FAMILY MEDICINE. 20 YEARS LATER

FAMILY MEDICINE. 20 YEARS LATER

The article presents an analysis of the development of family medicine in Russia over the past 20 years. The advantages of organizing primary care by the type of general medical practice are emphasized. The data on the role of the Department of Family Medicine of the North-Western State Medical University named after A.I. I.I. Mechnikov in the development of the Institute of General Medical Practice in St. Petersburg and Russia. The importance of international cooperation for the implementation of scientific research is emphasized. The main principles of continuing medical education and changes in the system of higher and additional professional education are outlined.

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Discussions about the rationality of changing the system of care in primary health care by the type of general medical practice continue in our country to this day. Among a number of health managers and representatives of narrow specialties, there is an opinion that a general practitioner can work only in rural areas. How can such a position be explained? A misunderstanding of the essence of the specialty, a desire to emphasize that Russian citizens living outside megacities should receive different medical care, unlike city dwellers? Let's try to turn to history and consider the main distinguishing features of general medical practice.

In 1991, a document published by the World Organization of National Colleges and Academic Associations of General Practitioners (WONCA) formulated the requirements for this specialty [1]. Along with the coordination of care, which is an important function of the general practitioner, the comprehensive nature of medical care was emphasized, which distinguishes general practice from other medical specialties, as it includes not only treatment, but also prevention, rehabilitation and health promotion. This document specifically emphasized that this care should be available to patients at all times, and the role of general practitioners should be not only to coordinate, but also to manage the allocation of health care resources.

A general practitioner should be aware of a wide range of problems that a patient comes to him with, and be able to recognize the disease at early undifferentiated stages, determining the tactics of managing a patient based on syndromic diagnosis. Of course, in difficult cases, in order to clarify the diagnosis, he may need to consult a specialist, but the general practitioner will continue the further management of the patient, who, as a rule, has a complex of problems, not only medical, but also social, on his own.

Is the development of general medical practice only a tribute to international trends? Are there any historical prerequisites for the development of this specialty in our country? Let us recall the development of zemstvo medicine in the 80s of the 19th century.In 1864, after the abolition of serfdom in Russia, Zemstvo began to form and the need for a universal doctor appeared, which could provide comprehensive assistance to various groups of the population, including low-income, unable to use the paid services of a personal family doctor. About the high demand for Zemstvo doctors, which were able to provide medical care available to various groups of statistics, indicate statistical data. By 1870, the number of Zemsky doctors in the main provinces of Russia was 756, and by 1890 – 1805. With each decade, their number increased by an average of one and a half times. It should be noted that the emergence of Zemsky medicine has become a certain incentive to create a system of postgraduate training of doctors [2].

In constant improvement, Zemstvo doctors who worked in the Russian outback, who did not have permanent access to the medical literature at that time, with which one could find answers to questions that arose in real practice could be found.

Thus, the formation of Zemstvo medicine predetermined the feasibility of postgraduate training of doctors and, as a result, the discovery of the Clinical Institute at the initiative of Professors N.F. Zeeter and E.E. Eucode and under the patronage of the Grand Princess Elena Pavlovna and Catherine Mikhailovna. This institute was the first institution for improving doctors not only in Russia, but also in the world [3].

It is now difficult to assume that our country would have passed that our country would have passed if there were no known events in 1917. It should be noted that a lot of health care was done. Creating a polyclinic service at that time allowed accessible medical care for adult and children's population. However, in 30-40 years. The process of specialization of medical care has begun, which by the 60s spread to the outpatient network. Sectionary therapists have increasingly turned into controllers delegating their powers to specialists. Moreover, in those years, graduates of medical universities were appointed to the positions of precinct therapists and pediatricians without additional training in the internship or clinical order. Mandatory postgraduate training in the therapy on therapy was introduced only in 1999. It is important to note that the specialty "district, or polyclinic therapy" in the register of medical specialties was absent and missing to this day! In primary medical care institutions, the representative office of district doctors did not go beyond 13-15%. The rest of the medical positions were envisaged for specialists. Under these conditions, the precinct therapist, limited by various regulatory acts, gradually losing the functions of the attending physician for their patients, which had a negative effect on their satisfaction with the work of polyclinic institutions in general.К сожалению, за последние 20 лет не произошло смены парадигмы оказания первичной медицинской помощи. Общая врачебная практика лишь дополнила существующую участковую терапевтическую службу, несмотря на успешную реализацию многих международных проектов и изменения в законодательной базе, которые должны были бы привести к ее реформированию.

