Honest - on the way out! How Medicine Optimizers Get Rid of Doctors

Julia Suntsova

The "optimization" of healthcare in Russia has launched the process of mergers and acquisitions of polyclinics, hospitals and ambulance substations, which inevitably leads to massive cuts.

Valuable personnel are leaking into private medicine. Budget medicine is saved by the "last heroes", for whom the life and dignity of a person is not an empty phrase.

We have already written about an alarming trend – the bullying of doctors in different cities of the country, which ended with the suicides of doctors, paramedics and nurses.

Today we will tell you about several more cases of harassment of doctors. Thank God, they all remain alive, but in fact they lose their life's work, they are expelled from the profession with a wolf ticket, they experience severe despair if they remain working in their places.

BUDGET INTEREST INSTEAD OF PATIENT NEEDS

Optimization came to the ambulance station in Volgograd in 2010.

The doctor Mikhail Nikolayev worked then in the intensive care team. The leadership immediately changed: there were doctors – economists were appointed.

- People are unskilled, they do not understand the realities of working in an ambulance. The organization of medical care is viewed exclusively through the prism of financial transactions. It is necessary to dial calls in any way, to fulfill financial plans so that next year the state and the CHI fund do not cut budgets. The interests of patients with such a worldview are pushed to the farthest place. To their eyes, these people began to call us, ambulance staff, "carriage cattle". Many doctors could not stand the new orders. Layoffs have become massive. Colleagues just ran to other regions. We lost half of the paramedics then.

Mikhail Nikolaev, as a result of the "reforms", also ended up in St. Petersburg, but several years before that he honestly tried to save his native Volgograd ambulance from collapse.

According to the existing regulations, one doctor and two paramedics rely on the resuscitation team. But in the pursuit of reporting, the number of calls multiplied (they began to take everyone in a row by ambulance), there were already not enough doctors, and then the final collapse came. People with an economic education began to defraud brigades.

"They could have taken one or both paramedics from me at once, put them in empty cars to increase the number of teams in the reports. In fact, instead of one full-fledged brigade, three non-brigades turned out. And this is intensive care, where lives depend on the speed of manipulation! Do I need to outline the consequences? Of course, according to the management, one doctor can cope with two hands, instead of six hands at the same time. The question is – will the patient stay alive after such a slow resuscitation? It's like sending one firefighter to a fire instead of a calculation, that's all. In addition, the load on the remaining doctor increases greatly, and this sooner or later leads to mistakes. But the new management took little interest in these subtleties of resuscitation staffing", - says Mikhail Nikolaev.

For a month, the doctor wrote reports to his superiors about the understaffing of the teams, they did not really respond to them. One of the complaints was simply returned to his hands with the note "Don't get smart!"In one of the morning shifts, both paramedics were taken away from Mikhail Nikolaev at once and offered to transfer from the intensive care unit to a linear non-specialized team, which actually means a demotion and a transition to a less qualified position.

The doctor, referring to the place of work assigned to him in the employment contract – the "resuscitation team" - refused to carry out the order of the management. He was reprimanded for refusing to work.

Nikolaev did not give up. He created a trade union cell at work and headed it, made statements to the media, where he spoke about the working conditions of doctors in the city ambulance service. In response, organized harassment started against him in local public places. The doctor was accused of schizophrenia, unconventional sexual orientation, working for foreign intelligence, political ambitions, attempts to live with the light of the chief doctor.

Despite the pressure of the administration, a collective appeal addressed to the governor for improving working conditions was signed by 600 out of 1000 employees of the Volgograd ambulance.

Then the administration of the medical institution issued instructions to subordinates - not to have common affairs with the "rebel" and not to start conversations. To anathematize Nikolayev was called upon at general production meetings.

Meanwhile, the ambulance administration continued to adjust the working conditions of ambulance workers. As a result, there were problems with round-the-clock crews. Doctors and paramedics did not take night shifts, as they stopped being paid 100% as before (now they paid only 40%). Decided to die at night – most likely, there will be no one to save you.

