Medical education is being shortened by a year: how the quality of treatment will change. What will happen to medical students after they graduate this year? Future doctors are most frightened by patients
Natalya Litvinova
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The All-Russian seminar “Organizational and methodological issues for conducting primary accreditation of graduates - 2017” was held on February 16 at the First Moscow State Medical University named after. THEM. Sechenov.
An intensive training course consisting of two blocks - theoretical and practical, was offered to the chairmen of accreditation commissions - representatives of non-profit professional organizations who will carry out a large-scale campaign for the primary accreditation of medical university graduates in the summer of 2017.
The organizers of the seminar are the Ministry of Health of Russia, the Union of the Medical Community “National Medical Chamber” and the Methodological Center for Accreditation of Specialists.
The seminar was moderated by the Vice-Rector for scientific work And vocational education First Moscow State Medical University named after. THEM. Sechenov Sergey Shevchenko. Opening the seminar, he conveyed wishes for successful and fruitful work on behalf of the rector of the university, Academician of the Russian Academy of Sciences Peter Glybochko.
Calling for the creation of an effective framework for initial graduate accreditation, laying the foundations from the very beginning successful work for many years to come, President of the National Medical Chamber Leonid Roshal addressed the seminar participants. He noted that along with the development of professional standards, primary accreditation “is a specific work that was transferred by the Russian Ministry of Health to the National Medical Chamber, a state-public form of management of educational activities.”
Director of the Department of Medical Education and Personnel Policy in Healthcare of the Ministry of Health of Russia Tatyana Semenova explained that the seminar is being held at the reference Methodological Center for Accreditation of Specialists, created on the basis of the First Moscow State Medical University named after. THEM. Sechenov. And ideally, it is under such conditions that accreditation should take place. She also spoke about the legislative norms that regulate the transition to the accreditation procedure for medical and pharmaceutical specialists. Accreditation is being introduced in stages, from January 1, 2016 to December 31, 2025.
Detailed explanations about who will undergo accreditation, how the commission is formed, what documents are required for admission and assessment of a specialist are contained in the order of the Ministry of Health of the Russian Federation dated June 2, 2016 No. 334n. Tatyana Semenova explained the need for accreditation as a “global era of change.” New technologies, Federal State Educational Standards and professional standards are being introduced, and requirements for managing the quality of medical care are being unified. In general, specialist accreditation is a special form of examination consisting of several successive stages.
Director of the Methodological Center for Accreditation of Specialists Zhanna Sizova made a presentation and explained in detail the features of each stage. Each stage is an independent exam, which gives the right to admission to the next stage. Primary and primary specialized accreditation include: testing, assessment of practical skills (abilities) in simulated conditions, solving situational problems.
Each stage is assessed by the accreditation commission in a pass/fail format. The stages of testing and assessment of practical skills are considered passed if at least seventy percent of the answers and practical actions are correct. The stage of solving situational problems is considered completed if at least ten out of fifteen possible questions are answered correctly.
University graduates who have passed accreditation can begin working in primary care - as local therapists in polyclinics. Graduates of residency will face a more difficult exam - primary specialized accreditation, which gives the right of admission to specialized medical activities. Three attempts are given to pass each stage of accreditation.
Zhanna Sizova spoke in detail about all the intricacies of primary accreditation and invited the seminar participants to move on to the second - practical block of the seminar - a demonstration of the procedure for primary accreditation in the specialty "General Medicine" and familiarize themselves with the stations of the Objective Structured Clinical Examination (OSCE) to test the mastery of professional competencies of graduates. Stations for cardiopulmonary resuscitation, emergency and emergency medical care, physical examination of the patient, medical examination were presented - to test the competencies that correspond to the labor functions of a local therapist in accordance with the professional standard.
The practical block aroused great interest among the seminar participants. In general, the seminar provided full information on changes in the procedure for admission to professional activities of graduates of Russian medical universities and, in fact, became the start of the primary accreditation of graduates of medical universities in 2017.
In 2017, more than 37 thousand graduates of medical universities in eight specialties will undergo primary accreditation:
Natalya Litvinova
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The scheme of education in medical universities in Russia has changed radically. Due to cancellation of internship Many are afraid that dropouts will come to clinics. The introduction of new medical standards divided doctors into two classes.
