Sunday 25 August 2013

Dear Mr Assad

Dear Mr Assad

I am a card carrying member of the Pacifist Society of Ireland and as such I have no particular axe to grind in the conflict between yourself and your opponents.  I see and hear that Mr Cameron and Mr Obama are considering "serious action" against you and your colleagues if you have been using chemical weapons or weapons of mass destruction in your civil war.

I understand that the situation is particularly grave and everyone is locked into an endgame of sorts, one that must play itself out to the usual brutal conclusion. Your opponents want to take control of the government by fair means or foul, and you want to hold onto to power (somewhat understandably) by similar means. You have no choice but to hold onto to power, because you know that if and when you loose it, you may end up being dragged naked through the streets of  Damascus having been bludgeoned to death, like Mr Kadafi.  Or you may pen-ultimately  be ferreted out from a dugout and formally executed like Saddam.

You have no choice but to hang in there to the bitter end. Unfortunately for you, the West has decided to approve the rebels application for recognition of their activities as a 'Democratic Struggle' and once their application was successful, your regime effectively reached its sell-by date.  Your number is up as they say, the writing is on the wall, perhaps the same wall that was written on at the start of your troubles?

The only available option is a trip to the plastic surgeon, or an application for asylum in one of those countries that have yet to be entirely disciplined by the West.  Of course this cannot happen because you would have to bring your auld pals, and cronies with you, and judging by your longevity thus far, there must be a right gang of them.

From what I understand yourself and your pals are members of a particular Muslim sect and this particular sect has control over the military and much of the wealth in your country. The other Muslim sects have been financially and politically marginalized over the years through the selective giving of; favors, titles,  fancy jobs contracts, and the usual stuff that goes on in politics. Now you are in an awful mess because you have sown the time-honored  seeds of  revolution that leaders have been planting since before the queer wan in France told all the punters to go and eat cake.

Them that doesn't have, want to get a hold of the goodies from them that does have.  In the middle east once this racket starts, the 'have-nots' invariably declare that they want a share of the goodies in the name of 'democracy'.  And once the big 'D' is wheeled out, and the application for a "Democratic Struggle" is approved by the powers that be, well to make a short twist of it:  yourself and your pals are doomed.

We in the west have a moral obligation to lend money and weapons and soldiers to anyone who might be fighting in an approved democratic struggle. Even if they couldn't give a hoot about democracy and just want to get a hold of the money and power that leaders like yourself  have been holding onto for so many years and dishing out to your pals, and them that bows in the same direction or believes that Mary was a virgin, or whatever it is that distinguishes between your sect and them that has no money.

Once the new crowd get in they will want to dish the goodies out to their pals who do be bowing in the same direction or cracking their eggs open on the big end and so on.  Its been the same since time began and will be the same for as long as them that have not, want to get a hold of the goodies from them that have. Yer man Marx tried to make everyone equal, and sure enough, he only made things worse.  Human's it would seem are as yet too stupid to live up to either Communism or Democracy materialism and greed always gets in the way.

The main reason I am writing to you is about this ghastly business of you gassing your own people with chemical weapons. You may or may not be guilty of this I know nothing of these things. However I do know that you are a physician as I am myself, and although doctors have been guilty of rather horrific things in the past, and although medical training is no guarantee of compassion or humanity; I feel that on the balance of things it makes these allegations slightly less credible than if you were a full time General, or a Banker, or had appeared on the balcony firing a shotgun into the air like Saddam before he had his deserts.  If appearance and previous employment history are anything to go by then you might well be a nice fellow altogether? There are some lovely pictures of yourself and your family on Wikipedia, and apart from the hairstyles and the get-up, yis look like nice people, who would open the door to a stranger or drop a few bob in the plate of a Sunday.

What makes me most suspicious about these allegations is the fact that they seem to be part of a formula that has worked in the past, a preamble to American led air strikes and invasion by the back door.  Just as the "weapons of mass destruction" myth was created in order to brainwash the plebs and invade Iraq without UN approval.

