Some Family Doctors Do Everything that’s Expected of Them, and More. Others Don’t. Why?
When the state, doctors and patients are after each other’s mistakes, everybody loses.
This story was originally published in Romanian in June 2021. Read the Romanian version.
On May 16th, 2021, a day after the massive lifting of restrictions, the pedestrian area in Brașov was extremely busy. Cafés were full and people were walking maskless, shoulder to shoulder, right past the street signs that until recently had mandated wearing one. Down the street, in three blue tents, a handful of doctors and nurses were running a vaccination marathon, third weekend in a row.
The time was 5PM, and there still were people waiting to get a shot. Some just walked right in and asked for a triage form, otherwise they would change their mind. Others – foreigners or tourists – were asking politely if they were allowed to get a shot as well, as in their countries they were still waiting for their turn. A couple was there to support their 24 year-old son, working in IT in a German company, who was getting his shot because he didn’t want to miss potential work trips. The parents weren’t planning to get vaccinated; they did not deny COVID existed, but they were convinced we were all lab rats for some vaccines that had not been tested thoroughly. This pandemic has changed everything, nothing will be the same again, they both lamented.
I had come to Brașov because it seemed to be one the most dynamic counties in the vaccination campaign nationwide – in May and June it constantly ranked fourth, because it went where the people were: it organized weekend marathons and vaccination sites at the theatre, at the swimming pool, at the skating rink, in malls, at the airport, and even at Dracula’s castle.
I wanted to learn why more than half of the 350 family doctors in the county had also got involved. 12 out of the 20 vaccination centers were managed by family doctors, another 100 were actually working in the centers, and 74 more started vaccinating with Johnson & Johnson in their private practices.
I will admit I was also curious to learn what they felt about everything that we, and the state, had requested from them in the past year: to take care of all the patients who suddenly had been denied access in the hospitals, to monitor COVID patients who were treated at home, to make appointments for them on the vaccination platform, and now – to vaccinate in their offices. I knew of family doctors who had made appointments for 700 patients, and of anti–vax doctors who had made none, and said that, should the vaccine become mandatory, they would take their children out of school.
Nationwide, that day ended with a double–record: the least COVID cases in a year (565) and the highest number of vaccinated people in one day: 101,000. 3,400 of those were in Brașov.
The doctor no longer scared by bureaucracy
The next day, I went to Lisa, a village 80 kilometers away, where family doctor Nicolae Boulescu was giving Johnson & Johnson shots to his patients. He had already administered the first 25 doses, and was waiting for the next lot.
As in every mountain village, in Lisa, houses wind along the main road – high–gated houses with large backyards that, on that crisp spring day, smelled of lilac and sounded like blackbirds and chainsaws. People must have been busy around the house, as the village was still: no one in the small square outside the city hall, no one at the downtown store. It made you wonder who the tomatoes–filled boxes, the rubber boots, the Christmas candy and the chocolate bunnies were waiting for. Outside the metal store door, yellowed fliers demanded mask wearing and thanked people for “their understanding and cooperation”.
Dr. Boulescu’s practice was in the same small building as the pharmacy and his private home.
Only one door separates his office from his kitchen, so that it was convenient to reach the computer in the middle of the night, when he was scanning for vaccination appointments for his patients. And it’s in the office where he keeps his exercise bike he uses to recover after a stroke.
He needs no boundaries between work and private life. On the contrary, he believes that family medicine means first and foremost availability, being there when people have nowhere to go and the ambulance is far away. Therefore, even during the state of emergency, when some doctors consulted by telephone only, he kept the office open.
Dr. Boulescu is 65 and moved to Lisa 35 years ago, in 1987, with his wife, an architect, and two small children. They were tired of the misery and the cold in Bucharest. They were looking for a better life, and they knew Lisa from hiking in the mountains.
