Don't leave UNINFORMED!
In recent years thousands of dentists have left Romania for other countries, to practise dental medicine under conditions they desire and that others promise — a worrying aspect for the health system. But the gravity of the situation consists in the fact that for a large part of those who leave, integration on the labour market and the lifestyle for which they make many compromises are not what they wanted.
The main objective of the Stay a Doctor in Romania campaign is the retention of doctors in the country; however, for those whose future plans are set for another territory, we want to highlight a reality to which they do not have access and to encourage informing themselves down to the smallest details for a change on which their professional and personal future depends greatly.
The study we have launched for the long term — namely the questionnaires destined for doctors who have already left, as well as for students and doctors who have set out to make this change — includes testimonials and interviews with doctors who have been through medical systems and working conditions both in Romania and in other countries, and brings to light a censored reality.
Next we will speak with Dr. Eliott Sote, part of the team of doctors at Dent Estet, of French origin, who got involved in the Stay a Doctor in Romania campaign to tell us about the dental medical system in France. Coming from a family with a pharmacist mother and a civil-servant father, he attended the Faculty of Dentistry at UMF Cluj-Napoca, then practised for a year as a dentist in France, Occitanie Region, the city of Cahors. He has now chosen to be a doctor in Romania because he likes Romanians, our culture, and the challenges.
Why did you choose Romania for your studies?
Initially it was not settled that I would leave for Romania; after the baccalaureate I entered the faculty of medicine and pharmacy in France, and at the end of year 1 there is a very selective competition. The number of places at the faculty of medicine in France is always limited and stagnates; they are not supplemented, while the number of inhabitants and implicitly of candidates has grown. For those who try to enter medicine immediately after the baccalaureate it is almost impossible to succeed at the first attempt. In short, medical studies in France are a long story. At the end of that year, unfortunately — or rather now fortunately — I did not get a place. And after this failure, I found out from my sister's philosophy teacher that she had heard that French students who are extremely motivated to do medicine can go to Cluj-Napoca, and the faculty offers them studies in French. When I heard that, I looked into it and seized the chance to leave on an adventure. The letter of acceptance from UMF Cluj-Napoca in the summer of 2009 was one of the greatest joys of my life so far. And that is when my story with Romania and Romanians began.
Did you practise dentistry in Romania?
Only as a student during faculty. The faculty required a quota of procedures for each subject; my goal was always to exceed that quota so as to reach the level I wanted as quickly as possible. In Romania it is hard to build a patient base, so at the beginning on the basis of acquaintances, then with business cards, and further with recommendations, I reached a good patient base that allowed me to do everything during faculty and to finish dentistry prepared to start in a practice. Also during the summer, the faculty offers us the possibility to work further for summer practice, so I stayed with my patients. In years 5 and 6 I went to two practices in Cluj to be an assistant and at the same time to draw inspiration from their protocol. I gave a great deal of time, energy, and seriousness to my patients in order to succeed with their treatment plan, and they appreciated that a lot — and even today some former patients have remained friends.
How was your integration on the labour market in France?
It was easy; jobs are sought everywhere in France, but it matters a great deal where you work and with what team. Initially, as a first experience, I did a week of "remplacement" — that is, I replaced a dentist who was going on holiday and I took care of her selected patients and emergencies. And after that I chose to collaborate with the dentist with whom I did my summer placements, so everything was prepared for me; I knew where I was going and with whom I would work. But even if everything was prepared, that does not mean adaptation was easy. I worked as a collaborating doctor and received patients from the doctor who owned the practice. Being difficult to create a patient base, especially at the beginning, he kept his base of loyal patients and directed toward me the new ones or those he no longer wanted. And little by little I created my patientele. Here I want to emphasise that it is very important where you start and with what team; I opted for a 64-year-old dentist for his experience and the possibility of taking over the practice afterwards. But if it were to be redone I would not start the same way; I would start again with a young team and a very well-equipped practice.
What was your title in France? What specialty?
