Dr. Yekaterina Chatskaya: “Doctors Are Pushed to the Limit”

Dr. Yekaterina Chatskaya: “A Year Ago There Were Three of Us. Now There Are Six Times as Many”
Confederation of Labor of Russia (KTR)
May 20, 2016

Dr. Yekaterina Chatskaya
Dr. Yekaterina Chatskaya

Dr. Yekaterina Chatskaya, a gynecologist at Moscow Municipal Clinic No. 180 and a leader of the Moscow local of trade union Action told Novaya Gazeta what it is like to be a trade unionist when Russia health care has entered an area of turbulence.

Yekaterina Chatskaya is a gynecologist at Moscow Municipal Clinic No. 180. In April 2015, she was involved in a work-to-rule strike by Moscow physicians, meaning that doctors spent as much time with each incoming patient as was necessary and ignored newly introduced, stringent patient-intake standards. Novaya Gazeta found out what happened with the strike and personally with Dr. Chatskaya over the past year.

How did last year’s work-to-rule strike end?

I kept a diary of my patient intakes. We analyzed the standards that took shape during the course of the strike and sent them to the head physician. It turned out our figures were similar to those issued by the Health Ministry. But the problem is that the Health Ministry’s standards are recommendations. They are not obligatory, meaning that they virtually don’t function in practice.

For example, in Moscow, a gynecologist’s standard intake time varies from twelve to fifteen minutes at different hospitals, but the federally recommended initial appointment time is twenty-two minutes. That is a fundamental difference.

In the blogs and appeals written by physicians, they say they are fighting to increase appointment times by three minutes. Do these minutes add up to something in actual practice?

Of course, they do. I have a fifteen-minute limit for seeing a single patient, and I see patients for six hours in a row without a break, meaning this limit does not include a lunch break or even a simple trip to the toilet. Over this six-hour period, according to the standards, I should be able to see twenty-four patients, who have registered in the electronic data base. But it is virtually impossible to keep up with this pace. There are complicated patients, and there are urgent cases. Old women dress slowly. They require a special approach. And you must not hurry pregnant women at all, whether someone is pregnant for the first time or has had a miscarriage in the past. But when the intake period lasts longer than six hours, it is inevitable that doctors make mistakes. Your concentration is reduced, and your eyes are tired.

You really feel by the end of the intake period that you are losing concentration and can make a mistake?

That is exactly why I started thinking about how long it takes to examine a patient in reality. Before the strike, my official intake period lasted seven hours, but in fact it came to eight hours without stopping. After the strike, we succeeded in getting six-hour schedules, while everything is still the same at other clinics.

Has what happened last year changed anything about your team?

At first, a lot of people wanted to support me, but when a group letter was drafted and we took it to other doctors for them to sign it, people got scared. The head physician called me into his office and said it was extremism, that I was going against the regime, although there were no political demands at all in the letter. Certain colleagues stopped speaking to me altogether.

But the turning point came. A year ago, we organized a local of the independent trade union Action (Deistvie). Initially, there were three of us. Now there are six times as many. We managed to stop the introduction of so-called effective contracts. One of the points in the contracts was that incentive pay would be based only on the decision of the clinic or hospital director. My pay consists of 20,000 rubles base salary and roughly the same amount in incentive pay. Under the so-called effective contracts, incentive pay would have included work assignments that are not part of my job description. Theoretically, if I had refused to mop the floors on the orders of the department head, I could have been stripped of my incentive pay. We wrote to the head physician and the prosecutor’s office. The prosecutor’s office acknowledged the decree facilitated corruption and ordered it abolished. This was a victory. But many clinics have switched to the so-called effective contracts.

Your latest protest campaign has targeted the Moscow Health Clinics Standard. What don’t you like about it?

The standard has led to a collapse at work, and not only at our clinic. During the flu epidemic, GPs were working over twelve hours a day. One doctor made a house call to a patient at one-thirty in the morning, and before that she had been seeing patients since eight in the morning, and then went out on house calls. Another colleague of mine worked three weeks without a single day off.

