••Fall 2006/Vol. 10, No. 3

Medicine Around the World

 

Editor's Note: As part of our series on medical practice around the world, we present an article on rural general practice in Romania. Although a few of the author's problems are similar to ours, most are quite different. This article has been translated for us by Roxana Covali, MD, PhD, a Romanian radiologist.
-- Vincent J Felitti, MD

To become a general practitioner, after I had graduated the Gr T Popa University of Medicine and Pharmacy in Iasi, Romania and became an MD, I passed the national examination to enter general practice residency in June 1999. I then studied and worked as a resident physician for three years in big university hospitals in the following specialties: surgery, pediatrics, psychiatry, dermatology, internal medicine, infectious diseases, obstetrics and gynecology, and one year in an urban primary health care unit (dispensary) for adults and children. After every stage I had a written examination and a practical examination. During certain stages (pediatrics, surgery, obstetrics and gynecology) I even worked as an "on-duty" physician, and during the surgery stage I also worked in the emergency room where I became accustomed to diagnosis and treatment of emergencies.

Upon graduation, I had two choices: go directly to the countryside to work in a dispensary or pass the very difficult national examination for entering the general practice residency and, upon completion, work as a "specialist" general practitioner. There were positive and negative aspects to either choice. I chose the second, harder, option.

I learned and practiced many techniques I could not have learned otherwise. I treated difficult cases that can be seen and treated only in university hospitals, which greatly widened my medical horizon. The graduates who chose to go directly to the dispensary in the countryside became simple general practitioners. A few years ago, the Health Minister gave an order making all general practitioners with more than eight years in a dispensary in the countryside "specialist" general practitioners, without any examination or any period of university hospital work and study. They of course were very happy, but this left my specialist colleagues and me few open places to practice.

The Gr T Popa University of Medicine and Pharmacy in IASI, where Dr Florescu studied.

After these three years of study and work, I passed the examination for the professional degree of "specialist" general practitioner, which included a written, a practical, and an oral examination with a board made up of three medical university professors. About one month later, I passed an employment examination and my grades allowed me to choose a village dispensary close to my hometown, so I can commute by train. To sign a contract for health services with the health care system, I had three months in which to sign up on my "general practitioner's list" at least 500 people who had paid their health insurance taxes.

A general practitioner, specialist or not, is paid according to his/her list. Every person on the general practitioner's list represents a certain number of points, depending on age (neonate, adult, elderly). For every point, a fixed amount of money is given by the health care system to the general practitioner. From this money must be paid the nurse's wages, the practitioner's and the nurses health care and social security taxes, water, electricity, firewood for winter heating, and first aid medicines. The remaining money belongs to the doctor. Unfortunately, there are situations when this remaining money is lower than the minimum national wage (±$125 USD per month).

If your list includes 2000 or 3000 patients, then you may earn more and are a very fortunate general practitioner. Many general practitioners have 1500 or fewer patients on their list and must fight to keep them there. There are cases when a patient comes in the dispensary late in the evening, or at night, finds only the physician on duty, (not necessarily the patient's personal general practitioner), receives emergency treatment, and then is asked for personal data. Next time the patient goes to the dispensary s/he may find out that s/he has been added to the list of the emergency physician, even if s/he did not request this relocation, or agree to it.

On the other hand, when the payment-point system was first introduced in the late 1990s, those physicians already in dispensaries were the first to compile their lists, and they already had many patients. As the number of general practitioners in the dispensaries grew year by year, and the number of patients was constant, the newly arrived physicians had to make their own lists from depleted populations. These newly arrived physicians were happy to write a new patient on their list, while the previous physician was not happy to lose one. There were even situations when the patient was written on somebody else's list without asking for it. Newspapers wrote a lot about the arguing between general practitioners who fought to retain their patients.

At the end of the 1990s, when few general practitioners worked in the urban or rural dispensaries, the point value was high and it was said that general practitioners made good money. It was even said that the incomes of these rural general practitioners were greater than the wages of physicians who worked in hospitals where the basis for salary was different. At a time when there were few physicians working in rural dispensaries in the 1990s, newspapers related their good incomes to the point system and thereby encouraged physicians to choose to be general practitioners. As the number of general practitioners in the dispensaries increased, incomes stabilized or slowly decreased. For the same work, payment slowly became less from one year to the next and the lure of the point system decreased.

In 2004 my village became a town and the minimum number of patients on a physician's list to contract with the health care system rose dramatically to 1000. Meanwhile, step by step, I managed to buy for my general practitioner's office a refrigerator, a glucometer, a small sterilization device, and surgery sets. In 2004, because there was no hospital in this new town a "Permanent Medical Center" was organized. Physicians are on duty in their own offices, and the one on duty has to pay for the nurse and the medicines used.

When I began my practice, most of my patients were unemployed gypsies (an ethnic minority), beneficiaries of the social security system, who had not been included on the lists of the three other physicians working there before my arrival.

One day, a young gypsy woman came in, accompanied by a relative. In order to consult her, I invited the relative out. At that moment, the patient became visibly anxious, and did not want to undress. I spoke nicely to her, trying to calm her down, but it was useless. She insisted that her relative enter the room, too, and be with her. I invited the relative back in, and the patient relaxed. After I established the diagnosis, both women started to ask questions about the possible disease, at the same time.

I prescribed some medicines, including antibiotics, for the severe cold she had, explained to them how to take those pills, and sent them home. When they came back for the check-up, several days later, the patient felt better, but not as good as I expected. I asked a lot of questions and finally I got the explanation: she swallowed the antibiotics with wine, because she knew that wine is good for health!

That's why now, when I prescribe antibiotics to gypsy patients, I always tell them not to drink wine while they take the pills, if they want a good result. And many of them seem unconvinced.

There are other situations when I explain to both gypsy spouses the treatment, and after I finish, the husband will explain to the wife something, I do not know what, in their own language. They say he explains the treatment to her, but I do not understand why, because she understood the Romanian language, and had asked me questions about the disease. Before they leave, I always ask the wife once again: "Is it all clear to you? Do you have any questions?"

The poor, unemployed, generally uneducated gypsies, remain an unsolved problem in Romania. They do not want to listen to the physician's recommendations, nor do not want to obey certain medical requirements, but they do want good medical results. Special attention and a lot of patience must be paid to these individuals who are socially assisted and paid a certain amount of money per month by the state.