Young Bulgarian doctors respond to the claims of Toshko Yordanov, who said that his words were taken out of context. The State News Agency decided to "put them back in context" and asked the young doctors to comment on them - sentence by sentence.
Together with a group of young doctors, the State News Agency team listened to the entire statement of Toshko Yordanov - in its full context. And he spoke with Dimo Yankov, a neurosurgeon at the University Hospital "St. Ivan Rilski", Nikol Hristova - a young Bulgarian doctor who is completing a specialization in anesthesiology in Austria, Mina and Raina, who specialized in a state hospital in Bulgaria, and Konstantin, who specializes in a private hospital.
Nikol Hristova and Dimo Yankov speak with their real names. Mina, Raina and Konstantin asked the editors to change their names.
„A resident is a resident. This is part of their training. These are not young doctors.“
DV: Is that right? What work do residents do in hospitals?
Dimo Yankov, a neurosurgeon at the University Hospital "St. Ivan Rilski": This is outright nonsense. The moment each of us has taken the state exams, he becomes a doctor. And any doctor you want to be responsible for your health should continue to learn throughout their lives, not just during their basic medical course or during their specialization. I am still a student, even though 12 years have passed since my graduation and nearly 5 years since acquiring a specialty.
Nikol Hristova: When I graduated, the corona crisis began. All the people who graduated in January 2020 entered Covid wards from March. There they did all the work, stayed alone on shifts and took care of seriously ill patients. And after the pandemic, many of the doctors during specialization continue to give shifts alone, without another specialist in the ward. Not to mention the fact that the residents are also burdened with administrative work. Every doctor who has graduated from medicine, including the resident, has the right to perform all medical activities and is a full-fledged doctor.
Mina: Where do I start? We admit patients, prescribe therapy and tests, monitor whether it is being performed, and discharge patients. We communicate with consultants in different specialties when this is necessary for our patients. In some cases, this includes taking a patient to the consultant's office. We also follow up with the patients themselves after they are discharged, performing check-ups, adapting their therapy, or referring them to other specialists. Due to the low number of nurses, a large part of the nursing manipulations are performed by resident doctors. More than one or two colleagues have covered nursing duty when there is a gap in the schedule.
How is medical work paid
DV: What is the salary of residents in Austria?
Nikol Hristova: From the moment they start, they are in the top 10% of society in terms of salary. Night work is paid double, unlike in Bulgaria. Every additional hour - too.
„The main problem and these slips that the lady showed us are the low salaries mainly in private hospitals.“
„The proposal was (…) to discipline private hospitals to give at least as much as they give in public hospitals (…) On the spot they said „Yes, that's good“, because it solves their problem, after they started looking for new problems.“
DV: Are the salaries of the residents low only in private hospitals?
Konstantin: I am in a private hospital, my girlfriend is in a public one - my salary is 400 leva more than hers. That is simply not true.
Mina: I started with a basic salary of 900 leva in a public hospital in 2020. My last pay slip during my specialization at the same hospital was for a basic salary of 1800 leva four years later. Speaking with my specialization colleagues from other state hospitals during that time, we discussed salaries, and theirs were nowhere near higher than that. The salaries of all healthcare workers are a mockery of the fact that we chose to stay and live in our homeland.
Dimo Yankov, neurosurgeon at the University Hospital "St. Ivan Rilski": I am not familiar with the situation in all hospitals and clinics, but I personally specialized in a state clinic, in one of the most profitable, if not the most profitable hospital in Bulgaria. My first paycheck for a full month worked was less than 500 leva. Indeed, this was at a time when rents in Sofia were 1/2 of what they are now, but certainly not enough. In order to reach some normal finances, I started working a significant amount of overtime and taking on an impressive number of additional shifts. And yes, the labor inspectorate would not approve. All this continues to this day. The residents I have the pleasure of training are subjected to the same initiation rituals with elements of harassment. There is certainly an improvement, but we are far from normal conditions.
„Specialists, are you aware of what would happen to you if you studied abroad, for example in Italy? There, in order to be a specialist in something, there is an educational qualification, according to what you achieved as a student. If your success is as high as possible, you have access to specific specializations, which are later expensively paid, but if you are not, you cannot apply.”
„If you are in Italy, they will send you somewhere - from Rome they will send you to Sicily and you will have a five-year employment contract, because the educational institution invests in you. Yes, you will receive normal money, but you will work there for five years.“
DV: How is it in Austria and Germany?
Nikol Hristova: There are many problems with this statement. The specialists there were sent based on their success. And why aren't specializations in Bulgaria awarded based on grades or exams? In Bulgaria, you only get a specialty if you know someone and they arrange a place for you. Or if you worked as a caregiver for four years before that, because there aren't enough nurses and you know the team. There are probably exceptions to getting a place without knowing anyone, but that's rare. In Germany and Austria, you go to a job interview, they look at your CV and your performance. Based on that, you get the place or not. You are absolutely free to apply to any hospital.