They have begun to drive away specialists. How? For example, a GP has to refer a patient to an endocrinologist. But to do this, he or she has to write up a full justification for the referral, get the chart and referral signed by the department head, and manage all this within the twelve-minute limit for the appointment. Management have been strongly advising GPs not to refer patients to specialists but to threat them themselves. Naturally, the endocrinologist sits there without any work. After some time has passed, management decides that since such a small number of patients come to see him, the clinic has no need of his services. Our clinic fired a mammalogist, a dentist, and an endocrinologist in this way. There is very big queue to see the gastroenterologist. But our clinic immediately set up paid appointments to see him. If you have the money, you will be served right way.

Getting an ultrasound appointment has become a disaster. In late 2014, one ultrasound specialist went on maternity leave, a second was cut, and a third resigned of her own accord. For several months, a single specialist examined pregnant women in the entire district of Mitino. It even came to blows at the terminal when two women fought over an ultrasound appointment voucher. Another big minus of the reforms has been the virtual abolition of the principle of neighborhood health care.

Now you can make an appointment with any primary care physician at a clinic. Is that a bad thing?

In our conditions, it is a bad thing, because it leads to the unavailability of medical care. For example, my primary care neighborhood covers six thousand people, although according to the standards I should be serving two thousand two hundred people. When my appointment bookings for fourteen days in advance open up at 7:30 on a Monday morning, the appointment vouchers are already gone by eight in the morning. Patients can now choose a doctor themselves, and naturally they choose doctors with good reputations. Inevitably, these doctors will be overbooked. Patients assigned to these doctors as their neighborhood doctors are simply unable to get an appointment to see them, although they will be seeing many patients from other neighborhoods.

An absurd situation has developed. The municipal health department monitors the availability of specialists. On our clinic’s overall chart, there is constantly a red light next to my name, meaning that I violate the norm, because patients sign up to see me two weeks in advance. A good doctor is not profitable to a clinic because she or he skews the statistics.

How much do you earn?

My take-home pay is between twenty-five and thirty thousand rubles a month. My last paycheck was 35,000 rubles [approx. 465 euros a month per the current exchange rate—TRR]. I have been working at this salary since April of last years. I am not paid a kopeck more, only the mandatory minimum.

Does the Moscow health department know about this situation?

Yes. We regularly appeal to them. The last appeal by primary care physicians was sent to them on March 31. After that, we got paid a little more.

Doctors are pushed to the limit. Seeing the shiny pictures on the TV, our patients imagine that everything is alright with medical care, and if something is wrong, it is the doctor’s fault. A patient can come and sit outside a doctor’s door for an hour: that means he is a bad doctor. It was that way at first, though now, it is true, patients have begun to realize that if there is a queue, it means the doctor is good. I was reprimanded when an urgent care patient got wedged into my schedule, and I was unable to see another patient before my lunch break. I asked her to wait, but when I came back fifteen minutes later, she was filling out a complaint in the department head’s office. I was reprimanded, even though the patient was seen the very same day after my break.

Would it be easier if the Health Ministry issued strict regulations rather than recommendations?

It would be ideal. We have written several times to the Moscow health department asking them to establish regulations in keeping with the Labor Code and the Russian federal government decree stipulating that a doctor should see patients for no more than thirty-three hours a week. The reply we received was meaningless, as always.

Meanwhile, our head physician issues orders that violate the recommended norms.  These two realities do not intersect at all.

For example, hardship pay has been abolished throughout Moscow.  Even our radiologists lost additional holidays and pay. But the federal decree clearly stipulates that medical workers who come into contact with HIV and tuberculosis should receive both additional pay and additional holidays.

Source: Novaya Gazeta

Translated by the Russian Reader. Thanks to Valentin Urusov for the heads-up

Moscow Doctors Go on Work-to-Rule Strike

Work-to-Rule Strike: What Moscow Doctors Are Fighting
Julia Dudkina
March 25, 2015
snob.ru

Moscow doctors have declared a work-to-rule strike. Disgruntled by personnel cuts and the introduction of time limits for seeing patients, they said they would now work strictly by the rules, without overtime. We found out how the strike has been going in the capital’s clinics.

“Our working day is not set,” explains Dmitry Polyakov, a neighborhood general practitioner at Diagnostic Center No. 5. “When forty-five people pass before your eyes in a single day, you feel awful.  And there have been staff cuts, many specialists have left, and their patients are referred to us. People are unhappy, of course, and they take it out on us. By the end of the day it is often difficult even to focus one’s eyes, let alone concentrate. Salaries have fallen, incentives to work have decreased, but the workloads have grown.”

