The family medicine system in Romania faces a series of structural problems that risk affecting the population’s access to preventive medical services. According to family doctor Sandra Alexiu, president of the Association of Family Physicians Bucharest-Ilfov, the decreasing number of doctors, the aging of the professional body and difficult working conditions threaten the functioning of primary medical care, especially in rural areas.
The role of family doctors, debated at the Healthcare Forum by Adevărul
The role of family doctors in prevention will be one of the topics discussed at the Healthcare Forum by Adevărul, an event that will take place on March 24. The topic will be debated by Dr. Sandra Alexiu (primary family physician, training instructor and president of the Bucharest-Ilfov Association of Family Physicians) and Dr. Cosmina Berbecel (primary family physician, member of the Vaccinology group of the National Society of Family Medicine), in dialogue with journalist Irina Petraru.
Truth is an unbiased mediator that brings together all relevant voices in the field. Health is not just a service, but a critical infrastructure that supports the functioning of society. The truth facilitates a balanced and constructive dialogue between those who can bring changes in the direction of the health system: governors, doctors, hospital directors, investors, managers of companies in the field, patients and experts in digitalization.
Fewer and fewer family doctors
We spoke with Dr. Sandra Alexiu about the problems that family medicine faces. According to her, the most acute are the decrease in the number of family doctors and their uneven distribution throughout the country. Rural or isolated areas are the most affected.
“Probably the most important problem is the fact that there are fewer and fewer of us and we no longer cover – as would be normal in a country with primary healthcare – the areas that are somewhat more isolated and located in the countryside.
Age is an issue. The average age in family medicine is around 57-58 years. A quarter of the family doctors are already retired, they work as pensioners, and half of us are from the period of the “decrees”, and this means that in a maximum of 10 years we will witness massive retirements in the health system, in primary medical assistance. Nothing happens to compensate”draws the doctor’s attention.
At the same time, the phenomenon of medical migration continues to erode the system. From 1998 to the present, more than 4,500 family doctors have left Romania, says Dr. Sandra Alexiu, and the most frequent destinations are France, Germany and the United Kingdom.
“They are attracted there by the fact that the system greatly facilitates the profession and takes care of the patients in the respective areas, the local community is very involved. Of course, those of us who remain are faced with low incomes, with point values that do not reflect the real value of health services. And we are faced with a lack of facilities, with inadequate spaces, due to the lack of involvement of the local community. And a high degree of fatigue, of frustration, because we are somehow disregarded as a specialty.”
Why don’t more young people choose family medicine
According to the family doctor, the specialty he represents is frequently chosen during the residency, but many young doctors later give up or go to practice abroad. The problems arise, says Dr. Sandra Alexiu, when they face the reality of the system.
“When they come across the bureaucracy and the lack of communication with local communities and the way doctors are effectively prevented from opening offices in areas where they are not well covered, they give up. Because it is easier to obtain a specialty recognized in the European Union and to find work in other countries. Or to do the family medicine residency only as a passage to residencies in other specialties, where you can find places more easily in areas where you are either closer to home, or there is assured transportation; or there are cities where the facilities are more important and it is easier for doctors to monitor their patients in relation to services from other specialties”.
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In rural areas the situation is even more complicated and that is why many doctors give up, says Dr. Sandra Alexiu.
“If you are in an isolated rural area, you must be very well prepared; you can’t get there without training and experience, because you’re basically on your own. If you don’t have local support, if you don’t have good diagnostic equipment and all the necessary instruments to be able to carry out multi-diagnostics, it’s hard to cope alone with all the pressure of the local community for primary care, not only as treatment, but also as prevention. Let’s not forget that lately we are talking about prevention. Although, at the present time, a large part of the payment in family medicine is based on the number of insured persons, in the rural areas there are many patients who are uninsured. They are consulted, but the rates that are settled are small. Medical education is very deficient. And you simply cannot start working in a cabinet with your bare hands, without equipment, without an adequate space and without everything you need to carry out a modern activity”.
The rural environment could run out of family doctors
If the situation continues at the current pace, there may be no more family doctors in the rural areas, draws Dr. Alexiu’s attention.
“There are already hundreds of localities in Romania, from the countryside, where we no longer have family doctors. It is not at all something very remote and very distant”.
Under these conditions, doctors who still practice in nearby areas are overworked. Patients in communities without a doctor move to other offices, which leads to congestion and a high workload.
“There are doctors who have not been able to go on vacations for years. We have colleagues who cannot go anywhere because they have no one to leave the office with. There is no substitute and we are not allowed to leave the business without having a substitute or someone appointed to take our place”says Dr. Sandra Alexiu.
Direct consequences for patients
How does the absence of a family doctor translate for patients? Dr. Alexiu explains:
“Considering that the family doctor provides primary medical care, i.e. that first contact, the person you go to whenever you have a problem no matter how small, the person you go to do preventive checks, situations in which you need to be screened, balance exams, vaccinations, the consultation of the small child, if you have nowhere to do all this, it is obvious that the main blow is given to the health of the people. (…) In practice, the accessibility of a large percentage of patients is completely lost. In communes, in villages, but also in small towns. There are also small towns where there are no family doctors”.
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Family medicine, essential for prevention
In recent years, public authorities have spoken more and more often about the importance of prevention in health. However, according to specialists, this strategy cannot work without a solid network of family medicine.
“We can talk about prevention here and there, in areas where there are doctors. But, statistically speaking, we cannot talk about the systematic application of preventive measures if you don’t have family doctors. The main specialist in the system who does preventive control is the family doctor.
There are also solutions discussed at the moment, such as caravans or mobile centers, but unfortunately, in the hypothetical situation where we will have many, which could cover rural areas, where there are no doctors, they will not provide medical services systematically; I pass by and do that from time to time, I’m not there all the time so you can talk to me like a doctor who is part of the community every day”the family doctor thinks.
Persistent technical problems when it comes to the health card
A discussion about the problems in family medicine could not end without the situation of the computer system, which periodically has technical problems. The activity of doctors is thus hampered. Even at the moment things are not good.
“We have been in a deadlock since October. The card doesn’t work now either. (…) We cannot activate new cards, we cannot unlock cards that have been blocked, we cannot enroll new patients without a card. Regular consultations, referrals and prescriptions can be issued even if the card does not work, but enrolling a new patient or checking eligibility still has big problems.” draws Dr. Alexiu’s attention.
