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Migration of skilled anaesthesiologists from low to high-income economies

Urgent action needed

Mitre, Călin; Breazu, Caius; Mitre, Ileana; Filipescu, Daniela

European Journal of Anaesthesiology (EJA): March 2016 - Volume 33 - Issue 3 - p 157–159
doi: 10.1097/EJA.0000000000000382

From the University of Medicine and Pharmacy, ‘Iuliu Hatieganu’ Cluj-Napoca, Romania (CM, CB, IM), and Emergency Institute of Cardiovascular Diseases ‘Prof. Dr C.C. Iliescu’, Bucharest, Romania (DF)

Correspondence to Caius Breazu, Regional Institute of Gastroenterology and Hepatology ‘Octavian Fodor’ Cluj-Napoca, Croitorilor 19–21str, Cluj-Napoca, Romania Tel: +40743010012; e-mail:

In recent years, there has been a significant increase in the demand for anaesthesia in Europe and worldwide.1–3 There is no doubt that improvements in patient safety, with a 10-fold reduction in risk and an anaesthesia-related mortality rate of 0.5 to 1/100 000,4–6 have significantly contributed to the expansion of the specialty. Safer anaesthesia has created an imbalance by increasing demand for the anaesthesia workforce whilst the number of available anaesthesiologists has declined. The effect of this on the national health policies of European countries over the last 10 years has been dramatic. Studies that have attempted to assess the causes of the imbalance and its potential evolution over the next few years have based their figures on those reported by the economically developed countries.2,7,8 However, all the member states of the European Union (EU) are inextricably interdependent in terms of workforce trends over the continent as Western countries seek to address their shortage of anaesthesia providers by importing migrant professionals from less-affluent Eastern countries.2,9 Not surprisingly, this migration of a skilled workforce has had a negative impact on the health systems of the source countries. In this Editorial, we shall consider this migration and its impact on the discrepancy between the demand and supply of the anaesthesia workforce that appeared in Romania after joining the EU in 2007.

In common with other European states, the increased need for anaesthesiologists in Romania has been driven by a number of factors. There has been growth in the number, diversity and complexity of surgical interventions. Outside the operating room, the spread of anaesthesia activity has widened, especially in the fields of gastroenterology and radiology, where the presence of the anaesthesiologist has become mandatory. And in the intensive care medicine departments, that part of the workload managed only by anaesthesiologists has expanded. But the most important reason for this imbalance between demand and supply of anaesthesia personnel in Romania is the migration of the qualified staff to economically developed countries, particularly Germany, France, Great Britain and Scandinavia. The situation in Romania is worsened by a chronically under-funded health system, which has resulted in a shortage of anaesthesiologists, especially the young professionals, and has put greater pressure on the remaining medical staff. When looking back at the numbers of anaesthesiologists in 2005 before Romania joined the EU, there were 1138 anaesthesia and intensive care medicine specialists and 469 trainees.10 If we consider that all these trainees would have become specialists after 2005, Romania should have counted around 1600 anaesthesiologists in 2012. However, a survey performed between 2008 and 2012 in 35 county and six university hospitals that included the majority of Romanian anaesthesia and intensive care medicine departments recorded, in 2012, only 956 professionally active specialist anaesthesiologists in Romania. This figure represents a decrease in the anaesthesia workforce of approximately 40% compared with 2005. It seems that 30% of Romanian anaesthesiologists have left their jobs between 2008 and 2012.11 As a consequence, between 2005 and 2012, the density of specialist anaesthesiologists has decreased from 5.2 to 4.75/100 000 inhabitants.10,11 After correcting for ageing, change of specialty, retirement, part-time work and death, the analysis of the labour force revealed that migration of Romanian anaesthesiologists to Western countries was the main cause for this decrease. We anticipate that the number of anaesthesiologists in the Romanian labour market will fall by approximately 5% per year over the next 5 years.11 The migration of Romanian anaesthesiologists fits into the general trend of Romanian medical staff migration. Between 2008 and 2013, approximately 13 872 physicians of different specialties left Romania to high-income European countries, indicating a significant brain drain.12

Anaesthesia nurses have not been immune to this trend; 40% of anaesthesia and intensive care medicine nurses have migrated from the county and 45% from university hospitals between 2008 to 2012.11 This double impact on anaesthesia activity is more serious in Romania than in other European countries.

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Why is Romania an important donor of anaesthesiologists?

