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Practice of gastroenterology in Romania
PRACTICE OF GASTROENTEROLOGY IN ROMANIA
A Survey on the Practice of Gastroenterology in Romania
Ioan Sporea 1 , Alina Popescu 1 , Roxana ªirli 1 , Viorela Enãchescu 2 , Alexandra Deleanu 1 , Eftimie Miuþescu 3
1) Department of Gastroenterology, University of Medicine and Pharmacy Timiºoara. 2) Department of Internal Medicine
- Ambulatory, University of Medicine Craiova. 3) Department of Gastroenterology – West University “Vasile Goldiº” Arad
Abstract
Aim of the study: To get data on the current practice of
Gastroenterology in Romania. Material and method. We
obtained data regarding the number of gastroenterologists
in Romania from the Centre of Statistics of the Ministry of
Health and Family (CSMHF) and the National Centre of
Training for Medical Personnel (NCTMP). We sent a
questionnaire to all the Centers of Gastroenterology in
Romania inquiring about the number of gastroenterologists
and fellows, and about the gastroenterological procedures
performed. We compared these data to that of 17 European
countries. Results. The total number of gastroenterologists
in Romania on January 1, 2005 was 175 (123 specialists and
52 senior consultants), and the total number of fellows in
training was 133. Romania has a small number of
gastroenterologists - 0.83/100,000 inhabitants, expected to
reach approximately 1.4/100,000 inhabitants in 2010.
Regarding the abilities in gastroenterological procedures,
we obtained data from 98 gastroenterologists. They have
good performances in diagnostic gastroscopy (97%),
colonoscopy (81.6%), abdominal ultrasound (79.6%), but a
poor performance in ERCP (10.2%). Less than half of the
gastroenterologists (46.9%) perform proctologic procedures.
Data regarding the training program of the Romanian fellows
are disappointing: only 69.1% of them perform gastroscopy,
33.8% colonoscopy, 2.9% ERCP, 64.7% abdominal
ultrasound and 14.7% proctology. Conclusions. The number
of gastroenterologists in Romania seems low compared with
most European countries. They do not acquire a uniform
satisfactory mastering of gastroenterological procedures
during their training program. This should be improved
according to the guidelines of the European Diploma of
Gastroenterology.
J Gastrointestin Liver Dis
September 2006 Vol.15 No.3, 313-316
Address for correspondence: Ioan Sporea
Department of Gastroenterology
Str. Ion Bulbuca no.156
Timiºoara, Romania
E-mail: isporea@excite.com
Introduction
Romania’s alignment to the European Union includes
reaching certain standards of performance in various
domains, among which medicine should not be neglected.
The training in gastroenterology, as well as the practice of
gastroenterology in Romania must coincide as much as
possible with the models of the European Union. The
European Diploma of Gastroenterology, a document issued
in 1993 by the European Union of Medical Specialties
(EUSM) and the European Board of Gastroenterology
(EBG), aims to impose a standard training for all the fellows
in gastroenterology from Europe (1-3). It also statutes the
minimum requirements that training centers must fulfill in
order to be acknowledged as an European Centre of Training
in Gastroenterology.
The idea for performing this study was given by a recent
paper by Lamy and McNamara that analyses the practice of
gastroenterology in Europe (4). As such an analysis had
not yet been performed in our country, our aim was to assess
the practice of Gastroenterology in Romania and to compare
it with the data presented in the above-mentioned study.
Material and method
The first step was to obtain data regarding the number
of fellows in gastroenterology and the number of
gastroenterologists in Romania at the 1 st of January 2005.
The source of these data was the Centre of Statistics,
Ministry of Health and Family (CSMHF) and the National
Centre of Training for Medical Personnel (NCTMP). We
compared the number of gastroenterologists and future
gastroenterologists/100,000 inhabitants with data from other
European countries.
We also sent a questionnaire to all the 36 Centers of
Gastroenterology in Romania (University Clinics, Departments
of Gastroenterology or Internal Medicine with
Gastroenterology compartments, Gastroenterology
Outpatient Clinics), by e-mail, fax or regular mail. The
questionnaire asked about the number of specialists and
fellows in gastroenterology in the department and also if,

314
and how many of them, were performing gastroenterological
procedures required in this specialty: diagnostic/therapeutic
superior digestive endoscopy; diagnostic/therapeutic
colonoscopy; endoscopic retrograde cholangiopancreatography
(ERCP); abdominal ultrasound; liver biopsy;
percutaneous ultrasound guided therapeutic techniques;
proctology; diagnostic laparoscopy.