In France doctors do not specialise in a particular branch during their studies. It is considered that you finish dentistry and you are a dentist, capable of performing any procedure. As a general practitioner, a large part of your turnover comes from your prosthetic cases. Other doctors prefer to orient toward implantology with periodontology because you are freer to set your own prices. Endodontics is not a recognised specialty with us, but exclusive endodontists are beginning to appear who receive all the complicated cases and set their own price. But practically at the beginning, in any branch of dentistry, you need to build a solid patient base and have a certain local reputation. For this reason, at the beginning it is hard if you start alone because patients are afraid of the unknown, especially when it comes to dentistry. A great deal of time and patience is needed to become known among patients for certain treatments and to benefit from their trust and recommendations, independently of studies.
How was the collaboration from a financial point of view?
With us there are several possible contracts, but approximately all those who start choose collaboration at a percentage; my percentage was 60% to me and 40% to the practice, of the procedure price. And I had the necessary materials and equipment at my disposal. However, after that calculation I had to pay the technician, in the case of prosthetic work. So if I had a good month in terms of turnover, that meant I had done a lot of prosthetics and that at the end of the month I would have a lot to pay the technician, so I end up more at a 50/50 as a collaborator. Apart from that, all basic treatments (consultation, scaling, fillings, endodontics…) are imposed by the state and by our social-insurance system and you are not allowed to change them by a cent (there is a PDF file with the state price list); your only possibility to set your own prices was on the prosthetic side, for which you were free to fix your price. I remember a very nice 70-year-old patient whom I appreciated a great deal and who could not open her mouth very much, and for an hour I struggled to do a large occlusal filling because of a deep carious cavity on 27, and at the end I enter the procedure in the computer and it comes out "occlusal filling on one surface = €16.87" — the patient herself did not understand such a small price after so much work. Through this example I want to say that I often felt I was working for nothing. And many times the resources invested in the medical act were greater than the financial part I was left with. However, I had the family's support and that stopped me from worrying. But I do not know how those who start independently or without experience of the working mode in France manage.
Another thing that seems important to mention is the working pace; you need a large turnover of patients per day and per week to be profitable. And for example if in one day you have done 15 fillings, you have the impression that you have worked a lot, but in terms of turnover you would have been better off doing a single crown because at the end you finish with more than double. In conclusion, at the beginning it is hard; you need to build a base of serious patients who come and pay and who need prosthetic work. That is why some doctors have the temptation to buy a practice with thousands of patients, but in fact it is not the number of patients that matters but what percentage of them need or will need prosthetic work.
And we must talk about all the things that have to be paid besides the percentage and payment for the technician; every month you receive things to pay — payment to the dentists' college €422/year, malpractice insurance, complementary insurance, pension, URSSAF, accountant, the body that checks accountants, the bank fee for the professional account and the machine for bank cards, and at the end of the year taxes come. I was lucky because for pension and URSSAF in the first two years you pay minimum contributions, but at the end of two years they are recalculated. So with us it is said that in the first two years every month you must set aside half of your monthly salary to prepare for taxes and recalculations.
How many assistants worked in the practice where you practised?
One, and not with me. I never had an assistant; I always worked without one. It is an extra cost for practices that they do not take on. €1,500–1,700 monthly pay to an assistant represents about €3,000 including taxes, and you need to be an active doctor for too many years and with a very large patient base to afford that. The doctor in whose practice I worked had his own assistant. And I benefited from her help only in the case of impressions for prosthetics, because those were procedures from which the practice also received an important percentage. Being a common interest, he put the assistant's support at my disposal. However, those were the only moments when I worked with an assistant.
It is very hard to work alone; it increases your working times, you cannot schedule very many patients in a day, and I also have French colleagues who finished with me and still cannot afford an assistant and also do sterilisation on top. And that is another activity that takes from the time dedicated to the doctor's activity.
Without an assistant in the practice, who manages appointments?
In my case the assistant answered the phone and made telephone appointments, but for my colleagues who work alone there is an online platform where doctors register and on which patients, depending on conditions, availability, and other filters, receive a list of practices/doctors they can go to. And doctors in turn can personalise their agenda according to the schedule they want in a week, the availability they have in a day, etc.
How well equipped was the practice regarding the apparatus needed for treatments?