- Yes, salaries have been raised, but allowances for seniority and night shifts have been reduced to a minimum. Reports with graphs are beautiful, but the real salaries of ordinary employees have not changed. But the salaries of the senior management have grown well," says Mikhail.

In 2016, the chief physician Roman Lyashchenko started the "modernization" of the Volgograd ambulance fleet. Out of 100 ambulances, less than 10 remained in the property (90 cars were written off). How did you solve the problem? We signed an expensive outsourcing contract - new cars were supplied by a private organization under a five-year contract. 

- The administration was interested in sending outsourcing machines to calls as often as possible. Their departure was paid more expensive. Resuscitation teams were transferred to these new cars, reanimobiles were also used for household needs and transportation of superiors to meetings... Their remaining 10 cars were often idle. In terms of performance, conditions have worsened. The contractor's cars were cramped. But the main problem was that we had to drag equipment back and forth, constantly remove it and drag it from the habitable cars to new ones and back. In the process, the equipment could be lost, it was more difficult to control the presence or absence of everything necessary. This fuss delayed the departure of the intensive care unit, the waiting time for the patient increased, - says the resuscitator.

In 2016, Mikhail Nikolaev was fired one day for allegedly repeatedly violating labor discipline.

The court subsequently declared the dismissal illegal. The reprimands were canceled, the doctor was compensated for forced absenteeism and reinstated at work.During those four months, while Nikolaev was suing, the chief doctors changed twice in the ambulance.

The first optimizer Roman Lyashchenko was demoted and transferred to a branch. There he had to work as a doctor on linear ambulance crews - that is, in the system with an acute shortage of personnel, which he himself built while at the helm.

But news about the prosecutor's checks came from the branch. One of them revealed a corruption component in public procurement. It turned out that the division where Lyashchenko worked had purchased drugs with an expiring expiration date from a contractor company associated with his own wife.

In the fall of 2019, Mikhail Nikolaev continued the struggle for the staffing of brigades and decent working conditions in the ambulance. In September, the entire ambulance substation submitted applications to switch to one rate.

The new chief physician Roman Morozov again reprimanded the resuscitator Mikhail Nikolaevich allegedly again for refusing to go on a call. The doctor again challenged the reprimand through the court, proving that the acts of refusal were falsified by the dispatching service at the direction of the management.

- All this time the harassment has not stopped. Regional media colorfully described how I leave children to die. Pressure 24 hours a day, blatant lies, public slander. The employer who organized the harassment and illegal dismissals did not bear any responsibility even despite the court decisions. All this greatly affects the desire to fight for a collapsing ambulance," the doctor summarizes.

In 2020, the resuscitator Mikhail Nikolaev moved with his family to St. Petersburg, where he continued his medical practice.  

SURGEONS WITH CLEANING RATES

In the fall of 2018, optimization overtook Lotoshinsky Central District Hospital (Moscow Region).

The new chief physician Alexander Peresypkinsky "on the basis of the efficiency calculation" abolished the rates of emergency surgeons.  Doctors received notifications about the reduction, in which they were offered a choice to consider vacant positions:

- 0.25 rates - polyclinic surgeon for a salary of 10.220 rubles,

- 0.25 rates - the doctor of the emergency department for a salary of 7.726 rubles,

- 0.5 rates - nurse (ka) FAP for a salary of 6.238 rubles,

- 1 rate - territory cleaner for a salary of 7.706 rubles,

- 1 rate - a cleaner of office premises for a salary of 7.706 rubles.

At the same time, from the usual round-the-clock shifts in the surgical department, doctors were forced to switch to "home duty". The administration sent out the relevant agreements to the surgeons for signing. 

The news about the reduction and further "prospects" of employment fell on the surgeon Rustam Bokiyev like snow on his head. It became clear that the new management arrived solely for a beautiful entry in the workbook, possibly for bonuses, which, according to the law, can be written out from the funds saved by the hospital.

"Home duty" actually means that you are sitting at home, and you can be called to the hospital at any time of the day or night, you are obliged to appear at the first request. But 100% of the cost of an hour will be paid only for "actually worked hours, taking into account the time of moving," sitting at home is paid half as much. That is, you can forget about part-time work and part-time jobs, because you have to be at a low start all day long. You will have to become a teetotaler forever, because you cannot come to the operation in a state of intoxication, and when you will be called, you do not know. And they will pay two kopecks for such actual slavery", - says Bokiyev.

