March 12, 2011
INTERVIEW:Dr. FLORIN CHIRCULESCU
Florin Chirculescu is the chief of the Thoracic Surgery Department at the “Spitalul Universitar” Hospital of Bucharest. He is also the trade union leader of the Doctors’ Federation “Dr I. Cantacuzino”.
In February 2009, surgeon Florin Chirculescu addressed a public letter to Ion Bazac, who was, at the time, Romania’s Ministry of Health.
The letter’s pretext was “the Slatina mediatic scandal”. A 62 aged man had died in Slatina’s hospital without receiving any medical care. For almost four hours, the man had been sent from one department to another, doctors refusing to take responsibility of him. The media extensively covered the case, thus determining Romania‘s Ministry of Health to sanction Slatina’s hospital medical staff. Things could have stopped here.
However, doctor Florin Chirculescu decided to take this chance to denounce the general deficiencies of the Romanian health system: “Would you feel surprised if I told you that Romania’s medical practitioners did NOT feel shocked by “Slatina case”? Would you find it strange if I told you, fearing the whole medical stuff will be blamed for it, that I am “ready” to witness a similar denouement in the department I coordinate?”, Florin Chirculescu asked rhetorically Romania’s Ministry of Health in his public letter.
The letter talked openly about the lack of medical staff, the poor condition of Romania’s hospitals, and Romania’s doctors’ negative public image.
One year later, surgeon Florin Chirculescu explains why Romanian health system is “stuck” in the same situation. Or, perhaps, even worse.
The 9 failures of the Romanian health system
1. There are no treatment and diagnostic protocols in Romania.
If these protocols existed, patients could bring to trial the Romanian state for failing to respect the recommendations.
R:Are there other EU member countries who did not implement treatment and diagnostic protocols?
FC: No, I don’t think so. All European countries use protocols. Yet, if Romaniatried to implement these guides, too, the next moment, the Romanian state would be obliged to admit the protocols can’t be respected. Because of the severe lack of funds. This is the real problem. Both medical investigations and therapy require funds .But health is not a priority for Romania’s leaders. So they prefer to forbid the existence of protocols.
R:How much money from the country’s budget are directed towards Health sector?
FC: In EU member countries, we talk about a minimum of 7-8% .But in Romania, it’s only 3%.
2. In Romania you can leave the hospital sicker than you came, or even dead.
Unfortunately, excepting the few cases that become media scandals, there is no data available on how many people are affected by the poor medical conditions.
R: As a direct consequence of the fact that are too few funds directed towards Health in Romania, are patients treated with less adequate medicine than they should benefit from?
FC: Yes, of course, this happens often. One example is that of antibiotics’ treatment. In case of infection, we are supposed to test the patient before administering the treatment, in order to identify which kind of antibiotic he would respond to.
However, many hospitals in Romaniado not have testing kits. So one may have an antibiotic, but not the corresponding testing kit. Doctors can’t tell whether the patient will respond or not to that specific antibiotic. Or, the other way round, it happens a hospital does the tests, but lacks the needed antibiotics. So doctors can’t administer the patient the most adequate medicine.
Another recommendation about antibiotics’ treatment is that one should NOT change the antibiotic once the treatment had started. The patient should be given the same antibiotic for a minimum of 5-7 days. However, in Romania, it is possible to be out of that specific antibiotic in only 3 days; so if there’s nothing left of it, and the medicine is too expensive and the patient can’t afford to buy it himself; the antibiotic is replaced with another one.
R: So what happens with the patients in this case?
The treatment’s efficiency is diminished. People stay longer in the hospital. Doctors may learn, after consulting international protocols, a patient should be given a specific antibiotic. But if the medicine is not available in the hospital, the patient is given another antibiotic. So treatment is prolonged and risks may appear. For example, the patient may develop antibiotic tolerance.
R: Given these facts, how would you comment on Romania’s hospitals’ death rate?