He had just finished his three–year internship – a shorter residency, after which you became a general practitioner –, at a time when the dictator Ceausescu had decided there was no need for specialist physicians. The district director had given him a pediatric constituency in a poor area in Bucharest’s Sector 5, where he cared for babies up to 1 year old.
As an intern, he had worked in a dispensary on the ground floor of a block of flats, along with three other doctors who cared for adults. The young doctor Boulescu did a lot of prevention and education work with the young mothers, in a time „without so many pills and syrups”. He also cared for the women who had had an abortion, which was a crime and would send one to jail in communist Romania. He gave them amoxicillin and metronidazole to prevent infection, and advised them to call an ambulance if their condition worsened. He also worked the mandatory two or three 24–hour shifts per month, for free.
At a time when doctors received positions where they were needed, not where they wanted or where they had their family, the hospital manager in near-by town Făgăraș, who also managed dispensaries in the area, could not believe it that a young doctor really wanted to move there. Dr. Boulescu remembers the conversation they had, in the winter of ’86 –’87: “Well, Doctor, people in Lisa have a very strong personality,” the director told him. “If you behave well and end up being up to par with their current doctor, Munteanu, you can stay for 100 years.” Munteanu had been a much–loved dispensary doctor, who had recently killed himself.
Dr. Boulescu was distrusted for a year or two. At first, people didn’t even want to host him in their houses; what if he’s from the communist party? Dr. Boulescu realized the villagers accepted him when, one night, he caught two people stealing from the cooperative, the state-owned company that managed the land and animals, and they didn’t shy away. “He’s our doctor,” he heard, before they parted ways. Then, right after the ’90s, people started asking him for advice on how to invest their savings, because people in Lisa have never been poor.
For over 15 years now, Dr. Boulescu has been the only doctor. He has 1,300 patients, of which only 1,000 have health insurance, and he also does 24–hour shifts three times a month. Most of the time, his job is to deal with emergencies and monitor patients with chronic illnesses, but he’s never shone away from cutting the ingrown toenails of women who’d worked all their lives in the field, or from convincing them that AstraZeneca did not put the vaccine in their blood pressure pills (a patient had shown him, vigilantly, that the name of the company on the box was the same).
Precisely because he’s lived through all the regimes and all the health ministers after the Revolution, the ongoing changes and the bureaucracy no longer impress him. Dr. Boulescu got to live both the times when family doctors were employed by the state, in dispensaries, and the “privatization” of family medicine, in the late 1990s, when family doctors’ offices became private legal entities, responsible for managing their own funds.
In the mid-1990s, he bought a computer at his own initiative, but the local public health authorities suggested he didn’t need it: he was a doctor, not a computer scientist. Now he can’t do anything without a computer, at least two printers and multiple software: no free prescriptions, no referral tickets, no patient records or monthly reports.
Dr. Boulescu tries not get stuck in bureaucracy and, if the state asks him for an additional service, as long as he thinks it’s in the benefit of the patient, he does it. So, when the state asked him to monitor COVID-19 patients at home last summer, he did so. He signed the contract and collected the extra money offered. When the state asked him to make vaccination appointments for his patients on the digital platform in January, he did so. Not many, 80, for those who asked for one.
Then, in the spring, when the state asked him to vaccinate against COVID–19 in his office, he complied. He knew there would be many people who didn’t have the money to go to nearby Făgăraș to get the shot, or even have the confidence to get it.
About some family doctors who refused to register their patients on the platform, on the grounds they are wasting time, he says that they are just showing “false infatuation”. “So what if I help that man? I’m the one responsible for his health. Where should I send him?” And about the doctors who did not want to vaccinate in the office, he rhetorically asks: “Who is supposed to do it? The mayor? The notary?”
He doesn’t think it’s out of place for the state and the whole society to expect all this from family doctors. What does frustrate him is when doctors and patients go on a hunt for each other’s mistakes.
Normally, he should have retired this year. But he started building a house and extended his work contract for two years. He knows that if he leaves, it will take time until another doctor comes to Lisa.