In addition to seeing patients in clinic, a neighborhood GP has many other duties, such as visiting ten to fifteen patients at home. Plus, there is paperwork: outpatient charts, registration stubs, and discharge sheets. Much of the paperwork has to be filled out during the doctor’s free time. And yet salaries have been rapidly shrinking. Whereas before they had been as much eighty and even one hundred thousand rubles per month, neighborhood GPs are now paid around forty thousand rubles a month [approx. 640 euros at current exchange rates].

“We have a very large flow of patients,” complains Yekaterina Chatskaya, an OG/GYN at City Clinic No. 180. “There is no one to see all the patients; the workload is colossal. It happens that you work nine and ten hours a day. I basically don’t see my husband and child, and I make only forty thousand rubles a month. If we were at least provided with stationery supplies. Yesterday, I was issued paper for my printer for the first time in five years. Usually, though, I have to buy supplies out of my own money. But the main disaster is the lack of time for examining patients properly. The Health Ministry allots ten to twelve minutes for each patient, but it is impossible to meet this standard.”

Elena Konte, a GP at the first branch of City Clinic No. 220, had hoped that the start of the work-to-rule strike would simplify things. If she didn’t have to work overtime, she would manage to go home on time, and fill out outpatient charts that had piled up from last week. But a nurse who was supposed to help with patients took ill; a conference was scheduled for the middle of the day; and a mysterious “inspector,” a doctor from an outpatient center, suddenly showed up as well.

“This never happened before. I am sure she came because of today’s strike,” says Elena. “She didn’t say anything about the strike, but she asked about how much we have to work and inquired about the UMIAS (Unified Medical Information Analysis System). I think she was horrified by how much unnecessary scribbling falls on us and how much running around the entire clinic we do searching for patients’ test results: after all, they’re not even recorded in the computer at our clinic. Of course, it’s uncomfortable working when you’re being observed all day. But at least they paid attention to us.”

Elena Konte managed to see all her patients that day, but she was unable to complete all the outpatient charts. The first day of the work-to-rule strike failed to solve the problems that have accrued over the past months for staff at the first branch of City Clinic No. 220.

“At first, there were six doctors working eight neighborhoods in our second general practice department,” says Elena. “Then, one of the neighborhood GPs was sent to retrain as a family doctor, and there were five of us left. In February, yet another doctor was transferred to a neighboring branch. But this is winter, the peak time for upper respiratory infections. And the workload is such that it is like we’re working two positions. The strain is very hard, both physically and mentally. Yesterday, I got to the clinic at 8 a.m., and went home at nine in the evening. But I will continue to participate in the strike. They have already promised to reduce consultation hours from five to four hours, and have added another position in reception.”

Downstairs, on the ground floor, two old women were vigorously discussing the news from the world of medicine.

“They all got laid off. Who is there to do the work now?”

“Exactly! And in a couple months, they say, there will be further layoffs. They have to go on strike.”

If the strike has gone unnoticed for both patients and physicians at this clinic, things are quite different at Diagnostic Center No. 5.

“Today, I managed to see everyone who came by appointment, and even finally filled out all my paperwork in normal handwriting and finished working with the outpatient charts that had piled up,” says neighborhood GP Irina Kutuzova. “Maybe the bigwigs won’t notice the strike at first, but when an emergency occurs, everyone will get it.  Generally, it is hard to work in the present circumstances. You cannot examine a patient who has come by appointment longer than ten minutes, but some patients require much more time. And it often takes twenty minutes to fill out a sick leave form. I get forty to forty-five patients a day; it is a constant blitz. And there is another whole crowd of patients who come ‘just to ask a question.’ As a result, people get disgruntled: they literally kick open the door and voice their complaints. By the end of the day, it all becomes a blur, and I don’t have the strength to write out prescriptions. But today I had thirty-seven patients. Also a lot, of course, but better nevertheless.”

In the hallway, an elderly woman catches my hand. She is waiting in the queue for the next room.

“Young woman, you’re not a patient? Maybe you know whether they’ll see me today or not?” she asks hopefully.

Her name is Galina Bordo, and she has been waiting her turn for nearly two hours. A few weeks ago, she had a tumor removed, and now she must have regular checkups. The doctor’s visiting hours ended twenty minutes ago, but the last patient still has not come out.

