Exodus of Polish doctors could threaten health system
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7451.1280-a (Published 27 May 2004) Cite this as: BMJ 2004;328:1280All rapid responses
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When I was 26 years old I dreamed about leaving for the USA.
I think, most of us had dreams like that. Much has happened since 1994.
Free people movement is real fact. The dreamers are leaving ... but to
the UK.
Well, I have been sitting next to my anaesthesia machinine and thinking.
What is the same procedure performed like over THERE? How do THEY manage
the same problems? So, why not go THERE and become ONE of THEM? Well, will
they accept me? Will I accept myself in new circumstances? What would my
family say?
All in all I am very determined. Oh, I should say WE are. We ara not going
to ruin Polish Health System (if it exists at all). All we want to do is to
have our dreams come true. If we were 10 years younger we would leave. Why?
Because, every single person CAN and OUGHT TO realise his/her own dreams.
NOBODY is going to take revenge, as most is accused of.
Maybe, one day, Society of Polish Anaesthetists would appear in UK, or,
maybe not!
Competing interests:
None declared
Competing interests: No competing interests
A FIRST-HAND PERSONAL ACCOUNT OF THE THINKING OF YOUNG POLISH DOCTORS
I would like to respond to the opinion presented by the
representative of the Polish Chamber of Physicians. I want to tackle a
couple issues not brought up by Mr Szweczynski which would shed some new
light on the whole topic. This is mostly a personal story but it best
illustrates some part of the reality of Polish medicine. I focused on four
facets of the problem: money (the most prominent argument in the article
by Jane Burgermeister), lack of training positions, poor quality of
training, limited access to scientific resources.
1. Money is an important factor prompting young people to take into
account the possibility of going to other countries. According to survey
conducted 4 years ago 90 % of my young doctor friends are supported by
their often affluent parents because otherwise they would not be able to
pay for their bills (not to mention their families and kids). I and some
of my friends were working as students and it gave us the opportunity to
make good money being involved in other activities even after graduation
from medicine. I am a graduate of both medicine and a 5-year English MA
program at the University. I used to teach English for language schools as
a student and worked for the publishing company. I already had a family
and that made me look for more income than just for my needs so I might
have not been a typical student back then. But now when most of my friends
have wives and kids, they are facing the same dilemmas.
A lot of Polish doctors work as drug representatives for pharmaceutical
companies. They make about four times what you get at the hospital plus a
car, cell phone etc. It still lures some people into that business and
some of them never come back into clinical medicine.
I am a young doctor currently enrolled in the PhD program with one of
the medical schools. I do not specialize, just do my research, have
classes with students but do not treat patients. I get about €200 from the
medical school as a scholarship and that is just enough to pay the
apartment bill (not the rent which would take the whole amount) and the
home phone bill. All the rest of my expenses (food, gas for the car,
electricity, cell phone etc.) I need to cover with the extra money I make
on the side (in my case with the publishing company). This other job I do,
running my business with just my computer, DSL internet and my cell phone,
provides me with many times more than I get from the med school. That is
very depressing because I would rather get €1000 (like in PhD programs in
Germany) just to be able to survive and commit myself to just medicine and
research, but once you can make easy money doing other things, which takes
you 3 hours every day, you are not willing to resign from it.
2. This is my main problem but a lot of my friends are faced with it
as well. The limited number of positions available for specializing is
outrageous. Every year about 200 doctors graduate from my med school and
later they are offered the total of some 100 positions for specializing,
most of them in internal medicine. After 13 months of internship which is
mandatory and paid for by the state (again some €200) you are faced with
the reality. If you want to specialize after that you have two pathways
that you can apply for:
a) rezydentura - which is paid for by the state and anyone who
completed the internship is eligible, the best
option, a little bit more money than with a hospital job (€300)
This type of positions is almost nonexistent right now because of the
government's lack of funds. I am eligible only for this kind of position
because I am not employed by the hospital ("etat").
b) "miejsca pozarezydenturowe" - "job positions"
· positions for the people who hold jobs (the so-called "etat") with
hospital or medical school,
· positions for people in the PhD program who are affiliated with the
professor in the clinical specialty department (before even if you were
enrolled in the PhD program in basic sciences you could apply for this
type of positions)
· positions for volunteers who sign up the hospital job contract but
don't get a penny
"Miejsca pozarezydenturowe" - "job positions" are the most desired
pathway because there is a good chance that there will be positions
covering the needs of the "job-holders" in the given region.