“I still like what I do,” he told me.
How did family doctors get to vaccinate against COVID–19?
I left Lisa thinking about how happy with himself Dr. Boulescu was. He didn’t seem to want to prove anything to anyone anymore, and it didn’t make sense to fight what was being asked of him, as long as he thought it was his responsibility. Maybe because he was at the end of his career or maybe because he came from a world where you did what you were required to do, without questioning it. However, to him the goal seemed more important than the means.
But I knew not all family doctors think like that. Especially those who entered an already privatized system, and who feel they have to fight to get their message across. For many, what the state has asked of them in the last year has not been so easy to accept.
The coordinator of the national vaccination campaign, dr. Valeriu Gheorghiță, spoke for the first time about COVID vaccination in family doctors’ offices on March 30th. Half of the 11,000 were expected to comply (based on a survey by the Federation of Family Physicians’ Associations). It was thus estimated that 500,000 people would get the shot from their family doctors each week. Gheorghiță also announced they would be paid extra if they did this.
By the beginning of June, only 3,000 of them had signed up and 2,400 had actually started. Half of them were in rural areas, half in urban areas, and had vaccinated a total of 137,000 people. After a slow start, the pace picked up, but it was obvious that 500,000 people a week was an unrealistic target.
Initially, I did not understand why the reality was so different from the survey, especially since there was extra money involved. It all started to make sense only when I learned how family medicine works and what power relations are at play with other actors in the system.
In the late 1990s, as part of what became known as Romania’s “healthcare reform”, the health insurance system was introduced, and family medicine was “privatized”. Overnight, doctors went from state employees to small entrepreneurs (called “healthcare providers”), who had to attract patients and run their medical practice as a small business.
It goes like this: every two years, doctors sign a contract with the national health insurance authority, send a monthly bill for the services provided, collect their money, and pay their expenses: rent, utilities, medical equipment, computer software, and the salaries for themselves and the nurse.
In a way, the state has become their main client, one with a lot of power. The state decides under what conditions a new medical practice can be set up, the minimum number of patients on the list (800), the number of hours provided (5–7 in the office, plus 2 on the ground, every day), the type of services they can offer (consultations, referrals, vaccinations, minor surgery: surgical thread removal, wound sewing), their number (no more than 4 consultations per hour), plus the fixed cost for each medical service and for each person on the list (the so–called “per capita payment”).
Basically, family medicine practices are a hotchpotch of a public and a private system, in which the possibility of development is limited, but the taxes are many.
The per capita payment is like a subscription, the president of the Federation of Family Physicians’ Associations, Dr. Raluca Zoițanu, told me; it’s how the state makes sure that practice stays open.
An optimal number of patients (which allows you to see them all and also support the expenses) is 1,800, says Dr. Zoițanu. This is confirmed by Dr. Boulescu, who, with only 1,300 patients, says he needs to do the 24–hour shifts in order to support himself. (A 2021 People’s Advocate report showed that the number of patients per office varies greatly throughout the country, with a median of 2,200 and a maximum of 4,700. Basically, in the counties where doctors retire and are not replaced, the remaining ones end up with endless lists of patients.)
Usually, a practice has only one doctor and one nurse, but there are exceptions, where the main doctor hires an extra one, a nurse or a secretary. There are also doctors in rural areas who used their savings to build a micro–polyclinic (basically, a second business) in order to get more money in.
Thus, family doctors operate in a system which offers little autonomy and possibility of growth: they are allowed to provide few extra services and ask for a fee. People with no health insurance are asked to pay a modest fee, but rarely can they afford it. So doctors either do not consult for a fee at all, or consult for free. On the other hand, if they see more than the average of 20–28 insured patients who are allowed per day, they will not be paid for the extra.
