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English Language Page However, chief physicians are rather content with this situation. The problem is that a more or less acceptable level of pay is only possible when a doctor occupies more than one position. Should the workload of doctors be reduced and brought in compliance with the existing norms “the pay would plunge below the subsistence minimum.” Despite that most of the clinics are staffed to not more than 55—75% of the required level all doctors’ positions as a rule are occupied. For example, the Moscow psychiatric clinic #13 is staffed with doctors to only 56% of the required level but these doctors occupy 92% of all doctors’ positions available at the hospital and manage to more or less effectively handle the flow of patients. The Lipetsk regional psychiatric clinic is staffed to 60% of the required level but all doctors’ positions available at the hospital are occupied. The situation is a lot worse in the regions where due to various reasons there is a serious shortage of medical personnel and clinics are staffed to not more than 50% of the required level. It is the following psychiatric institutions:
In such institutions the problem of insufficient staffing with specialists and inability to provide qualified psychiatric care is very serious. For example, doctors of the Kostroma specialized psychiatric clinic with intensive observation can only fill 70% of positions; only 74% of doctorial positions are filled at the Oryol regional psychiatric clinic, and at the Vladimir regional psychiatric clinic #4 — only 64%. The psychiatric department of the District hospital of the Komi-Permyatsky autonomous district is unable to find three physicians to put together an expert commission, and at the Stavropol territorial psychiatric clinic #2 which is located in a rural area doctors are loaded with work to such a degree that they cannot afford leaving the premises of the hospital even for a weekend and are induced to permanently reside on the territory of the hospital . Some physicians of the Prokhladnensk district psychiatric clinic of Kabardino-Balkaria carry double and heavier workloads. Undoubtedly, such situation negatively affects the therapy process. The problem is that it is practically impossible to improve this situation because the existing working conditions and the low level of pay do not facilitate an influx of new qualified specialists. Most of the working specialists are either individuals of the retirement age or very young people who have just graduated from medical schools. Specialists of the middle age who might provide their institutions with a reliable perspective are extremely hard to find. According to Articles 54—56 of the Foundations of legislation of the Russian Federation on the health care of citizens, psychiatrists working at psychiatric institutions must have a specialist certificate that is issued by state health care institutions responsible for the provision of post-diploma preparation of doctors and medical personnel of the middle level on the basis of a qualifying exam. Once every five years the psychiatrist must undergo qualification improvement courses and have their certificate renewed. In addition to that, doctors who are willing to constantly improve their qualification and have their professional level officially registered may undergo attestation on the basis of the results of which they receive a certain qualification category (there is a total of three of them — second, first, and supreme). The attestation is voluntary and is entirely up to the specialist but given that the qualification category is taken into account at the time of employment, especially when it comes to certain positions, and affects the level of pay most of psychiatrists strive to undergo attestation and once every five years to confirm their current category or receive a higher one. Lately the specialist certificate exam, as well as category attestation exams, has obligatorily included questions on the Law on psychiatric care and other legislative acts pertaining to individuals with mental conditions, as well as on the Code of professional ethics of psychiatrist adopted by the 1994 plenary meeting of the Russian Society of Psychiatrists. Qualification improvement and category attestation courses are now offered on the commercial basis almost everywhere which is why physicians in certain institutions are practically deprived of the possibility to improve their category. For example, at the Orenburg regional psychiatric clinic #1 only 48% of physicians have a qualification category, at the Rostov city psychiatric clinic (Kovalyovka settlement) — only 17%, at the Republican neuro-psychiatric dispensary of Kabardino-Balkaria and the psychiatric department of the District hospital of the Komi-Permyatsky autonomous district — less than 50%. The most serious situation was observed at the Prokhladnensk district psychiatric clinic of Kabardino-Balkaria which in not in a position to afford paying for the courses and therefore has no specialists with a qualification category at all. Doctors working at the Republican psychiatric clinic of Alania and both psychiatric clinics of Voronezh — regional and municipal — have to pay for qualification improvement courses themselves. For many doctors it is an expense that they cannot afford because courses cost 4000-5000 rubles which is a monthly income of the physician. In most of the regions physicians have to give up training held in Moscow and St. Petersburg and other large training centers and limit themselves to courses offered in the nearest regions, which results in disruption of long-term professional links and sometimes — even in serious discrepancies in diagnostics and therapy. On the other hand some physicians do not see much sense in the improvement of their qualification. They think that the quality of training programs is low and not worth “the hassle especially considering that the pay raise is insignificant (approximately 300 rubles).” Legal awareness of doctors in many regions is clearly insufficient. Not too many chief physicians know who can represent the patient at a court hearing on involuntary hospitalization (some of the interviewed doctors thought it was patients’ relatives) . The level of knowledge that they possess on the Foundations of legislation on health care of citizens, and Articles 31 and 62 that guarantee the right of citizens to information on their health condition in particular, is very low. Not all of the surveyed doctors are knowledgeable enough on what they may and what they may not tell patient’s relatives. Chief physician of one of the departments of the Krasnoyarsk territorial psychiatric clinic #3 admitted: “I do not have the law, the folio is so enormous,” which indicates that he probably has never read the law at all. The staffing of clinics with medical personnel of the middle level is significantly better than with physicians. Many hospitals (for example, the Novokuznetsk city psychiatric clinic #12 of the Kemerovo region, the Kirov regional psychiatric clinic, the Krasnodar city psychiatric clinic, the Republican psychiatric clinic of Alania, the Republican neuro-psychiatric dispensary of Kalmykia, the Republican psychiatric clinic of Karelia, the Republican psychiatric and tuberculosis hospital of Marii El, Shadrinsk neuro-psychiatric dispensary of the Kurgan region, Yaroslavl regional psychiatric clinic, Chita regional psychiatric clinic #1, Pskov regional psychiatric clinic #1, etc.) are staffed with medical personnel of the middle level for up to 95—100%. Note that it is the middle-level personnel that largely determine the success of the therapy process by executing indications of doctors. Nevertheless, there are still hospitals in which the number of medical nurses is not enough to enable the institution to work effectively. It is the following institutions:
The worst situations were observed at the Oryol, Sverdlovsk, and Tula regional psychiatric clinics in which the number of medical nurses is twice as less than required. Naturally this cannot help negatively affecting the therapy process and reducing the quality of medical assistance. Modern psychiatry implies combination of psychiatric care with social, psychological, and psychotherapeutic care for which purpose staffing schedules of psychiatric institutions provide for positions of social workers, psychologists, and psychotherapists . But so far the required specialists are not to be found in most of the hospitals. This problem is common for the entire country. The number of qualified specialists is small, while the clinics are not in a position to offer attractive working conditions. Out of the 10 positions for psychologists and 10 positions for psychotherapists accounted for by the staffing schedule of the Bryansk regional psychiatric clinic #3 only two are filled. At the Vladimir regional psychiatric clinic #4 only three positions are filled out of the 14 available. The Perm regional psychiatric clinic experiences a shortage of psychologists, the Orenburg regional psychiatric clinic #2 — psychologists and psychotherapists, the Oryol regional and Tula city psychiatric clinics — psychologists and social workers, the Chukotka regional neuro-psychiatric dispensary — rehabilitation specialists and social workers, the St. Petersburg psychiatric clinic #1 named after Kaschenko — social workers. Note that it is these specialists that bring psychiatric care up to the modern level by supplementing the medical element with psychological and social ones, which are not less important for patients. |
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