It is a great pleasure to undertake the medical editorship of Cardiology Professional. While it is neither a news update nor a peer-reviewed journal, it has elements of both, providing a quarterly digest of advances in cardiology, reviews of clinical problems and articles on subjects of major current concern to the Irish cardiological community.  

As medical editor, I would like to address some of the major problems facing consultants and trainees, paying particular attention to the patient’s perspective. I will welcome relevant contributions about this somewhat neglected area.

Since my retirement from public hospital practice, my patients have consistently identified three major issues that cause them distress. The first is delays in access to elective assessment, and the dreadful experiences of many in emergency departments (EDs) that continue to attract considerable publicity. 

The next problem is the frequent lack of continuity of care by the clinical service that is primarily responsible for the patient’s treatment. This occurs mainly at weekends and is a bigger problem in smaller hospitals. Patients and their families often feel that they are ignored or forgotten by their own carers and this is a serious cause of dissatisfaction and anxiety. 

The feeling of neglect and consequent failure of communication that may be engendered often provides the initial stimulus for subsequent complaints and legal action. Such problems are often blamed on the doctors and at the very least reflect poorly on our perceived capacity to organise inpatient services.  

I became acutely aware of this problem after two recent incidents. During a flight back to Dublin I sat next to a social worker who looks after young people with special needs in a rural area. She told me about the many difficulties caused by funding cutbacks: routine services are severely restricted and lack of round-the-clock cover has led to some tragedies.    

Having ascertained that I was a physician, she told me of her recent experience of delayed service and poor communication in a hospital. Just days previously, her severely jaundiced mother was admitted acutely to a country hospital widely regarded as an example of good practice. No problems were encountered in the emergency department.

Prompt investigations included a CT scan and an ultrasound. The results of these tests were not available by Friday afternoon, the second day of admission. She was not seen by any doctor, let alone one familiar with her case, until the following Tuesday. 

Quite understandably, the nurses felt unable to give any significant information about the likely diagnosis or management.  It was not until Tuesday morning that she was informed that the jaundice was probably due to drug hypersensitivity. Over the weekend, mother, daughter and the whole family were left in the dark as to the likely nature of the problem, the results of the investigations and the opinion of the medical staff treating her.  

It is astonishing and disturbing that a patient can occupy a bed in an acute hospital for a three-day period without been seen by any doctor, let alone one directly concerned with her treatment. This incident accords with others reported by patients over the past few years.

Personal experience

I had a similar experience immediately after my arrival in Dublin: I learnt that a very elderly relation had been admitted to a Dublin suburban hospital on the previous day. Her symptoms suggested a transient ischaemic attack, a diagnosis not subsequently confirmed. 

Evaluated rapidly in the ED, treated properly and moved to an appropriate ward within a reasonable time, she had almost totally recovered when I saw her on Saturday morning. On Friday, she had been told that a CT scan was negative, but that she would need to have an echocardiogram and an MRI at an associated hospital.  

These could not be arranged until the following week, and her family was advised that she should remain in hospital over the weekend. When I saw her, she was well and her capacity to function independently had returned to its previous level. The advice of the competent and efficient charge nurse to stay until the tests had been carried out was accepted, albeit with some reluctance on her part. She was eventually discharged nine days after admission.  

The prolonged admission was partly to ensure that an elderly patient could be safely discharged to her home environment. It was also partly due to the unavailability of standard investigations in an acute medical hospital. It was compounded by the weekend unavailability of a doctor familiar with her problem. 

Even if such a doctor had seen her, he might have judged it to be better that she remain in hospital because she would not have priority for CT and echocardiography as an outpatient. Nor could the social services, if needed, have been provided with the same expedition. 

Being aware of these problems, I was able to explain them to the immediate family but I doubt if anyone other than a doctor could have allayed their anxiety.