Basically, “there are situations when the state considers us private businesses, and treats us accordingly, with all the obligations at stake”, says Dr. Zoițanu. And there are situations when the Health Ministry and society impose additional services on them, as if they were public sector-employees (as was the case during the pandemic). That is when the “privatization” of the system and their minimal autonomy work in their favor, and some refuse.
The doctor who supports vaccination, but doesn’t want to convince anyone
After Lisa I went to Ghimbav, a chic Saxon town, 5 kilometers from Brașov. Officially, the city has 5,000 inhabitants, but there are probably more. You can still see the German spirit in the fortified church, the wide streets and the old town architecture. On the other hand, the influx of locomotive factories built in the last 15 years can be seen in the carefully marked parking lots and the new pavements on sidewalks.
On May 18th, Ghimbav city center smelled of fresh asphalt; the next day the schools were to reopen, and there was an effervescence worthy of the small provincial bourgeoisie.
There was also a fuss in the downtown dispensary, which Dr. Nadia Butum shares with two other family doctors. Dr. Butum has lived in Brasov and has been working in Ghimbav for 15 years. Her office is an explosion of color: on the left wall there are dozens of pictures of the babies she took care of over time, and on the other walls and on the high cabinets there are paintings of her girls, 7 and 13 years old. Under the window there’s a children’s corner, with a pink table, a blue chair and a transparent toy box.
Somewhere behind the tile wall, on the hanger, there was a purple T-shirt with the Hogwarts emblem. It’s one of the doctor’s favorites. Dr. Butum is 44 and likes to tame the white, scrupulous medical robe with a butterfly pin, small silver butterfly-shaped earrings and colorful surgical masks.
She just loves butterflies. She’s got one tattooed on her ankle, along with two dandelion fluffs. The first tattoo, a heart with the girls’ initials, was done on her right wrist two years ago, when problems with her husband began. They got divorced last September.
While I was there, Dr. Butum had 11 scheduled appointments – and at least as many unscheduled consultations, on the phone or in the emergency room. Since the pandemic, she learned to schedule patients every half hour (not every 15 minutes, although she would be allowed to). At first she did it so that she could disinfect and ventilate between patients, later she realized it helps her to handle the unexpected. As a rule, if you don’t have an appointment, she won’t see you. And when she does see you, she’ll not let you leave without your next appointment, even if it’s in three months’ time. That’s the only way she can juggle the 2,300 patients on the list, without fear of being wrong. She also has patients who come from other towns and villages, because they wanted her and only her.
Her medical practice works like a well-oiled machine: she consults and fills in the patient’s file (she doesn’t want to give up diagrams and handwriting for all the software in the world); the young resident doctor joins the consultation and prepares the documents for the next patient, while nurse Felicia Tudoran takes the calls and makes the appointments. Both the nurse, with whom she’s been working with for three years, and the doctor herself know by heart the numbers of the patients’ files, their addresses and kinship relations. The resident is amazed; she’ll finish her six-month internship in June, but can’t wait to be back.
“What’s extraordinary is that patients have so much confidence in her, that they come here with the specialist’s decision and say, ‘Look, are we doing this?’”, the resident says. “That means trusting your family doctor to make the ultimate decision for you.”
Dr. Butum is a combination of rigor and patience. Rigor in how she does her job and patience to calm the newborns who come in for their regular vaccines, to explain to the young man how to collect his urine, and to the woman whose nose is bleeding how to get treatment. She would like to have more time for counseling and prevention. To the mother who came in with her week-old baby, for example, she told directly not to be embarrassed to ask for help in the family. Don’t do the ironing, get some sleep, she said. Don’t cook, but steal some time for yourself.
She speaks with no hesitation or preciousness. “The specialist doctors have the feeling they are mighty and great, and that family doctors are less worthy”, she pours out one of her biggest professional frustrations. She believes hospital doctors disregard family doctors as being poorly trained and “scriptologists”. “Indeed, there are some doctors who only give patients [referral] tickets,” she admits, “otherwise they wouldn’t think that way.”