FC: Well, I can tell you in medicine, death is a result of many agents. There’s no single cause. Every case is unique and pills are just one aspect of the medical treatment, one part of the problem. So, one should not generalize whenever discussing death’ causes. Of course, it would be unreasonable to affirm that the lack of medical material and medicine does not influence the overall Romaniahospitals’ death rate.
R: How many people would you estimate have died in Romania’s hospitals?
FC: Hospitals’ death rate is not yet considered a national problem. Such estimations should be based on scientific data. And there are no studies available on this problem. So, if I talked I’d be tempted to exaggerate and I’d make people panic. This would be unfair. Our leaders should panic, sincethey aresupposed to take action to improve the situation.
R: Who should ask for these studies?
FC: Romania’s Ministry of Health, of course! But our leaders do not want to hear about Health. If a scientific study proved a lot of people died because they lacked drug “X” and medical endowment “Y”, this would no longer represent a Health issue, it would immediately grow into a public politic scandal. It would reveal the Ministy of Health and National Insurance House’s managerial incompetence.
3. In Romania’s hospitals there is a lack of drugs and basic medical endowment such as bandage, adhesive bandage, gauze, surgery thread.
Very often, patients or their relatives are asked to buy themselves the needed medicine or materials.
“Today, we were supposed to have a medical operation. But we postponed it because we were out of surgery thread. Luckily, this time it was not an emergency. A patient donated us 500 euros to buy surgery thread. But this is not a solution! It’s not the first time we postpone surgery because of lack of materials. Whenever we are confronted with emergences we are forced to improvise”, told the press doctor Chirculescu on 28 May 2010 when the “Spitalul Universitar” Hospital ‘bank account was left only…. 3 euros.(Agerpress)
R: Can you make surgery now at “Spitalul Universitar” Hospital? Do you have gauze, thread, and bandage? What about physiological serum?
FC: At this moment, yes. We overcame the terrible situation we were in 2-3 weeks ago when we were left no money in our bank account.
R: But how could this happen to such a big hospital from the capital of Romania?
FC: Precisely, because our hospital is a big one and patients from all over country come to us for treatment. During the last years we spent a lot and we accumulated debts. Now Romania’s law says we must pay these debts before we make acquisitions. We had few funds at our disposal, so our hospital preferred to pay first the debts. And, well, I guess that was what we were left: 12 lei (less than 3 euros)!
R: Do you still ask patients to buy themselves what is needed for treatment?
FC: Yes, but now we only ask for antibiotics. And also, today, I asked a patient to buy a 36 euros electromyography needle. You know, we are out of needles and we can’t afford them. The EMG needle is statically less vital than surgery thread, for example. So that’s why we asked the patient to buy it himself.
R: However, all over the country, basic medicine is still lacking. What about Romania’s other hospitals?
FC: Well, I can say the “Spitalul Universitar” Hospital is a really nice and beautiful place compared to other cities’ hospitals. Just go to Oltenia or Campulung! Have a look at the hospitals they got there!
4. If you plan to go to the hospital in Romania, you must not forget the bribe. However, be careful, if doctors will think you are poor, they may not take care of you.
Recently, the rulers came up with a new anti-corruption solution: the co-payment system. The patient should pay for certain medical services in public hospitals. However, some doctors are against putting in practice the projected measure. They say co-payment will not eliminate bribe, but only force people pay twice.
The President of the Romanian Medical Association (Colegiul Medicilor din Romania) prof. dr. Vasile Astărăstoae publicly criticized the co-payment system idea: “the consequence of introducing the co-payment system now, in times of economic crisis, would mean at least 40% of population will not benefit anymore from medical care”.
R: How do you judge doctors that ask for bribe from very poor people?
FC: I don’t even want to judge them. They should be out of the health system! I never agreed and I’ll never agree with bribe, regardless how difficult is Romania’s doctors economical situation. It is inhuman to ask for money from someone who is poorer than you!
R: People often talk about doctors who refuse to do their job because they are not given bribe or they are given too little money.
FC: Personally, I never met such a person. But I heard stories. Unfortunately, there are many such stories. As a trade union leader, I am often confronted with this problem when I came to speak in front of the public. People have lost confidence in doctors. But I am against bribe and fortunately, many of my colleagues think the same way!