Первые экспериментальные проекты, осуществлявшиеся при поддержке международных фондов, целью которых являлась подготовка врачей общей практики, появились в конце 80-х г. прошлого столетия. Не остались в стороне и образовательные учреждения. По инициативе ректора Санкт-Петербургской медицинской академии последипломного образования (в прошлом — Ленинградский ГИДУВ) профессора С.А. Симбирцева и проректора по учебной работе профессора Н.Н. Гурина еще задолго до издания правительственных приказов и распоряжений в СПбМАПО в 1988 г. была начата подготовка врачей общей практики из числа участковых терапевтов и педиатров. В 1989 г. в СПбМАПО была открыта кафедра общей врачебной практики, которую возглавил профессор В.Н. Петров, а в дальнейшем — профессор Ю.М. Губачев. Подготовка врачей проводилась одновременно и на кафедре терапии № 1 (заведующий — профессор А.А. Крылов, по инициативе которого были проведены первые циклы переподготовки по общей врачебной практике для городских врачей), и на кафедре судовой медицины (заведующий — профессор Н.Н. Гурин), где осуществлялось обучение врачей для Гатчинского района Ленинградской области. Следует отметить, что если врачи, подготовленные для города, оставались в тот период времени невостребованными, так как еще не было законодательной базы для их работы, то для врачей Ленинградской области после обучения были созданы условия, позволившие им реализовать полученные знания и навыки в реальной практической работе. Это способствовало сохранению кадров для формирования общей практики после выхода соответствующих нормативных документов, регламентирующих работу данной службы.

Приказ Минздрава РФ от 26.08.1992 № 237 «О поэтапном переходе к организации первичной медицинской помощи по принципу врача общей практики (семейного врача)» положил начало внедрению новой специальности. Были введены специальность и должность врача общей практики (семейного врача), квалификационные характеристики врача и медицинской сестры общей практики, типовые учебные планы и программы профессиональной подготовки специалистов, определены права и обязанности врача общей практики.

Появление приказа Минздрава стало стимулом для создания кафедр семейной медицины в ряде других образовательных учреждений. Была открыта кафедра семейной медицины в Московской медицинской академии им. THEM. Сеченова (ныне Первый Московский государственный медицинский университет им. И.М. Сеченова), с момента основания ею заведует академик РАН И.Н.Denisov is the Minister of Health and the author of the aforementioned order of the Ministry of Health. There were departments of family medicine in Samara, Khabarovsk, Arkhangelsk, Tver, Yekaterinburg and other regions of the Russian Federation.

St. Petersburg became one of the first regions to adopt, at the level of the Health Committee, the Concept of a phased transition to the organization of primary medical and social care on the principle of a general practitioner (family doctor) in 1995, and subsequently the target program "Family Medicine". This program received financial support from the city administration during the period 2001–2004. It should be noted that many circumstances contributed to the creation of the city program and its implementation. This is the initiative of SPbMAPO for the training of general practitioners, which has already been mentioned, as well as the implementation of international programs that have created conditions for the training of such doctors abroad and equipping some medical institutions in accordance with the requirements outlined in the order of the Ministry of Health.

The first centers of general practitioners (such as in St. Petersburg State Budgetary Healthcare Institution City Polyclinic No. 46) were established in 1995 under the Tacis program (Technical Assistance for the Commonwealth of Independent States, Technical Assistance to the Commonwealth of Independent States) using the experience of European countries .

In 1995, a joint program of cooperation between SPbMAPE and the University of Iowa (USA) was launched, which included the training of a group of family medicine teachers. The grant funds made it possible to equip and open the first family medicine center (FMC) at SPbMAPO on the basis of the Academy's educational and clinical complex (Prosveshcheniya, 45). FMC for the first time in the practice of medical educational institutions of the city began to provide medical care in accordance with the compulsory medical insurance program.

The creation of the family medicine center was the reason for the revision of the principles of teaching the specialty "general medical practice (family medicine)", previously held on a stationary basis. To implement new approaches to the training of general practitioners, a new educational unit was created – the Department of Family Medicine, which was opened in 1996 by order of the Rector of SPbMAPE Professor N.A. Belyakova (head of the department – professor O.Yu. Kuznetsova). From that moment on, the training of family doctors at SPbMAPO was focused on this department. The experience of training general practitioners, accumulated since 1988, close cooperation with colleagues from the University of Iowa contributed to the creation of a methodological foundation for further improving the training of these specialists. It should be noted that cooperation with teachers of the Department of Family Medicine at the University of Iowa has been going on for 20 years. The inspirer and initiator of joint scientific research, the exchange of teachers, the organization of internships for young family doctors is Professor J.Джогерст, который получил статус приглашенного профессора СЗГМУ им. I.I. Мечникова за вклад в развитие нашего сотрудничества.