Since 2016, future local pediatricians and therapists begin studying under a shortened program, which involves six years of training. Potential surgeons, cardiologists and other medical specialists will have to spend 8 to 11 years studying.
As it was
Previously, all doctors studied for seven to eight years. It took six years to study at medical school, and then either an internship for a year or a two-year residency. Moreover, in some specialties it was necessary to go through both of these steps. However, for many medical specialists, one internship or residency to choose from was enough.
An intern and a resident are considered something like students in a medical institution, since they are not on the staff and do not receive salaries. They do essentially the same thing as a doctor, with only one difference - all actions are performed by interns and residents under the vigilant supervision of senior colleagues.
It is not surprising that many, trying to quickly get rid of this half-hearted status, choose a one-year internship as the next step after university. However, from 2017, medical graduates will no longer be tormented by such a choice.
How will it be
Now, starting from 2017, medical university students will be taught according to new educational standards. Immediately after the institute, graduates will have the right to immediately, without any additional training, work in clinics (as therapists or pediatricians). For these purposes, much more practical training was introduced for training students, both with patients and on simulators.
Rector of the First Moscow State Medical University named after I.M. Sechenov, Professor Pyotr Glybochko, shared his thoughts on how the new education system will be implemented:
“Now, in the first year, educational practice in caring for therapeutic and surgical patients is expected. In this regard, it is planned to introduce a training module “Basics of Patient Care” in the amount of 36 hours (24 hours will be allocated for practicing skills on dummies and simulators in our own training center and 12 hours for practice in clinics). Sophomores will study “the fundamentals of nursing” for 72 hours, and they will also have work and practical training in the simulator training center.”
For third-year students, they want to add hours of practical courses in emergency medical care. They are going to develop additional training modules for fourth- and fifth-year students in specialized departments of surgery, therapy, obstetrics and gynecology.
And here, too, you cannot do without simulators and dummies. In the sixth year, classes on medical simulators will be held in the form of consultations with teachers from departments of the chosen profile.
“A medical university graduate must be ready for independent work immediately after receiving a medical degree. Let this be primary health care - outpatient clinics - but our graduates will be prepared for this work already during the standard university program,” summed up the rector of the First Medical University.
However, not all teachers in the field of medicine see such bright prospects. Simulators and dummies are, of course, good, but they cannot replace living patients.
“In my opinion, immediately allowing graduates to work with patients would be a big mistake. A doctor needs certain skills for this,” Professor Viktor Frolov, dean of the RUDN Faculty of Medicine, expressed his concerns.
Also, the overwhelming majority of specialists seriously doubt the productive work of yesterday’s students in clinics. It is unlikely that the skills acquired at the university will be enough, but after the introduction of new standards, graduates will have even less knowledge.
“To free up time for practical training, we had to narrow the programs in certain areas of medicine, such as neurology or, for example, surgery. These courses will be taught in a more general, theoretical form,” explained the Ministry of Health and Social Development.
It turns out that if previously a medical graduate was something like a “universal soldier” who could, with the help of a medical reference book, understand most diseases and pathologies, now certified local doctors will have only a theoretical understanding of many diseases.
The issue of obtaining a full-fledged education is becoming increasingly relevant. After the federal standard of education for the third generation came into force Russian Federation The approach to training future doctors will change. Since January 2016, internships have been abolished for those who have chosen dentistry and pharmacy as their specialization, and since 2017 – for pediatric and medical and preventive faculties. The innovations apply to those who have entered a medical school since 2013. Let’s take a closer look at what such innovations bring to the training of doctors, and how they will train medical workers in Russia.
The essence of medical education reform
New state education standards state that graduates of medical universities must be absolutely ready to start working in the healthcare system. This is what explains the need to cancel internship training. Starting from September 2017, this form of higher professional training will be completely abolished.
In 2017, many doctors will start working without internship training
Let us remind you that until recently, even a local doctor at a clinic had to have a certificate confirming completion of an internship and successful passing of a qualifying exam. Now, one diploma from a relevant university will be enough. According to the main provisions of the new approach to obtaining medical education, students of medical universities will master healing techniques on simulators or in hospitals and clinics assigned to the university.
