The issue of medical personnel acute shortage is constantly being discussed in the media and power structures [1, 2]. Certain activities taken to support state medicine do not make the situation less tense. In this regard, personnel changes are researched with a focus on economic problems [3]. The famous proverb saying that ‘money can’t buy happiness’ is widely applied in medicine. Thus, we wondered which moral reasons urged medical personnel to leave state healthcare and shift to commercial structures or abandon the medical profession. To answer the raised question, a sociological survey was conducted by the Volgograd State Medical University and Healthcare Committee for the Volgograd region in May-June 2023.

Purpose: To determine the priorities of managers of medical organizations within a common Russian region while trying to deal with staffing of entrusted structural subdivisions and determine ethical and legal reasons why healthcare professionals leave state medicine shifting to commercial structures or other spheres of activities.

Objectives:

• To find out which problems of regional healthcare raise concern of managers of medical organizations.
• How to prioritize the resources for problem solving.
• Which activities used to eliminate the healthcare staffing issues are considered by those surveyed as the most effective ones?
• Which changes in the work of medical organizations can be supported by their managers?
• What exact changes in personnel policy are essential for regional healthcare?

Method of research. A special questionnaire intended for heads of regional state medical organizations was developed. The results were processed with Google-forms and SPSS system, generalized and interpreted. 94 regional medical organizations were included into the research with their heads being the participants. The sampling was continuous. 94 questionnaires were selected.

Interpretation of results. Heads of medical organizations are mainly represented by people of pre-retirement age (42% of those surveyed are 51 to 60 years old). This produces both a negative and positive effect. It is positive because these people have extensive working experience; most trained medical managers belong to this group (25 to 31 and over years of experience in 42% of those surveyed). But they will soon retire, and not everyone will be able to stay in their current position. And this is a negative effect. In the future, shortage of medical managers is possible. Over one third of the surveyed have occupied a superior position for over 15 years. Thus, the principal objective is to prepare a reserve of personnel. A second higher education or an academic degree give more opportunities to get a job at a private hospital.

Having assessed the staffing of doctors as unsatisfactory or satisfactory, it can be seen that it accounts for one-fifth or four-fifth of all points, respectively.

It can be mentioned that medical managers participating in the survey believe that a) the shortage of doctors is a pressing issue; b) the shortage accounts for 1/3 of the required part (evaluation of the scoring result). According to the survey held in October 2022 by hh.ru, the shortage of medical and social workers was 17% (in 2022, the Volgograd region was in need of these professionals — KP.RU). This differs from the shortage found during our survey by almost 2 times. Why so? The answer is simple. Head physicians and their deputy chief doctors understand well enough how many qualified professionals the hospitals need to function effectively. But their opinion doesn’t affect the statistics because doctors are allowed to work at one and a half or one and twenty-five hundredths rate. In this case, we’d be getting the 17% of doctors who are lacking and make functioning of the entire industry incomplete. So, both our research data, and data of hh.ru are justified.

The surveyed estimate the staffing of paramedical personnel as unsatisfactory as well, though it is believed to be higher as compared with doctors. Special attention should be paid to the situation with paramedics. In the proposal of the Ministry of Health of the Russian Federation it has been said that some functions of physicians should be handed over to nurses [4]. A violent reaction in the medical society made it impossible to include the issue about the attitude to this initiative in our research as the proposal was assessed too emotionally. But let us compare the abovementioned fact and changes in secondary professional medical education.

Since September 1, 2023, medical students from secondary vocational educational institutions will spend less time studying [5]. This is stated in novel federal educational standards approved by the Ministry of Education. For some specialties, the training period will be reduced by one year. The period of training under such programs as General Medicine, Laboratory Diagnostics, Medical Optics, Medical and Preventative Care, Pharmacy, Nursing Care, Orthopedic Dentistry, and Preventive Dentistry is 1 year less. The period of training after the 9^th class under these programs (except Preventive Dentistry) is 3 years and 10 months now and will be 2 years and 10 months next year. For preventive density, it is 2 years and 10 months now and 1 year and 10 months later.