В 1997 г. был учрежден медицинский научно-практический журнал «Российский семейный врач», в редакционный совет которого вошли преподаватели различных образовательных учреждений, в том числе зарубежных, а также практические врачи, заинтересованные в развитии семейной медицины. Этот проект был реализован при поддержке Королевского британского колледжа врачей общей практики. Профессор Л. Соусгейт, доктор П. Тун, профессор П. Мак-Крори также внесли большой вклад в развитие преподавания семейной медицины в нашей стране. Стоит подчеркнуть внедрение на кафедре новых принципов оценки знаний, включая объективный структурированный клинический экзамен (ОСКЭ), создание тестов множественного и расширенного выбора. Эти оценочные средства коллективом кафедры начали применяться уже в конце 90-х гг.

Отдельного упоминания заслуживает история развития центра семейной медицины. Первоначально к ЦСМ были прикреплены 4 тыс. пациентов, проживающих в близлежащих районах. На сегодняшний день к ЦСМ прикреплено 7,5 тыс. человек из разных районов города, а также сотрудники, студенты, ординаторы и очные аспиранты университета. В нем работает 5 семейных врачей, 9 медицинских сестер. Руководство центром осуществляет заведующая Ж.В. Плешанова, прошедшая путь от клинического ординатора кафедры, семейного врача до руководителя этого подразделения. Постепенно возрастала интенсивность работы центра семейной медицины. Так, в начале деятельности количество посещений пациентов составляло 12 тыс. в год, а в настоящее время этот показатель равен 52 тыс. С 1999 г. помимо взрослых пациентов семейные врачи осуществляют оказание медицинской помощи беременным и детям. Совместно с кафедрой врачи центра семейной медицины участвуют в научных исследованиях, планируют и защищают кандидатские диссертации, получают дополнительную подготовку на циклах профессиональной переподготовки по другим специальностям, расширяя свои профессиональные компетенции и объем медицинской помощи. Преподавательский состав кафедры оказывает консультативную помощь прикрепленным пациентам с наиболее тяжелым течением заболеваний. Об эффективности созданной модели говорит низкая потребность в вызовах скорой помощи при обострении заболеваний, а также более высокое качество оказания помощи больным с рядом хронических неинфекционных заболеваний в сравнении с другими подобными центрами, что подтверждено научными исследованиями, о которых будет сказано ниже. Опыт работы ЦСМ был использован при реорганизации студенческой поликлиники, расположенной на территории Университетского комплекса на Пискаревском пр., д. 47. В новом подразделении в июне этого года начали работать семейные врачи, также прошедшие подготовку на кафедре, при консультативной поддержке преподавательского состава.The patients of this unit will be primarily students and staff of the university.

It should be emphasized that the Department of Family Medicine was formed at a time when the need for the training of general practitioners for practical healthcare began to form and most of the doctors who were trained were provided with jobs in general practice departments that appeared as part of the City Target Program in all administrative districts of St. Petersburg.

In the future, other medical universities in St. Petersburg also joined the training of general practitioners. In 2006, the Department of General Medical Practice (Family Medicine) was opened at the St. Petersburg State Medical University. acad. I.P. Pavlova (head of the department – Professor N.L. Shaporova).

After the merger of SPbMAPE and SPbGMA them. I.I. Mechnikov in 2011 and the creation of the North-Western State Medical University. I.I. Mechnikov (Rector – Professor O.G. Khurtsilava), the Department of Family Medicine, along with the training of general practitioners, began training senior students in the specialty "polyclinic therapy". This made it possible for future doctors to form a holistic view of the patient and the role of primary health care in the healthcare system, and, upon transition to the 3rd generation Federal State Educational Standard, to expand the scope of training in accordance with new professional competencies to the basics of general medical practice.

Given the importance of developing the institute of general practitioners, the priority direction of the teaching activity of the department was the training of doctors in residency and the retraining of district therapists and district pediatricians in general medical practice (family medicine). Over 20 years of the department's work in residency, more than 300 residents were trained, and 956 doctors received the right to work in a new specialty after professional retraining. Given the specifics of postgraduate education that existed until recently, thematic improvement cycles were also a popular form of training, which allowed doctors to confirm their certificate once every five years. 1561 doctors from St. Petersburg and other regions of our country were trained on such cycles.

