Between retirements and doctors who quit, local health authorities and private suppliers struggle to find specialists willing to cover shifts in many departments. Thus, substitute teachers are used by the hour
Aaa white coats wanted. Until recently, it was only local health authorities that struggled to find specialists on the market. Today, even private providers (corporations and cooperatives) are struggling to recruit doctors to lend to hospitals at more attractive wages. Why the staff available to cover the shifts left uncovered by those who have retired or been fired, an increasingly rare commodity. It is especially true for the emergency rooms, but not only.
Deserted calls
The announcement of the Sardinia Region, published on 1st June and expired on 10th, for the assignment to external bodies of the emergency room shifts (of 12 or 24 hours, from 80 euros gross an hour), for three months (from July to September), in 12 principals of the island, gone completely deserted. No offers were received even for the one announced by theAusl of Reggio Emilia to find the emergency-urgency doctors needed to reopen the two emergency rooms in Scandiano and Correggio. The deadline for the call was 6 June and in the absence of participants we extended it until 16 but without success – he explains Cristina Marchesi, the general manager of the company -. The facilities had been closed in February 2020, with the outbreak of the pandemic, because they did not allow the separation of the “dirty” and “clean” paths. In the meantime, we have done the renovations but, without doctors, the services cannot restart.
At least 2-3 years to rebalance the situation
The shortage of specialists in the departments is profound. Bisogner grit your teeth for a few more years, at least two-three, before seeing enough specialists come out of graduate schools to fill the gaps in the workforce, the result of bad planning in the past that ignored retirement spills. To remedy the situation, the Ministry of Health then brought the training contracts in medicine from 8 thousand in 2019 to 13,400 in 2020 and 17,400 in 2021.
Alternate doctors by the hour
While waiting the health authorities try to plug as they can. One of the most widespread solutions, particularly in the Northern and Central regions, is the use of doctors on call provided by external services (companies and cooperatives). The substitutes by the hour are used above all in the emergency rooms to prevent them from closing down. No one, or at most one person, showed up at both fixed-term and indefinite employment competitions. A year ago we were forced to outsource some shifts to a cooperative – he says Monica Calamaigeneral director of the Ferrara Ausl -. The coin-operated doctor it costs us about 40 per cent more than a structured one: 90 euros gross per hour by day and 120 euros at night. The director of Asl Cuneo 1, Giuseppe Guerra, he admits: Two of our four emergency rooms, that of Saluzzo and Ceva, open 12 hours a day, go on only thanks to the doctors of the cooperatives. But – adds Guerra – we also contract out shifts of anesthesia and gynecology. It is no longer just the emergency urgency that clings to cooperatives.
Today the lifeline for other medical branches, from Gynecology to Radiology, Anesthesia, Pediatrics, Orthopedics and Nephrology. Alternate anesthetists by the hour are more and more frequent. At the hospital in Seriate from Monday to Friday we have 4 to 5 who cover shifts 8-20, 8-18, 8-14 or 8-15, even on weekends if needed – he says Vincenzo Aquilina, contact person of the Italian hospital resuscitators association (Aaroi) for Asst Bergamo Est -. They are also present in the hospitals of Piario, Alzano and Lovere. Hired doctors have become the backbone of several departments of Pediatrics. Cooperatives are present in almost half of the pediatricians in Veneto – he says Simone Rugolottohead of pediatrics at the Rovigo hospital and national councilor of the Italian Society of Pediatrics (Sip) -. Lombardy, Valle d’Aosta, Piedmont, Liguria, Emilia Romagna, Marche and Calabria also benefit from it. In many cases, the token doctors are retirees or former hospitals who have ditched the public. Other sources of support are freelancers and trainees.
Riccardo Brachet Contulsecretary of Union of Executive Doctors (Anaao) for the Aosta Valley: The Orthopedics department of the Parini hospital in Aosta should have 15 specialists on the staff, instead it has only seven and for the emergency room services it makes use of 4-5 tokens per week. The ASL of Alessandria is also asking for help from external orthopedists. Outpatient activity in Novi Ligure ensured thanks to them – he confirms Antonello Santoro, Anaao Company Deputy Secretary -. While in the Casale Monferrato garrison a retired nephrologist has been hired from a private company since May for 12 hours a day, from Monday to Friday, to guarantee the dialysis service. There is only one employee, out of the six required, and one trainee.