We collected and analyzed the data obtained. In addition,
we inquired which gastroenterological procedures required
in our specialty are performed by gastroenterologists and
by how many of them. We compared these data to the
European practice of gastroenterology.
Based on the number of gastroenterologists and fellows
in gastroenterology we tried to establish the number of
gastroenterologists in our country, now and in the near
future (when the fellows in gastroenterology, now in training,
will become specialists). We also compared these data to
that of 17 European countries (4).
Results
From the data provided by the NCTMP we found out
that the number of fellows in gastroenterology on the 1 st of
January 2005 was 133. In the spring of 2005, after undergoing
the board examination, 14 of them became specialists in
gastroenterology (Table I). From the CSMHF we found that
the number of fellows training in gastroenterology on the 1 st
of January 2006 was 121.
Sporea et al
Table II Current European gastroenterology manpower (adapted
from Lamy & McNamara) (4)
Country
Austria
Belgium
Denmark
Finland
France
Germany
Greece
Ireland
Italy
Luxembourg
Netherlands
Portugal
Spain
Sweden
United Kingdom
Norway
Switzerland
Romania
Population
(millions)
8.121
10.262
5.349
5.181
59.521
82.193
10.565
3.820
57.844
0.441
15.983
10.023
39.490
8.883
59.832
4.503
7.206
21.0
No. physicians
30 115
40 131
15 102
15 794
177 138
282 737
43 030
8 469
335 786
1 095
48 987
31 087
171 494
24 600
102 631
13 547
22 718
32 000
No.
gastroenterologists
262
390
121
53
2953
2007
356
25
N/A
19
138
340
1616
169
390
171
211
175
No.
gastroenterologists
/100.000
inhabitants
3
3.8
2.28
1.03
5
2.44
3.39
0.65
-
4.7
0.8
3.4
4
1.9
0.6
3.8
2.9
0.83
Table III presents the data obtained from the questionnaires
we sent, regarding if, and how many Romanian
gastroenterologists perform various gastroenterological
procedures.
Table III Number of gastroenterologists performing various
gastroenterological procedures in Romania
Table I Number of fellows in gastroenterology in training, year of
training and training centre
Procedure
Number performing the
maneuver/total number (%)
Training
centre
Bucharest
Oradea
Cluj
Iaºi
Târgu-Mureº
Timiºoara
Total
5 th year
(specialty
examination
March 2005)
5
1
2
4
1
1
14
5 th
year
11
1
6
2
1
2
23
4 th
year
14
1
9
8
0
1
33
3 rd
year
16
1
11
7
0
0
35
2 nd
year
6
0
2
3
0
0
11
1 st
year
9
0
4
4
0
0
17
Total
61
4
34
28
2
4
133
From the 36 centers of gastroenterology that received
our questionnaire we obtained data only from 26 (see
Acknowledgements).
From the questionnaires we obtained data about the
practice of 98 gastroenterologists. The total number of
gastroenterologists in Romania (CSMHF) is 175 (123
specialists and 52 senior consultants.
We calculated the number of gastroenterologists/100,000
inhabitants in Romania and we compared it to that of 17
European countries (Table II).
Based on the number of fellows in gastroenterology we
assessed the number of gastroenterologists of our country
over the following years (up to 2010) and we compared it to
that of the European countries.
Diagnostic superior digestive
endoscopy
Therapeutic superior digestive
endoscopy
Diagnostic colonoscopy
Therapeutic colonoscopy
ERCP
Abdominal ultrasound
Liver biopsy
Percutaneous ultrasound guided
therapeutic techniques
Proctology
Diagnostic laparoscopy
95/98 (97%)
72/98 (73.4%)
80/98 (81.6%)
59/98 (60.2%)
10/98 (10.2%)
78/98 (79.6%)
63/98 (64.2%)
30/98 (30.6%)
46/98 (46.9%)
1/98 (1%)
Table IV Proportion of fellows in gastroenterology that perform
(have been taught to perform) various gastroenterological
procedures in Romania
Procedure
Diagnostic superior digestive
endoscopy
Therapeutic superior
digestive endoscopy
Diagnostic colonoscopy
Therapeutic colonoscopy
ERCP
Abdominal ultrasound
Liver biopsy
Percutaneous ultrasound
guided therapeutic techniques
Proctology
Diagnostic laparoscopy
Number/total number (%)
47/68 (69.1%)
12/68 (17.6%)
23/68 (33.8%)
11/68 (16.1%)
2/68 (2.9%)
44/68 (64.7)
16/68 (23.5%)
1/68 (1.4%)
10/68 (14.7%)
0/68 (0%)

Practice of gastroenterology in Romania 315
We also analyzed the abilities of Romanian gastroenterologists
as compared with those of European gastroenterologists,
regarding various diagnostic and therapeutic
gastroenterological procedures (Table V).
