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Right now, Dr Pishoy Gouda should be experiencing the trials and tribulations of intern year.
Instead, the NUI Galway medical graduate is lost to Ireland, in a situation that brings to mind the lyrics of an old Beatles classic concerning hellos and goodbyes.
The HSE faces a desperate shortage of doctors, yet has effectively driven some away due to an insufficient number of intern posts for non-EEA graduates of Irish medical schools (see panel).
Dr Gouda was keen to stay in Ireland following graduation this year. However, he could not access an intern place and has had to return to Canada.
Dr Pishoy Gouda
“I had originally planned on staying in Ireland for a few years, doing locum jobs, which are abundant, after the intern year,” Dr Gouda tells the Medical Independent (MI).
“However, you cannot locum unless you have completed the intern year. At this stage, I am quite disappointed in the way that the Irish healthcare system has treated people in my situation; like second-rate physicians.”
Under employment law, EEA citizen graduates must be considered first for intern posts. If non-EEA graduates have no posts to fill, there is no means of entering medical practice in Ireland.
In the high-stakes arena of doctor recruitment and retention, many argue that this is an avoidable ‘own-goal’. But with anecdotal evidence emerging that Irish students are wilfully contemplating internships abroad, there are even deeper questions about the ability of the health sector, including its internship element, to retain Irish-trained doctors.
What are doctors like Dr Gouda missing out on, and is the intern year encouraging or discouraging retention?
Intern training is delivered by six Intern Training Networks, which are designated and funded by the HSE. By press time, the Executive had not disclosed its funding provision in this area.
The HSE runs the national intern match system, which before 2010 was handled locally by medical schools whose graduates interned at affiliated hospitals.
Following implementation of the recommendations on medical training in the Fottrell Report (2006), there has been an incremental annual increase in the number of EEA graduates from Irish medical schools. In 2010, the number of funded intern posts was 512 and this rose to 684 in 2014, according to the 2014 annual report of the National Doctors Training and Planning (NDTP) division in the HSE.
Prof McGovern warned of ‘critical and immediate decisions’ to be taken
However, determining the appropriate number of posts for EEA nationals each year is posing a significant challenge for the Executive (see panel at bottom).
In recent years, there has been an expansion of intern posts into other specialty areas, such as general practice, and access to more posts in the private sector. The Bon Secours Hospital, Cork, has provided internships for a number of years. In 2014, the Beacon Hospital in Dublin introduced three intern posts (oncology, GI surgery, gastroenterology), while this year the Mater Private, Dublin, initiated intern posts in cardiothoracic surgery and cardiology.
Ms Ruth Whelan, Clinical and Academic Manager, Beacon Hospital, tells MI it has much to offer interns, including a strongly consultant-led clinical environment and access to technology, such as electronic health records.
Nevertheless, while there have been interesting and positive developments in intern training, some key training, lifestyle and IR issues remain unaddressed nationally.
According to a statement to MI from UCD School of Medicine, which drew on a range of individual opinions from relevant parties within the School, resourcing of the intern programme is a key issue, among other notable factors affecting trainees’ lives.
“Fundamentally, the programme needs to be resourced fully,” states the UCD commentary. “Currently, the HSE provides less than 45 per cent of the cost of programme delivery, with the balance borne by respective medical schools. The HSE focus of attention appears to be on administrative control rather than working with medical schools to build an attractive programme that would be the first step in retaining medical professionals within the Irish health system.”
“The construction of intern posts with multiple location changes through the year and change of employer mitigates against an intern trainee building a meaningful connection with a single hospital, or indeed hospital group. The change of employer has practical tax management issues for trainees who have to resign four times in a year to take up their next placement. The presumption of mobility of trainees is a particular problem for graduate entrants who may have mortgage and/or family commitments. The current intern matching programme system does not accommodate casual vacancies that occur throughout the year (eg, illness, maternity, parental leave, etc). UCD Medicine believes it should be possible to accommodate such vacancies. Failure to do so demonstrates a lack of support for trainees with young families and particularly impacts upon female trainees.”