You are not on good terms with the Israeli's and rumour has it that you have been supplying arms to Palestinian "terrorists".  One would think that a chap like yourself with all that education, would have had a bit more sense, and been able to recognise that the Israeli's call the shots with American foreign policy. Geographically, and metaphorically your country is behind the Palestinians and for that reason alone your cards have been marked for quite some time.  Had you developed nuclear weapons in time you might be safe but without them you represent a military push-over, and your inevitable demise will represent  a major source of happiness, stability and longevity to Israel, not to mention NATO control of the entire fertile crescent from the Mediterranean to the Persian Gulf. Unfortunately for you, most of the oil rich Arabs are busy gorging themselves on oil revenues and have been rendered obese, diabetic, and blind to the overthrow of their, culture, religion and political landscape. Tis a pity that you cannot see the bigger picture and the 'blue-print' for the middle East, as it  becomes increasingly obvious with each American led invasion.

Your pal Mr Putin and the Chinaman will continue to do what the Americans repeatedly do for their biggest arms customer, and pull out the veto-card at any hint of United Nations sanction.  As a result  the UN is confined to it's familiar form of a paralysed-duck whenever the goodies of a resource rich Middle Eastern nation are about to be carved up and dished out to friends and relations, in accordance with the overall plan for the Middle East.

Without the UN, the formal international court of appeal has effectively  been transferred from the Hague, to CNN, Sky, Fox News, and the BBC, or more correctly the multinationals and big business who sponsor politics, make the jobs, and pay the piper's advertising revenues.  All that remains is for the west to do is to drum up enough brainwashed support against your regime, to justify the transition from covert to overt  military intervention.  Once this happens, you and your cronies can effectively kiss your collective arses goodbye.

I didn't read the application myself, however as soon as your opponents applied for recognition of their rebellion as a 'Democratic Struggle' your days were effectively numbered.  As such the carnage and mayhem that are both prelude and sequel  to your inevitable departure, are merely perfunctory matters, as are the innumerable innocents who are to pay the collaterally damaged  price for the transition to 'freedom' .

How it all works (FYI) is rather simple. The rebels appeal to the west for recognition of their struggle as a 'democratic struggle', and deserving of military and financial support. They agree tacitly and formally to eventually pay for the overthrow of the present government in; lump sum, fee simple and by installments after the fact etc:  They fill in the requisite application forms and petitions, show their credentials at the gate, and make the necessary promises of payments in natural resource, raw materials and development or post-liberation re-building contracts etc etc. 

Western authorities and backing industrialists  will then consider the application on the following basis.

1)  Does the country in question have nuclear power and weapons of significance? If the answer is yes, refer to the UN. Does the country in question have enough; gold,oil,uranium, gas, coal, natural resource, strategic position etc., that will make western intervention economically and politically worthwhile?  If the answer here is is yes proceed to question number 2. If the answer is no refer to the UN.

2)  Do the rebels themselves have a snowball's chance in hell of toppling the existing regime? If not,  how much will it cost (in terms of money and body-bags filled with Tennessee farm boys) And how much risk is involved in covertly stirring up the requisite amount of sedition and political instability that might make revolution practicable?

3) Are the rebels willing to call their new regime a "democratic" regime, and thereby permit western multi- nationals to enter the country and 'purchase' at low-cost the nation's natural resource which can then be exported, refined and manufactured into product after the 'revolution'?

4) Can the new government be relied upon to pay NATO back in hard cash, national resource, contracts etc., for its "liberation"?

5) Will the new regime agree to buy weapons of mass destruction and furnish it's future; army, air-force, and navy, solely from western 'democratic' suppliers vis NATO member states?

In general depending upon the answers to the above questions the rebels application for 'Democratic Struggle' may or may not be approved. Once approved however....the rest as they say is  History.  When the Americans invaded Iraq the process was entirely the same.

You see Mr Assad your biggest mistake was probably aligning yourself with the Russians rather than the Americans (although you were probably aware that the Russians were and are busy transforming themselves into another version of America, but the transformation will prove too late for you) You made the mistake of purchasing your military hardware from Russia and China, and you did this because you were not fond of America's relationship with Israel.  As such you made the mistake of letting ideology get in the way of good business sense. Had you been purchasing your military hardware from America, like the Saudi's or the Israeli's you would be safe as houses and the rebels in your country would be considered in the same vein as Palestinian 'terrorists'.

You see, relatively poorer countries like my own little island nation, export; cattle, potatoes and American made Viagra tablets. That's how we make our shillins. But these kinds of exports are in the haypenny place when it comes to military contracts for jets, tanks bombs bullets, warships and submarines.