„None of you wants to go to work in the countryside. Everyone wants to go to Sofia or to the big cities.“
„In Sandanski, the hospital offers a high enough salary, provides a municipal apartment, and there are no applicants.“
DV: Are there adequate places and good conditions for specialization in small towns?
Nikol Hristova: A specialty includes many separate modules. I specialize in anesthesiology. I looked specifically at the hospital in Sandanski to see what departments it has - you won't learn to anesthetize children there, because there are no pediatric surgeries. That is, if you go to specialize there, you will only learn part of the things. In Bulgaria, all more complex cases are referred to the big regional cities. You can eventually get a specialty, but whether you can put everything into practice is a completely different question. My hospital in Austria has a certain type of surgery, but they send me to other hospitals, where the modules I lack are covered. Because when I finally get my specialty diploma, I need to be able to do all these things.
Are there good conditions everywhere in Bulgaria?
Raina: Good hospitals are concentrated in big cities. Not to mention that if you don't have the specialty you want, what do you do? And even if you do, who trains you there, what equipment is there? And I'm not from Sandanski anyway.
Mina: The statement strongly reminds me of the mandatory distribution of doctors from the social welfare system. Today you graduate, tomorrow you're the only doctor in a village. Study, what's stopping you? You want to become an ophthalmologist? Too bad, they need an internist there. But you get housing. I don't know what the salary is in Sandanski, nor what kind of apartments this guy is talking about, but going to work in another town, leaving your loved ones, friends and life behind, is not an easy decision, and it's unlikely that anyone would just take it for some abandoned housing. Adequate conditions for training exist in large hospitals, which we know well are not in small towns.
„You want to graduate, to specialize in whatever you want, regardless of whether you have the necessary knowledge that you have accumulated, because you graduate with different grades and not everyone becomes a good specialist afterwards, because here everyone can specialize in whatever they want.“
DV: Is that right? Does everyone specialize in whatever they want without the necessary knowledge?
Konstantin: In Italy it is like this - for the more desirable specialties there is a score ranking, those with better grades enter with priority. In Bulgaria it is not like this. If you have the relevant connections, you can specialize in whatever. There is no application regulation and even if there is - it is not followed.
Raina: I wouldn't even talk so much about salaries. There should be rules according to which you apply for a given specialty. Even those who have a perfect six - the so-called Golden Hippocrates - if they have ordinary parents without connections, can go and apply for a place and be laughed at. You stand there waiting for someone to take pity on you, to like you and to let you specialize.
“You as students will demand that the state pay you a salary next time while you study.“
„When I was a student, it would never have crossed my mind to ask for a salary that was higher than that of my professor, he added. That's what you want right now – with the percentages you proposed, if you calculate them, you should have equal or higher salaries than some of your professors.“
DV: Do medical students want such things?
Nikol Hristova: Mr. Yordanov asks how students can almost ask for money at all. In Austria and Germany, when you enter the sixth year, before you have a diploma yet, you do the so-called practical year. Even then, every student works on an equal footing with doctors and receives over 800 euros, which is more than the salary of specializing doctors in Bulgaria.
The problem with salaries has been around for years. If the salaries of nurses increase, the salaries of doctors, as well as those of residents, must also increase directly. The problem is systemic.
"Go to Italy, go, pay yourself, work for five years in some village in Sicily and come back here happy.“
DV: To those who specialized abroad: Would you return “happy” to Bulgaria?
Nikol Hristova: I don't know what payment is involved. You don't pay anything, they invest in you, including funds to become a better specialist. Going abroad is not easy, no one wants to leave their homeland and be a foreigner in another country. But when you can afford a decent life, have a normal income, you have no other choice. Under these conditions, the chance of returning to Bulgaria is close to zero.
„And if you think that everyone abroad is waiting for you with open arms in the medical community, I wish you success“
DV: Aren't they waiting for you?
Nikol Hristova: If we couldn't find places, we wouldn't be leaving. Obviously, we have found places. When you start working as a doctor abroad, they try to keep you in every way. If you have proven that you can handle it, they will not let you go.
„I wish you success, a system cannot hold empty positions.“
Why is there a massive shortage of doctors and nurses
DV: Are there no empty positions in the system?
Mina: The shortage of nurses and other healthcare specialists is clearly a figment of everyone's imagination except for Mr. Yordanov.
Raina: Things are scandalous. First of all, with the nurses. There is not even one nurse per doctor, which is beyond any norms. With doctors too - in Sofia there is this problem, in other settlements people are left without personal doctors. There simply aren't any.
"If you don't work here, we will be forced to bring in specialists from other countries who will work for $500 happily, as much as the state can afford.“
„You are not some chosen part of society that should receive more money than the rest, because paramedics are also not well paid and are neglected.“
DV: Are there such specialists who work for $500 happily in Bulgaria? How does one live on $500 in Bulgaria?
Konstantin: For ten years we have been waiting for some young ambitious Filipinas to come to replace the pensioners in the system, but they still haven't come. I don't know why. Maybe $500 is not enough for them. I don't think Mr. Yordanov's statements should be taken seriously. Mr. Yordanov is a screenwriter, his politics is more of a hobby. At least the result of his speech is favorable, people have united around a cause.
