Ievina Alka

1
New Doctors andResidentship Education in Latvia
Data of Riga Stradina University and Project by
the Latvian Association of New Doctors Presented
to Latvian Medical Association
Ievina Alka Latvian Medical Association VILNIUS2
6 27 SEPTEMBER 2005
2
Excerpts from Medical Treatment Law

• Medical education the aggregate of knowledge
  and skills conforming to the medical education
  programme recognized under procedure prescribed
  by law, which is certified by a diploma issued by
  an educational institution (Medical Treatment
  Law, as amended on 8 April 2004)
• Postgraduate education continuous education of
  medical practitioners in the form of
  specialisation or raising of qualification after
  obtaining a diploma from the medical educational
  institution (Medical Treatment Law, 1 October
  1997)
• Specialisation part of continuous education
  that takes place in accordance to the accredited
  education programme following a standard of
  profession and rules of speciality (Medical
  Treatment Law, as amended on 27 May 2004)
• Improvement of a professional qualification -
  part of continuous education in a relevant
  speciality that takes places in accordance to the
  freely chosen education programme whose content
  and time for completion is not subject to
  regulation (Medical Treatment Law, as amended on
  27 May 2004)

3
- Continuous Education - Postgraduate
Education - Specialisation - Qualification
raising

• Residentship Education

4
Goal

• Provision of education, incl. training of
  practical skills for obtaining the qualification
  of a specialist

5
History- specialization
courses - internship - residentship since -
1990.
6
Residentship

• Post-graduate training of a doctor in an
  official language, in a contractual employment
  relationship with a health care provider
  institution implementing educational programme,
  for the acquisition of a speciality in accordance
  with a accredited professional residentship
  educational programme in medicine. (Medical
  Treatment Law, as amended on 27 May 2004)

7
State Funded Residentship Education
Proposals from the Agency for Health Statistics
and Medical Technologies

• Demand from sick-funds for family doctors
• Demand from health care provider institutions for
  specialist doctors
• Data from doctors labour market
• - number of doctors working outside profession
• - expected number of retired persons
• - number of unemployed doctors
• - vacant position for doctors
• ? Epidemiological data from all regions

8
Normative Enactments

• Medical Treatment Law, 1 July 1997
• Law on Higher Education 17 November 1995
• amendments
• law of 27 December 1996, (LV, 10 Jan. No.
  9/10/11)
• 23 November 2000, law (LV,12 Dec. No. 448/449)
  
• 20 May 2003, Ruling of the Constitutional court
  (LV, 21 May No. 75)
• 6 January 2004, Regulation of the Cabinet of
  Ministers No.1 (LV, 9 Jan. No. 4)
• 3 June 2004., law (LV, 10 June No. 93)

9
Normative Enactments
3. Regulation of the Cabinet of Ministers of
13 March 2001., No.120 Regulation on funding of
residentship education and posting of resident
doctors (LV,16 March, No.43) amendments
Regulation of the Cabinet of Ministers of 3 June
2003, No. 292 (LV, 6. June., No.85)