The auld rules of the market place are universal and you can only sell a thing when there is a want for it.  In the west there isn't a want for half of the things that we buy and sell.  However when that is the case you have to create a want or a market, that's what advertising is for.

In the same respect there is no point in the Americans and the British making bombers and tanks and machine-guns and the like, and there being no market.  These products need a war if they are to be consumed. That is what war is for, and Syria  has the privilege of being the next biggest market opportunity since Saddam appeared on the balcony waving a shot gun in the air.  War as they say is not just good for business but essential to it. I recall reading that during the Iraq war the American stock exchange made some of it's its greatest jumps and leaps in the history of that fine establishment.

One thing you might be overlooking is the fact that when NATO liberated Kuwait and invaded Iraq, the Kuwaitis had to pay for that liberation. In essence the Americans secured the greatest arms deal in modern history, as every bullet, bomb, rocket, roll of jacks-paper on one of them Aircraft-carriers, is still being paid for.  The bill was delivered on to the Kuwaitis, who have passed much of it on to the Iraqis who are busy paying it back in crude, with interest of course. Not to mention when the new government was installed, all the various contracts to rebuild oil wells, gas stations infrastructure, factories and hospitals and the like have been,  dished out to what Bush called 'the coalition of the willing'.


For those countries that are engaged in the very expensive business of making weapons of mass destruction, new and growing markets are essential to national economic prosperity and even stability.  As such the sales reps have figured out that the best form of military sales is 'retrospective-sales' of the 'liberation' kind.  War first, and bills later. It is a much easier process altogether, gets rid of the old-stock that is about to go off, and cuts out all the haggling over prices.  And of course after the fact, when the Country in question has bee duly liberated the contract for military hardwarwe goes to the liberators. As the people at Brother, Xerox and Cannon know only too well, its not just about the sale of the printer, the real money is in the refills.

 In my estimation the crowd that gets in after you will be no different to yourself. As soon as they get in they will be dishing out the goodies to their friends and relations and to those who bow in the same direction, crack their eggs open at the big end, or whatever are the features that distinguish their sect from yours. However their wont be as much of a share to go to their friends and relations as a big dollop of your nations resource will have to be given over to the west, who will pay them pennies and then turn that natural resource into product.

This disproportionate 'sharing' will undoubtedly be mitigated by the fact that we westerners, with our insatiable multinationals and insatiable appetite for product are far better at digging up resource than non democratic countries such as yours. And although you will be paid pennies for your natural resource we will dig it up faster than you could have ever dreamed possible, and as such the new regime will have plenty of pennies to share with their family and friends.

Personally I see no difference between yourself Mr Obama or Mr Cameron,  Mr Putin, Mr Bush or Marie Antoinette. To my mind yis are all singing from the same hymn-sheet. However in the interests of equality and in the hope of staving off the inevitable carnage and mass destruction for a little longer, I would suggest that when you choose to murder and exterminate your opponents, that you follow established precedent and call your victims "Terrorists", or card carrying members of  "Al Qaeda" (whoever they are when they are at home?).  If you wish to have a share of the moral high ground then you might include the prefix "suspected" in your descriptions, this however remains entirely as an optional extra.


Yours etc

Myself and the brother.

Thursday 15 August 2013

The American Hero.

I recall watching a comedy sketch some years ago wherein the wife comes home to find Himself in the hay with another woman. When she enters the bedroom, the other woman jumps from the bed, hurries into her clothes and flees the scene. Meantime the wife is distraught and she begins crying with the usual; 'how could you?' and the 'where did it all go wrong?' palaver.  Her husband arises from the bed and rather casually dresses himself, completely blanking his wife's questions and tears, as though she wasn't in the room. He finishes dressing, makes up the bed, and retires down-stairs where he takes up a familiar post on his arm chair and begins to read the paper, as though nothing of any significance had just occurred.

Herself follows him down-stairs and into the sitting room, she spends a few moments staring at him in shock and confusion, to which he continues to quietly read his paper.  Shaken and upset she goes into the kitchen where she puts on an apron and some gloves and starts to prepare the dinner, her anger and tears melting into confusion. Some moments later he comes into the kitchen and asks her how was her day at work,  entirely oblivious to the preceding trauma. She replies with some typical response and the sketch ends with the pair sitting down to dinner as though absolutely nothing out of the ordinary had occurred. Undoubtedly my description does not do this somewhat mesogonisitic sketch much justice, however the humorous point being made is that reality, past, present or future, is what you make it, or in some cases what you insist it to be.