During the pandemic, when many hospitals treated COVID patients exclusively, and others accepted emergencies only, “we were the only ones who saw the patients, despite the risks”, she says. Unlike some doctors who took long holiday leaves during the pandemic, she only stayed home when she was on medical leave, and even then there was someone replacing her. She’s also frustrated because patients go to see the specialist by appointment only and show them a lot of deference, while at the family doctor they claim to come in at any time and ask directly for referral tickets or prescriptions.
She calls the pandemic “the big bang”. The virus “knocked her down” twice: the first time she didn’t know (she found out in June of last year that she had antibodies), the second time it sent her to the hospital for three weeks, on oxygen, and three more weeks at home. It happened after a month of working non-stop, taking double shifts to replace her own family doctor, who’d been run over by a car. She’s convinced that if she hadn’t been so tired, COVID would not have hit her so badly.
When she returned to the office, some patients received her with tears in their eyes and did not ask for any further evidence the disease existed. She got vaccinated among the first doctors in Brasov and can’t wait for the third dose.
On the other hand, she doesn’t want to persuade anyone to get the COVID shot. She tells them what the risks are, and what she herself went through. She says she can’t fix the damage done by the media, with all the fake news and the panic induced, with the exaggeration of risk of thrombosis and all the deniers given time to on TV.
However, she does make the difference between the role of the family doctor in prevention and vaccination, and the COVID-related services the state asked of her during the pandemic. She didn’t agree to the additional COVID patient–monitoring contract, because the paperwork and the bureaucracy seemed too much. “It would have made me available 25 hours out of 24. We really are at their disposal, but please don’t call me at 3 at night because you cough a little more than at 8 in the evening.”
Over the past year, she’s had over 200 COVID-19 patients, with whom she has, however, kept in touch. “Not with everyone every day, but where there was need every day, we did that.” More than once, her dual SIM phone froze from so many messages and photos of blood test results, that she started using the nurse’s and the resident’s personal phones as well, in addition to the landline in the office.
Two of her COVID patients did die. One hadn’t even told her he had symptoms, and another went to the hospital too late. She will forever wonder why they didn’t trust her, she, who knew so much about each and every one.
Monitoring COVID-19 patients who got treatment at home fell on the shoulders of family doctors in the summer of 2020, and it required doctors to call them daily to check some vital parameters, to change their treatment if necessary, to send them to the hospital if they got worse and, after 14 days, once they were officially declared COVID-free, to sign off medical leave forms.
Because this service was not included in the contract family doctors already had with the Health Ministry, in October 2020 a ministerial order demanded that it be included in a separate contract, and paid 105 lei (20 Euro) gross per patient. This is when many refused to sign the contract, claiming that non-negotiated things were required of them and that they were asked to prescribe COVID treatments without an official treatment protocol (which came much later, in April 2021). Even without agreeing to the contract and getting the extra money, some doctors did monitor their patients, because they felt it was their duty. So did Dr. Butum.
When the request came to also make vaccination appointments and waiting lists on the digital platform for their patients, she refused, because it was too complicated. People changed their minds, did not get the appointment messages, or others would get the shot at work; she didn’t have time for that. Plus, Brașov and Codlea were a bus-ride away, had many vaccination centers and all the available vaccine options. When we spoke in May, she estimated that half of the town had already got their shot.
Precisely because people had so many options and because it was impossible to know who was left unvaccinated, she also refused to do the Johnson & Johnson shot in her practice. It would have been a waste of energy and resources. On the long run, she thinks COVID will become a seasonal vaccine, which family doctors will eventually administer. And she will, as well, but “without the current additional contracts and bureaucracy”.
She didn’t think the Ghimbav vaccination center, set up in the school gym, was really needed either, but no one asked her. It was more like the mayor’s desire to have one. The mayor was also the first to get the shot, on May 7th, the opening day. Dr. Butum found out from the hairdresser that she would be the one managing it – the decision had been made and she could not refuse, because her relationship with the municipality, which owned the building were her practice was, was important. She usually stays away from politics (when you ask her which party the prime minister comes from, she says „the yellow one”), but when politics risk interfering with her work and her patients’ interests, she knows better.
