Is there a two-tier training system in Ireland – one for the Irish and another for non-EU doctors? Pat Kelly gets the opinions of doctors, the training organisations and representative bodies
According to many non-national and Irish doctors working in Ireland, there is an elephant in the room regarding attitudes tow-ards certain doctors, which manifests itself in an unspoken but well-known ‘glass ceiling'.
Many doctors, Irish and otherwise, believe that very few nonnational doctors are making it onto specialist training schemes and that these doctors get ‘stuck' at a certain level, despite ample experience and qualifications.
Figures from the ICGP show that in 2009, there were 319 Irish applicants to the GP training schemes. Applicants from other EU countries numbered 30, while there were 44 applicants from non-EU countries.
Of these, 116 of the Irish applicants were successful, while only two applicants from non-EU countries were accepted, along with two applicants from inside the EU.
The figures translate to a success rate of 36 per cent for Irish applicants, with more than one in every three applicants from this country securing a post on a scheme.
However, for applicants from other EU countries, the figure falls to one in 15 and for non-EU applicants, just one in 22 make it onto the training schemes.
The ICGP was given an opportunity to respond to the comments made in this article but has chosen to reserve its position until the feature is published.
The RCPI stressed its commitment to equality in the service and rejected any notion that foreign doctors are in any way treated differently.
"The RCPI is committed to developing and maintaining the highest professional standards in medicine," the organisation told the Medical Independent in a statement.
"Entry onto medical training programmes should always be on the basis of the applicant's qualifications and competencies. Trainees in our basic and higher specialist training programmes include doctors from over 30 countries across the globe, from Australia to North America, Africa, Asia and the Middle East and almost a third of fellows of the College hail from outside Europe."
Similarly, Prof Arthur Tanner, Director of Surgical Affairs at the RCSI, said the College has a very clear approach to equality issues.
"We are committed, as an equal opportunity employer, to implement equal opportunities in all our employment policies, practices and procedures," he told the Medical Independent.
Training
"To this end, the RCSI ensures that the principles of employment equality are applied to recruitment, promotion, training, career development and to all terms and conditions of employment. Recruitment positions in the RCSI are open to all suitably qualified candidates, subject to educational and experience criterion relevant to each specific post being met."
The IHCA rejects the notion that there is any form of discrimination or the existence of an uneven playing field for non-EU doctors.
Mr Donal Duffy, Assistant Secretary General of the IHCA, said: "We have not come across incidents of discrimination. We have no involvement with GP training schemes but what I can say to you is that since I started here 13 years ago, there has been an increase in non-national consultants being appointed in this country so there has been no discrimination that I am aware of. We have never had anything on our desks that would give us grounds for concern. A high proportion of our members are from third countries - I stress, not ‘Third World' countries, from third countries, from overseas, outside the jurisdiction, but this issue is not on our radar."
Despite these statements, the perception of an uneven playing field remains and is not limited to non-national doctors.
GP Dr Ruairi Hanley has experienced first-hand the difficulties that non-Irish doctors face in terms of career advancement. The problem is not perceived, said Dr Hanley; it is a real facet of modern Irish medicine.
"It appears that very, very few non-EU doctors are accepted onto SpR or GP training schemes," he said.
"Why is this happening and why is no-one asking? I don't want to go into individual cases," he continued.
"I am aware of doctors who feel their careers have suffered as a result of racial discrimination. The vast majority of non-EU doctors that I have met believe racial discrimination exists in Irish medicine. The majority of Irish doctors refuse to accept this, which I think is very disappointing. I know who I believe."
Inequities
Dr Hanley went on to point out what he sees as subtle inequities within the system. "My view is that there is a certain amount of passive racial discrimination in Irish medicine," he said.
"I am not accusing specialist colleges of being racist. However, I suspect certain ‘criteria' are created for higher training posts that have the effect of ensuring that Irish doctors get in and non-EU doctors stay working 90-hour weeks in unfashionable rural hospitals."
"Our non-EU colleagues are the backbone of our health service and I believe they are treated very badly," he continued.
"They work in the worst jobs in the worst conditions for decades. Unfortunately, very few Irish doctors are prepared to acknowledge this publicly. Their apparent reluctance to criticise a system because it benefits them is not very noble."
Dr Hanley said he reflects the anger and frustration felt by many Irish doctors who emphathise with their non-EU colleagues. "I find it depressing," he said.