The American Philosopher Noam Chomsky has suggested that moral bankruptcy is so blatant in the administration of American politics that the institution does not bother to conceal the contradictions anymore; Invading Iraq without UN approval, the fantasy of weapons of mass destruction, control over the material resource of Iraq, Afghanistan, Libya and in time Syria, failing to sign up to Kyoto and in its dealings with Israel, and Industrial lobbyists.  All of it puts one in mind of the ostensibly faithful and yet entirely deceitful husband who has just left the arms of a harlot.

We westerners choose not to see the lust for oil, destructive consumption, and brute materialism that have undermined the noble ideals behind American Democracy, we are as willfully deluded as the cuckold wife.

Undoubtedly America itself has come to believe the hero-myth that has been relentlessly and universally promulgated by Hollywood for the past six decades. Just like; John Wayne, Mr Ingalls, Mr Walton, Mr Cosby, Sly Stalone etc etc, America can do no moral wrong. Wrongness in a truly moral sense is as impossible for America as it is for it's Big Screen personifications. It is as inconceivable that Mr Ingalls could be capable of true immorality, as it is inconceivable that the American administration is capable of true moral transgression, of lying or being deceitful.

As in an episode of Little House on the Prairie, if we are to witness Mr Ingalls engaging in an immoral act this would be met with the immediate assumption that either Ingalls is being controlled by an external force or influence, or (if he is acting independently and within his faculties), that he is acting for the greater good, the good of his family,  the good of his community, and the Christian God. These are the coordinates within which his character (and that of America) are defined, and all of these come before Ingall's own desires for himself.   As such his immorality can never manifest as a true immorality, and we willingly accommodate his 'immoral' behaviour with a temporary shift in our own moral boundaries.

In other words we the audience, with our knowledge and beliefs as to the character of 'The American Hero', we are willing to shift our moral standards in order to accommodate his 'breech', because we know or believe that he is acting for the greater good, because he himself, or the American hero is the personification of moral goodness. We merely wait with some nervous anticipation, for Hollywood to provide the necessary justification for Mr Ingall's temporary transgression, the justification that will set our minds at ease and return reality to its normal more familiar coordinates.

After years of unwitting media programming we ourselves have come to wholeheartedly  believe our 'American Hero' to be an important determinant of our contemporary reality construct. America has saved the world innumerable times already on the big screen. It continues to do so; in different spaceships, with different antidotes, and different faces behind the mask of the hero. America has saved us from; Aliens, Plagues,Dictators, Terrorists, Genocidal Maniacs, asteroids, saboteurs, assassins of the president, global-warming, global-cooling and global annihilation from an ever expanding myriad of potential sources.  In short America has saved us and itself from every imaginable danger, other than the most imminent and prescient danger of itself.  Indeed, having saved us a thousand times already, the majority of us are readily willing to hold his/her hand as our indefatigable hero leads us towards the abyss of ecological and social collapse.

When America invades Iraq, destroys global ecology, or follows the dictates of Israel, we know and believe that it commits these moral transgressions for the 'greater good' and as such it requires no justification, no forgiveness and no further delusion.

With catastrophe upon the horizon the world has no choice;  if it is to save itself it must unmask the American Hero and look further down the path to see where that hero is bringing us. The opposite will be achieved and the Hero Myth is only deepened by acts of violence against America. We must encourage revolution within America, we must encourage the American Hero to take off his own mask and see the truth of what he has become.

Thursday 8 August 2013

An Astronomy of the Real

An Astronomy of the Real.
 
Astromers get their kicks from looking at the stars. I prefer to direct my gaze in the opposite direction and look at reality, it is as interesting, and there are far more discoveries to be made there. When we look even further, beyond the immediacy of reality, on into the past, we see strange customs, behaviors and beliefs, strange dress and attire. Yet we must temper our laughter with the reminder that the future will find us as ridiculous as we find the past, perhaps even more so.
 
It is easy to point to the immense catastrophe that is the Irish health service, to its inequality, ineptitude, and its dysfunctional marriage of socialism and extreme capitalism. Every day there is reference to waiting lists, costs and inequality. One day we may grow tired of the same old analysis and finger pointing? Having worked in New Zealand for four years in a general practice training scheme, it is very easy to imagine how it could be so much better; and yet having had some experience in the Gambia in West Africa it is even easier to imagine how things could be much worse.
 
