Unit 11 - Contemporary Medicine: The Healthcare System through Socio-Political Lenses
UNIVERSITY GRIGORI T. POPA OF MEDICINE AND PHARMACY (RO)
In this unit, the authors have employed a mix of learning objects aimed to introduce the topic to learners. Faithful to the learning objects strategy approach, objects (official reports, newspaper articles, research articles, videos, interviews) have been chosen to help learners develop their understanding of clinical practice. In addition, issues related to medical ethics become more aware of the relevant role that medical social sciences play in the education of a physician. Furthermore, by comparing the Romanian healthcare system example with their own systems, students have the opportunity to practise their communication skills by discussing in class issues related to contemporary medicine.
The Romanian health system is as an example of how communism's legacy has impacted the evolution of the healthcare system in the post-communist period all over Europe. The first learning object is a reading adapted for the learning objectives of this unit from articles and interviews published in medical journals and it is divided into two main sub-topics: the history of the Romanian healthcare system and the current state of Romanian healthcare.
These topics are further highlighted by a juxtaposed interlude concerning the very recent history of the Covid-19 pandemic.
The first sub-topic outlines the evolution of medicine in the Romanian Principalities by describing the rudimentary character of the field as medical healthcare mainly coped with the epidemics of the time. In this sense, learners are provided with information on the region and level of these epidemics. Next, medical practice is discussed in terms of precarious social healthcare in Romania before the communist period.
The reading continues by highlighting the gradual improvement of the sanitary situation in the country and also Romania’s alignment to the medical practice standards of Western and Eastern Europe. Specifically, it is important for students to note that several physicians had been sent abroad to gain medical experience and acquire practical knowledge in the clinical practice of the time. As reflected in the reading, learners should also keep in mind that the communist regime in Romania brought (ideological) changes which became noticeable in clinical practice, bioethics, medical sciences, social medical sciences, affected and restricted communication between doctor and patient, doctor and other official bodies. This is because doctors feared the repressive system that threatened their practice and changed the system of values they were previously accustomed to. Students will find out that the openness towards the Western world characteristic in World War II era was replaced by the Soviet model (Russian language and specialists included), which dictated in medical aspects especially at the level of subjects prone to interpretation (biology, genetics).
Another intricate issue during the communist years as illustrated by the reading and, for which efficient solutions are still needed to the present day, is the selection of medical personnel in healthcare. Professionalism-based selection was replaced by nepotism, political criteria, social origin, hence the rise to medical power of inefficiently trained staff. Reputed personalities (such as Dr. Emil Gherman) were persecuted and removed from rightly occupied positions, while others were punished because they did not adhere to mainstream ideology or they lacked ‘correct’ political affiliation.
Subsequent to this chronological incursion into the political-historical aspects that helped shape Romania’s healthcare system, the fragment about Romania’s take on the Covid-19 pandemic is opportune for not only does it reflect the country’s positioning within the similar international context but it also connects it to its past anticipating, at the same time, the current status of its healthcare system.
The second sub-topic in the Reading is represented by healthcare in Romania nowadays, after the fall of the totalitarian regime in 1989. Thus, the learning objective aims to propose integrative solutions to cope with the serious health problems of the Romanian population. This requires medical students’ proactive action and identification of prevention measures and design of solutions for treatment of widely spread chronic diseases (e.g.: cancer) and for the avoidance of risk factors.
Among other sensitive issues, there is the matter of restricted health services addressed to the poor living in rural areas and especially those suffering from chronic illnesses and the fact that they seek less medical help than the wealthier or more educated population. In addition, the millions of people that do not pay social security contributions for various reasons represent an area of concern. Other shortcomings of the Romanian health system include under finance sources, which is more serious than that of other EU countries. Within the framework of the learning objects strategy approach in the Reading, students are given the opportunity to reflect on the sources of these problems, the weaknesses of the institutions included and the necessary steps for suitable solutions.
Another policy issue presented as a starting point for discussion is that of closing hospitals that led to absurd situations (evacuating patients under treatment, moving equipment to new locations accompanied by doctors’ refusal to leave the old location) and street protests. This is placed in the context of the need of reorganization of hospitals and the controversial issue about too many prescriptions given by doctors to patients without control from regulatory bodies.
Other challenges of the contemporary Romanian health system deal with the issue of the need for prevention strategies in order to reduce the population’s poor health conditions (an important consequence of which represent the huge number of cases of obesity, cancer, diabetes, drugs or alcohol abuse) at national and local level. In addition, medical brain drain as consequence of the professional mobility dramatically affects healthcare implementation. This also means the relocation of doctors from rural to urban areas, which leaves the rural areas underserviced. Last but not least, the Reading invites to reflection on generic problems of the European public health systems, in general and Romania’s, in particular, in which topics such as underfunding, despite the high costs or excessive bureaucracy, fail to respond to the population’s needs and contribute to the diminution of trust in healthcare systems.
The second learning object used in this unit is a case scenario which includes two interviews, one with dr. Vasile Ciurchea, president of the Romanian Health Insurance House and the other with Prof. Dr. Corin Badiu, Chair of Endocrinology at the Carol Davila University of Medicine and Pharmacy, Bucharest. They are supported by a third YouTube interview with dr. Eugen Tarcoveanu, surgeon and university professor, former head of surgical clinic and director of St. Spiridon Hospital in Iasi conducted by dr. Richard Constantinescu, author and iatro-istroiographer, head of the discipline History of Medicine and Curator of the Museum of the University of Medicine and Pharmacy Grigore T. Popa of Iasi. This last interview is part of a series on Romanian Medicine before and after Communism initiated and coordinated by dr. Richard Constantinescu and which is included among the results of the European Erasmus plus project called Alcmaeon, Project number: 2018-1-ES01-KA203-050606.
The first interview focuses on ways of increasing the efficiency of the National Health Insurance House by managing internal slippages to prevent fraud and corruption, dealing with the leeway often invoked in the running of the system operated by NHIH and diverse internal dysfunctions. It also suggests that the way of communication (with the press or partners) needs reviewing. It invites students to investigate about NHIH strategy to deal with chronic patients. The second interview outlines the challenges of Romanian residency programs and proposes solutions for them: the inclusion of highly traditional specialties in internal medicine residency programme, the reduction of the training time for resident doctors and the impact of various distortions on the quality of medical education with concrete examples (a resident in general surgery who had not witnessed a breast cancer intervention in 6 years). Examples of solutions, also adopted by Western countries of the EU (such as Germany), include a more regulated training of resident staff by specialist trainers. Finally, the last interview given by dr. Eugen Tarcoveanu is included as a new learning object that supports the topics under discussion. It has the format of a video available on YouTube and it was chosen because the professor, who had been a reputed figure for the field since the communist years, talks about the transition period from communism to the new developments, in his quality of witness and actor. His medical celebrity lasts to this day and he pinpoints positive aspects of Romanian medicine and surgery after World War II, which he considers to stay proof of its European lineage and dependency on the new technologies. The professionalism of medical staff (such as doctor Buțureanu) owes a lot to the international contacts and the works published internationally: despite the damages caused to doctors, communism also contributed to the increase of the physicians’ clinical sense during the totalitarian regime and the fact that during this era the medical health system relied very little on imports (for devices, pharmaceuticals, etc.) raised doctors’ capacity to practise well the medical profession based on experience and learning from books.