Table V Gastroenterological procedures performed by European
gastroenterologists) (Lamy & McNamara) (4) vs. Romanian
gastroenterologists (%)
Gastroenterological
procedure
Gastroscopy
Colonoscopy
ERCP
Ultrasound
Endotherapy
Laparoscopy
Proctology
All emergency
endoscopy
Liver biopsy
Percutaneous ultrasound
guided therapeutic techniques
Europe
100%
100%
82%
41%
88%
29%
82%
29%
-
-
Romania
97%
81.6%
10.2%
79.6%
Gastroscopy 73.4%
Colonoscopy 60.2%
1%
46.9%
Superior 73.4%
Inferior 60.2%
64.2%
30.6%
In some domains we show up well: diagnostic gastroscopy,
colonoscopy and very well in abdominal ultrasound
(EU-41% vs. Romania-79.6%). But we found great
deficiencies in Romania regarding some procedures,
especially ERCP. While in Europe 82% of the gastroenterologists
perform ERCP, in Romania only 10.2% of them
master this technique.
Discussion
The practice of gastroenterology varies very much in
Europe, regarding the number of gastroenterologists/100,000
inhabitants and the gastroenterological procedures mastered
by them in each country.
Generally, gastroenterology is a specialty in demand;
there is little unemployment in the field of gastroenterology
anywhere in Europe (4). In the mean time, depending on the
number of gastroenterologists, the mean waiting time for a
gastroenterological public consultation varies from country
to country, Portugal and Norway having the longest waiting
period (4). Also, Portugal has the longest waiting period for
hospital admission; Ireland had the longest mean delay for
both private consultations and admissions: 3 months and 1
month, respectively (4).
Table II presents data regarding the number of gastroenterologists/100,000
inhabitants in various countries from
Europe. There are some countries with a large number of
gastroenterologists, meaning more than 4 gastroenterologists/100,000
inhabitants (France, Luxembourg or
Spain). There are also numerous countries with more than 3
gastroenterologists/100,000 inhabitants (Belgium, Greece,
Norway) and countries that are poorly “covered”, with less
than one gastroenterologist/100,000 inhabitants (The
Netherlands, Ireland, United Kingdom). In some countries
like The Netherlands some of the prerogatives of
gastroenterologist are taken by the specialist in internal
medicine who can perform gastroscopy. All these data reflect
the great variability in the organization and functioning of
the medical systems in Europe.
Regarding the number of gastroenterologists in
Romania, we are almost at the bottom of the list in Europe
with a very small number of 0.83 gastroenterologists/100,000
inhabitants. Only United Kingdom and Ireland have a smaller
number of gastroenterologists/100,000 inhabitants (0.6 and
0.65, respectively). France has a 6 times higher number of
gastroenterologists/100,000 inhabitants than Romania.
In the perspective of the year 2010, we calculated that
Romania can reach about 280-300 gastroenterologists for
21 million inhabitants (1.4 gastroenterologists/100,000
inhabitants) still close to the bottom of the table in Europe,
surpassing only the United Kingdom, Ireland, The
Netherlands and Finland, and continuing to have 3 times
less gastroenterologists than France, Luxembourg or Spain.
The cause of the discrepancy between the good
mastering of some gastroenterological procedures and the
low number of specialists performing ERCP (Table III) is
probably the lack of equipment in some centers and the lack
of performant radiology equipment.
We were also surprised by the small number of Romanian
gastroenterologists who perform proctologic procedures as
compared to Europe. In this case, the cause is the lack of
preoccupation, since the equipment needed is inexpensive
and easy to get (and probably already exists in all the
departments of gastroenterology). It is a strange fact that
81.6% of the Romanian gastroenterologists perform
colonoscopic examinations and only 46.9% of them
proctologic examinations. However, we must emphasize that
in Romania, by tradition, surgeons perform most of the
proctologic examinations, while in European countries such
as France, the gastroenterologist performs interventional
proctologic procedures.
It is surprising that in Europe only 29% of the
gastroenterologists perform emergency diagnostic and
therapeutic endoscopy. In Romania, even if, maybe, the
question was not clearly formulated, it is encouraging to
see that 73.4% of the gastroenterologists perform
therapeutic superior digestive endoscopy and 60.2% of them
perform therapeutic colonoscopy.