The innovation assumes that students of pediatric and medical-prophylactic faculties will practice practical skills under the guidance of specialists from assigned medical institutions already in the fifth and sixth years of study. Dentists and pharmacists will undergo this practice as early as the fourth and fifth years of their education.
The main goal that can be achieved by abolishing internships is to solve the problem of the shortage of medical personnel in the so-called “primary practice”. Representatives of the Ministry of Health came to the conclusion that the problem will be solved if, in the near future, a graduate of a medical university, admitted under the target quota, immediately after receiving the certificate of completion educational institution will have to work for three years in the therapeutic or pediatric department of a clinic.
It is assumed that the first place of work will be an institution located in the area from which the recruitment took place. “State employees” who studied on scholarships will have to return the money spent on them to the state after graduating from university. The system is reminiscent of the distribution practice that existed under the USSR and causes reasonable concern among students.
The young doctor will receive a job in the area from which the recruitment took place
Not everyone dreams of going to the village for “working out”! Only after three years of medical practice as a therapist or pediatrician will the former student receive the right to enter residency, where he will be able to become a more specialized specialist in two years of study. The question of completing residency remains relevant for those who plan to engage in surgery, transplantology, cardiology, neonatology and other specialties.
New in the accreditation procedure for health workers
Let us note that 2017 will bring another new thing for doctors: the certification procedure will be replaced by accreditation combined with state exams. It is expected that this measure will improve the quality of education. Mandatory accreditation was introduced in 2011. According to the adopted law regulating the field of health care, in 2016 the accreditation procedure comes into force - a procedure on the basis of which a doctor’s readiness to carry out professional activities is determined.
This examination will be required every five years. The Ministry of Health plans to create a general register of medical specialists, which will publish information about the level of education and advanced training of doctors. Thus, patients will be able to evaluate the professional skills and competence of existing doctors and independently choose their attending physician. It is worth noting that the Ministry of Health has not yet announced clear requirements for assessment criteria or rules for accreditation.
Presumably, this will include testing knowledge through testing, providing a portfolio and examination at the simulation center. Doctors who successfully pass the test will receive an “individual certificate of admission to specific types of medical care.” Accreditation of 2016 graduates will be carried out by specialized universities, and current doctors will undergo it over a five-year period in specially created centers.
The Ministry of Health plans to create a general register of health workers for patients
Criticism of medical education reform
Many healthcare experts note that these innovations seem very dubious to them. The previously existing system of training medical specialists assumed that practical knowledge was acquired by interns, firstly, without distraction from the theoretical component of training, and secondly, under the strict guidance of established practitioners who assumed most of the responsibility. Some doctors even express the opinion that this measure is purely populist.
Of course, yesterday’s students, who will fill the vacancies of therapists and pediatricians, will eliminate queues at clinics (today in Russia the quota of local doctors, estimated at 40 thousand people, has not been filled). Doctors also fear that in this way the Ministry of Health will create artificial competition, because if a doctor’s place can easily be taken by a yesterday’s graduate, then it is more difficult to defend the right to a salary increase.
According to Alexander Kogan, doctor of medical sciences and oncologist, only internship provides an opportunity to prepare highly specialized medical practitioners. The abolition of this stage of training and its replacement with practice during training will lead to a reduction in the hours allocated to microbiology, biochemistry, physiology, so that future therapists will miss out on some important theoretical training. It is simply impossible for yesterday’s graduate to be ready for real work immediately after receiving the “crust.”
Everyone is worried about the question: will yesterday’s students cope with real work?
This opinion is also supported by pediatrician of the highest category Svetlana Novichikhina, who has a PhD in Medical Sciences. She believes that in the future this innovation will lead to a reduction in the number of specialized specialists. Her conclusions are based on a simple calculation: a student studies at a medical university for six years, after which he works for three years in a clinic’s therapy setting. By the time it is possible to enter residency, the physician will be 27 years old.