In Romania, the anaesthesiologist is trained to be competent in both anaesthesia and intensive care medicine. The duration of training is 5 years and the quality of teaching and training in anaesthesia and intensive care medicine was recognised by the European Academy of Anaesthesiology and the European Board of Anaesthesiology Hospital Visiting Program in 1996. The Romanian Society of Anaesthesia and Intensive Care has continuously worked with the Universities and the Ministry of Health to upgrade the educational training programmes of anaesthesia and intensive care medicine. Romania has been a host of the Part I (MCQ) Examination of the European Diploma in Anaesthesiology and Intensive Care since 1996.

In 2010, the Part I (MCQ) of the European Diploma in Anaesthesiology and Intensive Care was nationally adopted as the entry qualification for those seeking specialist status. Possessing good specialist training and foreign language skills, young Romanian anaesthesiologists easily find jobs in Western European institutions. Although Romania offers high-quality training, it seems that the trainees are leaving the country even before the training cycle is completed, particularly in their last 2 years.11 The trainees seem to be following the same pattern as the qualified staff as shortages of trainees exist in many high-income European countries. Although 723 anaesthesia and intensive care medicine training positions were filled between 2008 and 2012, at the end of 5 years, only 565 trainees emerged at the end of 2012 to complete their training, a dropout rate of approximately 22%.11 Romania loses twice from this migration of its trainees, firstly from the poor yield of the financial investment in education, and secondly from the loss of emerging new specialists who are required to fill the positions needed in the national hospitals. The situation was further worsened by the 2009 global financial crisis, which resulted in the freezing of vacant positions in the health sector leading to a serious staff shortage in anaesthesia and intensive care medicine. As a result, only 60 and 72% of anaesthesia and intensive care medicine physician positions in county and university hospitals, respectively, were filled by 2012. The situation was similar for vacant posts for anaesthesia and intensive care medicine nurses.

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How to fill the gap?

Medical staff migration from Romania has multiple causes such as the need for professional development and the desire to practice in well equipped hospitals in a well structured environment and to enjoy the esteem of society recognition and higher financial reimbursement. For example, the wages in some Western countries are 15 to 20 times higher than in Romania.

The effective working time of Romanian anaesthesiologists also exceeds the national and European recommended number of working hours.11 This results in a high incidence of burnout among anaesthesia and intensive care medicine physicians; one-third of those in a study group were affected.13 The principal consequence of the reduced number of anaesthesiologists is that, to ensure that medical services continue to be provided safely and to a high standard, in accordance with the Helsinki Declaration of Patient Safety in Anaesthesiology, staff who remain in the country are grossly overworked.14

To equal the average number of anaesthesiologists per one hundred thousand inhabitants of the developed countries of the EU, Romania needs to provide about 250 specialist anaesthesiologists per year over the next 5 years, assuming that they would stay and practice in the country. This is a difficult task as the current figure is less than 100 new specialists per year. Paradoxically, Romania is filling the gap by approaching anaesthesiologists from neighbouring countries. However, the immigration of anaesthesia and intensive care medicine staff from the Republic of Moldova, for instance, does not represent a long-term solution. To date, Moldavian anaesthesiologists have been reported in 21 county and six university hospitals.11

In our opinion, there are few solutions to this problem. One requires governmental measures that would increase investments in the health system and motivate young anaesthesia and intensive care medicine trainees to stay and practice in Romania. At present, efforts are being made to improve the situation nationwide by unlocking job positions in the health system and implementing national programmes to provide the necessary resources for anaesthesia and intensive care medicine departments. Nevertheless, any action would need a significant national increase in wages to stem the migration flow. An interesting lead to follow-up is the development of European legislation that would establish financial compensation for workforce donor countries. This strategy might support improvements to the national health system and make it more attractive to local specialists.

In conclusion, Romania is facing a dramatic shortage of anaesthesia and intensive care medicine professionals. Urgent and tangible measures are needed both nationally and at the European level to stop a brain drain that may affect the EU health systems across the continent. In latter years, we have witnessed the continuous movement of anaesthesiologists from North to South and from East to West in Europe. To manage workforce migration, a comprehensive European workforce strategy is needed. The ‘WHO Global Code of Practice on the International Recruitment of Health Personnel’15 could standardise the level of medical staff training and better control its use in European hospitals.

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Acknowledgements related to this article

Assistance with the Editorial: none.

Financial support and sponsorship: none.

Conflicts of interest: none.

Comment from the editor: this Editorial was checked and accepted by the editors but was not sent for external peer review.

This article was checked and accepted by the Editors, but was not sent for external peer-review.

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