To manage a vaccination center means making sure that you have the necessary medical equipment, PPE and doses every day, that they don’t expire or are left unused in the evening, it means making staff schedules, but, most importantly, being available 24/7. It’s just normal then, that when others decide for you and you have little room for maneuver, frustration grows; the only way you can maintain your autonomy is by not signing the contracts or saying “no” directly.
It’s even more frustrating because all this management work is not paid; the state has not found the money for it. The rest of the staff is paid.
It turned out the doctor was right: there were slots when no one showed up. In early May it became possible to show up without an appointment, and that made any planning even more difficult. On the first day, although 5 people were on the waiting list, 60 came to get the shot. When I was there, 6 had been scheduled, but 18 showed up, and for the next day only one had registered.
We had time to talk: we wondered where the new furniture and all the equipment bought for the center would end up, after it closes (she would not have minded a new refrigerator at her practice). We wondered how much it costed to run a center and how its efficiency could be measured.
For the first time in years, she had a two–week holiday on her agenda that summer, because she needed a break like she needed air. She knew the pandemic wasn’t over; on the contrary, she was pretty sure a new wave will hit in the fall.
Why some family doctors get involved in the vaccination efforts, and some don’t
I had no idea every center had its own security guard. Or that there’s only one set of keys, handed over from one manager to the other, and that a report is made for every move. Or that the municipality can also ask for new vaccination centers to be set up, as was the case here. I would not have imagined there would be long hours when no one showed up.
Many of the family doctors I spoke to were deeply unhappy with the way the state and the public have treated them during the pandemic. They were done hearing on TV about “the need for family doctors to get involved, too”, as so many were already involved: many of the doctors who vaccinate in centers – or who managed them – were family doctors; but very little people were aware of that.
In addition, they kept hearing they will get paid for all these extra efforts. In reality, the money promised in January only reached their pockets late April, but, again, the public didn’t know that.
They were angry that this public discussion about money had left the impression that they only do things if they get paid. If so, they would have stopped as soon as the first payments were delayed. ‘I got involved because I don’t know how else we’re going to get out of this pandemic,” a doctor in Brașov told me. “Our work is just unknown.”
One of the key reasons the vaccination campaign was doing so well in Brașov compared to other counties was the involvement of the Public Health Authority’s director, Andrea Neculau. She is also a family doctor, and took over the management of the Directorate very early in the pandemic, after the former director had resigned.
She is the one who translates and implements the ministerial decisions, because she understands how all the stakeholders think. “Family doctors are a colossus of 11,000 people,” Dr. Neculau told me. “It’s difficult for Colonel Gheorghiță [the head of the national vaccination campaign] to understand that doctors are not army officers. In the army, you don’t question orders. Whereas doctors did not respond like in the army, hence the disappointment.”
Just as she understood where her colleagues’ refusals were coming from. She ran countless Zoom sessions and made a WhatsApp group with all the family doctors in the county to clarify the ambiguities the new rules had left behind. For example, in order to vaccinate in the private practice, you don’t need different IN and OUT ways or additional operating permits; only vaccination centers have to have those. And doctors don’t have to vaccinate outside the normal working hours, as Gheorghiță erroneously said in press conferences.
Basically, there’s nothing different from the regular vaccination that family doctors do every day, “only psychologically things are different, because of COVID,” she said.
Since taking office, Dr. Neculau has understood the money circuit in the public system, which she would very much like to simplify, but would not know where to start. Instead, she implemented change and transparency wherever she could and had the authority. Since May 2020, with the support of the Romanian Business Leaders organization, her Directorate was the first to set up a digital platform which is still being used today by COVID hospitals in the county, family doctors and private clinics that perform COVID tests.