Nikol Hristova: I just want to note that I checked how it is in Afghanistan - the salary of young doctors there is about 500 dollars. So I don't know if it will work out with Afghan doctors. Toshko Yordanov is a person who has no idea how a doctor's day goes. He says that we think of ourselves as “God's chosen ones” - we are responsible for people's health, we don't leave things in the hands of God, but we save lives. Not being able to afford your rent and bills while working this job with this stress is absurd.
„In England, you will have to go to the doctor, if you follow their health path, which is state-run, which we are talking about here, you will go to the doctor in a month and you will either be cured or dead for that month. In Italy too, if you get sick and go to the emergency room, you know that there is "green", "yellow", "red" and with the flu and a temperature of 40 degrees you are not an emergency – you will stay for 15 hours.“
„In Bulgaria, good, bad, poorly funded system, every citizen, including those who do not pay contributions, has very quick access to a doctor. This is a fact.“
DV: Do all those who walk on the health path die in Western Europe?
Nikol Hristova: Oh... the problem in Bulgaria is that there is not enough prevention. In England, for routine check-ups like cervical cancer, for example, you get messages every year that you have to go for a check-up. If you have some acute illness that requires emergency hospital care, you certainly get it. What is the proof? In Bulgaria, life expectancy is about six years shorter than in Great Britain and Western Europe as a whole. The fact that Bulgaria has more hospital beds per capita does not matter when there are no staff - doctors and nurses.
Mina: Does he know what this about colors is all about? I will explain it to him. Triage is a system for assessing the severity of the patient's condition in order to provide immediate help when it is needed. It is practiced here too, just to clarify, and yes - it is necessary that urgency has full priority.
„Most of my fellow doctors here, when they specialized, paid themselves. They weren't paid.“
DV: Did doctors pay themselves for specialization before?
Dimo Yankov, neurosurgeon at the University Hospital „St. Ivan Rilski“: Yes, until 2015, the practice of young doctors paying themselves for wanting to study, examine patients and keep medical records, be on duty and whatnot was widespread. We can go back even further in the history of medicine. But how far back in time do we have to go for the system to appeal to those who have no experience in functioning in it?
Nikol Hristova: And currently there are tripartite contracts in which you work in one place, and they pay for your specialization in another. To some extent, this still exists today.
Mina: I am not sure that the concept of “paid specialization“ is very clear even in our circles. As far as I know, colleagues who specialized in this way received a regular salary, but they had to pay out of their own pocket when a given module of their specialization was not conducted in the hospital where they worked. They do not have the right not to conduct it, as this would mean not being allowed to take the state specialty exam, since the types and number of modules are precisely determined for each specialty. I don't know any older doctors who worked completely without pay during their training, to say that there was such a thing in the past.
What are the differences?
DV: How would your life have been different if you had chosen to specialize in Bulgaria instead of Austria?
Nikol Hristova: I worked as a nurse before I left. I didn't have any supplies. On weekends, there was a box of gloves left, which might not be enough. I had to pay for water and toilet paper. If I had stayed in Bulgaria, I wouldn't have been able to afford to pay rent because I don't have my own place. I had to live with my parents until I was 31, until I specialized, and that was in case I started earning enough money to afford a place to live. In Austria, my training is financially covered, I have additional leave, which I have to dedicate only to additional qualifications, congresses, courses, etc. In Bulgaria, access to these things is difficult and you have to set aside from the rest of your leave to attend them. In Bulgaria, many of the European and American standards are not respected. The difference is extremely large.
Raina: Here you go to conferences in your free time. You pay for yourself. You take your leave. They neither send us to such forums, nor do they cover our expenses.
DV: What should be done so that people like you are not forced to leave Bulgaria?
Nikol Hristova: I thought about this issue for a long time. I would not have left if my salary was 4,000 leva and I knew that I would be able to ensure a normal, good life despite the poor conditions. In Bulgaria, many people are willing to endure specialization with this salary, so that they can then open private offices and charge 150 leva for an examination. But the idea behind raising salaries is not to force people to go to private offices, which are expensive for patients, but to ensure adequate care for everyone.
Konstantin: A decent salary is a good first step to start solving the problems in healthcare. The process of seeking specialization is humiliating - you go and pray. If you are eventually liked and hired, you start receiving money that makes you wonder why you went through all this trouble. Given the conditions and salary in Bulgaria, the level of our healthcare system is good. Attention should be paid not only to doctors - to nurses, orderlies, paramedics.
Raina: First of all, it's the way you apply for a specialization. If you don't have connections, it can waste a lot of time. Then there's the salary and working conditions. I don't think young people are attracted to working in moldy, crumbling conditions with equipment from 50 years ago. Nowadays, you read from textbooks from Western Europe and the USA. There you see things in pictures that you can never see in practice here. Otherwise, for 500 dollars - it's about 800 leva. You can pay your rent or go shopping 1-2 times. As residents, we live almost exclusively in the hospital anyway - to prepare sleeping quarters there and settle in.
Alexander Detev talks to young doctors.