It is an interesting thing to watch a patient pass into the tube of an MRI scanner, or watch the fiber-optic image of an endoscope pass along someones bowel. One cannot help but wonder if human beings are so intelligent, if we can organize our intelligence so that it can thrombolyse and stent; how is it that the relatively simple task of governance, should remain so remote? Of course once the question is asked, the fun begins because everybody has an answer, and the answer usually coincides with a personal agenda. Yet it is those who have no personal agenda whom are best suited to provide a truthful unbiased answer. However without an agenda, without something to gain, what is the point in raising ones head above the parapet? Clearly (and indeed from personal experience) in the world of Irish medicine ones voiced opinions can mean the difference between a place on a general practice training scheme in Dublin, or perhaps having to take ones family to New Zealand.
 
A recent article in this paper highlighted the fact that doctors on training schemes felt 'under pressure' from their superiors to provide 'very positive feedback' on the forms used to evaluate their training. In Irish medicine a crucial ingredient to 'getting ahead', is towing the line and keeping your mouth shut. Much to the annoyance of the establishment however, there are always a few who are simply interested in 'getting by', rather than getting ahead. It is these people who are deemed to be dangerous, the 'loose cannons' to be silenced or simply ignored.
 
The question remains, how is it that we physicians of the modern world can describe the pathogenesis of a prion, and yet remain oblivious to the pathology that undermines our health service and our politics?
 
When I returned from New Zealand in 2009, I registered with the medical council and paid my yearly subscription. Three months later I was sent another bill for another registration fee, when I called to complain, I was informed that a medical council year runs from July to June, and despite the fact that I had just paid them in March, another registration fee was due in June! What could I do? Only pay this council of doctors who prey on doctors. According to an article in the IMT (May 16th2012) the medical council pays 820k per annum in rent for its comfy offices at Kingram House and; More than €60,000 was paid to staff by way of a bonus payment in 2010, among its 49 employees.”
 
Recently membership of a CME group has become mandatory for all GP's. The ICGP charges some 270 for membership to its CME scheme, it also bills the HSE for teaching, and allows drug companies to also pay for and sponsor each of the mandatory 'meetings'.. which usually involve a random speaker speaking on a general subject from the generality of medicine. It is absolutely impossible to garner what is gained from the entire process, other than maintaining an overdraft somewhere at the ICGP. The mercenary philosophy at the heart of the ICGP has reached dizzying heights in recent months with the announcement that the ICGP is to “open the membership door” to GP's who are practicing in Ireland but have no formal training in General practice. According to the college website the application fee for these 'back door' entrants is the modest sum of 7000.00 (no there aren’t any extra zeros!) Bear in mind college membership translates into a GMS list and as such the cost may not be as high as its seems. Of course when we read between the lines its 'Ireland for sale' and business as usual.
 
When I were a lad and was studying medicine at the RCSI, I was (and remain) utterly amazed how that noble institution can charge its majority of non-national medical students in the region of 50k per anum in fees. Three years of that training is conducted primarily at Beaumont hospital, where Paddy is not only the charitable guinea-pig but he pays the bills; from the toilet paper to the canulas, and the wages of the NCHD's who (out of the generosity of their hearts and the memory of their own inadequate training), provide the most valued 'training” for those who can afford a place at the registered Charity that is the RCSI.
 
From its private medical schools in Bahrain, to its new high end private nursing home in Drumcondra and its city centre property portfolio RSCI must be one of the most successful charities in the western world, (Vincent de Paul and the Samaritans should be taking a gold leaf from the golden book)
History will undoubtedly laugh at the ironies of Irish medicine, ironies that are clearly underpinned by a single defining philosophy. It is this same market ideology that defines the political modus-operandi of the state. Ironically we are very very clever at maintaining the singular stupidity which underpins most of our medical and our political woes. 
 