10
4. Regulation of Cabinet of Ministers of 23 July
2003, No. 315 Regulation On the Minimum
Requirements for Education Programmes for
obtaining professional qualification of a
doctor. (LV, 26.
January., No. 109) 5. Rules on doctors
specialities as approved by the Ministry of
Health or Ministry of Welfare of the Republic of
Latvia
11
Normative Enactments
6. Regulation of the Cabinet of
Ministers of 28 September 2004 No.804 Regulatio
n on employment remuneration system for medical
practitioners of state financed institutions and
social workers
12
State funded residentship education
Centre for Professional Medical Education
TENDERS
Health Care Institutions with teaching rights
Institutions of Higher Education
Pretenders for Residentship
GP
Specialists
13
State Funded Residentship Education
Tender procedure for award of contract from state
to conduct residentship education programme of
specialist doctors
Tender procedure for award of contract from state
to conduct residentship education programme of
family doctors
Tender results
14
Contracts
Contract Partners Object of Contract
Ministry of Health Health Compulsory Insurance State Agency /Centre for Professional Medical Education Health care provider institution /Institution of Higher Education Funding of Residentship Programme
Health Compulsory Insurance State Agency /Centre for Professional Medical Education !!! Resident Posting after completion of residentship programme Refund of invested resources in cases of ill founded failure to complete programme or failure to work for at least 3 years in accordance with posting
Institution of Higher Education Health care provider institution accredited education programmes- - managaement, - supervision, - evaluation of education quality, - document certifying education ? Payment for teaching staff
15
Presently resident doctors in Latvia are
Remuneration for work (Salary? Scholarship?) Regul
ation of the Cabinet of Ministers No.120 Funds
received pursuant to the Article 4.1. health care
provider institutions and institutions of higher
education use for Remuneration of resident
doctors work. Employment contracts stipulate
entitlement to remuneration level of the 15th
category LVL 94 (after taxes appox. LVL 64)
Employment Contract with Hospital (Paying
resident doctors may or may not conclude it)
Full time employed doctors for the time period
required to complete full training in the
relevant specialty (Gailezers Hospital,
P.Stradina UniversityHospital)
Funds earmarked for education
RSU Resident doctor is a full time employed who
spends part of his study time in health care
institutions hospitals, outpatient clinics,
family doctors clinics etc. or the purposes of
undergoing practical training
Law on Education, Art.55 (4) Educatees have the
rights to receive scholarships, credits, benefits
and other type of material assistance following
the procedure determined by the Cabinet of
Ministers. Scholarship? (LVL 58,- from the
scholarship fund of an Institution of Higher
Education)
Study contract
Funds earmarked for education
LU residentship training is a postgraduate
training of a resident doctor (doctor) in
contractual employment relationship with a health
care provider institutionin a health care
provider institution with teaching rights or in
an institution of higher education in medicine.
At the same time a resident doctor is a student
at Latvia University.
Contract with Health Compulsory Insurance State
Agency /Ministry of Health that contains the
persons undertaking to engage in studies at
residentship programme and provides for
conclusion of employment contract and stipulates
the persons submission to the government posting
System for 3 years after completion of
Residentship programme
Government procurement for education in
residentship programmes is financed from state
budget according to the annual law on
state budget Approx. LVL 265,- (including
resident octors salary/salary for
work?/ substitution)
16
Resident doctor is a doctor (rights and
obligations are determined in cooperation with
Latvian Medical Association by adopting rules of
profession for the regulated profession of a
doctor)
Full time employed Doctors for the time period
required to complete full training in the
relevant specialty
Doctors salary (in Latvia there are some 500
resident doctors) (every year starts 176)
Employment contract with hospital
Paying resident doctors also conclude employment
contracts and are salaried, but paying only for
their theoretical part of education
Scholarship? (from state budget funds that are
assigned for education in residentship
programmes)
Institution of Higher Education resident doctor
shall be deemed to be a part time student in a
contractual employment relationship with a
health care provider institution with teaching
rights who is at the same time engaged in a
postgraduate training in a health care provider
institution with teaching rights or the
institution of a higher education. The
institution of a higher education organizes
Evaluation of knowledge and only exercises
control over the practical training (through the
head of the residentship programme by way o f
weekly visits,counselling, control etc.)
Study Contract
Money earmarked for education
Government procurement for resident doctors
education is financed from state
budget according to the annual law on state
budget LVL 265 (excluding resident doctors
salary altogetheor providing for
certain scholarship)
Contract with Professional Education
CenterHealthCompulsory Insurance State Agency /
Ministry of Health and undertaking to submit
oneself to the posting by the Ministry of
Health that has to be given prior to
the commencing of a residentship programme
17
Contracts
Contract Partners Object of Contract
Resident doctor Health care provider institution / Institution of Higher Education Employment contract (funded by state)
Resident doctor Institution of Higher Education Fulfilment of obligations on the part of persons admitted to the residentship programme
Health Compulsory Insurance State Agency Resident doctor Conditions for remuneration of funds invested in education (in 5 years)
18
Article 26 (1) of the Medical Treatment Law

• Medical practitioners who have been certified and
  registered in the register of medical
  practitioners may independently engage in medical
  treatment within their competence (as amended on
  8April 2004) (amendments of 27 May 2004)
• (2) The persons that have completed accredited
  continuous education programme (specialization?
  postgraduate training?) that is a continuation of
  a previous secondary professional or higher
  medical education in the form of specialization
  or raising qualification may qualify for a
  certificate of a medical practitioner in a
  relevant specialty.