"Senior representatives of our profession have said very little about this issue in the past. I get very irritated when I hear doctors righteously lecturing the rest of us on discrimination in society, racism et cetera, yet they appear reluctant to acknowledge what is going on in their own profession."
"My main reason for leaving hospital medicine was that I grew tired of working in overcrowded, under-resourced hospitals operating in a culture of administrative incompetence," he said.
"Being Irish, I was lucky, in that I had a choice of potential careers open to me. I fear that many of my non-EU colleagues are not getting the same opportunities that I had. They are still there, doing the same job and getting paid less. I have not forgotten them, nor will I."
Dr Hanley is insistent that the issue must be addressed. "The first step is to acknowledge the problem exists at all," he explains.
"The IMO should publicly recognise the enormous contribution that these colleagues have made to our health service. They should openly condemn any racial discrimination that exists and support those who wish to progress their careers into areas dominated by Irish doctors."
"The career progression of non-EU NCHDs should be investigated and those involved in higher specialist training should be asked to explain why they believe non-EU doctors are not getting onto higher training schemes. Then they should outline clearly what these doctors should have to do in order to get onto the higher rungs of the ladder.
"Were it not for these colleagues, our entire hospital system would collapse in the morning," he commented.
"I believe it is time that young Irish doctors showed more respect to their non-EU colleagues. I have grown very weary of the arrogance of some people who swan around our ‘centres of excellence', while looking down their noses at those vastly more experienced than them working 100-hour weeks in small rural hospitals. That attitude makes me angry, to be honest."
Double-standard
Dr Syed Altaf Naqvi is a Consultant General Surgeon at Limerick Regional Hospital and founder of the Overseas Medics of Ireland (OMI), an organisation established to provide a voice for non-Irish doctors and bring them together for social and professional support.
He came to Ireland in 1985 and has witnessed all the accompanying changes in the Irish health service. He is unhappy with the current selection system for training and among other things, he claimed that there are, in effect, two different training schemes for Irish and non-Irish doctors.
"Since 1998, I have been struggling, trying to make a system where there should be one way of training, rather than two or three training systems. Ireland is the only country in Europe that has two systems: one for Irish graduates and another for non-Irish graduates and that system has to go. There should be one system, so anybody coming to the country should have this system, finish in six years, get his CCST (Certificate of Completion of Specialist Training) and go home.
"That is not happening here. One reason for that is that the authorities, whoever they may be, I'm not sure, but they are the policy-makers; they are afraid that if they actually do that, these trained foreign doctors may not go home and will compete within this country, a small country of only four million people and limited jobs. But my point on that basis is this: this is the employment area; it's not a training area.
"If the person is the best, why should he not be in the HSE rather than the NHS? If he is not the best, don't give him a job and that's the way it should be, but training should be equal; there should be no double standard for training."
Dr Naqvi is of the opinion that non-Irish graduates are sent to a certain type of hospital, whereas Irish graduates are sent to what he described as "the good teaching hospitals".
"There is the Irish residency programme, which is for foreign graduates mostly and there is the SpR training programme, which is for Irish graduates only and this should not be happening."
He said non-Irish graduates reach a glass ceiling, where they find it extremely difficult to progress beyond a certain point.
"Foreign graduates sometimes stay for 10 years or 15 years in the same position because either they are not getting the CCST or they are not appointed to consultant posts, so they are stuck in their registrar positions for the long term and then they are faced with a cul de sac and they just don't go anywhere. Their children are grown up and they just stay there and do the same job, on and on and on.
Injustice
"If the foreign graduates are not trained or eligible, don't give them a job. We don't want second-class doctors in this country, we want people to go through the proper channels, to be well trained," he stressed.
Dr Naqvi has been trying to raise the profile of this issue since 1998 but matters moved too slowly for his liking: "We decided that the IMO were not going to make enemies because of us. We needed to have our own organisation to allow us to say what we feel, how we should be treated, so that's why in 2003 we created the OMI.
"It's a nonpolitical organisation to look after professional and non-professional issues, social activities, and so on."
He stresses that he is not motivated by any negative personal experiences, but rather by an overall injustice within the system.