The problem of such "organizational and staff measures" is not only that the incomes of doctors are falling, but also in the critical deterioration of conditions for patients.

The day shift in the surgery department ends at 15.42, the day surgical teams leave. And if earlier one full-fledged team remained on duty in the hospital for the evening, night and until morning, now it is no longer there. An emergency patient arrives - the team must first be called out of the house bit by bit. Previously, those on duty at home were only an addition to the round-the-clock staff on duty in the department, they were called as surgical assistants. 

"What is emergency care? Here the patient enters the surgery department, and the surgeon who receives him there urgently organizes the process. Namely: prescribes blood tests, ECG, EGDFS (stomach), ultrasound, radiography, gives orders to the anesthesiologist, nurses and nurses about the preparation of the operating room and the patient, calls the assisting surgeon just from home duty. The operating team is always at hand and gets into work immediately. Now, when an emergency patient arrives, everything is just beginning to barely move. While both surgeons are getting from home to the department, the process is not started. It is clear that with such an organization, "emergency care" is no longer an emergency", - the surgeon says.

And patients lying in hospital are legally guaranteed the supervision of a certified doctor. In the case when we have eliminated all the rates of emergency surgeons, they are simply not physically in the hospital at night, only nurses take care of patients. Nevertheless, if something happens to the patient during this time, the same surgeon is apparently responsible for everything, according to the papers, then he is on duty, at home - not at home, there will be no difference in court.

Optimizers, perhaps, seriously counted on a night surgeon from the reception department of the polyclinic, who would be torn in two and run marathons to the hospital and back during the night, and would combine two bets out of a sense of conscience, that is, for free. Yes, but according to an employment contract, the surgeon of the emergency department cannot leave this department during his working hours. 

With notifications of reduction, Rustam Bokiyev and two more of his colleagues went to the chief physician in January 2019 and asked their questions. To whom, after the end of the day shift at 15.42, should patients be transferred for observation? If an emergency surgical intervention is necessary after 15.42, who will operate?

According to our interlocutor, the chief physician only answered this:

"You'll think of something about surgical assistants". 

"We are a public hospital, not a private sharashka, and we must clearly know who, where, when and how the patient will be operated on. Acting on luck, we endanger people's lives and health. Moreover, such connivance can easily fall under Article 237 of the Criminal Code of the Russian Federation (concealment of information about circumstances that pose a danger to human life or health), 238 of the Criminal Code of the Russian Federation (performance of works or provision of services that do not meet safety requirements)", - the surgeon notes.

Rustam Bokiyev refused to switch to home duty without an official contract and remained working only for the basic "bare" rate. The rest of the surgeons, according to him, were "persuaded" by the Hippocratic oath and soft blackmail – the management put pressure on the episodes known to them with "unregulated gratitude from patients". Rustam did not have such skeletons in the closet, so he alone continued to ask urgent questions to the chief physician, after which he received six reprimands in the period from 2018-2022. He challenged five in court and even achieved symbolic monetary compensation for the imposed nonsense. 

"Once he refused to admit a "non-surgical patient" to the hospital of the surgical department - there was a personal instruction from the authorities to put and "dig out" the drunken son of a nurse. Another time, he seemed to be late with the issuance of a discharge document. Another reprimand is for not transferring the patient under observation (to an absent surgeon on duty). Three times they considered that he had been rude to junior and middle staff - "a violation of generally accepted norms of medical ethics and deontology." And there was also a complaint to the Ministry of Health of Russia from an official of the regional Ministry of Health: the activity of surgeon Bokiyev is destructive, which hinders the normal functioning of the Lotoshinskaya CRH (they found an enemy of the people)!", - says the doctor.

However, the judges did not find any contact with the Code of Professional Ethics of the Doctor of the Russian Federation in the "violations" imputed to the surgeon. Non-fulfillment of official duties was also not detected. The reprimands were canceled. One of the six reprimands could not be challenged, as Rustam Bokiyev says, due to the fact that he acted without prior consultation with a lawyer. 