It is likely that by this age many will have time to start a family and children. Let’s say that as a therapist, a doctor earns 20 thousand rubles, and during residency training he will be able to receive about 2 thousand stipends, and within 2-5 years. It is quite natural that family people are unlikely to be able to afford this. So there will be enough therapists, but you may lose good surgeons, orthopedists or gynecologists.
According to the new standards, doctors will be able to acquire additional specialties during residency, having passed accreditation in a special center.
(Kazan, July 8, Tatar-inform, Nadezhda Gordeeva). In Russia, internships for graduates of medical universities are canceled starting this year. In 2017, former students will begin to “emerge” from universities as local therapists and pediatricians. The rector of KSMU, Alexey Sozinov, announced this in an interview with Tatar-inform news agency.
As the agency’s interlocutor clarified, obtaining additional medical specialties will require residency training, which will last from one to five years. As well as obtaining accreditation. Particular attention will be paid to practical training and visits to medical simulation centers.
“At the stage of an objective-structured clinical exam, a young doctor performs a certain type of task related, for example, to providing emergency care to a person. Assignments are formed depending on the specialty. And this is controlled by all accreditation commissions, the composition of which is approved by the Russian Ministry of Health. The commission includes representatives of professional associations, the university community, and employers. After passing these stages, you can receive personal accreditation to work at the level of a general dentist, pharmacist, or general practitioner,” he said.
After a certain period of training, an aspiring doctor will be able to obtain accreditation for new specialties. “Accreditation is one of the new products that appear in the system of admitting doctors to professional activities,” noted the rector of KSMU, adding that it applies to all medical workers who will thus confirm their qualifications.
A. Sozinov said that a federal methodological center for professional accreditation has been created in Moscow. “This year, dentists and pharmacists received accreditation. Nurses will appear in this system from 2018. Only from the methodological center can you receive an assignment. Each accredited person is registered in federal center, receives access and assignments from Moscow. At the first stage, testing takes place online. One of the principles is minimal human participation, everything is automatic. About 5 thousand test tasks have been prepared for dentists, and more than 3 thousand for pharmacists. They are in the public domain, you can study and prepare. If you score less than 70 out of 100 points, you just don’t get further,” he said.
A. Sozinov recalled that previously working doctors and nurses had to “go through a cycle of improvement” once every five years - pass an exam and receive a certificate. “Now, according to the new system, every year a doctor needs to continuously collect 50 credits of educational activity. WITH in English"credit" is translated as "trust". That is, in fact, a person should devote one hour a week to learning something new. You need to earn at least 50 credits a year, and 250 in five years. If you don’t score, you won’t be allowed to be accredited,” he explained.
Existing specialists will need to improve their skills in educational organization, attend trainings, conferences, seminars, etc. “It is necessary to prepare abstracts for symposia, conferences, and seminars held by public and professional medical organizations accredited at the federal level, not for profit. There is a need for training in educational interactive modules on the Internet; a special website has been created for this,” noted the rector of the university. “The completion of this system and admission to the next cycle is personal accreditation.”
“The new system is based on the ideology of quality. We proceed from the fact that a doctor must meet the requirements - professional standards. If you don’t comply, it means you can do more harm than good,” he believes.
According to the representative of the medical university, as a result, an account of the quantitative and qualitative training of specialists will be formed, and there will be an opportunity to develop in the direction necessary for Russian healthcare. “If a doctor does not meet the requirements, then his work experience and experience may not be in demand,” he assured.
A working doctor, according to him, needs to compile a so-called “portfolio” within five years - “treatment results, characteristics from the place of work, reviews from patients,” etc. “At the same time, testing and interviews will remain. But instead of simulators there will be real life,” emphasized A. Sozinov.
He also clarified that five years will pass between initial and repeated accreditation, but during this period it is possible to undergo initial specialized accreditation. “A doctor can acquire fundamentally new competencies and master new technologies,” concluded the rector of KSMU.
Graduates of medical universities in St. Petersburg have passed state exams and are preparing for three-stage primary accreditation. Those who successfully pass it will receive a certificate of accreditation - a document with which they can get a job as a local therapist or pediatrician in a clinic starting from August 1.