My point here is that there are very few positions available, quite a lot
of graduates who cannot even apply for the draft (which takes place twice
a year) and a growing number of doctors who simply want to leave Poland
for that reason. Since I am only eligible for "rezydentura" I have not had
a chance to even fight for the positions for the last two years since
there were none of interest where I live. This trend does not seem to
change and what I am dreaming of now is to go abroad and start
specializing. Polish system of postgraduate medical education does not
need me and since nobody cares I do not care either.
3. The quality of training in Poland is very questionable. Once you
get into specializing program of your dreams (let it be "job position")
you can get frustrated pretty fast. There is some schedule for
specializing on paper but few follow it and you may be asked to do
whatever your superiors want you but it will least likely be a planned
training program (making you a good specialist acquainted with all
clinical situations in your field or thoroughly trained under supervision
by people who care about your medical training).
That is why I and my friends seriously think about going to UK or
Scandinavia where I heard the quality of training is excellent and once
you get into the program and actively participate in allotted tasks, there
is no way you can miss something. You have to be successful and complete
your training (under good supervision) able to face all clinical
challenges yourself. We do not even think about the money, we just want it
to be enough to make us stay away from doing stuff on the side to cover
our basic expenses. I and a lot of my friends view it as an
investment in ourselves. The only problem is that the UK wants mostly
fully-fledged consultants and I have not yet found offers for starting my
training there but I am working on it.
4. The drafting and training system in Poland is pretty complicated.
If somebody conducted a very thorough review of all the paper regulations
connected with specializing, the positions allotted for training to
hospitals and checked the people who actually specialize there, it would
turn out that about 40% of doctors specialize with some irregularities in
the actual procedure e.g. occupying the position in Warsaw (on paper) but
actually spending their whole time in Otwock (the names of the cities were
used as an example only).
5. The access to scientific information offered by our medical
schools is limited esp. when you compare it to the leading academic
centers in Western countries. I do not want to get to the issue of funding
shortages of Polish science in general but it is enough to say that we
often have to turn to hacker-like modus operandi to acquire scientific
articles or have access to certain databases. We simply cannot afford to
buy them or it would take ages if you ordered it official way through
librarians.
Conclusions.
The system is sick. I would never like to be a patient here unless I had a
lot of money. There is a lack of transparency in ever-changing policies
concerning patients and that also affects the training of doctors.
The ridiculous amounts of money paid to doctors could be tolerable if
after years of hardship during your specializing you knew that you will be
an expert in your field and some brighter future opened for you. But that
is unfortunately not the case. The quality of training is below European
average but that does not mean that the doctors are bad. The supervisors
are often excellent clinicians but they usually lack time, incentive (e.g.
fear of competition) or simply teaching skills to make young doctors truly
learn something.
As a matter of fact the money is not a major issue for me or my friends,
it is simply the lack of perspectives, the lack of clear path one can
follow to find personal fulfillment in medicine and science.
Polish Chamber of Physicians should not take a criticizing stance
faced with the current exodus. This organization is not even able to
change the situation. There must be a very deep change in the system of
healthcare, training and opportunities for the people that will make them
stay in Poland. This requires the change in mentality, first of all. Our
medical establishment is well aware of what medicine looks like in Western
countries and US. We have to learn from the best and that is why Poland
should invite doctors from the EU, pay them well and let them change the
face of our academic medicine and that will influence the thinking of the
rest of the community.
Polish health system is so sick that this exodus is a normal reaction
of intelligent people. The greatest threat to the system probably comes
from the politicians who are changing something in it every couple of
months supposedly fixing it.
Thank God we are in the EU and some new opportunities open for us. This
may be beneficial for Poland after all, since most of us will come back to
the place which is so weird that only we can really understand what is
going on here.
Competing interests:
None declared
Competing interests: No competing interests
I'm a junior md from Poland. It's not true, that the ONLY reason for
leaving Poland are poor wages. Of course 250-300 euros/mothly is not much,
but there is more important reason for junior doctors to leave the contry
-- NO OPPORTUNITY to develop medical skills. There is a big problem to
begin a residency program (shortage of locums) and in becoming a
consultant. For example in the spring examination session there was 1
locum in anaesthsia for over 200 potential candidates in Lower Silesia
District. Moreover the number of unemployed young doctors is still increasing,
many of them have started a career in a different field, for example, in
pharmaceutical companies. Saying "that exodus of doctors on this scale
could jeopardise the country’s health system" is a big exagerration.
Polish health system has been in a huge crisis for at least 3-4 years.
Unfortunately leaving this country is the only way for many of us.
With regards, Wiktor Szczudliñski, MD
szczudlo@wp.pl
Competing interests:
None declared
Competing interests: No competing interests
Being a young Polish doctor I can see many more issues related to
this so-called exodus than just money. The issue of salary is of course
important but it is just one of the reasons behind doctors leaving Poland
and looking for work in the EU. There are at least two other important
reasons: education and professional perspectives.
