11 Feb, 13 | by BMJ Group
While the words “healthcare reform” are forbidden in Russia, healthcare is changing quickly. Over the past three years, three federal laws have been rewritten: the basic healthcare law, a law on drugs, and a law on compulsory insurance. 2012 ended with a federal law on education coming in to force.
This is a shot in the head for medical education. From now on in medical schools, staff will be funded for one teacher/professor per 12 students (instead of per eight students as in previous years). The standard workload of a university professor in a classroom is now up to 900 hours per academic year (an increase from 800 hours per year).
In 2012, all medical schools were forced to switch to a new standard curriculum. This is set out in a long and detailed document, strictly prescribing the content of disciplines, the hours of teaching, and the sequence of disciplines during training. Its content is badly written, and nobody wants to take responsibility for it. There are inconsistencies, for example, tuberculosis and tuberculin use is mentioned nine times, but HIV infection is mentioned only once. The document includes the obligatory “Physical culture” classes and “History of the Motherland.” History of the Motherland is intended to take up the same amount of classroom time as chemistry. Hygiene, public health, and epidemiology are considered to be separate disciplines. The hours meant to be devoted to learning about public health are fewer than those for “Emergency and disasters medicine.” What we have ended up with is a mixture of some innovation combined with the old outdated basic content and structure.
The purpose of the new curriculum is to have medical graduates with minimal training start their work in primary care. This has been explicitly pronounced in the new healthcare law. While over the past 60 years in the Soviet Union and Russia there had been an effort to develop postgraduate training, from now on it is not obligatory for medics to work in a polyclinic. The reason for this is to fill the many vacant positions of “uchastkovii therapist” (which means a therapist for a catchment area). This job had been changed during the Soviet era to a kind of nurse practice by Western standards, but with some doctor’s functions, like prescribing drugs. Instead of training better doctors for primary care, the Soviet Union created polyclinics staffed with gynecologists, urologists, ophthalmologists, etc. These “specialists” were not fully trained, but were sufficiently trained to imitate together the equivalent of “general practice.”
In Russia there were two kinds of postgraduate education: “internatura” (one year) and “ordinatura” (two years). During this training period doctors have student status. It means that they have small state subsistence, rather than proper wages. They do not collect their social insurance, and their very low income makes them vulnerable in case they fall sick or have a child (payments to families are means tested). As a result, students from low income families are pressured into going into primary care with minimal training, and tend to remain in this job forever.
Last year the ministry of health decided that “ordinatura” should be available only to graduates from the “internatura.” This has forced all students to go to primary care quickly in order to retain the possibility of paid training, as the government did not fund the “ordinatura” in 2012 at all. It means that only students from affluent families can afford to access extended training. All other graduates from the “internatura” have to go to primary care and work in the most unattractive position of “uchastkovii therapist.”
In 2011, in an attempt to fill the vacant doctor’s positions, the ministry of health decided to fill them with nurses, without providing a specific description of what functions the nurses would have to perform. Because nurses are in short supply as well, the new law offers the possibility for students who did not finish their medical degree to work as a nurse. The nursing profession is going to be derecognised. The federal law on healthcare does not mention nursing as a profession. In the 1990s some medical schools started to provide nursing degrees at a university level, but that was stopped two years ago.
The new legislation has also maintained the outdated structure of training for specialists, eg one doctor with basic training in surgery (two years) can switch to plastic surgery after only four months of additional training. In reality even this very short postgraduate training is shortened and/or falsified, as we know well from the reports.
Finally continuous medical education still does not exist in Russia. There is still an “intermittent” Soviet model, that was introduced 50 years ago whereby once in every five years doctors are retrained away from their place of work and they have to pass an exam for certification. It is so ineffective, that doctors consider it to be useless. To be “retrained” and ”certified,” doctors frequently bribe professors at the institution of postgraduate education so that they do not have to attend useless classes. The certification process is totally ineffective. Almost 100% of doctors going through the exam succeed the first time.
Under the new legislation this process of examination is named an “accreditation.” The only difference will be that instead of pretending that all specialists are full trained, under the new law every specialist will have the accreditation on a specific volume of training.
It is amazing that medical professional societies in Russia do not object to the destruction of the medical education.
Vasiliy Vlassov is a professor of medicine at the Higher School of Economics, Moscow. His research interests are in epidemiology, evaluation of diagnostic tests, public health, and especially health care delivery with scarce resources. He is the co-founder and current president of the Russian Society for Evidence Based Medicine.