Graduates have two options: someone will be able to enter residency, this is about 40-45% of the total number of 6th year students, the rest will go to work for us in primary care, - Chairman of the Health Care Committee Valery Kolabutin reported at a meeting of the St. Petersburg government . According to him, thanks to the innovation from the Ministry of Health, a double increase in young specialists is expected in clinics.
Let us remind you that in the midst of state exams, the Ministry of Health No. 212n “On approval of the Procedure for admission to training in educational programs higher education" Graduates regarded it as an obstacle to entering residency. On the one hand, they heard that there will be changes this year, but they only found out what changes now. In accordance with the order, their fate will largely be determined by a single test within the framework of accreditation. But in addition to testing, achievements for all previous years of study will be taken into account, each of which is assessed in points. The most a large number of Yesterday's student receives points for medical experience acquired during or after training. For those who do not achieve the required number of points, but receive accreditation, the direct path is to local therapists or pediatricians. Moreover, the number of “free” budget places in universities has been sharply reduced: it is assumed that mainly “target students” will study at state expense, since there is a shortage of doctors with “narrow” specialization in the regions. In large cities and in rural areas, on the contrary, there is a shortage of therapists.
When the order came out, everyone was nervous and worried, it caused a resonance in the student community, say graduates of First Honey. - Now everyone is calming down, looking for ways out of the situation. Of course, residency training is mostly done for commerce. But there are few places there either. The rest are forced to either change their chosen specialty, become therapists, or leave medicine. And many, probably 25-30%, are inclined to choose the last option.
Repay
The system proposed by the Russian Ministry of Health will be tested for the first time this year. This is an attempt to fill the shortage of doctors in primary care. For a long time, the Ministry of Medical University Graduates has been trying to solve this problem.
To distribution from the Soviet medical system high school We couldn’t return in its pure form - it would be illegal. Although there was logic in it - if you are studying at state expense, be so kind as to repay the debt to the state, and then do what you want. The same logic works in the current situation, when, says the Vice-Rector for Academic Affairs of the First St. Petersburg Medical University
Of course, the Ministry of Health does not force graduates into clinics. But against the backdrop of a reduction in budget places for residency and changes in the rules for admission to it, the choice for many becomes obvious. 6th year student of the Faculty of Medicine, PSPbSMU named after. Pavlova Elena Artemyeva wanted to continue her residency training and become an otolaryngologist. According to the new rules for admission to residency, she has all the advantages for admission - a diploma with honors, participation in scientific and social activities, experience working in a medical organization. However, there are simply no budget places in her specialty based on the general competition at First Med. All of them are distributed between target audiences and “payers”. The girl was unable to receive the targeted referral, despite contacting medical institutions and authorities:
The fate of those who are not ready to pay for residency has been determined - let’s go to work in local therapy,” says Elena Artemyeva, she has already come to terms with future work in a clinic.
Andrei Yaremenko does not see anything unusual in the fact that the state is reducing opportunities for doctors to obtain a narrow specialization every year:
Every person wants to be unique and get a lot of money. But the state needs doctors with minimal qualifications in maximum quantity and with a minimum wage. This is an eternal conflict between man and state, and not only in Russia. For example, if you want to become a professional, you need to go through a huge and difficult path and invest a lot of money in your education. If you are ready to be a general practitioner, then simply write an application and they will immediately send you to work somewhere in Oklahoma, notes the vice-rector.
Future doctors are most frightened by patients
The trouble is that many schoolchildren, when choosing a profession, do not go to medicine, but to a prestigious university. They study well, as a rule, receive diplomas with high scores and go into the industry. Then there is a meeting with the patient and it turns out that the dad who can “resolve the issues” is not around, but there is a patient who was dissatisfied with the quality of treatment and has complaints. Meeting a patient face to face can be very dramatic. Unfortunately, not everyone is ready for it, just as they are not always ready for small initial salaries. These people leave healthcare almost immediately.
Therefore, for the chief therapist of St. Petersburg, Vadim Mazurov, the admission of graduates to work in clinics raises many questions.