“I heard they started a strike today. Good for them, it’s the right thing to do. Otherwise, in today’s environment, with the queues and unnecessary paperwork, they don’t cure anyone,” Bordo says.

According to the healthcare workers union Action (Deistvie), twenty employees at six clinics have been taking part in the work-to-rule strike by Moscow doctors. In the near future, twenty-two other health care providers may join them.

“Our goal is not to cause a collapse, but to show how and under what conditions doctors work,” explains Andrei Konoval, Action’s organizational secretary. “To demonstrate that under normal, unhurried service, the number of patients who can be seen in a day is reduced by one and a half to two times.  This means that it is necessary to increase the number of doctors and medical facilities. Even if there were only one brave doctor willing to participate in the strike, we would still go through with it.”

Andrei Khripun, head of the city’s health department, has already dubbed the strike a “political provocation,” and claimed that it had failed, because “Moscow clinics are operating in normal mode.” Although that had been the point of the strike: to work according to the rules.

________________

Valentin Urusov
March 25, 2015
Facebook

Today, a comrade and I went to a medical facility to hand out leaflets (the appeal by striking doctors to patients). Fortunately, people have been reacting quite positively to the doctors’ strike and have gladly agreed to support them. Many people took leaflets to hand out at home.

I called one of the strikers and asked whether she has felt pressure from management. She said she had, but since they are determined and have really enjoyed working according to the law, the strike could continue for quite a long time. But now they are able to spend exactly as much time as they need on a patient, and not what officials want them to spend.

What is interesting is that if women have taken something on, they’ll definitely see it through to the end, unlike most of us men. I think it would be better if officials started listening to what they’re saying and stopped destroying healthcare while it’s still not too late.

One shady type drove up in a car and asked for a couple of leaflets. Then he pulled away and photographed us. Apparently, he was a spy. Security behaved properly, and at first they even tried not to notice us. Later, though, they asked us not to make trouble for them and go outside. That was even more convenient for us, and we handed out more leaflets.

Tomorrow, we will go to the other strike sites and notify patients. I think it would be great if everyone who was going to a hospital or clinic would take several such leaflets along and hand them out there. So, friends, don’t stand on the sidelines so that you’ll regret it later. Make your contribution to the common cause. The text of the leaflet is below. Anyone can print it out.

Dear Patients,

On March 24, a “work according to instructions” action, which journalists often call an “Italian” strike, was launched at several Moscow clinics. Its gist is that doctors who have decided to draw the attention of authorities to the disgraceful state of medical care have started to work in complete accordance with the Labor Code and the standards of care.

We have worked in inhuman conditions for years. Our workday often lasts nine, ten, and even twelve hours. However, rather than increasing staff and creating normal working conditions, health officials have begun laying off physicians and reducing the time patients can be seen to mere minutes. But the workload and amount of paperwork have only grown. In our view, such excesses only serve as cover for bureaucrats pursuing a policy of commercializing healthcare: the longer the artificially generated queues in clinics are, the easier it will be to make patients pay.

From March 24, we have decided to hold consultations based on established standards. Moreover, if a patient’s condition requires more time than is laid down in the regulations, we are not going to speed up examinations, because haste poses a threat to the person’s life and health.

We ask for your understanding and support. We are in the same boat, on the same side of the barricade erected by “optimizing” officials. We will do everything we can to ensure that no problems with the provision of medical care arise. Eight days ago, we warned our chief physicians, as well the Moscow Department of Health and even the Russian Federal Prosecutor’s Office, of the need to ensure that patients whom we do not have time to examine during our shifts are seen.

If you are, nevertheless, unable to get an appointment through the negligence of management, we suggest you send a complaint to the Department of Health. (Believe us, it helps!) In the complaint, you should write that the physician you wanted to see had warned management of possible problems in connection with “work to rule,” but management failed to take the necessary organizational and personnel measures. You can do this on the site mosgorzdrav.ru in the section marked “For the public” > “Petitions from the public” > “Receipt of petitions from the public.”

We would be grateful if you would sign the online appeal in support of the issues we have raised. To do this, simply type in the address goo.gl/nxJ8C5.

Together we will make the system work for the benefit of patients, not bureaucrats.

Your Doctors