The optimization carried out at Lotoshinskaya Central District Hospital does not formally contradict the current federal and regional orders of the Ministry of Health.

There is a clarification in regional regulatory legal acts that if there is no possibility of providing round-the-clock surgical care in a hospital, the patient can be routed to another hospital, where the rates of surgeons on duty have not yet been reduced. In the case of Lotoshino, they are redirected to the Volokolamsk Central District Hospital (the distance between is 33 kilometers) - they have not yet optimized a round-the-clock surgeon, traumatologist, gynecologist, pediatrician and round-the-clock diagnostics with CT and MRI machines. 

However, according to the spirit of the law, the focus of financing medical institutions on the number of patients is nothing more than discrimination of the population on territorial and quantitative grounds, the doctor argues.

"The system itself is not focused on helping patients, but on ensuring that these patients arise as often as possible, preferably always. But after all, this very formulation of the question is fundamentally wrong. If our federal standards are tied to quantitative indicators, if the state and the CHI fund are ready to pay only for patients, then no one will ever recover in our country. No one will take care that there are as many healthy people as possible. In the case of surgery, it is generally an anecdote. In order for people in small district hospitals to have access to a round-the-clock surgeon and emergency surgical care, it is necessary to increase operational surgical activity. How's that? To drive out the economists who arrived with their accountants with axes and scythes every day to hunt? The healthcare reform based on the principle of creating family doctors has failed. A large number of decrees and orders in the healthcare system is compensated by the non-necessity of their implementation. How can we rebuild these tuned Potemkin villages now?", – asks Rustam Bokiyev.

Trying to convey his thoughts to the ideologists and performers of the "optimization of medicine", Rustam Bokiyev appealed to the Prosecutor's Office, the Investigative Committee, the Ministry of Health of various levels, Roszdravnadzor, etc. departments. An answer came back from the prosecutor's office with haughty semantic rhetoric: a simple surgeon should not go into a healthcare organization and argue what is effective and what is not. Then Bokiyev decided to become a local deputy, and thanks to the support of his fellow villagers, he succeeded. Now, when necessary, he submits his appeals to the competent authorities no longer as a "simple surgeon", but on a form. Most of the deputies of the local council support Bokiyev's initiatives and requests. The range of issues has also expanded. In Lotoshinsky district, since 2019, not only round-the-clock surgical care has become less accessible, but also obstetric, gynecological, infectious, etc.

The other day, Rustam Bokiyev won an administrative lawsuit against the district prosecutor's office in court. The judge ordered the supervisory authority to issue motivated responses to the applications of a citizen with deputy status. The surgeon of the Lotoshinsky central district hospital, Rustam Bokiyev, still does not let go of the question - How to build medical care in his hospital in such a way that it saves, and does not cripple people's lives, and that doctors receive a decent salary? 

A DRIVER BRANDED AS A DISSIDENT

Vitaly Lupyrev, an active member of the trade union, also asked a lot of unpleasant questions to the new management sent to optimize the substation, the driver of the ambulance 18 of the convoy of the depot No. 4 of the State Unitary Enterprise Automobile Plant "Mosavtosantrans". 

For an active life position, the employee was sent into exile. From the substation next to his house on Nakhimovsky Prospekt, he had to go to work in New Moscow. In fact, this means + 3.5-4 hours to shift.

The confrontation with the administration began with the issue of covid allowances.  The employer did not pay them, and Vitaly was immediately warned: "If you don't stop pumping your rights, we'll fire you". But he didn't listen.

An initiative group of doctors and ambulance drivers reached the Prosecutor General's Office, and the supervisory authority obliged the employer of the State Unitary Enterprise Automobile Plant of Sanitary Transport "Mosavtosantrans" to pay 506 ambulance drivers in Moscow federal allowances for work with coronavirus infection – in total, the debt to employees amounted to 17.6 million rubles.

After the victory with federal surcharges, an initiative group of drivers led by Lupyrev tried to fight for unpaid regional covid surcharges. This dispute is still being considered in the courts.