Recently a patient of mine told me that she bought a barbeque that was guaranteed for 25yrs, we both laughed when she reminded me that she is 73 yrs old, and the barbeque will likely be under warranty when she is dead and gone. In a sense our problems are not unrelated to the fact that we have perhaps lost sight of our mortality? Few of us like to be reminded that we will not out live the plastic bag in which we have carried our groceries home, and yet it is groceries and the materials we leave behind that defines much of our daily living. Perhaps a more lasting legacy would be a shift in our way of thinking? Perhaps instead of being governed by 'the markets' we might dispense with them and define a new philosophy, one that is compatible with something more than our consuming ourselves to extinction. 
Recently my wife and I attended a talk by the English philosopher Alain de Botton at Liberty Hall as part of the Dublin writer's festival. De Botton mentioned Joyce and how lucky we  Irish are in terms of our cultural heritage. I wanted to put my hand up at the end of the talk and ask Alain which did he think would be more likely to be found on a Dublin coffee table; a copy of Ulysses, or a dog-eared copy of the Argos catalog? 
 
We are indentured to the ideology of the markets, it is a primitive ideology that defines the institutions of health and politics. Unless we change that ideology and put a different bible on the coffee table, we shall remain as impotent as Bloom the astronomer, looking a skirt and shooting off at the stars.

Dont rock the boat!

Don't rock the boat!

We are led to believe and indeed most are of the opinion that there are significant problems with the establishment of modern medicine as it exists today. In general terms there are two kinds of medicine in Ireland; community and hospital medicine, and each area has its own assortment of 'problems'. There is no shortage of solutions, and the usual form of a solution is the one that might afford the greatest benefit to the individual or group proposing the solution.  The present Governments solution is from the old formula of the free pint, and the carrot of free GP care is repeatedly  dangled in front of the public nose.  What both the problems and the solutions lack is the ability to look at the Health Service from an entirely objective vantage, and to be prepared to accept that we ourselves public and professionals are as much a part of the problem as the entity at the end of the pointed finger.

In respect of General Practice a significant portion of the 'blame' for our grossly inadequate system of community medicine lies fairly and squarely with the body responsible for training General Practitioners. As Bertrand Russell states of philosophy, the same can be said of a College or institution, in that 'the highest compliment one can pay to a philosophy is to be brutally and objectively critical of it', yet criticism of Irish institutions is rarely met with introspection and usually met with consequence for those making the criticism.  In many respects Ireland has never evolved out of its status as a colony, we remain a subject people in need of masters and the Institution, be it the Banks, Medicine or the Legal profession remain our masters. We wouldn't have it any other way.
 
At present there exists two medical systems in Ireland; community and hospital medicine, and most of the problems within one system are a consequence of the problems in the other. Waiting lists for procedures, overcrowded casualties, ill-affordability and lack of services in the community, are all related by the simple reality that there is no clear distinction between hospital and community medicine. The dogs on the street are aware that an enormous portion of the 'treatment' that occurs in the hospital could easily be conducted in the community; here we are all in agreement. Where the conflict and antagonism begins is when we attempt to discern why this should be so, and how it might be remedied.

Realistically we will never be capable of implementing community or hospital services unless we can arrive at a satisfactory answer to this question. I assert that the answer is twofold; GP's do not manage community medicine properly because in the first instance they are not trained or confident enough to do so, and secondly because they have not the time, are not inclined or incentivised to do so.

In the first instance the lack of training is the fault of the ICGP, the Medical Council, and the Medical Colleges, and the second part of the problem is the fault of; the State, the patients and the GP's themselves.

The Colleges.
After medical school and a one year internship at the hospital, What to you have to do to be a GP in Ireland? The answer quite surprisingly is Nothing! Any medical graduate on the General Register can hang a plaque on the wall and practice as a Private GP. He or she can work in the out of hours service (largely staffed by non specialist trained GP's), he or she can provide locum cover, or be employed at any GP practice in the state. Indeed were it not for the army of non specialist trained 'GP's working in the Irish system, community medicine would very likely collapse.

So what is the point or the purpose of specialist GP training in Ireland? In a fundamental and practical sense the only purpose of specialist training in Ireland is that a GP might be eligible for a 'medical card list' whenever such lists rarely become available. Non specialist GP's can see and treat medical card patients anywhere and at any time throughout the state, however to obtain formal 'ownership' of a list of such patients one must be a trained GP. It's an entirely Irish solution to an Irish problem, that has everything to do with money and nothing to do with medicine.

The actual end purpose of specialist training and the specialist register in the Context of General Practice exists solely to control who can access the lucrative medical card system. It is a means of reducing the numbers amongst whom the cream-pie must be divided. Once again it is reasonable to reiterate that the only difference between a member of the Irish College and a non-member is the ability to own a list of medical card patients. In practical medical terms both are fully licensed to practice in the exact same manner and see exactly the same patients. The difference is one of ownership, possession, contracts and quite simply, money.