The platform made the flow of information much faster: when a lab uploaded a positive test result, the Directorate would register the person as a COVID case, send them the quarantine or isolation decision, and their family doctor would be alerted, in order to monitor them and, later on, to upload their medical file. Plus, if they had COVID suspects, family doctors could ask the ambulance to test them at home. Otherwise (in other counties), it was the family or the patients themselves who had to put these pieces of information and documents together.
Dr. Neculau would like the system to be patient-centered, not bureaucracy-centered, as it is now. Otherwise, bureaucracy (sometimes just complicated, sometimes utterly useless) risks to become a justification for not getting involved. “I’m 52 years old, and I don’t think I would have taken a step back once, with or without the extra money,” she says.
📍 Hoghiz and Comăna
Doctors don’t campaign for the COVID vaccine, for fear of losing their patients’ trust
After Lisa and Ghimbav I went to Hoghiz, a town 60 kilometers from Brașov. 5,000 people, six villages and three family doctors. Dr. Lucian Comșa, 41, was wrapping up a COVID test.
“Rural medicine is beautiful,” he told me. “You have to cover many things that in a city you would solve with a referral, because you know most likely the patient has no money to go see a specialist, and he would get worse.”
He told me how he took a 7cm-long copper wire out of someone’s hand, a live butterfly out of someone else’s ear, or how he assisted a child who’d been run over by a cart loaded with wood. He told me what tools he uses, how he sterilizes them, how he fixed a room for COVID testing only. “And then I hear people saying doctors get 250 Euro for every patient they declare as a COVID case…”
This is just one of the rumors that ran around his village, Hoghiz, and nearby Comana, where the family doctor is his wife, and where they also live. I wasn’t surprised. A woman across the street had just told me minutes before that someone she knew had a relative who died of COVID, and got 600 Euro. She was a 60-year-old person with diabetes and heart issues who did not want to get the shot, because she’d heard on TV it was dangerous.
Over the past months, there had been over 100 COVID cases in Hoghiz. Dr. Comșa monitored 40-50 of them, and four died in hospital. Many had hidden their symptoms, afraid of testing and hospitalization, others were convinced tests were fake, that they’re already positive when you buy them. “They are afraid of the disease, but they’re more afraid of the stories woven around the disease,” he said.
His wife, Cătălina Comșa, heard the same stories. Some also told her they can’t afford to be sick and stay home for 14 days, as they need to work in the fields. Before Easter, the whole of Comana had been quarantined after an outbreak at the school.
“It was terrible,” she said. The hardest part was convincing them to go to the hospital when their condition worsened; one man died because he didn’t go.
She talks about rural medicine as passionately as her husband. Tachycardia in a 30-year-old man, heart attacks, anaphylactic shocks, countless road accidents. That’s why they’re there.
They moved from Brașov to Comana in 2008. They had finished their residency in family medicine and were going to work as paramedics for a while. Just before they started, their son fell off the bed and became paralyzed on his left side. After getting treatment in Bucharest, they were told to move to the countryside, so that the boy could move around in the fresh air all the time.
Even now, when their son is in the 8th grade and the daughter in the 11th, and they live on their own in Brașov, the Comșas do not regret moving to the village.
But I do understand why moving to a village is a complicated decision for a young doctor. It’s a life choice that no one supports: no help with the housing, no relocation allowance or public investment in the medical practice, that local authorities could easily and legally provide.
In Brașov county there are now five localities (around 17,000 people) with no family doctor. This means they either spend more, and travel more to go see a doctor in another village, or they don’t, in which case they are denied even the basic medical services they are entitled to.
The average age of family doctors in the county is 55, and a third are over 60 (they are allowed to work up to 67). Doctors getting too old to work is a sad reality for the whole country: 37% of family physicians nationwide are over 60. Add to that 300 localities with no doctors and too few entering the profession.
This specialty should attract about half of the doctors in a generation, but barely a third are interested in it, Dr. Neculau told me.