Those who attend Medical Massage and Midwifery programs will study 4 months less. In the Ministry of Education, it is believed that the reduced period of training will improve the quality of education and ensure faster supply of the required personnel in medicine. But is it possible to develop the skills of compassion, mercy, kindness, and an ability to talk to a patient among future paramedics during such a short period of time? [6–8].

In our research, the issue of medical care quality has been raised. The surveyed highly appreciated the quality of medical personnel training on a 10-point scale; 43% of the surveyed scored it 7–8 points, which is good. Nobody gave a rating of 1, and 1 person scored it 2. The average scores of 5–6 points were awarded to one fourth of those surveyed, meaning that training of medical personnel is associated with unrealized opportunities. This is particularly relevant when it comes to the outflow of highly qualified professionals from state healthcare. Well prepared specialists are in high demand, their labor conditions should correspond to the qualification. So, it may happen that only those whose qualification was scored 5–6 points will continue working for state healthcare. That is, as the survey shows, probably a fourth part of personnel from state medical institutions.

Those respondents who assessed the outflow of personnel to commercial medical organizations were subdivided into three groups and had various views to the problem. Serious concerns are raised in 23.5% of them. 14% of them believe that the problem is either exaggerated or nonexistent. 59.2% (main group) admit there is a problem but do not make tragedies out of it. In this regard, it is necessary to take into account the long-lasting debates about the state and private medicine. A large group supports transition to state medicine, just as in Soviet times. According to the second group, private medicine is much better. And the third group states that an equal balance between state and private medicine is required. In our survey, all three approaches were presented. It is necessary to determine a position of the regional Healthcare Committee, because its policy forms the basis of an action plan for all medical organizations.

The same division in groups exists in relation to the attitude of those surveyed to migration within the medical society. Exploration of the question results in latent data about the attitude of medical managers to the regional healthcare system. Indeed, one of the reasons for personnel outflow is to admit that labor conditions and attitude to medical professionals is better in some other region of the country than at home. These respondents are scared of personnel departure to other regions (22% of those surveyed). They do not only admit there is such a possibility, but also have no doubts that it will be implemented because things go better at another region. Meanwhile, they refer to what their colleagues tell them or to Web-based materials.

At least 27% of the surveyed are not impressed with the departure of their colleagues to another region and take into account two complementary considerations: a) it is a personal choice; it does not matter whether the new location is better or worse, the person knows what he/she is doing; b) the situation is almost everywhere the same, being in the profession is the most important thing to do.

The third group, which is the largest (49%), admits that the problem exists. However, it is not known whether anything is done to solve it, as the question is investigated during another research.

The organizational interest obviously includes not the attitude of medical managers to the outflow of personnel (departure to another region or transition to the private hospital) but rather the reasons for it. It is commonly perceived that doctors change jobs searching for a higher salary. This fact was neither confirmed, nor denied by our research. Let us note for now that only 26.9 of the surveyed believe that the situation with remuneration is though not tragic but dramatic enough (1 to 5 points inclusively). At the same time, 72.1% of the surveyed provided rather positive assessment of the remuneration (6 to 10 points inclusively); only 1 person believed it was excellent.

What produces the strongest effect on the personnel outflow, in the opinion of medical managers? They believe that the main reason for the outflow is the low level of social security of medical personnel. The level was considered as unsatisfactory and satisfactory by 46.4% and 47.3%, respectively. The score of 6–7 points predominates among positive estimates. Very few assigned 8–10 points hereto. The data can be interpreted as a need of healthcare professionals in a higher rate of social security. It is obvious that special activities are required in this regard (to raise the value of the profession, expand the legal field regulating the labor of healthcare professionals, and improve the system of incentives, which nowadays consists of local acts, whereas the system of punishments operates on a permanent basis, reduce labor expenses on NON-medical types of work, etc.).

57.1% of the surveyed assessed the personnel-related situation in state medical organizations as positive (excellent, good, satisfactory). Meanwhile, the majority opted for the ‘satisfactory’ response. 43% of those responded gave a negative assessment (rather unsatisfactory, unsatisfactory, critical). Though positive estimates prevail, the distribution shows that medical managers are not sure about tomorrow. The personnel departure continues; and though the situation is typical for the Russian healthcare in general, every region has its specific features. In the Volgograd region, the paradox is obvious: due to good professional training, local healthcare professionals are in high demand both in private medicine, and in other regions. This makes the staff base of the region weaker. The surveyed were asked ‘Who is to blame?” and “What should be done?” (questions, which are traditional for Russia), though in a different form.