The criticisms
We are at the gas barrel and, ahead of this step, we do not know what to expect – he comments Fabio De Iacodirector of the emergency room of the Maria Vittoria hospital in Turin and national president of the Italian Society of Emergency Medicine (Simeu) -. According to a survey by our company, the cooperatives maintain the emergency room of all the companies in Friuli, half of those in Piedmont, 60 percent in Liguria, 70 percent in Veneto, 35 percent in Lombardy and so on. The South still remains immune. De Iaco underlines the risks involved. These are mostly new graduates without specialization. They are unrelated to the clinical procedures of the team, to the care pathways of the ward and of the entire hospital. But for emergency interventions you have to be ready and a doctor who arrives one day by plane from another region and you don’t know when he returns, how does he do it? It is also easier for them not to discharge the patient from the emergency room at the end of the shift for not taking responsibility, and this only clogs up the ward.
The weekly working time beyond any control. No one guarantees us that the doctor hired respect the 11 consecutive hours of rest per day and the maximum 48 hours per week set by the European directive. They can work for several cooperatives and at the same time work as freelancers. There are those who work 20 shifts a month instead of 14-15. Or who, for example, can do 80 hours in a week with the risk of repercussions on their psychophysical well-being and on the ability to provide assistance to the patient to be treated.
Employees are also under stress. Since the beginning of the Covid emergency, I have accumulated more than 600 overtime hours a year, says the head of the Emergency Department of a province in the Veneto region. In Sicily, on the other hand, a committee of the directors of the first aid of the island has been set up asking the Region to keep non-specialist doctors recruited during the health emergency after 31 December 2022, even with atypical contracts, explains Massimo Geracihead of the emergency room of the Civic hospital of Palermo.
Economic rewards
To address severe staff shortages and attract ward work by reducing the use of outsourcing some Regions are applying economic incentives. The region Veneto raised the hourly rate for additional services in Emergency services to 100 euros gross (from the 60 required by the national collective bargaining agreement). Same compensation as Piedmont has decided to recognize doctors traveling to the emergency rooms of other regional health agencies (while for internal workers the salary goes from 40 to 60 euros on weekends, holidays and night hours), until 31 December. Today in some hospitals this figure is also offered to internal employees. We need to be competitive with cooperatives and increase the salaries of doctors, says the president of Simeu.
The Aosta Valley from January until 2024 it recognizes an additional 800 euros gross per month in paychecks to doctors who decide to work in its facilities. Sardinia has allocated 13 million euros to help small hospitals in difficulty outside the cities of Cagliari and Sassari. To give an example – reads a press release from the Region – a medical manager working in one of the hospitals identified as part of a project that should give his willingness to cover a minimum of four nights within a month will receive a prize of 400 euros for each shift.
For those arriving from another hospital: additional six hundred euros per turn for doctors whose headquarters are within 50 kilometers and 690 for those over 50. Finally, Calabria he asked the Ministry of Economy for recognition of a disadvantaged area, which gives the right to the disbursement of indemnities to attract health workers.
The reorganization of the departments
The strategy for plugging the holes may require one remodeling of the activity of less crowded departments. The hospital must be flexible. Thanks to a reorganization of the staff rotation, we have recovered hours of work to be reintegrated in the emergency unit. In this way we have already reduced the hours entrusted to the cooperative from 27 to 17 and by August we will no longer need external support – declares the director of the Ferrara Ausl, where it has also existed for three years. the figure of the bed manager, responsible for ensuring the appropriateness of admissions, the management of beds and discharge plans -. From October, the “see and treat” model for minor emergencies will also start, entrusted to nurses, to streamline the workload of doctors.
The proposal of training and work contracts
Anaao, the main union of hospital doctors, proposes to the Government to introduce the training and work contract for trainees starting from the first year. They are the only basin to be able to draw from. Fellows should not be treated like eternal students, they can learn by serving in the ward as happens in the rest of Europe, stresses the outgoing national secretary Carlo Palermo. Which insists on the possibility of hiring on a fixed-term basis the trainees from the third year according to the provisions of the Budget law for 2019 and the Calabria decree (also by the Health Trusts that are not part of the training network through an individual training project drawn up by the respective graduate School). Another essential goal for Anaao is to raise salaries: It is not possible that in Italy a doctor earns an average of 80 thousand euros gross a year while in France and Germany 120 thousand, in Great Britain even 130 thousand and in the Netherlands 200 thousand, concludes Palermo.
June 27, 2022 (change June 27, 2022 | 17:17)
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