The purpose of the current paper is to present the message of the Presidential Lecture given during the first congress of arthroscopy organised in Romania, in March 2016, by the Romanian Society of Arthroscopy and Sports Trauma (SRATS). The goal was to present the evolution of medical care in Romania over the years, with the remarkable progress made in the first half of the twentieth century and the current status of arthroscopic surgery as seen from the point of view of medical professionals, as well as from a governmental point of view.

At the beginning of the nineteenth century, Romanian medicine was still rudimentary, trying hard to deal with major epidemics. The evolution of medical assistance, medical education and health system organisation was dependent on economic, social and cultural factors. The main changes in society generated by the Romanian Principalities’ Union (1859), the Establishment of the Monarchy (1866), the winning of the War of Independence (1877–1878) and the Great Union (1918) had a huge economic impact. This rapid economic growth generated an important development in Romanian medicine, so that, during a period of about 80 years, starting from the second half of the nineteenth century, the standards of medical care in Romania were very close to those in the Western European countries.

The first steps towards developing medicine in Romania were made by Prince Barbu Stirbey in 1853, who invited the French doctor Carol Davila to organise and manage the health service of Wallachia. In 1855, he established the Minor Surgery School, which was subsequently converted, following the French model, into the National School of Medicine and Pharmacy. In 1867, Carol I of Romania approved the foundation of the Faculty of Medicine in Bucharest. The first professors were exclusively educated at medical schools abroad (Gheorghe Polizu, Nicolae Turnescu, Iacob Felix, Stefan Caspa and so on). In 1879, as a result of the increasing demand for medical care, the Faculty of Medicine in Iasi was founded. In 1919, after the Great Union, another university was founded in Cluj, including a Faculty of Medicine, whose teaching staff included great personalities of the time like Iuliu Moldovan, Iuliu Hatieganu, Gheorghe Bilascu, Iacob Iacobovici and Victor Papilian.

Romanian medicine thus turned progressively into European medicine. Not only the professors of medicine and some of the doctors educated or specialised at important European medical centres but also the structure of the health system, as well as the university organisation, was similar to those in the west. Medical care in Romania respected the European standards, and there was a permanent connection, an active exchange of ideas between Romanian and Western European medicine.

While in the late nineteenth century, medicine in Romania was practised by a small number of foreign doctors or Romanian doctors educated abroad, from the beginning of the twentieth century, many important medical personalities contributed to the development of both Romanian and European medicine. This rapid evolution continued until World War II.

In 1895, Wilhelm Conrad Röntgen produced the first radiograph—of his wife’s left hand. One year later, Prof. Dr. Constantin Dimitrescu Severeanu succeeded in obtaining the installation of an X-ray device at Coltea Hospital. In 1902, a radiology department was founded at Coltea Hospital; it was headed by Dr. George Severeanu who had specialised in Vienna and Berlin.

Prof. Dr. Thoma Ionescu (1860–1926) studied medicine in Paris. Between 1885 and 1890, he became a surgical intern at the Hospitals of Paris, and between 1892 and 1895, he was a professor of anatomy at the Faculty of Medicine in Paris. He was awarded a prize by the Academy of Medicine in Paris for his work entitled Retroperitoneal internal hernias, and he wrote the chapter on the anatomy of the digestive tract for the Handbook of Human Anatomy, published under the co-ordination of Prof. Dr. Poirier. In 1895, he decided to return to Romania and became head of the Surgery Department at Coltea Hospital. He continued his international scientific activity, created the magazine Archives des sciences médicales in Paris and participated in international congresses with reports and communications, and in Europe and America, he demonstrated the potential for high spinal, suboccipital anaesthesia.

Prof. Dr. Ernest Juvara (1870–1933) studied medicine in Paris. In the Handbook of Human Anatomy published under the co-ordination of Prof. Dr. Poirier, he supervised the drawings and even created some of them. Together with Friteau, he published Quinze leçons d’anatomie pratique, illustrated with 84 drawings and diagrams of his own. Together with Legueu, he published a work on the septa connecting the superficial and the deep aponeurosis of the hand, named the septa of Legueu-Juvara. In 1895, he returned to Romania, and in 1899, at the young age of 29, he became professor of anatomy in Iasi and subsequently professor of surgery in Bucharest, at the Brâncovenesc Hospital. His surgical procedures, Delorme-Juvara and Juvara-Merle D’Aubigné, are still in use.