Not everyone could provide responses. But those who did admitted that they were most concerned about a decrease in the number of both doctors, and paramedical personnel. This is hardly news, as the research sponsor was concerned about the same issue. The stated reasons for the personnel shortage were unexpected. It is widely believed that migration within the medical community exists because of insufficient remuneration. But it was not among the reasons named by our respondents. In their opinion, the main reason for medical personnel shortage is the lack of the state-supported graduate distribution system. Devaluation of profession is in the 2^nd place. Increased workload, high physical and mental loads are in the third place. Focus on the moral components of the profession (hoping to implement such principles of bioethics as justice and benefit) is clearly visible here [9, 10].

The first reason can be interpreted as a sign of social maturity of respondents (medical managers). They take a realistic view and focus on the future. The regional authorities, however, can’t decide on the introduction of any distribution form for the graduates, as the initiative lies at the federal level. But now the targeted admission, student’s agreement advocated by the Prime Minister of Russia, and some other forms can be regulated at the regional level. It is necessary to monitor the effectiveness of their application and adopt the best. Probably being aware of the difficulty in obligatory distribution, the respondents failed to note it in their recommendations for the authorities (the proposal came from 1 person only).

A decreased value of profession is another reason for personnel shortage, which requires special attention. First, it means that respondents are devoted to their profession. Second, the value of the profession can and should be raised at the local and regional levels. However, it is necessary to collect proposals of doctors and have a comparative analysis with opinions of patients about the status of a doctor. There is a great deal of such trials. So, it is advisable to find out the opinion of doctors using a focus group method. This is how the dynamics of physicians’ satisfaction with changes in medical professions can be traced.

The third mentioned reason for personnel shortage is rather the shortage consequence. But it is a vicious circle, as the personnel shortage increases the load on medical personnel, the increased load provokes the retirement, again resulting in the shortage of personnel. It is obvious that the circle needs to be broken. But at what point should it be done? Reply to the question ‘Which proposals concerning the supporting measures of medical workers from state medical institutions should be submitted for consideration by the regional authorities, in your opinion?’ will be the answer. Principal expectations of respondents here are associated with the measures of social support and social protection of medical workers. Thus, the first position is occupied by remuneration of medical professionals employed by state medical organizations to make the initial payment while obtaining a loan for the purchase (construction) of residential premises and health resort treatment at regional sanatorium establishments at the expense of the regional budget. Increased one-time financial assistance to young specialists with higher and secondary medical education employed by rural medical organizations holds the second position. Monthly financial assistance to the mentor who accompanies a beginner within a medical organization onsite or online as per the approved adaptation plan is in third place.

It should be noted that medical managers are concerned about the position and perspectives of young specialists. It supports the conclusion that the managers are set up for the prospect and suggest activities, which can be implemented by the regions. This is a consistent position, as respondents do not commonly consider the measures of social support of medical workers as sufficient enough (52.7%) though admitting that the measures are being implemented currently (59.1%).

Thus, the question “What should be done?” has a definite answer: it is necessary to take care not only of patients, but of medical workers as well [11]. In their replies, they mentioned what kind of care and protection they seek. This can be highlighted in brief conclusions.

CONCLUSIONS

1. Managers of medical organizations acknowledge that there is an outflow of health personnel, and, as a consequence, its deficit in entrusted organizations. They do not believe that the situation is critical. However, they are concerned about development of measures associated with reduction of this process.
2. Outflow of personnel from state medical organizations to private medicine or other regions occurs due to unsatisfactory social support and social protection of healthcare professionals. Some of these problems can be solved either at the federal or regional levels. Not only patients, but also medical professionals require protection, attention and comprehension; in our country, the system of ethical and legal support is lacking [12].
3. At the regional level, it is possible to enhance the value of a medical profession, develop the mentoring system, and implement the system of regional incentives and rewards. The system of intergenerational transfer of profession-related values with an extremely important role of a mentor, which is currently underestimated yet, needs to be supported desperately [13, 14]. A mentor is a moral agent engaged in the formation of a medical graduate both as a professional and a human being.