking for non clinical days in addition to study leave. Softened up by higher incomes and the removal of the SR bottleneck, trainees were bamboozled into significant changes in training. The first was the 7 year rule – a minimal of 7 years of training. The logic behind this was the UK trainees were quoted as stating that they “didn’t feel that they were ready for consultancy after 6 years” [nobody bothered to ask the Irish trainees – but we told them anyway that we disagreed]. This was a patent absurdity – all Irish graduates went on to do fellowships abroad at that stage, so training time was at least 8 years plus a year in the doldrums if you failed your primary or didn’t accrue sufficient brownie points to get into the SPR system. As a hedge, the College, then in it’s infancy, introduced the “year 3 out” system: you could take a year off at year 3 SPR and do a fellowship then; of course you had to be back in a year to recommence your training. It was inevitable that this would leave a huge hole in training numbers – year out trainees couldn’t be replaced – there would be empty slots. Would anybody be back within a year? Unsurprisingly, chaos followed. Hospitals never knew from one 6 month period to the next whether or not they would be getting a full compliment of SPRS.

Simultaneously, the number of anesthesia trainees in Ireland mushroomed, driven principally by the need to have an epidural service in every general hospital in the country. Hospitals clamoured to obtain BSTs, hired lots of “non scheme” NCHDs, and loose criteria for training, the need to reduce the frequency of call and various college sponsored “programs” (7/6 etc) meant that the number of NCHDs in anesthesia in Ireland grew relentlessly over the past decade. With the bloated SPR system and light touch regulation of training, NCHDs that in the past spent most of their training time in Dublin, Cork or Galway, were now trotting up and down the country every 6 months, often on a provincial towns circuit to provide service, rather than obtaining competency based training. This led to a generation of tired, bored NCHDs, that often found it difficult to return from Australia to finish their “training”. Yes, after 7-8 years you couldn’t help but be a competent anesthetist – but it only takes 3 years in the United States.

Drunk on high salaries and 21st Century Irish hubris, the trainees plodded along: the Anaesthetist in Training Group – once a potent force with year reps, reps to AAGBI, IMO and GAT, became a shadow of itself (an now appears to have disbanded).* The caliber of trainees, frankly, fell – in some cases – quite sharply. In recent times, the economic crisis seems to have snapped a lot of heads into focus….

The last 12 months has seen the resurrection of Irish anaesthesia. The BST programmes have become hyper-competitive to access. The distribution of trainees has streamlined. The year out has been closed off. And now, training has been shortened to 5+1 (as opposed to 7+whatever). Five plus 1 means that you only have to do 5 years of training in Ireland: the 6 year, required for CCST, can be spent doing fellowship training abroad – assuming that your competencies are in place. In this the College is taking a calculated risk – 1. that among all of those “general” jobs around the country, the competencies are actually there, 2. with theatre closures and other austerity measures modules may suddenly evaporate, 3. senior registrars at year 5 will want to stay and do fellowships. On the surface one would assume that the more ambitious would head for the stars after 5 years – but this has not been the case in other specialties, particularly radiology, that introduced a +1 year. Do you really need to do a fellowship abroad to be an anesthetist in Ireland? No – but all of us that have travelled believe that training abroad has improved us as doctors, as people, and broadened our viewpoints.

Where are the other challenges in this system? Our specialty needs to become more family friendly – too many trainees are spending their weekends (and non clinical days I would think) criss crossing the country to spend time with loved ones and children, while exiled away from home. The re-regionalisation of training will certainly, and welcomingly, improve this. For example, trainees in the WRAT`s/SPR scheme will come to the West for 3 full years – 2 of which will be spent (one presumes) in Galway. Presumably they will then move on to Dublin and stay there for the next 2 years and decide themselves how to spend their fellowship year.

Annualised intake is going to be a problem: with staggered intake, most large hospitals had 1 or 2 beginners every 6 months, and they gradually moved onto the call system three months in. This was not problematic – now beginners will arrive once a year and there will be a lot of them. In the United States, of course, 30% of residents switched over every July – summer was a very busy time for everybody concerned, but once September came, the new residents carried a relatively greater burden of call. We really cannot do that in Ireland – particularly if the European Work Time Directive ever becomes enforced. Summer may be savagely busy for mid level trainees.