5. Medical care, as a high quality service, is only available to those who afford an expensive treatment in Romaniaor a medical visit abroad.
The European E112 regulation is still relatively unknown in the country. The E112 form enables Romanian citizens to ask for free treatment in another EU member state, providing they prove they can’t be treated in Romania.
R: What chances has a poor man to be well-treated in a Romanian hospital?
FC: Well, he clearly has fewer chances than a wealthy man! I’ll tell you why: all over the world, medical care is expensive, health is expensive! The Romanian health system might be down-and-out, but there is no health system in this world able to cover all population’s needs! So, yes, those who are wealthier afford better medical services than the rest, that’s it.
R: Did you witness situations when patients used the E112 regulation to go abroad for treatment?
FC: Recently, many patients told me they want to go abroad for treatment and they went. However, I believe they covered the costs themselves. None of them asked me to sign those papers. I think more and more Romanians will choose the private health system of another country for treatment.
R: Why the private health system?
FC: Let’s say one is accepted in a public state hospital of another country. Ok, but then one discovers one is on a three-month waiting-list. Being really ill, one can’t wait that long. So, the person switches to the private health service.
6. The Romanian public health system is underfinanced. This is the main cause of hospitals’ decay.
Also add up to this: generalized corruption in the administration system and leaders’ petty political interests.
R: You mentioned before there should be alternative financing sources for public hospitals. Which ones?
FC: First of all, the patient himself. The health system is not able to cover all the costs, but some patients could really afford more. One recognizes these patients by the clothes they wear, their expensive mobile phones…If these wealthy patients got insurance at an Insurance House other than the National one, money could go back to hospitals. Then, of course, there is the Church and the NGOs.
R: Which are the problems of the National Insurance House?
FC: First and foremost, the main problem is that there is only one Insurance House in Romania. There is no competition. There are no alternative options for patients. In other countries, there are more public Insurance Houses and people are free to switch from one another, if they are not content. Well, this is not possible in Romania.
R: Why do you consider the National Insurance House inefficient?
FC: Our National Insurance House is politically controlled. The money that get to the National Insurance House do not always go back into the health system. Whenever a new political party comes to power, a new National Insurance House director is appointed. This new director’s sole purpose is to re-direct as many as funds as possible to the Ministry of Finance. A National Insurance House should be accountable in front of the public, not in front of the politicians!
7. Recent health system reform proposals might prove to be equally uninspired. One example: transferring hospitals to municipalities, in an attempt to decentralization.
Starting 1st July, the Ministry of Health will transfer hospitals to municipalities, thus ending its direct coordination upon all the country’s health units. However, decentralization in the Romanian context might not be such a good idea. Some units might cut hospital beds which would“terribly affect patients who come from smaller villages”, says dr. Manole Ilie, manager of the OdobestiHospital. For example, cutting beds at VidraHospitalwould seriously affect medical care in the municipality, since VidraHospitalserves a community of 12 villages and 44000 people.(Ziarul de Iasi, 7.06.2010).
R: What do you think about the decision to transfer hospitals to municipalities?
FC: Well, the majority of Romania’s mayors proved highly inefficient solving daily life problems such as ensuring water or gas utilities; what about hospitals’ complex issues?! I don’t think they can handle it. I’ve heard some mayors don’t even want it.
R: What if municipalities run out of money, too?
FC: Well, being a trade union leader, I participated at the officials’ meeting and the funny thing is, they never talked about funding. They were simply making future plans, just like sitting together at a beer and discussing how it’s going to be…
R: This transfer is actually about reducing costs…
FC: Precisely. Theoretically, this was supposed to be a decentralization process. But whenever they discussed concrete situations, they were talking about merging hospitals, which means, as far as I know, centralization!
R: Which negative outcomes might have this (de)centralization process?
FC: Well, for example, in a municipality of 50-60000 people several smaller hospitals will merge into a single medical unit, having only one acquisition committee. This equals disaster.
