Dr. Călin Bumbuluț – Head of Delegation

Dr.  Gindrovel-Gheorghe Dumitra – Member

Dr. Mădălina Vesa – Member

Family Medicine in Romania

By dr Călin Bumbuluț

From almost 37,000 specialists’ physicians in Romania, of all medical specialties, more than 11,800 are GP’s of which 9,588 are specialist family physicians, all members of the Romanian College of Physicians, which is a non-governmental National Medical Association and a National Accreditation Association in autonomous relationship to any public authority. Together with the Romanian Ministry of Health, the RCP is a competent authority in regulating the medical practice in Romania, and is part of the national mechanism of recognition of medical qualifications as shown in the Dir. No. 2005/36/CE.

The National Insurance Health House -NIHH (Casa Naţională de Asigurări de Sănătate-CNAS) was first established in 1999 and subsequently, the law was many times modified and completed. It settles a comprehensive providing a healthcare system for all citizens from birth to death. A new amendment is now being discussed, in the general context of a complete renewal of the National Health Bill.

Terms of practice are negotiated and contracted between the family physicians and the Departmental branches of CNAS, on yearly basis.

The family physician is the patient’s buffer and first contact with the healthcare system, as first person who is consulted and provides treatment and advice for any further medical act. This can take the form of a referral to a medical specialist or to the hospital system. The range of services provided by the family physician within the general medical services in Romania is considerable. As mentioned, the family physician is responsible for referrals of patients further in the system; each family physician is also responsible for current healthcare services of an average list of 1,800 patients. Care is delivered either by consultations at the physicians practice or by home visits including child and maternal care, vaccination of children, health examinations, and prescription of appropriate drugs. We are also in charge with the maternal care which consist in taking in evidence in the first quarter, monthly supervision from 3rd month to 7th month,  supervision twice per month from 7th to 9th month and including control at discharge from the hospital – at home, the follow up at 4 weeks after birth. There are no gynecologists in primary care, but in case of problems with pregnancy, with a referral, the case is taken over by gynecologist in ambulatory system or from hospital. From 7th month the OG’s control of the patient is mandatory, and the delivering of the baby is in responsibility of OG’s.

From 12,000 GPs in Romania, aproximately 6000 followed the postgraduate course in prevention of  cervical cancer, colorectal and breast cancer, which offer the posibility for doing the smear for PAP test. From those 6000 phisicians, who wanted, they signed contract with sanitary authorities for the smear test. The advice about contraception and also the pills or other means of birth control excepting the sterilet is given by GPs especialy in rural areas, and in towns by some of GPs with competencies in contraception.The treatment of cervical cancer is entire in the responsibility of gynecologist. The patient with positive smear test is referred by GP to the gynecologist.

Finally, family physicians/general practitioners are also responsible for on-call services when medical assistance is needed. Theses have been organized in on-call round the clock associations in each county. They provide emergency primary care especially during night hours, Saturdays, Sundays and holidays. In the system out-of-hours the patients can be consulted regardless of the doctor they are enrolled. In rural areas there are organized similar Centers which covers an area with few thousands patients. There are no consequences for physicians who don’t want to work in the system of out-of-hours, but their revenues are smaller for than those who are working. The patient in case of illness which cannot wait until he/she reaches the Family doctor where is enrolled, has an option to access freely and without paying the Urgency department, or the ambulance, or the out-of hours system of family physicians.

The general practitioner is in contact with each patient at least five times per year on average. The individual patient chooses from amongst a certain number of doctors within the area of the patient’s residence. A private practice must not have more than 2,200 patients, only if there is no other alternative. Most GPs are independent managers and some of them are working in a partnership or in group practices. The groups share auxiliary staff and facilities, not the patient’s lists. A very small share of GPs is employed in a practice owned by other specialists in family medicine. A full-time working GP has a practice list of approximately 1,800 patients.

The freedom to set up a new practice is restricted by general agreement between the National Health Insurance House, the county branches of Ministry of Health, the county professional association representatives, and the Romanian College of Physicians. The free practice is possible only for the members of the RCP. Under the terms of this agreement, an area where the overall ratio of patients on the list of a general practitioner is less than 2,200 will normally be declared closed to any new practices, but frequently this is not realized because of the intervention of governmental health authorities. However, a general practitioner may, in principle, practice outside the framework of the public social security system agreement but this is not a usual situation. In such a case, the patient would have to pay the entire fee by themselves.

Remuneration of general practitioners

General practitioners are remunerated partly according the number of patients on their list (50{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba}) and partly according to the services offered to the patient (50{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba}), paid both way by health insurance system accordingly to complicated national provisions. On-call service, smear tests and some prevention activities like the vaccinations are covered by funds coming from Ministry of Health.

GP training

It should be noted that Romanian GPs are medical specialists in Family Medicine on the same level as other specialists (surgeons, internists, etc) since 1992. To be allowed to practice as a GP/family physician, a graduate of a Medical School has to follow a postgraduate residency training program. The option for the residency in Family Medicine is made as for any other medical specialty and the only way to get the certification of specialist in Family Medicine, issued by the Ministry of Health.

The Romanian residency training program takes three years: 18 months in General Practice, 4 months in Internal Medicine, 4 and a half months in Pediatrics, 2 months in General Surgery, 2 months in Obstetrics and Gynecology, 2 months in Medical Oncology, one month each from Infectious Diseases, Psychiatry, Dermatology, Neurology, Diabetes, Epidemiology and Management, and last but not least two weeks of Bioethics. Hospital based training or rotations and monographic courses are considered as additional learning inputs in the training process. There is a Residency Booklet and Log-book with designated aims, general contents, specific targets and evaluation guidelines which guide trainees and trainers along the training program.

This training became mandatory for the new residents in Family Medicine training after 1993. Specific training programs and evaluation, in order to become specialists, were implemented between 2001 and 2003 for those GPs who did not pass the National Residency Contest (since 2005 only the specialists are accepted, according to the actual Ministry of Health regulations) and had been in general practice for at least 8 years.

The specialisation of Family Medicine is equal to the other medical specialties and should be recognised as such by EU legislation and primary care should be considered as a part of health care systems like all others.

If we all are going to reach a consensus on a european curriculum of specialisation in Family Medicine/General Medicine, as we are keen, included in the Professional Qualifications Directive, well, this is going to be a great succes and a deserved reward for our profession.

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