The German solution for on-call doctors, challenged: “Is someone painting your house out of passion?” DEBATE
Honorary adviser to the minister Alexandru Rogobete made a suggestion on how the problem of the shortage of doctors in the guards could be solved, describing the system in Germany. The Romanians explained in the comments what prevents such a solution from working. Meanwhile, hospitals are looking for alternatives.
The shortage of on-call doctors has become chronic PHOTO: Shutterstock
Doctor Iuliu Torje, the honorary advisor to Minister Alexandru Rogobete, made, in a post on Facebook, a suggestion about how the problem of the shortage of doctors in the guards could be solved, describing the experience in Germany.
“In Germany, this problem has been addressed through professional mobility. There are several platforms where hospitals can post uncovered guards and doctors can sign up online to pick them up.
The system works simply.
• the doctor creates an account, validates his skills and availability;
• hospitals publish on-call offers (specialty, date, location, remuneration);
• the doctor selects the guard, signs digitally and is paid directly for the service rendered”, wrote doctor Torje.
“Payment would be made through service contracts, digitally signed, with full fiscal traceability”
This system ensures continuity in medical assistance, the pressure on the employed staff is reduced, costs become transparent, there is equity and mobility between regions, the doctor pointed out. Such a system could also be implemented in Romania, and the Ministry of Health could manage a platform interconnected with public hospitals and local authorities, suggested Iuliu Torje. Hospitals could post on the platform the guards left uncovered, and validated doctors could apply directly, depending on the specialty, availability and proximity. “Funding could be provided by the authority that administers the hospital, county council, town hall or ministry, depending on the status of the unit. Payment would be made through service contracts, digitally signed, with full fiscal traceability. In order to make the system work, it is also necessary to regulate the status of “freelance doctor”, a doctor who can work independently, in several hospitals, in a collaboration regime, without unnecessary bureaucracy.
Moreover, the model could also be extended to pre-hospital medicine, ambulance, emergency centers, as well as nurses, who face the same staffing problems.
Such a platform would create a national network of medical resources, able to quickly cover needs on the ground and ensure continuity of care for patients”concluded the doctor.
This is where the discussions started. The major difference between Romania and other states is the payment of these guards, the main problem was raised which, even at this time, prevents state hospitals from attracting doctors in order to cover the deficit.
In Romania, the on-calls that doctors provide beyond the obligation in the contract are paid based on the 2017 salary, reaching a maximum of 500 lei/on-call, while in Germany and France, according to the doctors who reacted to the post, the payment is approximately 100 euros/hour. Doctors are required to have empathy, dedication and professionalism, but, they say, they are paid for 24 hours on call with the amount that a person who cleans an apartment earns in 5-7 hours.
“Ialthough it is good in theory, in practice no one will come (almost) to do on-call paid for the equivalent of 100€/24h, even on weekends for 200€/24h, given that in many western countries (probably also Germany), 100€ or close to it is the amount paid per hour of on-call (and sometimes even on-call at home, where the doctor travels for emergencies). So why would a doctor, even a young and starting one, agree to commute for that amount? Let's not forget that we are talking about the gross amount of which he will be left with maybe about 60% after taxes and expenses? Why wouldn't he rather go to another country either permanently or commute 2 weeks a month and work as a substitute doctor – locum/locum? The motivation – both financial and professional: working materials, equipment to be able to practice medicine at current standards, not those of half a century ago – is essential for this idea to be feasible in Romania”one of the readers of the post pointed out.
Someone else made another comparison, showing that a doctor in Romania also earns in 2 hours giving consultations in a private clinic the same as he would earn in an on-call in the state hospital.
The issue of the responsibility of those with management positions was also raised. “Section Managers/Heads of Wards have no legal liability if something happens due to understaffing, so they won't spend what little resources they have on guard coverage because
“6 euros per hour on call in Romania comes with swearing, scandal, threats and a hard-to-imagine malpractice law. So, for now, under the given conditions, this idea will never succeed”one more argument was made in support of the idea that the solution cannot, for now, be put into practice.
The doctors who expressed their point of view added that it is not only about the 24 hours of work, but to these are added the following eight hours of work also in the hospital. “I mean 32 hours continuously, how is it? And yes, guards are paid extremely poorly. A woman who comes to clean charges you 300-450 lei for a day of cleaning. A guard is paid about the same with 400-500 lei, only it's 24 hours. So the problem is with the system, not with the people”other commentators pointed out.