The data regarding the training program of the Romanian
fellows in gastroenterology (Table IV) are disappointing,
but maybe the questionnaire should have divided the
fellows by the year of training, since the training program is
a gradual one, beginning with simpler procedures and
finishing with ERCP and therapeutic endoscopy. Anyway,
we do not consider normal that only 14.7% of the fellows
are able to perform proctologic examinations.
The insufficient training of the Romanian fellows in
gastroenterology is caused, in our opinion, by several
factors:
- too many fellows in some centers (Table I) thus making
the adequate access to the small number of existing endoscopes
impossible;
- insufficient number of endoscopes in the training
centers of gastroenterology;

316
- the possible lack of interest of the trainers; in most of
the cases the trainer (especially in endoscopy) has too many
other activities and has not enough time to spare for the
adequate training of the fellow.
In a recently published editorial in the Rom J
Gastroenterology, Mulder et al commented about roughly
the same deficiencies of the endoscopy in Romania, mainly
regarding the fact that the majority of units are moderately
stocked with state-of-the-art-equipment (10). He suggested
that each fellow in gastroenterology should perform a
minimal number of procedures (1000 gastroscopies, 500
colonoscopies and 100-150 ERCP’s) during a training period
of 3 years and that each trainee should spend at least 10
hours/week in the Endoscopy Unit. In the same paper,
starting from the models of neighboring countries (11),
Mulder et al discuss the necessity of a correct reimbursement
of the endoscopic maneuver, as well as the funding necessary
in order to obtain adequate technical equipment.
The minimal number of endoscopic procedures proposed
by Mulder et al (10) exceeds by far those required by the
European Diploma of Gastroenterology (300 upper digestive
endoscopies, 30 haemostatic gastroscopic procedures, 100
total colonoscopies, 50 polypectomies or haemostatic
colonoscopic procedures, 100 proctologic examinations, 50
abdominal puncture and/or biopsy with or without
ultrasound control, 300 abdominal ultrasound
investigations), and those required by the American Society
for Gastrointestinal Endoscopy – ASGE (140 colonoscopies
and 130 gastroduodenoscopies) (12). Nevertheless, ASGE
acknowledges the fact that “these are minimum numbers
and that most trainees will require more than this number to
achieve competence” (12).
In one of his papers, Kirsch comments on the trainertrainee
relationship in the field of gastroenterology, insisting
on the fact that the trainer must be deeply involved in the
training program of the fellow, saying that ”...we can teach
him a few things also, everyday skills that his fellowship
may have overlooked. If he is smart, and we think he is, then
he will listen closely to us, even if he thinks he had already
seen it all” (13).
Conclusion
The number of Romania’s gastroenterologists at the
present time as well as in 2010 is very low compared with the
majority of the European countries
Romanian fellows training in gastroenterology do not
acquire a satisfactory mastering of the gastroenterological
procedures during their training program. The Romanian
Societies of Gastroenterology and Hepatology, and of
Digestive Endoscopy must contribute to the improvement
of training programs, probably by cooperating with the
NCTMP, the Ministry of Health and Family and the Romanian
College of Physicians.
Regarding the training program in Romania, there is much
to be done and the guidelines of the European Diploma of
Sporea et al
Gastroenterology could be a good model. The European
Diploma of Gastroenterology includes the minimum number
of procedures that a fellow must perform in order to be
recognized as a European Fellow of Gastroenterology. We
consider that this list of procedures must be the “the Bible”
for a fellow in gastroenterology. His logbook would enable
the trainer to continually monitor the training of the young
doctor.
Acknowledgements
The authors would like to thank to all the centers that
participated in this study, especially the contact persons
who answered the questions which made this multicentric
study possible:
Arad (E. Miuþescu, T. Duºe), Baia Mare (I. Mailatescu),
Bucureºti (M. Diculescu, C. Gheorghe, I. Dina, C. Chira, R.
Voiosu, G.Constantinescu, T.Bãdescu), Bistriþa Nãsãud (R.
Lezeu), Constanþa (F. Voinea, E. Dumitru), Cluj (P.A. Mircea,
S. Vãlean, A. Drãghici), Craiova (T. Ciurea, A. Sãftoiu, V.
Sbârcea), Iaºi (A.Trifan, C.Cijevschi), Oradea (C. Brisc, O.
Frãþilã, A. Lenghel), Râmnicu-Vâlcea (A. Scãunaº), Reºiþa
(E. Baºa), Satu Mare (I. Brândeu, C.Ursu), Sibiu (A. Frãticiu),
Suceava (L. Croitoru), Tg-Mureº (S.Bãþagã, D.Dobru,
L.Bancu).
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