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Physician shortage poses challenges to health care

Recently there have been frequent discussions in the media about the lack of pediatricians, family physicians and clinical psychologists in different Estonian towns. This, inevitably, raises a question: what has caused such systemic shortage of physicians and what can be done to solve this situation?

According to the National Institute for Health Development, in 2018 there were approximately 4,600 practicing physicians in Estonia. There are 347 physicians per 100,000 persons, which is the average in the European Union. In addition, there are 1277 dentists, 8317 nurses, 456 midwives and 3609 other health care professionals in Estonia.

Physician shortage by regions and specialties 

The shortage of physicians is very uneven across regions. "Geographically, the shortage is the highest in Ida-Virumaa, Southern Estonia and the islands. For example, Ida-Viru Central Hospital also employs many physicians from third countries. Some physicians who are registered as general practitioners actually work as medical specialists. Small hospitals do not have enough specialized physicians to cover necessary on-duty shifts, which is why in some places physicians are constantly on-call at home - for example, gynecologists in Põlva and Kuressaare," explained Katrin Rehemaa, Secretary General of the Estonian Medical Association.

As for specialties, the chairman of the Estonian Hospitals Association, Urmas Sule, mentions the shortage in internal medicine specialists, dermatologists, emergency care specialists, neurologists, oncologists and psychiatrists. “There are several specialties where the development of society puts additional pressure on the service. For example, in case of mental health, we should not only focus on psychiatrists, but the entire service package should have to be redesigned as demand increases - this means collaboration between different health care sectors and increasing demand for occupational therapists and other specialists,” said Sule.

The lack of family physicians, especially in rural areas, is also a frequently discussed and acute problem. "Calls for family physicians are not always successful and therefore, the Health Board has directed patients to other family physicians practice lists. This makes primary care harder to reach for patients and increases the workload of doctors," Rehemaa said.

According to Rehemaa, the problem could be alleviated by nationally managed regional policy of health care, which would provide doctors incentives to work in rural areas. Rehemaa believes that the Finnish system, where doctors' salaries increase in proportion to their distance from Helsinki, could serve as an example.

Despite the fact that large hospitals have only a few vacancies, this does not give a real picture of the shortage of physicians - potential positions will not even be opened, instead the work is divided between the existing physicians. As a result, physicians are forced to work overtime a lot. “There are so-called piece-shifts, where the work is paid, but the hours are not registered. Work intensity - how many patients there can be in the ward and per doctor at a time - is not well regulated. Physicians also have many additional tasks that are not directly related to treatment, ”Rehemaa described the concerns with the system. Sule says that assembling a hospital team is like doing a jigsaw puzzle - it is very difficult to find the right specialists, but a personal approach can be helpful here.

Physicians are aging, but there are not enough young ones coming up to take their places

In 2018, the average age for physicians was 50.8 years and for nurses 45.5 years. The average age has been increasing slightly but steadily over years but there are fewer young doctors coming in than older ones leaving their practice. "The average age of doctors in general hospitals is high and finding new specialists to replace all those who are about to retire is rather unlikely, as young people prefer to work in Tallinn and Tartu," Rehemaa is concerned.

Each year about 160-190 students are admitted to the Medical Faculty of the University of Tartu. In 2013, the Faculty of Medicine admitted 419 students, out of whom 142 were enrolled in the clinical practice curriculum. The clinical practice curriculum has a nominal duration of six years, and those interested can continue with four years of doctoral studies.  In 2019, 128 young people completed the clinical practice curriculum.

The Ministry of Social Affairs, the University of Tartu and the Estonian Hospitals Association together with other employers in the medical field are involved in the planning of residency vacancies. Their common goal is to improve access to medical care and ensure the number of physicians needed.

“Acquiring a medical specialty in residency is a long process and planning for succession both at the state and hospital level needs a long-term perspective. The minimum demand for training of physicians was 70 physicians a year. As of today, this number has increased significantly and, in general, we can be satisfied with the volume of training of physicians. At the same time, we have to keep in mind that we will see the results of today's changes only in the years to come,” commented Sule.

Rehemaa also agrees that it has been a right step to increase the admission of the Faculty of Medicine. “Admission to the Faculty of Medicine has been increased in recent years, but bigger groups have not yet graduated. The number of medical specialists depends on the residency graduates, but the candidates for a residency program are selected by competition and not everyone gets to practice their desired specialty. In this case young people sometimes go abroad to become a medical specialist,” says Rehemaa.

Physicians going abroad

“Higher pay is still the first motivator for going abroad, but the main reasons for not returning to Estonia are heavy workload, poorer organization of work and extra workload with non-clinical tasks. For example, paperwork and poorly functioning digital solutions take a surprisingly big amount of time, which the doctor should use to treat the patient instead,” said Rehemaa.

In 2011, 141 physicians were awarded a certificate of professional qualification to work abroad, while in 2015, this number was 69, but since 2016 it has remained between 35-40. Today approximately 4,000 Estonian doctors work abroad.

Expatriation has decreased significantly due to collective agreements between physicians and other health care professionals' associations and the Estonian Hospitals Association, which has brought about improved working conditions and higher wages. This year, the Estonian Health Insurance Fund has already allocated 40 million euros for the implementation of the collective agreement, and next year this amount will be 48 million euros.

“Today, young physicians no longer think so much about going to work in Finland. Years ago, we were in a situation where entire residency teams left to work abroad. Today they go abroad for additional training, but then they come back again,“ Sule was optimistic.

“This change is largely due to increased wages, but in order to stay competitive, you need more. Physicians are professionals who are constantly developing themselves and want to work based on the latest knowledge - they need an innovative environment and tools for that,” says Sule.