Accuse them of making guards “just to get extra money” and there are so many cases in which patients are treated disrespectfully, but also that they also work at the state and at two or three other private clinics, the doctors replied: “Obviously, we do the guards for extra money. Have you seen someone paint the house out of passion? Install a power plant, an air conditioner out of passion, without asking for money? Everyone offers services to earn a penny. Why would doctors do otherwise? If you stayed 7 hours at the UPU, you stayed because the system is poorly organized, not because the doctors are stupid or lazy. They are too few compared to the number of patients who go to the UPU. So stop blaming the doctors!”. “If they have four jobs, they have their time, their families' time and they are rewarded for each of them. Leave the sarcasm, that you will still ask the doctors you don't respect to help you, to find another solution when you need it. And you will, because no one suddenly dies of old age. It is exactly this kind of attitude that causes doctors to limit themselves in the public system strictly to the obligations they have according to the law , 7 hours daily program and one mandatory guard/month”, the accusation that doctors have time for private jobs was also answered.
Attention was also drawn to the fact that patients come to the UPU to remove wires, to remove plaster splints, antibiotic testing, treatments, including changing/removing the tracheostomy tube, this under the conditions that the UPU should strictly treat emergencies and the problems mentioned above should be solved at the family doctor, at the permanent center, or in the outpatient clinic, with a referral from the family doctor. “For that you need an appointment, you have to wait, you come to the UPU and scream that you are not picked up at the zero moment or some, trickier, come with the ambulance, because we know you take us faster… There is triage, there are doctors, like me, who respect the seriousness of the cases. I am waiting for the moment when those who abuse the system are made to pay.” another doctor pointed out.
“The resident doctor has the highest compensation, because he is also the lowest paid by the state”
The Slatina County Emergency Hospital is one of the hospitals that at one point had only very difficulty covering the guards for certain wards or even this did not happen anymore. Over time, the problem was solved for certain specialties, but the hospital was still partially exposed to Cardiology, where two-thirds of the month is covered, and for another 9-10 days, patients with cardiology emergencies are transferred to the hospital in Craiova.
From January next year, it is hoped that there will be even fewer guards left to cover, as more resistant doctors are expected to be co-opted.
The medical director of SJU Slatina, doctor Florin Popa, says that the idea of establishing a platform where demand and supply meet is good, but “there is a nuance.”
“The nuance is that the doctor who wants to be on call chooses where to be on call, but somehow also depending on how he is paid. That's where I see a competition,” said the doctor. There are hospitals, such as the one in Târgoviște, which at this time manages to pay a guard with the equivalent of 800 euros, an amount that not many other hospitals can afford. Any hospital can do this only with a contribution from the local or county government, depending on the subordination of the hospital.
Also with the support of the credit orderer, which is the Olt County Council, SJU Slatina is currently paying at a different level the security of the residents who agree to come to Slatina and who collect four times more than the 300 lei that the state offers. The specialists and primary doctors who come from outside the hospital, as well as the doctors of the unit who agree to do additional shifts, are paid additionally, the amount increasing with the increase in the number of shifts provided.
“We pay doctors who are from outside better for their guards, and our doctors, depending on the number of guards, we also give them a supplement. Somehow we're trying to push all the doctors to be guards. You have nothing else to do at this time. And it's proven to work,” explained Dr. Popa. “The resident doctor has the highest compensation, because he is also the lowest paid by the state,” added the medical director.
Equipment used at reduced capacity also due to lack of doctors
Attracting young doctors has a double purpose: on the one hand, the problem of uncovered guards is solved, on the other hand, it is hoped that at least a few of the doctors will be attracted, seeing the conditions, so that in the future they will stay in the hospital in Slatina.
With the guard covered for the entire month, the newest machine that was put into operation in Cardiology just at the end of last week, an angiograph, could be used in another capacity, for example. “Each doctor is looking to have something to work with, to actually have something to do and to develop. This part of interventional cardiology catches on with us easily, easily”. Dr. Popa also said. For now, the angiograph is only used for scheduled interventions, but it is hoped that these will also be done with increasing frequency and a wider range of services will be provided. The doctor who performs them is a collaborator of the hospital, he comes from the Craiova County Emergency Clinical Hospital, and the hope is that soon doctors with this specialization will be attracted with a permanent contract and the interventions will become commonplace.