The statement adds: “The intern offer process is generally unsatisfactory, with insufficient time provided for the trainee to confirm their acceptance and make the necessary logistics arrangements to take up their first placement.”
Medical schools within their local networks handled the intern post allocation process before a HSE national matching system was established. According to the UCD statement, the strong element of mentorship fostered by the old process has been affected by centralisation.
Worryingly, the statement also refers to “anecdotal evidence” that Irish students across medical schools are “increasingly considering” overseas intern programmes, such as in the UK and Canada.
If this is a somewhat newer concern, it builds on long-running issues associated with the intern year and the space it occupies in the troubled health service.
Dr John Duddy, Chair of the IMO NCHD Committee, says two of the key issues for interns are low pay and inappropriate tasking.
“The intern salaries are €31,000 a year, and that is less than the average industrial wage of €35,000 a year. That is something I think we need to get addressed, particularly as we’ve more and more graduate-entry students who are graduating now with high levels of debt. To make the intern year more attractive and more likely that they’ll stay in Ireland, we need to make their salary more sustainable …”
Dr John Duddy
Dr Duddy continues: “The big issue that comes up repeatedly for the IMO and the Committee whenever we are in contact with interns is the issue of task transfer as well, and how a lot of intern duties are essentially performed by other grades in other countries, yet it is still standard in Ireland that interns are expected to do ECGs, take bloods, do IV lines and so on. I think that is having a detrimental effect on their experience. Those are the two big issues that come up repeatedly for us.”
The NCHD Committee Chair adds that he has heard anecdotally of issues with the quality of some intern posts, including supervision and education, which he says demands greater oversight.
The Medical Council is responsible for inspecting clinical training sites for interns. Asked if there had been any occasion when the Council had to withdraw approval of an intern training site in the past five years, its spokesperson says this has not occurred.
The Council has, however, publicly identified issues at intern level that must be addressed.
Its trainee survey, Your Training Counts (2014), pointed to a significant problem with bullying and undermining of trainees in Ireland, especially younger trainees and interns.
Based on trainee-reported experience, bullying and undermining behaviours were “endemic” in the clinical learning environment. In total, approximately three-in-10 trainees reported personal experience of bullying and undermining behaviour, and this experience was over two times more prevalent than for their UK counterparts.
The prevalence of trainee-reported personal experience of bullying and undermining behaviours was greater among younger trainees and among those at the intern stage of training.
“That is something we’d hear about and probably have all experienced directly ourselves,” says Dr Duddy.
Bullying can come from various sources, including peers, more senior medical doctors or other staff in the healthcare setting, including nursing and administration.
Dr Duddy says it is a difficult problem to address in that it essentially requires a “culture change” throughout the health service. “But it is something we would want to tackle… the Medical Council report has shown that, if someone is bullied in the workplace, that increases the likelihood that they will emigrate.”
The Your Training Counts data identified another important issue pertaining to interns — that of preparedness for the intern year.
According to the report, approximately three-in-10 interns reported that their previous medical education and training did not prepare them well for intern training. The prevalence of this issue among trainees in Ireland was two-to-three times greater than among their UK counterparts.
For five-in-10 interns who reported that preparedness was an issue, lack of preparedness was a ‘medium-sized’ or ‘serious’ problem. For those who felt under-prepared, compared with their UK counterparts, trainees in Ireland were two times more likely to report that the problem was significant.
“While feeling unprepared was less-commonly reported with respect to clinical knowledge and interpersonal skills, the problem more commonly arose with regard to administrative duties and the physical/emotional demands of clinical work as an intern. It is important to note that the prevalence of feeling underprepared was not associated with trainee-related characteristics. Critically, the problem was no more or less common for interns, depending on their medical school of graduation or the intern training network overseeing their intern learning experience,” the Medical Council document notes.