Limited access to educational opportunities is more important issue.
Postgraduate medical education has been undergoing constant changes over
the last decade and so far it is hard to see the end of this process. This
instability makes career planning impossible. Not every graduate can start
the residency training because there are many more graduates than
residency training places. Only a small number of residents are paid by
Ministry of Health educational fund, the rest is being employed by
underfunded hospitals (with salaries significantly lower than figures
mentioned in the article) and some even work as volunteers. Limited access
to diagnostic and therapeutic tools also has it's role in decision making
process. How long can you pretend that everything is OK when you are
working on ten-year-old radiological equipment with no hope for a change?
How long can you tell MS patients that there is no hope for modern
treatment if the problem is mismanagement of funds by National Health
Insurance?
Another issue is future perspective. Professional development is
hampered not only by blocked career pathways due to medical oligarchy but
also by lack of willingness to change the system of money flow by the
government. Taking into consideration very limited resources spent on
public healthcare if the Prime Minister publicly rebukes doctors for
protesting against ridiculously low contracts proposed by National Health
Insurance then what can you expect in near future? Probably not something
positive.
Competing interests:
None declared
Competing interests: No competing interests
Deficit of Polish doctors as a result of Poland’s accession to the EU
From the research carried out for the doctoral dissertation purpose
it results that migration of Polish doctors has really significantly
increased after Poland’s accession to the EU. In the period from 1 January
2004 to 31 March 2007 2.738 Polish doctors obtained authorization to
practice only in six EEA countries (Denmark, Germany, Great Britain,
Ireland, Norway and Sweden). It is considerably high increase in
comparison to the period 2000-2003 when the right to perform the
profession in those countries was granted to 40 doctors. Data for the
period 2000-2003 does not include Sweden as the National Board of Health
and Welfare couldn’t deliver it.
In the analysed countries the number of doctors from Poland increased
especially in Great Britain. 1.633 doctors from Poland registered in Great
Britain in the period from 1 January 2004 to 1 January 2007. It is
considerably high increase in comparison to the period 2000-2003 when the
right to perform the profession was granted to 53 doctors. The second
country where the most doctors obtained authorization to practice in the
analysed period is Sweden. 417 doctors from Poland registered there from 1
May 2004 to 31 February 2007. Due to the lack of data before 1 May 2004 it
is impossible to compare the scale of migration from Poland to Sweden
before Poland’s accession to the EU and after accession. The next places
in regards to the number of doctors from Poland registered abroad in the
analyzed period are Germany (364 Polish doctors), Ireland (185 Polish
doctors), and Denmark (139 Polish doctors) and Norway (119 Polish
doctors). Analyzing the obtained data it can be noticed, that Germany is
the country with the highest number of registered doctors from Poland in
2000-2003. In this period in Germany registered 244 doctors from Poland in
comparison to 16 doctors registered in Norway and 8 registered in Ireland
and Denmark in the same period. So contrary to other countries, in the
case of Germany, the phenomenon of intensive immigration of doctors from
Poland took place already before 2004.
Analyzing the number of specialized doctors registered in 2004-2007
in six EEA countries it can be noticed that the most doctors from Poland
who obtained the right to perform the profession in that period – are
specialists in the field of anesthesiology (300). 222 anaesthetists
registered in Great Britain, 43 in Sweden, 16 in Denmark, 12 in Norway, 7
in Ireland and 4 in Germany. Data concerning anaesthetists registered in
Ireland is not full as registration of specialists is not compulsory
there. Data on the number of specialists registered in Germany is also
partial as it has been delivered only by 1 regional medical chamber
(Landesärztekammer) out of 17 existing.
Counteracting phenomena of doctors’ migration requires immediate
introducing of the complex reform of health care dealing among others with
implementation of guaranteed services and additional insurances. Moreover
the number of residencies should be increased. Remuneration at the
residency is not significant (around 500 euro gross), nevertheless it is
higher than with a hospital job (around 300 euro). Such level of
remuneration is the reason that hundreds of new doctors resign from work
and specialization in Poland and they choose more attractive job offers
abroad, impoverishing de facto the home health care. It appears that there
are over 4 thousand vacancies for doctors in Poland. On the one hand we
have deficit of the personnel, on the other hand there is a limited access
to specialties in Poland. Without introducing some changes, the scale of
doctors' migration from Poland will increase with the harm for the entire
society.
Joanna Leœniowska – PhD student at Warsaw School of Economics,
Institute of Foreign Trade Policy and European Studies
e-mail: asialesniowska@poczta.onet.pl
Competing interests:
None declared
Competing interests: No competing interests