In practical terms if the end result of General Practice training amounts to little more than entitlement to the lion's share of the community health budget, we should not be surprised to discover that General Practice training in Ireland is entirely lacking, and to a great extent irrelevant to the actual practice of community medicine. For example a significant majority of presentations in General practice have a psychological or psycho-social component, whilst General Practice training in Ireland includes merely the 'option' of a six month psychiatric post. Dermatology waiting lists in Ireland (mostly in the hope of a simple biopsy) are quite possibly the longest on the planet, and not surprisingly one could complete formal general practice training in Ireland without ever once having picked up a scalpel.

Many Irish GP's simply “do not suture” and GP's who work at the out of hours service in Dublin are specifically asked not to suture. Not because of hygiene or the usual palaver about infection control, but rather so as “not to set a precedent” . Undoubtedly most of the GP Members at the out of hours service are also Members of the ICGP and yet, how one could maintain ones membership of a college, fulfil the various requirements for continued education, and still remain unable or unwilling to close a simple flesh wound, is beyond incredulous, and speaks volumes in respect of our health service.

The disparity between training and the actual practice of Community Medicine is not only a product of the non-clinical and entirely financial endpoint of the process, but is highlighted by the fact that so many General Practitioners provide an exemplary level of care to their patients (including suturing) without any formal training in General Practice.

Unless General practice training becomes focused upon the task of producing community practitioners capable and competent in the provision of relevant community health services, we will continue to burden the hospital with that which could easily be managed in the community.

The Patient
Not being eligible for a Medical Card list, my practice is entirely private. I have in excess of 1500 patients and at most I see between 5-10 patients per day (from whom I extort the relatively modest fee of €50 a visit). I have worked for many years at practices with a significantly smaller number of medical card patients and yet I would see 20-30 medical card patients per day.
We don't like to talk about this reality because we are not fond of truths in Irish medicine, however the simple reality is that medical card holders present more often to the GP simply because the service is entirely and completely free, and when something has no price it has no value. Therefore if much of the practice time is spent entertaining frivolous free-consultations, there is little time to actually treat people. This reality is complicated by the fact that many practices are entirely dependent upon their Medical Card incomes, and as such will scarcely rock the boat upon which they sit, regardless of the fact that it might be full of holes and sinking fast.
How community medicine will cope, or whether it will survive the Minister's promise to turn every patient in the country into a medical card patient is beyond comprehension, but in traditional Irish style, it sounds great, and is a clever evolution of the Haughey (Ha Ha) era...'vote for me and I'll buy you a pint' or in this case “free” GP's visits.

The state
The state is probably the most significant contributor to the problems of Irish medicine, however this reality is at once complicated by the fact that the state is a product of we the people, of vested interests such as the medical establishment, the HSE, and of the gullibility of the people to swallow empty promises and accept quangos and bureaucracy as the end result of those same promises.

Unfortunately the state lacks the courage to draw an appropriate distinction between; the nursing home, the hospital and General Practice, and as such it allows the most expensive component of the trio... (the hospitals) to function in the capacity of providing care on all three levels. Not only are the hospitals incapable of doing this, but they must also expend stretched resource upon the education of fee paying medical students. Incidentally the fees being paid by almost a thousand medical students at Beaumont hospital are in excess of 35,000 per anum, all of which is paid to the registered charity that is the RCSI.

In short the State presides over a medical system where General Practice does not fulfil the needs of the community, the hospital cannot supply hospital services, and the state will notprovide a distinction between the two.

The GP's
No problems here, we are all perfect?

Sunday 4 August 2013

Sick Medicine

The hypocritical oath. 

There are few occasions in my career when I feel compelled to ask myself whether medicine was the right choice for me. No doubt many in the College and the Council would concur.  Today was one such day, one where I not only question myself as a member of the Medical Profession, but also as a citizen of Ireland.