“Interns who rated the quality of induction to the clinical environment positively were more likely to also report that they felt well prepared for intern training. Interns who felt less well prepared for intern training reported a poorer experience of the clinical learning environment; for those who reported the problem to be more serious, their experience of the clinical learning environment was worse.”
On follow-up to these findings, a spokesperson for the Medical Council points out that, early next year, it will be implementing ‘Safe Start’. This is an e-learning induction programme aimed at better supporting doctors new to the practice of medicine in Ireland. “We will shortly be announcing a significant research project that will be undertaken to inform this initiative,” says the spokesperson.
Additionally, the Council has completed a “stakeholder study” to better understand perspectives on the issues affecting the intern year — including trainee views — and has commissioned a research project to examine learning outcomes for the end of internship, specifically examining entrustable professional activities. “We will shortly be releasing a full consultation document on this subject,” states the Council’s spokesperson.
‘Entrustable professional activities’ is something of a buzz-phrase in medical education internationally. It is defined as “a core unit of professional practice that can be fully entrusted to a trainee, as soon as he or she has demonstrated the necessary competence to execute the activity unsupervised”. Common examples are ‘admit a patient’, ‘request and interpret investigations’ and ‘handover’, and stepwise levels of proficiency can be recorded.
The Council-backed research entails formulating a draft framework of outcomes for intern training in Ireland, taking account of good practise in outcome-based medical education and training, the current state of intern training in Ireland and the context of the Irish health system.
No HSE response to medical graduate’s intern letter
In July, NUI Galway graduate Dr Pishoy Gouda published online an ‘Open Letter to the Health Service Executive’ concerning lack of access to intern posts for non-EEA citizen graduates.
In a considered tone, Dr Gouda wrote that he saw sense in prioritising EEA citizens, as per employment law. After all, Irish citizens were more likely to contribute to medicine in Ireland for the long term.
But he noted that this was not the whole story. “Ireland finds itself in healthcare crisis, with shortages of doctors across the country, which are predicted to persist for several years,” he stated. “… the Health Service Executive is in the process of actively recruiting doctors at the Senior House Officer level (just after intern) from several developing countries, such as Pakistan and India.”
As Dr Gouda outlines, the HSE is sending away non-EEA graduates of Irish medical schools, while having to engage in the time-consuming and difficult exercise of recruiting junior doctors from other countries.
According to Dr Gouda, who graduated this year, it had been clearly stated by NUI Galway, pre-enrolment, that he would not be guaranteed an intern place. However, when he started medical school, “anyone that wanted an intern place got one”.
According to the HSE, the allocation of intern posts is based on Irish employment law, specifically the requirement for a work permit. Preference in the first round is given equally to three groups of applicants, with the allocation to a matched post based on centile rankings of the applicants.
These three groups are EEA-Irish medical school applicants; EEA graduates from outside the six Irish medical schools; and non-EEA graduates (Irish medical schools and non-Irish medical schools) who do not require a work permit.
Non-EEA graduates (Irish medical schools and non-Irish medical schools) who require a work permit may also apply, but are only appointed once all those in the above three groups have received posts, states the HSE.
Dr Gouda tells the Medical Independent (MI) he received no official response to his public letter from authorities.
“It doesn’t make any sense to me personally or to anyone that I have talked to,” he says. “The only thing that I can think of is that it costs money to create these intern positions, and the payoff (retention of international doctors) is not guaranteed. However, spending money on recruitment creates short-term results, which seems to be the focus of the HSE.”
Dr Gouda is working as a research assistant at the University of Alberta while pursuing a Masters in Clinical Trials at the London School of Hygiene and Tropical Medicine. He says he still feels a “sense of obligation to continue to work on improving the Irish healthcare system”.
A spokesperson for NUI Galway School of Medicine says its medical degree programme has an intake quota of 118 EU students and a non-EU intake of approximately 60 students.