It’s hard to make family medicine attractive, and not just in rural areas. It’s true that a few years ago doctors’ and nurses’ salaries increased – but only in state hospitals, not in family doctors’ offices. It is basically impossible to raise salaries in a family medicine practice without the state deciding on a higher cost per patient and per service provided.
Moreover, because the state also regulates the number of offices, a young specialist has few options: he or she either goes where no one wants to (usually to a village), either gets a practice donated to them, or has money to buy one (starting at 15-20,000 euros).
Dr. Comșa admits he didn’t schedule vaccinations for his patients; his wife did. He was infuriated by the malfunctioning platform and the state giving him money for entering data in a computer. “If you had given me a functional platform, I would have happily done it with no money.” He doesn’t vaccinate against COVID in his office either, because he misunderstood that he needed separate entries and exits for patients.
He refused to sign the patient-monitoring contract as well; he didn’t like the wording: “What do you mean the doctor has the obligation to… ? Are we in a despotic state?” So, like many others, he kept in touch with his sick patients, but did not fill in any official monitoring reports, that should have otherwise reached the authorities.
This is a situation that frustrates Dr. Neculau, because the work remains invisible, it’s like it never happened. “The ministry is asking me how many patients family doctors have monitored and, compared to thousands of confirmed cases, I can only report hundreds. This is a trap. It seems like family medicine didn’t do its job, when I know it did.”
Although Dr. Comșa didn’t do what we all would have expected from him during the vaccination campaign, he does have his patients’ best interest at heart. He would like to do more for them, but he can’t on his own. He wanted to lease the space of the former dispensary and bring in specialist doctors once or twice a week, so that people wouldn’t have to go into the city. But the other family doctors in Hoghiz didn’t want to get involved, and he couldn’t do it alone, neither financially, nor from a management point of view.
He would at least like to be able to collect blood samples in his office, and send them to a lab in town, as was allowed until 2014. “It would help me keep track of my patients’ illnesses,” he told me. This is no longer possible, because the state has decided that two medical service providers who get public money (himself and the lab) cannot be in contract with each other, because they risk siphoning money.
But does anyone think about the patients?, I asked. No, he answered with no hesitation.
I left Comăna slightly confused. The Comșas are the doctors you would like to see if you’re wandering around in a village and have a medical emergency. They would take good care of you and hand you over safely. You may get upset they didn’t get involved in the vaccination efforts, but do remember how many rumors and false accusations they had to fight off.
There’s a limit to how far you can push things, before you risk losing the trust patients have in you.
On the way back to Brașov, as I was passing through villages – some richer, some poorer, holiday villages and villages people rarely have reasons to leave –, I realized that for these people, family doctors are a guide in suffering and a beacon in navigating the medical system. The pandemic has reminded us that primary medicine is a safety net we cannot afford to lose.
In Brașov, there was one thing I saw everywhere I looked: queues at private clinics, queues at getting tested, queues at the pharmacies. We are a nation chronically ill, yet the most common disease is mistrust. Family doctors are convinced the state doesn’t trust them, while promising them extra money for extra services; but the money comes late and gives the impression they only do things if they get paid.
Even sadder, family doctors and hospital specialists do not understand – and rarely respect – each other’s perspective: “We’re only looking out for each other’s mistakes,” the doctor in Lisa told me.
There are so many dynamics to be fixed in an ecosystem that starts from the premise that one side wants to take advantage of the other. Family medicine and community care should be at the heart of the health care system. “They didn’t even understand the family doctor is the cheapest in the chain,” Dr. Boulescu told me. If family doctors really did prophylaxis and covered the medical needs in villages and small towns, the pressure on hospitals would be reduced. And costs as well.
Maybe the pandemic can be, yet again, a turning point. Or maybe we’ll end up agreeing with the man who accompanied his son to get the shot at the Brașov marathon: maybe nothing will be the same as before. But could it be better?
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