19
Article 33 of Medical Treatment Law (as amended
1June 2000)

• Persons studying at medical education
  institutions (perhaps also resident doctors?)
  within the framework of the educational programme
  may engage in medical treatment only under direct
  supervision of a certified medical practitioner.

20
Article 28 of Medical Treatment Law (as amended
1October 2000)

• The acquisition of a diploma of medical
  education shall permit the person, until
  certification in a specialty, to engage in
  medical treatment only under the supervision or
  guidance of such medical practitioner, as has a
  right to engage in the practice of medical
  treatment in the relevant field

21
The Status of a Doctor after University

• Doctor
• - trainee
• - without certificate
• Independent, but .
• Works under supervision of a specialist
• Change of attitude during the years of
  independence
• Appealing for hospitals and specialists as a
  cheap labour force
• Registration with Latvian Medical Association?
  Contract with Health Compulsory Insurance State
  Agency?

22
IS A RESIDENT DOCTOR A MEDICAL PRACTITIONER?

• Medical practitioners persons who have a
  medical education and who are engaged in medical
  treatment (Medical Treatment Law, 1 October
  1997)
• Certificate of a medical practitioner a
  document issued by the Latvian Medical
  Association, or the certification institution
  authorized by the Cabinet of Ministers that
  certifies the professional proficiency of the
  relevant person and indicates that the medical
  practitioner as a specialist is competent to
  independently engage in the practice of medical
  treatment (specialist practice) in the relevant
  field. (Medical Treatment Law, 1 October 1997)

23
The most pressing problemsAmbiguous legal
status of resident doctors

• Resident doctor considered student according to
• Law On Institutions of Higher Education
• Rules of residentship of Institutions of Higher
  Education (RSU, LU)
• Contract with the Ministry of Health on
  postgraduate programme
• Medical Treatment Law
• Resident doctor considered employee according to
• Labour contract concluded with Health Care
  institution
• Law On Regulated Professions and the Recognition
  of Professional Qualifications
• Medical Treatment Law

24
Why this Project?

• Increasing dissatisfaction on the part of
  resident doctors with postgraduate education
  system and their low salary
• Limitations, flaws and contradictions in
  legislation and other documents defining status,
  rights and obligations of resident doctors
• Lack of legislation that would enable a
  competition on the labour market in other EU
  countries
• Government posting system of new doctors

25
The most pressing problemsGovernment Posting
System

• Psychological factor
• Doctors degree at the age of 24
• Certificate of specialist at the age of
  28-30
• Posting by the government from 28 till 31/33
  
• Usefulness
• Most of the posted new specialists
  remunerate their postgraduate education in good
  faith
• Legality
• Provided for only in the Regulation No. 120
  of the Cabinet of Ministers and contracts drafted
  pursuant to this Regulation by the Ministry of
  Health/ Health Compulsory Insurance State Agency
  with residentship training institution and labour
  contracts by some Health Care Provider
  Institutions

26
Dynamics of state financing of resident doctors
Education
27
Presently only the rich can afford residentship
training,others must be allowed to work
28
ProjectNeeds to be done

• Draft a rules for non-specialist doctors with the
  right of practice (rules for doctors profession)
• Draft a rules for the registration of a
  non-specialist doctors with the right of practice
• Summon a working group for the implementation of
  a project (in co-operation with Latvian Medical
  Association, Institutions of Higher Education,
  health care institutions, Ministry of Health/
  Health Compulsory Insurance State Agency and with
  the help of legal experts)

29
ProjectGains

• Increase of salary according the current rate of
  increase for specialist doctors and pursuant the
  Regulation of the Cabinet of Ministers
• The right of independent practice in the chosen
  health care institution within the limits as
  defined in the Rules
• Become registered doctor in Latvia with the right
  of independent practice which is one of the
  necessary prerequisites enabling postgraduate
  training abroad

30
One cannot reproach the hungry for acceptinga
piece of bread from a stranger but perhaps it
could be possible to arrange that ones own
peopleprovide him with food!
31
Thank you for your attention!