The spokesperson adds that the relevant forums would be cognisant of the challenges facing non-EEA students with regard to intern posts. “The School and Intern Network have representation in all forums — Intern Networks Executive, Council of Deans, Intern Affairs Committee,” adds the spokesperson.
Dr Dermot Power, Co-ordinator, UCD Intern Network, tells MI that given well-documented doctor shortages in Ireland, “we shouldn’t be turning down, rejecting and forcing out people who could do very well in Ireland and could support the system”.
The IMO’s NCHD Committee Chair Dr John Duddy agrees that something must be done.
“I think we have an obligation to all graduates of Irish medical schools to provide them with an internship here, because the internship is a continuation of their medical education, and overseas students are essentially subsidising medical education for Irish students who come direct from school,” says Dr Duddy. “They are training in the medical system and would be valuable additions to the workforce here.”
A HSE spokesperson informs MI that its priority is to provide a sufficient number of intern posts for EEA graduates of Irish medical schools in line with recommendations of the Fottrell Report (2006).
“The availability of intern posts for international students of Irish medical schools is not a matter for the HSE.”
HSE projected too few intern places for EEA students
A HSE analysis of applicant numbers for the 2015 intern match found an “unexpected and significant increase” of approximately 100 additional EEA applicants from Irish medical schools compared to 2014, according to internal HSE correspondence in December 2014.
The correspondence was obtained by the Medical Independent (MI) following a Freedom of Information request.
The letter from Prof Eilis McGovern, Director of HSE NDTP to the then HSE National Director of Human Resources Mr Ian Tegerdine, warned that this presented a significant challenge to the system.
Prof Eilis McGovern
She informed Mr Tegerdine that, while the final number of intern posts required for July 2015 would not be known until mid-May, when exam results became available, the NDTP projected a shortfall of approximately 40-to-50 posts.
According to Prof McGovern’s letter, dated 17 December 2014, the HSE had been creating additional intern posts annually in response to the increasing numbers of doctors graduating from Irish medical schools, in line with the Fottrell report of 2006. Intern post numbers had increased from 500 posts in 2006 to what was then the current number of 684.
“In 2014, the expected peak in graduates had almost been reached and all EEA-IMS [Irish medical school] graduates successfully acquired intern posts. There were 51 posts over the required number, and non-EEA graduates were appointed to fill these posts.”
Prof McGovern warned her colleague that there were “critical and immediate decisions” to be taken in order to address the issue.
“It is recommended that approval is granted to create an initial 40 posts, with a reserve list of an additional 10 posts for inclusion at a later stage (May 2015) in the event of a lower-than-predicted attrition rate.”
The NDTP Director presented a number of possible options to create these posts.
These included conversion of SHO/registrar service posts, although she added that the challenges of delivering EWTD and 24/7 service demands “would suggest that this is not a realistic option”.
Another option was creation of “budget-neutral posts through overtime savings from the current intern cohort. The maximum number of posts estimated as feasible through this option is assessed at 10 posts”.
The final option presented was “additional funded posts, which would contribute to service delivery and provide a quality training experience”.
A number of potential factors for the projected rise were posited and Prof McGovern indicated this would be further analysed.
Last month, a HSE spokesperson told MI: “There were 43 additional posts created for the 2015 intern match at no additional cost to the HSE. No other NCHD posts were suppressed to create intern posts.”
According to the Executive spokesperson, there was “no single definitive reason” for the increase in EEA applications from Irish medical schools.
Included in the possible explanations was a higher-than-average number of repeat medical students; a higher-than-average intake to medical schools based on Leaving Cert re-checks and upgrades, resulting in additional students reaching the required points after the CAO allocation was completed; and an additional number of applicants who availed of the option to apply for internship up to two years after graduation from medical school, ie, in addition to graduates from 2015, graduates from the previous two years were also eligible to apply.