These two anecdotes reflect a major reason for dissatisfaction with the organisation of our hospital services. While patients recognise that the overall standard of care is good, they are rightly exercised by the unavailability of their ‘own’ doctors for long periods of time. This unavailability violates one of the cardinal principles of good medical practice – the delivery of timely and competent care and assessment, coupled with proper communication.  

Take the lead

It is not good enough for doctors to blame administrators and funders, although much of the responsibility lies at their door. Consultants should acknowledge the problem, consider the causes and take the lead in solving it.

Although it is easier to identify the problem than to provide a solution, the problem is not universal. The large metropolitan teaching hospitals, although inadequately staffed by international standards, often manage to deliver continuing care from a specialist consultant and trainee by rostering effectively within departments. 

Cardiology shows what can be achieved in the major centres when critical resources are concentrated effectively. It is highly desirable that this example, which has been driven by the necessity for providing critical cardiac care and, more recently, acute intervention, and achieved by a high degree of collegiality within the specialty, should be followed by other disciplines. 

When this is not possible because of lack of sufficient specialist staff, rosters should be drafted which ensure the availability of a member of the team primarily responsible for the patient’s care at all times. This model might also suit general internal medicine in smaller hospitals with fewer staff and help to alleviate the problem in the short term.

The currently planned major reconfiguration of the acute hospital services provides an opportunity for a long-term solution to this problem. This process is already underway. Many doubt whether there is sufficient commitment to real change by all stakeholders. Such commitment will only be achieved if medical practitioners, allied health professionals, administrators, managers and, above all, the organisers in the Department Of Health and Health Service Executive recognise the need for real change and co-operate in effecting it.  

Increasing consultant levels

The process necessitates an increase in the current consultant establishment to the levels already determined as necessary over the previous two decades. Effective deployment of these consultants mandates the concentration of acute services in a smaller number of hospitals, given that a critical number of patients is necessary for the efficient employment of a sufficient number of professionals on a round-the-clock basis. This is an inevitable development and one which should be welcomed. It should be coupled with the retention and upgrading of the smaller hospitals so that they can deliver optimal care for illnesses that can be treated by good nursing supervised by appropriate medical staff.  

Doctors should acknowledge the compelling need for these changes and guide their implementation. Consultants especially should be prepared to educate and to lead their patients and community in recognising the benefits of concentrating the care of the critically ill.

Altering work practices

It will not be easy for many who have worked for a long time to provide a service for their own community to become advocates for these changes. Indeed, for many consultants, these changes will require major alterations in working practices. Willingness to work on specialist teams with a sufficient number of colleagues to provide a 24-hour service, wholehearted acceptance of the need to increase the consultant establishment and acceptance of responsibility for continuing care for their own patients within their sub-specialities will be necessary. 

Junior staff sharing, increased collegiality and daily exchange of information at handover is crucial to the process. When not rostered, call availability for consultation (within reason), and a willingness to schedule short weekend visits and rounds could be built into a new contract, given appropriate safeguards. This would help to restore the professional nature of the original 1981 contract, which has been gradually eroded by a process of increasing industrialisation and an unwillingness by the Department of Health to recognise the principles of continuing professional responsibility and independence. These principles are essential to the protection of the patients’ interests.

These are but a few of the issues confronting those charged with the implementation of the reconfigured hospital system. 

Renegotiation of contracts

It is unlikely that the necessary changes can be effected within the context of the current consultant contract. It should be renegotiated or replaced by one that is suitable for contemporary consultant and specialist practice.  

This should emphasise the primacy of patient care and needs, and the necessity for maintaining an autonomous profession whose services are rewarded in an appropriate fashion and whose unique commitment to the continuing care of patients is once more recognised.  

If this was done, it might help to attract our best graduates to consultant posts in the public hospitals and dissuade many of the alarming number of consultants in posts who are considering joining those who have already resigned to take up private practice.  

Restoration of professional morale and recognition of the unique commitment and calling that is at the core of medical practice would be the best way of ensuring that our patients receive the care that they deserve in a timely fashion.