Along with long-term forms of education, the staff of the department worked on the creation of new educational programs that are most in demand in practical healthcare. Since an important activity of a general practitioner is prevention, the department has prepared a number of short-term thematic training programs dedicated to this problem. These cycles turned out to be in demand not only among general practitioners, but also among district therapists, whose duties, as part of the implementation of medical examination programs, included both preventive counseling of patients and targeted work with risk groups on quitting smoking and alcohol consumption that is hazardous to health.In close collaboration with the city center of medical prevention of the department expanded teaching on such cycles, which were in demand among the primary levels, which the number of trained professionals was 3889 people.

It should be noted that the teachers of the department have learning experience in basic and expanded resuscitation. Equipment of the department in the framework of the collaborative grant program with the University of Iowa made it possible to begin preparation of primary units in urgent medicine. The course of teaching was introduced a course of expanded resuscitation, which is mandatory for residents of any medical school abroad. Given the importance of this direction of training and the availability of relevant equipment, the Department of Family Medicine has committed itself to the obligations along with the departments of anesthesiology and resuscitation and emergency medical care for the preparation of the orders of other university departments. For 20 years, 5335 orders and interns passed this training.

The implementation of multidirectional and intensive pedagogical activities would be impossible if the department did not include highly professional teachers who are well known not only in our city today. This is Professor Department E.V. Frolova, D.V. Kandyba, O.M. Lesnik, Associate Professor, Department of L.N. Degtyareva, I.E. Moiseeva, A.K. Lebedev, TA Dubikaitis, MA Pohaznikova, V.D. Emelyanov, Assistants of the Department of G.N. Zakhevnova, N.S. TEMERIN. In the past 5 years, the Department's team has been replenished with new teachers who strengthened the communications of the Department with practical health care. It is Associate Professor I.V. Yubina, Assistants Yu.A. Zernik, O.A. Neumzhev, V.V. Bogdanova, having extensive experience in general practitioners and representing the second training center of the department based on urban polyclinic No. 54 (Chief Doctor – Yu.A. Zernik).

Heads of outpatient medical organizations – Chief Doctor of Urban Polyclinic No. 96 D.L. Motovilov and Chief Doctor of the City Polyclinic No. 86 R.I. Dremov, part-time teachers of the Department of Family Medicine, provide practical classes with students of the 6th Course on Polyclinic Therapy. This made it possible to create a basis for the transition to the new GEF 3+, the result of which the preparation of graduates for independent work in the primary health element in 2017. Young assistants play an important role in the implementation of the ideology of preparing family doctors, in the recent past graduate students of the Department: A.N. Andryukhin, P.D. Tajibaev, D.N. Zelenukha, K.V. Ovakambian. These teachers were trained at the department in graduate school and participated in international projects, which makes it possible to hope for further development of not only educational activities, but also the scientific potential of the department.

Relying on the experience of 20 years of the Department of Family Medicine SZGMU.I.I. Mechnikov, it should be noted that the effectiveness of the work of general medical practice is confirmed by a number of scientific studies that concerned both the study of the economic efficiency of this model of care and the assessment of its quality. In particular, a comparative study comparing the costs of maintaining the operation of general practice departments and departments of polyclinics showed that the GP model is more economical [4].

Within the framework of an international project devoted to the development and implementation of a model of a quality control system for primary health care, an assessment was made of the frequency of hospitalization of patients with diseases that can be adequately managed on an outpatient basis and do not require frequent hospitalization [5]. All institutions included in the study provided medical care according to the principle of general medical practice. However, the level of development of the new service was different. One of them was originally organized as an GP department (OVP-1), the second (OVP-2) was a polyclinic that completely switched to work on the principle of general medical practice. In the third polyclinic (OVP-3), both general practitioners and local therapists worked.

When assessing the level of total hospitalization, calculated per 100,000 population, significant differences were revealed between the medical institutions included in the study: in OFP-1, hospitalization was almost three times less than in OFP-2 and OFP-3. The most significant differences between OFP-1 and the other two centers were found in hospitalization for angina pectoris, hospitalization for chronic heart failure, long-term complications of diabetes mellitus, and obstructive pulmonary disease. It should be noted that high-quality preventive measures and dispensary observation of patients with the listed chronic non-communicable diseases could prevent the development of complications and the need to treat patients in a hospital. That is why these indicators can serve as a kind of indicators of the quality of care in outpatient settings.