They will have to immediately plunge into real life and work. It is not yet clear how ready they are for this,” says Vadim Mazurov. - Is the graduate’s level of training sufficient to prescribe instrumental and laboratory examinations? Will he be able to maintain documentation, engage in prevention, medical examination? Will be able to prescribe drug therapy to the patient, choose between the original drug and the generic, evaluate possible side effects? Of course, prepared by leading specialists, which the therapist uses in his work. But when patients with ARVI, coronary heart disease, irritable bowel syndrome come to him within an hour... You immediately need to have a whole library on your desk in order to use the possibilities of clinical recommendations. This type of work is a huge burden that requires serious preparation. I worry about these children.
According to Vadim Mazurov, administrations of institutions have not yet encountered such young and inexperienced specialists, so this year they will also need special attention and patience. After all, even after residency training, only a few young specialists came to work in clinics, and the personnel shortage was solved mainly by doctors from other regions of the country who already had work experience. According to him, for a graduate to feel at least relatively comfortable in a new position, it will take at least two years of work. “These guys will need help, identify mentors and prepare all the conditions for work,” says Vadim Mazurov.
The graduates themselves also count on support:
Of course, all students worry whether they will cope with the work. Perhaps at first we will be in the same office with a more experienced doctor,” says student Elena Artemyeva. - But we still have the skills - the last practice after the fifth year was at the clinic, the new educational standard prepared us for the work of a local therapist. And for depth of knowledge there is always a reference manual - it is not prohibited to use it.
At PSPbSMU named after. Pavlova note that they are ready to help their students - for this there is a Center for Interaction with Alumni and the possibility of telemedicine consultations:
They always have the opportunity to talk with a university representative if any problems arise. What's the worst thing? When a sick person comes to you, and you don’t understand what’s wrong with him, says Andrei Yaremenko and asks to treat graduates with trust. - Every year during the flu epidemic we send 6th year students to work in clinics. And we receive a lot of grateful feedback; they are attentive, intelligent, and will listen and help.
At the same time, Andrei Yaremenko admits that it is still difficult to call a graduate a full-fledged doctor who can carry out the entire scope of diagnostic and therapeutic measures.
It seems to me that there should be some kind of intermediate position between the future doctor’s graduation from the university and the beginning of his broad professional activity. When a person obtains a driving license in Germany, he or she must drive for some time in the presence of a more experienced driver. Something similar should be here. At one time there was a wonderful position - a trainee doctor. It was created for doctors who had a break from work for more than 5 years. They received a salary, but worked with a mentor. Only after this did they go full-time. There is also some kind of internship abroad: a young specialist has a mentor, he works in a team, absorbs medical traditions“, this is how he becomes a doctor,” says Andrey Yaremenko.
Forecast: Those who came to medicine “for love” will remain
To find a place in the district clinic, First Med graduates can use a specially created database of vacancies. The number of proposals, according to Andrei Yaremenko, is sufficient for everyone. But the problem is that many of the graduates do not need these jobs - they simply do not want to go work as local therapists.
Everyone has a dream. Let’s say a student dreamed of becoming the director of an aviation medicine clinic. The first goal on the way to his dream is to get into a clinical residency in extreme medicine. And now he has been given a serious barrier in the form of working in a clinic. And if he doesn’t want to work as a local therapist, he won’t do it,” notes Andrey Yaremenko.
According to Vadim Mazurov, even those students who go to work in clinics, “not out of love,” but out of despair, are unlikely to remain in primary care for a long time. This threatens clinics with staff turnover - young doctors will work for a certain period of time and again try to get into residency in their favorite specialty.
“This is another possible problem for the heads of the institution - they prepared the young specialist, created comfortable conditions for his work. And after a couple of years the person thanks them and says goodbye. But, on the other hand, there is no other way out of the current situation with the shortage of doctors in clinics. Maybe not everyone will run away in the end. When I see a young therapist while conducting certification, I usually ask why he works in primary care. Many answer that they simply liked it here and wanted to stay, says Vadim Mazurov.
At the same time, the chief therapist of St. Petersburg asks patients not to be afraid of young doctors:
“I think this still will not affect the level of examination and treatment of patients. After all, it depends not only on the therapist. Subspecialty specialists will also take part in the treatment. But there is also a catch here - the main thing is that a medical school graduate does not become a dispatcher, redirecting his patients to other doctors for backup. With this approach, we will not prepare a good specialist.
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