"I worked with some very nice consultants and I acknowledge that I have been trained equally. I have been respected and I will say that consultants like FX O'Connell in the Mater Hospital, Professor Hennessy in St James's and Don Courtney in Galway, they made me a great surgeon and I'm very thankful to these guys.
"But things have changed now. I am actually very positive about things and that is why I am still here now but at the same time, I politely try to convey my message to the authorities and say, ‘please, make a system that will make everybody happy because if the doctors are happy, they will be more motivated when treating their patients'. That's the whole idea of medicine."
He explained that the perception that many non-EU doctors have of not being treated as equals heaps more gloom on already overworked medical staff and part of his leadership technique is to stress the importance of keeping morale high.
"I always tell my SHO team that their morale should be high so that they will perform well. But all of the junior doctors say they are afraid to say anything against the system, against the consultants and they accept bullying because they need their reference - simple. Even the locum consultants are afraid; they have been misused and have to do more and these locum consultants say nothing because when I ask them, they say, ‘look, these are my referees and for the next job, these are the guys I have to keep happy'.
"These overseas people are very unhappy. They are stuck and they take the abuse and most of them don't complain."
Figures seem to confirm that if such incidences are commonplace, they are not being reported; Naas General Hospital, for example, only recorded one complaint of discriminatory behaviour of any kind for the whole of 2009.
As far as specific incidences are concerned, Dr Naqvi said he will never forget one particular occurrence at an IMO AGM during the mid-1990s.
"There was a motion for permanent staff grade positions for overseas doctors, the positions where the registrars are there for 10 years. One of the attendees stood up and used the term, ‘We don't want to pass this motion because if it is passed, the foreign graduates will get these posts and our guys will lose the positions', and that's the term he used; ‘our guys'. I believe that if the person is properly trained and right for the job, he should get the job."
Dr Naqvi said that word of a two-tier training system has spread to Eastern countries and is discouraging some doctors from coming here.
"During the boom, Ireland became popular in the East and that's why the doctors came to Ireland," he said.
"When we went home we talked about how lovely the people are and doctors loved to come here rather than the UK; it was a very popular place to come for training. But now, you know, we have three SHO posts vacant in our hospital because the foreign graduates are not coming anymore. People are trying to go to the USA where the training system is equal. The ICGP must review its policy.
"I'm still very positive and I still think I can make a difference for foreign doctors, but this is the way I see things as they are."
‘They are so scared, they don't want to say anything at all'
One practising SHO in the Munster region explained that while he has so far been treated with respect, he has seen many of his nonnational colleagues passed over for career opportunities.
"I have been in the country for three years now. My consultant and my colleagues have been okay with me but I have heard accounts from other department colleagues, saying that they have been sidelined because they are not Irish," he said.
"The problem seems especially bad in one particular regional hospital. From many people I have heard that there are a lot of problems in this hospital, just because they are not in the Irish training scheme or because they are not Irish. That seems to happen quite a bit, particularly there."
"One high-level, non-Irish doctor actually knows about this problem and he was trying to sort it out. The people I know in this particular hospital I am referring to, they were quite scared of the bosses so he [non-national, high-profile doctor] was fighting for their cause. There are other instances, but there was quite a big issue in this particular hospital, it seems."
The SHO also claimed that there is a virtual omerta when it comes to bringing these issues to the attention of the media and hospital management.
"A lot of people say that if they voice their concerns, they might be sidelined; they won't get their training or they might not even get the next job. That's why most of the guys keep quiet. In my case, it is the Irish people who have been helping me through and have been helping me in my training in my post. But some of my colleagues, they say that if they open their mouths and say ‘I have been sidelined', they are so scared, they don't want to say anything at all."
However he stresses that patients have been very positive towards him.
"The patients are really very friendly with me, actually. They ask me about my country and they are genuinely interested and they are no problem at all," he said.
"They see that there is a shortage of doctors and they see me working 48 hours, 60 hours continuously and it's like, ‘we know that just because you guys are here, our health system is running and the Government is not supporting you enough', so they are actually more concerned about us than anybody else."
"I've heard a lot of my colleagues saying that they have overheard people say, ‘oh, if our boys - that is, the Irish boys - don't get the jobs, then how can we get them to stay here?' A lot of people have told me that they have overheard consultants saying this," he said.
"But I don't find fault that much. If they give an equal chance to everyone and make it open to public notice, people will accept that but they say that it's a fair field, but even then, people don't get them [the training places]".