For the most part I had access to the apparatus required by the treatments performed. However, I considered that a strict necessity; I cannot say the practice was over-equipped or that a certain piece of apparatus was found in several copies. We managed with what we had, being two doctors. If I am to compare even with practices seen in Romania, here I have encountered more apparatus and quite advanced.
How important is patient recommendation in France?
It is almost the only way to attract patients with certainty — recommendation. However, it is hard to reach this point. In France, because of medical insurance you cannot set the prices yourself as a doctor who opens a practice. These are imposed by their system and must be respected. Higher prices or discounts are not allowed, which makes it harder to individualise your practice's services from the others. You cannot influence patients' decision to choose you very much.
Some practices have made a website on which they present the practice and the team and tips with recommendations for patients. That is how they try a little to differentiate themselves and have another way of attracting when the patient searches for a dentist in a city on the internet.
Dentistry in France in recent years is quite unstable; many things are changing and even if we still have an efficient health system for patients, I am curious to see how the market will evolve in the coming years.
Do you intend to stay in Romania?
For the moment yes. I do not know if forever or for how many years. But I like the people and I have always liked to travel, to see new things. And I have started a collaboration with a chain of dental clinics, Dent Estet.
There are many doctors or students barely out of faculty who leave Romania for other countries, including France. Do you know such people?
Yes, I have Romanian friends who have moved to France, Ireland, Germany, Switzerland… and practise. In general those who managed and integrated well in France were those who had an acquaintance in the field to teach them the system.
You told me how your integration on the labour market in France was. What can you tell me about the Romanians you know?
A large part of my experience as a doctor in France applies in general, nationality not mattering. A small part of the Romanian friends who moved there have succeeded in reaching the level they wanted, but they found themselves in certain favourable circumstances. For the rest, however, the difficulty I also encountered is valid. Romanian doctors who move their life to France for collaboration at a practice end up concluding that it is not so easy to have the patients you want, to perform complex procedures under the desired conditions, and to have the financial results that satisfy you. And from what remains for you each month, you will also have to calculate the taxes corresponding to the profession and afterwards personal taxes come.
I am surprised by doctors who purchase a practice in France and move here without having previous experience with practice here. I know they are promised a large number of patients and implicitly fascinating financial results. But it is not quite so. As I answered to other questions as well, medical insurance limits and hinders your financial progress. No one can guarantee and offer you a patient base, price differences are not allowed, and you cannot promote yourself. Results come very hard; they come with time. I believe the best would be to work first at a practice, to have contact with the dental-services market in France, and only then decide under what conditions to open their own practice.
I have Romanian friends who would return to their country, but the financial compromises and decisions taken so far do not allow them.
From what you know, how do Romanians become doctors in France? Through what sources?
For me there are two sources: the Romanian who knows French and has heard that in France you earn much better and leaves alone, and those who leave attracted by promises made by recruitment agencies. Very many Romanians are won over by figures and achievements guaranteed by recruitment firms. In certain areas in France it has become a network, because in localities where medical staff is needed, the town hall turns to recruitment firms and large sums are invested. Because they have a working protocol as follows: following the announcement to the recruitment firm, the town hall pays sum x to find out if there is any candidate, then another sum x to find out if the candidate accepts the professional conditions offered, then another sum x to receive the candidate's name, and so on. All the steps needed implemented cost and at the end you reach a sum even of €20,000 without guarantee that at the end you will have a doctor (that is what happened in the village where I was born). This is the main reason why, at least in France, recruitment firms have expanded their activity so much. It is a real business in certain regions and it works on the basis of the stories created and sold beautifully by these firms, to convince the doctor to accept the job and subsequently to cash the total from the town hall.
What do you convey to people who want to practise in another country?
Regardless of whether it is about Romania–France or any other countries, I insistently recommend informing yourself and possibly personal experimentation following that information. When you leave for a country, first of all you must know the language very well; patients are extremely attentive to that and do not come to you if they do not understand you perfectly; after that you must choose well the city you want and see how great the competition is (many times a smaller city or the countryside is better than a very large city). These are important aspects that must be taken into account, because they represent the comfort and lifestyle of the person concerned — and here I mean from rents to taxes for each city; everything is weighed before a departure in order to avoid any unpleasant surprises.