Tom is a 40yr old office worker, he and his wife Kate are the kind of soft spoken, gentle, introspective people who make General Practice a meaningful place to work. Three weeks ago Tom came to see me complaining of a tingling sensation down his left arm with occasional stiffness in the wrist.  The immediate suspicion of carpal tunnel syndrome was somewhat borne out during the exam and Tom was referred for physio and given a short course of anti-inflammatories. Tom saw the physiotherapist for two sessions during the week.. however matters came to a head during the following weekend when Tom noticed that his speech was becoming a little slurred.
Of an anxious disposition Tom presented to a nearby 'Swift' clinic, and after being examined he was informed that he may have had a “slight stroke” he was advised to go to A/e and given a letter. Whilst driving himself to A/E his nervous disposition evolved into anxiety proper and with Olympian self control he endured the six and a half hour wait in Beaumont casualty, to have a blood test, be examined and ultimately reassured that it was unlikely that he was having a stroke and allowed to drive himself home.

On Monday Tom presented to my practice once again, with an unexplained and unresolved slurring of speech and persistent neurological symptoms in the arm. Fortunately Tom has VHI, this was unfortunately of no use at the Swift clinic, but we will come to the financial costs in a moment. I referred Tom to a Neurologist at a private Dublin hospital. The following week Tom went to see the neurologist, who organised an MRI scan and after examining Tom recommended that he have some bloods done “there and then”. Tom was asked to pay 350 euros for his 20-30 minute consultation with the Doctor.  He was then informed that his blood tests would be an additional 300 euros. When informed the receptionist that the cost was 'a bit too much' and that he would rather have them done at his GP's he was informed that one of the tests was a 'special test', that could not be done at the GP's.  When he asked if he could have just the 'special' test done and have the remainder at his GP's, he was informed that this might be possible?  But that he would have to 'go through the public system to get the remainder his results ' and that this would greatly complicate things. Tom acquiesced and left the rooms of the neurologist after paying out some 650.00 euros for a 30minute consultation and some bloods. Although it is pure here say upon Tom's part he described his encounter with his consultant as being very formal and not at all friendly.. of course we only have Tom's word for that. 

This was on Tuesday morning, on Thursday he had his MRI scan. On Friday Tom's wife called to say that Tom was quite unwell, and that she was very distressed and worried on his behalf. It is important to reiterate here that Tom and his wife have been my patients for quite some time that they are very nice people, who don't complain and don't present to the Doctor's unless there is something wrong, and have a resolute faith in the medical profession.  I advise Kate to bring Tom to my surgery.

Once again this time on a Friday evening at 5pm Tom and Kate are in my office. On this occasion Kate is in tears, Tom has a hard time holding back his own tears, and I myself am emotionally shaken by the presentation. Tom has an envelope with his MRI films inside, he is pale upset, clearly hasn't been eating, drinking enough or sleeping well since he saw the Neurologist. After I examine him he asks me to look at his MRI scan which I do, whilst warning him that I am neither a radiologist nor a neurologist.

I do the decent thing and lie, I say that I can see nothing wrong with the MRI scan but that we will have to wait on the formal report and in the meantime we should try to deal with the other 'elephant in the room' which is our collective anxiety. I ring the private hospital on the off chance that the MRI might have been reported but of course the world of private medicine has gone home for the weekend.

I give Tom the only remaining tool in my arsenal of impotence in the form of a letter to A/E should his speech become worse over the weekend. I also give him my mobile number my refusal to take a consultation fee has the apparent effect of deepening Tom's anxiety, for which I give him a short term script for some anxiety pills.

Now for the Bills: First presentation to me  €50, two visits to the physio €80, visit to VHI €125, return visit to me €30, visit to the consultant €650. Grand total €925 euros. Tom has been out of work for three weeks, if we count the cost of his medication and the fees I have waived Tom's symptoms have cost him almost one thousand euros.  He must return to the Neurologist next week and was reassured before he departed that his next consultation would not be as expensive!  This will undoubtedly bring the grand total to some 1200 euros of which he is entitled to a 60 euro refund from his VHI.

Tom and his wife will spend the weekend worrying, awaiting the diagnosis which they most fear; a cancer a brain tumour, multiple sclerosis. The professionals, like myself who have treated Tom will sleep quite soundly this weekend, oblivious to the pain Tom and Kate will endure, oblivious to their fears and the financial burden that has been placed upon them. This is modern medicine in Ireland, this is the predatory nature of the relation between the 'system' and decent, hard working good natured people.

It is a good thing that the Hippocratic oath has been dispensed with, else we might add cynicism to the growing vices of our profession.