Further, there appears to be an evaporating pool of non training NCHDs in Ireland. Those that were hired from India & Pakistan during the HSEs global recruitment drive were underwhelming (to say the least) – with no obvious career plan or pathway. It has to be said – that after decades of training non EU medical graduates in anesthesia, we do have a responsibility to continue this into the future. It is inconceivable that non EU graduates will get into BST places in any quantity for the foreseeable future. So why come to Ireland at all? There is going to be an inevitable service gap in anesthesia in Ireland: who will fill the clogs of non training NCHDs in the future? Will it be nurse anesthetists (unlikely and unacceptable), nurse practitioners (certainly in pain and maybe ICU), permanent registrars (yes – they already exist and they will become more plentiful) or will they be post-CCST “specialists”?

I would hate to think that we are training a generation of talented young anesthetists to fill service level jobs in the HSE; with little career progression, subordinate to their consultant colleagues. Certainly promotional grades within the consultant body is a good idea (to prevent premature “retirement”), but the subconsultant grade is just a yellow-pack alternative. Not even the British have gone down this line. While it remains possible for our medical graduates to obtain employment in more remunerative health systems (North America, Australia, New Zealand), the Department of Health should thread lightly when dealing with future medical manpower. The current “high cost” model of consultancy is one of the great myths of Irish medicine: healthcare workers become expensive when they start getting additional payments for nights, weekends and bank holidays. Consultants provide out of hours services for very little reimbursement. Interestingly, many North American academic centers have replaced nurse anesthetists with physician anesthesiologists because, overall, they are less expensive: doctors are more flexible in terms of working hours, rest times, breaks and can do everything (a nurse cannot consent a patient for anesthesia!). The DOHC might be better of re-negotiating with the current consultant group than dumping on the specialists of the future.

Will the run-through training scheme produce a generation of anesthetists that are more likely than those currently finishing off their training to take “Specialist” (sub consultant) positions? You better believe it: a young doctor told day 1 that they would be guaranteed a consultant slot in 10 years – after 6 years of training and 4 years as a specialist – would jump at it [See Maslow’s hierarchy of needs (click here) – level 2 SECURITY!]. Don’t kid yourself, the majority of trainees engaging in anesthesia in 2012 will not head off to Australia or North America for 2 or 3 years, they won’t have a pile of publications when they apply for permanent positions, and they will likely, keenly, take permanent “specialist” posts.

How do we, as a fraternity combat the inevitable “dumbing down” of anesthesia:
1. We need to encourage research and academic endeavors as aggressively as we do exam preparation. Academics must be seen as a lifelong obligation – not just a box-ticking process to “get a job.”
2. There needs to be specialist pathways within the career of anesthetists: you need to decide that you are a researcher, an educator, a manager or an expert clinician. WIthout being one of the above you cannot become a consultant (as we know them today).
3. There needs to be a late training challenge: an exit exam, a thesis or the requirement to obtain an advanced degree to obtain CCST. For example – all final year SPRs might be required to submit a thesis to obtain a Masters in Anaesthesia.
4. There needs to be a secondary pathway into anesthesia in Ireland, for those that commenced training in equivalent systems abroad.
5. Fellowship training should be targeted towards need: there has been a constant stream of trainees going to Australia to become intensivists over the past decade – but where are the obstetric anesthetists, neuroanaesthetists, those that did ambulatory care, masters in education etc? If the HSE want s to employ the highest quality “specialists” they need to finance specific fellowships abroad – needs based – and trainees will travel knowing the type of job that they are coming home to.
6. Continued professional development needs to be encouraged, but not the current CME points accrual system. It astonishes me how few of our trainees are inquisitive – how little time is spent reading journals and researching dogma, how little time is spent in the library, how few “read” after passing their FCAI exam. Everything is easily obtained online now, everybody has smartphones and tablets – there is NO EXCUSE for anybody practicing anaesthesia not to be familiar with the contents of the current journals. On this site we share a twitter feed that points our visitors to worthwhile reading material. This is a strange phenomenon that appears specific to our specialty – can you imagine encountering an oncologist or a cardiologist that is unfamiliar with the latest literature in their field?

Overall, congratulations to the College for a brave effort to brighten up the future of our specialty. We don’t know where it will lead, but with good husbandry, collegiality and engagement, we might have to “wear shades.”

* I see that the College has gotten so fed up with lack of trainee representation that they have created the Group of Anaesthetists in Training (to essentially replace the ATI), and are providing facilities, IT support and secretarial assistance. While this is wonderful, one has to wonder – why they had to do it?