The difficulty is that the decree of the city of Moscow provided for additional payments for working with covid patients only to medical workers: a one-time payment of 25 thousand rubles and 1214 rubles for each shift worked. However, part of the regulatory legal acts in Russia does not refer drivers of the ambulance service to medical workers, and the metropolitan authorities took advantage of this. At the same time, paramedics and ambulance drivers are always one team, the composition of the brigade works hand in hand (this reality is fixed by the provision of the Order of the Ministry of Health of the Russian Federation No. 380n). The fact that there is such an additional payment to drivers as "forced" (for carrying patients) suggests that drivers are in contact with their patients in the literal sense of the word. So why are doctors and paramedics of the ambulance paid extra for working with covid patients, but drivers are not?

The Court of first instance did not stand on the side of the plaintiffs and refused regional covid allowances. Drivers of the Moscow ambulance are now trying to appeal this refusal in higher courts, and also appealed to the Constitutional Court of the Russian Federation with a claim of discrimination.

The activist activity of the drivers of the 18th convoy of the base of the 4th branch of the State Unitary Enterprise "Avtokombinat Mosavtotrans" was very annoying to the management, as a result, under the pretext of optimization, it was simply disbanded. Half of the drivers quit themselves.   

"I work on the children's intensive care team. The employment contract clearly states the place of work: ambulance substation No. 13, which is located near my place of residence. According to the traffic safety and labor protection magazine, a certain car is assigned to me. I was not offered to conclude any additional agreements. On the morning of May 3, I, as expected, open a shift at my supposedly liquidated substation, pass a pre-trip inspection, receive a waybill from the dispatcher, but as soon as I start driving away the car, my new boss appears, whom I see for the first time. He takes the keys from me and shouts: "You don't work here anymore, go to Zelenograd", - says Vitaly Lupyrev.

On his own and at his own expense, Vitaly gets to Zelenograd. There they give him a car, but they take away a waybill – they are not allowed to work in fact, determining for a backup car and removing it from the line.

At the end of the shift, he returns to his allegedly liquidated substation in Moscow and is noted in the closing of the shift.

On May 4, Vitaly wrote to the employer demanding not to interfere with the performance of duties, but he did not receive a response. On May 4, 5, 6, 7, history repeats itself, and on May 8 he is informed that he is fired. On May 16, an order of dismissal is issued "for a single gross violation of labor duties by an employee – absenteeism according to paragraph "a" of paragraph 6 of Part 1 of Article 81 of the Labor Code of the Russian Federation".

"The grounds for dismissal were: acts of 04.05.2022 on the absence of V.S. Lupyrev at the workplace, report of the head of column No. 3 * of 04.05.2022, notification of 08.05.2022 on the provision of a written explanation by V.S. Lupyrev, memo of V.S. Lupyrev of 11.05.2022 on the reasons for absence at the workplace, memo of the director of the carpool No. 1 * of 13.05.2022", - the court decision says.

In court, Lupyrev learns for the first time that he, it turns out, was moved temporarily (for a month) to a new place of work in convoy No. 3 of Depot No. 1 in Zelenograd, "due to production necessity".  

The court, in which Vitaly Lupyrev tried to appeal his dismissal, sided with the employer, considering that "the procedure for the dismissal of the plaintiff by the employer was observed".

"In this case, there was no transfer of the plaintiff to another job, requiring, by virtue of part 1 of Article 72.1 of the Labor Code of the Russian Federation, the consent of the employee, but the plaintiff was transferred from the same employer to another workplace located in the same area (part 3 of the same article), which did not entail changes in the terms of the employment contract defined by the parties, including the labor function", - the Dorogomilovsky District Court of Moscow, represented by the presiding judge Irina Alexandrenko, concluded.Nine years in the ambulance.

Resuscitation, emergency care, gynecology, obstetrics, firearms, knife. This is how Vitaly describes his work. According to him, a week after his dismissal, of course, he could not recover. It was hard to believe that it was possible to dismiss an employee just like that, while there was an acute shortage of personnel in the ambulance service. But a week later, it was decided to enroll in a private ambulance. He found a new job quickly - he works there to this day.