Scientific research carried out at the department in recent years is carried out within the framework of international projects, which contributes to the integration of the department into the international scientific community and requires compliance with high research standards. The results of this work are not only publications in leading international journals, but also changes in approaches to patient management, the creation and implementation of educational programs. Thus, the Russian-Belgian project "Crystal", to which the publication of Professor E.V. Frolova in this issue of the journal, made it possible to find new approaches to the management of elderly and old patients, contributed to the introduction of the principles of a comprehensive geriatric assessment into the practice of domestic healthcare and the creation of new educational programs on geriatrics for outpatient doctors.The implementation of another Russian-Belgian project of Respect, aimed at studying the prevalence of chronic obstructive pulmonary disease in St. Petersburg and Arkhangelsk, included the creation of a new remote cycle of alcohol training, the features of which are set forth in the Publication of Associate Professor MA. Packaging. The head of both projects from the Belgian side is Professor of the Catholic University of Levena (Belgium) Ya.- Degriz.

The importance of international integration in the implementation of large-scale scientific research is emphasized in the publication of the President of the Russian Association of Osteoporosis of Professor of the Department of Family Medicine O.M. Lesnaya devoted to the study of the problem of osteoporosis.

Not only the results of the research we held on the basis of the Primary Medical Aid on the type of research, but, not less important, and its relevance in practical health care are also important. The result of the twenty-year work of the departments of general practitioners of St. Petersburg was primarily the formation of a positive attitude of patients to this specialty, minimizing complaints from the serviced population. Over the past 10 years, the number of general practitioners in St. Petersburg has increased almost 2 times – from 249 to 496, respectively, the population of which they serve.

These positive trends are partly due and prepared on the programs of the ordinance and additional vocational education, which not only take into account international requirements, but also consonant with our time when the preventive orientation of the work of the primary health care doctor has become a priority. An organization of service has an important meaning.

In our city, one of the first in Russia, the branch of general practice was emerged, located in residential arrays, which makes primary health care more affordable and attractive for residents. It is not by chance that the general medical practice (family medicine) was interested in private companies that, as part of a public-private partnership in 2013, opened the first branches of family doctors in the Primorsky district of our city. Moreover, assistance for patients remains free, as these units are funded from compulsory medical insurance, and the investment of private companies in the repair of buildings and equipping offices are gradually paid off due to tax benefits. The first such experience was successful, and today the network of such clinics appeared in other areas of the city. Currently, 84 compartments of general medical practice operate in St. Petersburg, of which 16 are open within the framework of public-private partnership.

Unfortunately, the legislative framework did not reflect the differences between the organization of primary health care on the type of general medical care and the usual therapeutic service.The implementation of another Russian-Belgian project of Respect, aimed at studying the prevalence of chronic obstructive pulmonary disease in St. Petersburg and Arkhangelsk, included the creation of a new remote cycle of alcohol training, the features of which are set forth in the Publication of Associate Professor MA. Packaging. The head of both projects from the Belgian side is Professor of the Catholic University of Levena (Belgium) Ya.- Degriz.

The importance of international integration in the implementation of large-scale scientific research is emphasized in the publication of the President of the Russian Association of Osteoporosis of Professor of the Department of Family Medicine O.M. Lesnaya devoted to the study of the problem of osteoporosis.

Not only the results of the research we held on the basis of the Primary Medical Aid on the type of research, but, not less important, and its relevance in practical health care are also important. The result of the twenty-year work of the departments of general practitioners of St. Petersburg was primarily the formation of a positive attitude of patients to this specialty, minimizing complaints from the serviced population. Over the past 10 years, the number of general practitioners in St. Petersburg has increased almost 2 times – from 249 to 496, respectively, the population of which they serve.

These positive trends are partly due and prepared on the programs of the ordinance and additional vocational education, which not only take into account international requirements, but also consonant with our time when the preventive orientation of the work of the primary health care doctor has become a priority. An organization of service has an important meaning.

In our city, one of the first in Russia, the branch of general practice was emerged, located in residential arrays, which makes primary health care more affordable and attractive for residents. It is not by chance that the general medical practice (family medicine) was interested in private companies that, as part of a public-private partnership in 2013, opened the first branches of family doctors in the Primorsky district of our city. Moreover, assistance for patients remains free, as these units are funded from compulsory medical insurance, and the investment of private companies in the repair of buildings and equipping offices are gradually paid off due to tax benefits. The first such experience was successful, and today the network of such clinics appeared in other areas of the city. Currently, 84 compartments of general medical practice operate in St. Petersburg, of which 16 are open within the framework of public-private partnership.