In medicine, as in all other aspects of social life, communism brought about a total reversal of values. A single ideology, Marxism, was imposed. All the medical specialities were ideologised—genetics, for instance, became “a reactionary science” and the Soviet medical sciences were glorified. The selection criteria were of a political nature, and social origin was considered, not individual value. Manipulation and misinformation tools were used, such as lies, denunciations, blackmail and terror, in order to intimidate and even annihilate the opponents of communism who rejected any compromise. Complete isolation was imposed, forbidding any contact with the western medical world. Reading a western medical journal was almost regarded as a political crime, indicating a potential relationship with the “decadent world of western imperialism.” Chronically isolated and underfinanced, lacking access to high-quality information, Romanian medicine experienced a decline never seen before, throughout its long history. The discrepancy between Romanian and Western European medicine gradually increased during the Communist period, a discrepancy which, unfortunately, still persists today.

During the last 25 years, Romanian medicine has made important efforts to minimise this discrepancy. The old connections with western medicine have been resumed, and Romanian doctors have regained access to medical journals, courses, congresses and fellowships. Constant efforts are being made to modernise public hospitals, and private healthcare units have been inaugurated.

Having the opportunity to train in Western European countries made it possible for a leading group of orthopaedic surgeons to introduce arthroscopy in Romania in 1990. The beginning was very difficult, due to the lack of arthroscopy devices and the financial difficulty involved in purchasing them. Moreover, there was initial confusion that the financial investment involved in purchasing arthroscopy devices will further increase medical costs. It took a while to understand that rapid post-operative recovery with shorter hospitalisation and faster social re-integration as compared to open surgery substantially compensated for these increases in initial costs. Many technical compromises were therefore necessary when it came to developing arthroscopy until 2007, when, after prolonged efforts and difficult negotiations co-ordinated by the same group of orthopaedic surgeons who struggled to introduce arthroscopy in Romania, the Ministry of Health approved the acquisition of 36 arthroscopy towers intended for use at the major university centres.

From the very beginning, the imbalance between the real cost of arthroscopic procedures and the cost set by the National Health Insurance System represented a further impediment to the development of this type of surgery. During the first few years, the National Health Insurance System covered the equivalent of about 300 euros/arthroscopic procedure, similar to the classical surgical procedures. Invited by the Romanian authorities to guide the process of lowering the medical costs, the National Institute for Health and Clinical Excellence (NICE) introduced the concept of “Washing Knee” designed to discourage diagnostic arthroscopy. As a result, starting from 2011, the day surgery concept was introduced and the consequence was that less than 30 euros was paid for an arthroscopic procedure between 2011 and 2013. This amount resulted from a simplistic approach, taking account of the fact that, at that time, the average length of hospitalisation in Romania was 10 days. Subsequently, the health authorities reduced it to 5 days in order to promote the minimisation of unnecessary prolonged hospitalisation. Starting in 2014, the National Health Insurance System agreed to cover the equivalent of about 100 euros/arthroscopic procedure. Facing the evidence of the necessity for improved coverage of the costs of arthroscopic procedures, in particular ligamentous surgery, starting in 2015, the National Health Insurance System introduced a National Programme for Chronic Instabilities designed to support the treatment of 1300 patients/year at a supplementary cost of about 800 euros/patient. This was intended to support patient care according to the recent progress made in the diagnosis, treatment and post-operative rehabilitation of patients with sports pathology, as demonstrated to the health authorities by medical professionals.

In 2000, a national training programme in arthroscopy for orthopaedic surgeons, with a well-established curriculum and specific targets, was initiated by the Ministry of Health. From 2011, arthroscopy training became mandatory as part of the residency curriculum. All these measures have now materialised in the existence of more than 300 orthopaedic surgeons who practise arthroscopy in Romania.

The foundation of the Romanian Society of Arthroscopy and Sports Trauma (SRATS) in 2008 and the organisation in 2016, in Bucharest, of the first national congress of arthroscopy—the SRATS Congress 2016, with large-scale international participation were designed to further stimulate the evolution of this type of surgery. Starting in 2014, the establishment of the National Registry for Ligament Reconstruction was another landmark in the development of arthroscopy in Romania.

Continued efforts are needed for the reformation process that has already begun. Improved medical education and access to high-quality medical information modernised medical facilities and increased financial support to cover the direct costs of medical care and create a fair compensatory Diagnostic-Related Group (DRG) System are all mandatory in order to reduce the discrepancy between European and Romanian medicine.