Acquisition in a certain territory will become trust controlled. Those who lead acquisition committees are local political leaders. If there will be only one committee, its members will be free to decide which enterprise they favor in buying medicine from. Because of corruption and political interests, the acquisition committee might come to buy only very expensive drugs. Actually, this is already happening in Romania.
8. The acute lack of medical staff makes all health professionals overloaded at work. Doctors are discontent because they work too much and are paid too little.
There are too little doctors in Romania. In fact, the country has only half of the necessary medical staff, that is, only 3,8 doctors per 100 000 persons compared to 8,9 , European Union’ statistics . Furthermore, a Romanian doctor is responsible of 400 persons, twice more than the number of persons an EU doctor is supposed to take care of. At the same time, numbers show a Romanian doctor’s salary is ten times smaller that his European colleague’s. (Romania Libera, 10 february 2009)
R: How does medical staff’s scarcity impact on the overall health care activity?
FC: Well, it’s obvious that being fewer, we have less activity. For example, three years ago we were six people in this department and we did about 840 surgery interventions a year. Now we’re only 3 persons, so last year we managed only 700 interventions. My colleagues and I we often stay to work after hours.
R: You mentioned before that in Romaniaa specialist doctor may reach 30 medical consultations a day. So when does a doctor get tired?
FC: According to our laws, a doctor should not surpass the norm of 20 consultations a day. But, of course, there are no studies on the optimal number of consultations a doctor may do without growing tired and thus endangering the patient’s health .So in Romaniadoctors are “free” to work more.
R: What about other countries: are doctors working that much abroad, too?
FC: Not really. For example, EU norms say that a doctor may take a day free after a 24- hours guard. In Romaniano, one must keep working after a night guard. Also, some EU countries, among them Great Britain, already shortened the guard’s duration to 12 hours. Not Romania. Here, a doctor comes to the hospital at 7 a.m., does one’s guard , then follows his normal work schedule until 15-16 p.m. the next day. To sum up, more than 24 hours spent at the hospital, with no rest.
R: And are the doctors who work after a night’s guard still doing consultations?
FC: Of course. They even perform surgery, it happened several times. In these cases, the medical practice involves risks. For instance, when Romanian president Basescu needed to go under the knife and wanted to do this in Romania, the neurosurgery doctor said “no”. He told the President he was tired. And he was right to feel so. As you already know, president Basescu solved the problem by going to Vienna, Austria.
9. More and more young medical specialists choose to work abroad, yielding up with Romania.
The lack of any perspective forces thousands of doctors to leave the country or to go in for other, better paid jobs. The official statistics show that 6000 doctors have taken the needed official steps in order to work abroad. Equally, numerous young doctors are changing their career, choosing to be medical dealers, managers of medical enterprises, or businessmen. (Romania Libera, 10 february 2009).
R: It is well known that a lot of young doctors are leaving Romania. If you were now a 25-30 years old doctor, would you go abroad or choose to stay in Romania?
FC: If I had that age I would certainly be somewhere else. Gone this many a day. Anywhere west of Szeget, even in Hungary.
R: So do you consider the young doctors still working in Romania, “suckers”?
FC: Yes, I am myself “a sucker”. Yet, there are lots of reasons for not leaving one’s country: first of all, family… language no, anyway not for me, language is not a problem. I had a lot of tempting offers, but I understood that abroad I would have to perform below my working experience. And I actually like my job and career. I enjoy performing surgeries; one needs a lot of adrenaline. There are several medical jobs I wouldn’t do. This is the main reason I’m still around. Still… Don’t know for how long.
R: So is the emigration option still opened to you?
FC: I don’t rule it out. Adrenaline is not a substitute for money, and I need money for my child’s education. I do not find Romanian state’s educational offer satisfying, so I have to pay for additional tuitions. This means money.
If things keep going from bad to worst, I’d leave Romaniafor good. If in one-two years time, I don’t achieve the proposed goals through the Trade Union, I give up. It would mean there’s nothing more one can do in this country.
Author : freEUlance