Medical examination and prevention: from boring terms to real care
Free medicines, high-quality medical examinations, attentive therapists... Will it be in Russia? And if it will, what do we need to do for this to happen?
Last week, Russian President Vladimir Putin addressed the Federal Assembly with a message. The deputy of the State Duma from Tatarstan, Dr. Boris Mendelevich, in his author's column for Realnoe Vremya tells what Putin emphasised in the medical field and describes what steps are necessary for modern Russian healthcare. What we need to learn from the UK and the US, what it makes sense to punish medical organisations for, and how to evaluate the quality of medical services — read in our article.
Putin's message places focus on vaccination
The president's address is an annual address, which is of a strategic nature and sets the vector of work for the near future. As a doctor and a deputy who mainly oversees the healthcare sector, I will tell you what points, in my opinion, are important in the light of the development of domestic medicine.
Of course, I will start with vaccination. Despite a huge amount of controversy on this topic, yet from a scientific evidence point of view, vaccination is still the only tool that forms a collective immunity, and therefore reduce the rate of infection. And the country now has all the conditions for vaccination. Two vaccines are already available, and a third is on the way — in just a few days, it will appear in several Russian regions, including Tatarstan. To get vaccinated, you do not need to stand in long queues, in large cities it can even be done in shopping centres. So the maximum availability of the vaccine in our country is ensured. It's a little left to do — the good will of the citizens. Of course, vaccination must be voluntary, everyone decides for themselves what is worse for them — to get sick or get vaccinated.
Personally, I was one of the first to get vaccinated, and I support a scientific and evidence-based approach to this issue. But, of course, I remind you: vaccination is a medical procedure, and before it is carried out, you need to be examined by a doctor and understand whether there are any contraindications.
Speaking of the scientific-evidence approach, one of the positive news that was voiced in the president's address was the information about the promotion of scientific activity. It is necessary that our domestic science promptly responds to modern challenges and has all the infrastructure and other capacities to work. We understand that the huge outflow of talented students and postgraduates abroad is largely due to the insufficient technical equipment of many of our laboratories, outdated approaches to scientific work and, of course, a lack of funding. I really hope that the time will come when young scientists in our country will have the opportunity to comfortably satisfy their needs and realise their potential.
Despite a huge amount of controversy on this topic, yet from a scientific evidence point of view, vaccination is still the only tool that forms a collective immunity, and therefore reduce the rate of infection
We need to adopt best Western practice
However, on the pages of Realnoe Vremya, I would like to focus in more detail on the topic of fighting cancer and cardiovascular diseases. A huge work is going on in this direction now. It is important to pay attention to the activities of the primary link: prevention and early detection of the disease — we need to work ahead of the curve!
Therefore, in my opinion, the priority tasks are to strengthen prevention programmes, including medical examinations. This will give the opportunity to diagnose diseases at an early stage, and therefore get a better chance of a complete cure. I am sure that we need to continue to improve the system of medical examinations that has developed in Russia.
As an example, we can take ready-made, Western models. For example, in the UK, the emphasis is placed on screening — to measure the level of glucose, cholesterol, blood pressure, etc. It is important that the screening is carried out by the district physician during the year and he, getting acquainted with the results of the patient's tests, decides on the need for additional medical services. In Russia, in this format, medical examinations are not associated with the therapist treating the patient — there is a failure in the doctor's awareness. If he sees the whole picture in dynamics — he is more likely to make a diagnosis in time.
The second point is that in Britain, the results of medical examinations affect the salary of a doctor. The mechanics are very simple: if the district doctor has not examined all patients, then they are more likely to deteriorate in health. This means that insurance companies will suffer financial losses. To discipline everyone, if not all patients have been screened, the doctor gets less money. And this is clearly stated in the therapist's contract.
In the US, the situation is a little different. Insurance companies here are also interested in ensuring that people are screened in a timely manner, and they themselves monitor the work of the doctor. If it turns out that the patient was found to have deviations during the screening, and the doctor did not take the necessary actions, then big disciplinary and financial questions will arise for him. But in our country, the salary of the district therapist does not depend on the result of the medical examination at all.
Outpatient observation is the monitoring of patients who already have chronic diseases. In principle, the district doctor, the therapist should systematically invite such patients and study their state of health
What if you already have a chronic disease?
Another point is outpatient observation. It is often forgotten, remembering only about medical examinations. In my opinion, this issue should become the second cornerstone in improving the effectiveness of medical care.
In simple terms, outpatient observation is the monitoring of patients who already have chronic diseases. In principle, the district doctor, therapist should systematically invite such patients and check their state of health. And here I (and not only I) have a question: how often do chronic patients attend such medical examinations?
It's not that our doctors don't want to treat us. It should be understood that the ministry of healthcare has approved the recommended standards for the number of attached population — how many people must be supervised by one doctor. And this document needs to be finalised! Therapists work with an overload, and they just don't have enough time and attention for everyone.
And here another aspect immediately arises — the availability of medical care. People often complain to me at citizens' receptions and on social networks that they have to wait a long time for an appointment with narrow specialists, for example, a cardiologist and an endocrinologist. In my opinion, the main reason is that the federal legislation defines the recommended (this is important!) number of specialised specialists per 1,000 people of the population. As a result, in one region, the number of doctors per 1000 people may be higher than the recommended number, and in another, on the contrary, lower. I believe that the ministry of healthcare of Russia should consider the norm at the level of the minimum (not recommended!) value or punish medical organisations for non-compliance with these standards. Because the story of a single nephrologist or, for example, an endocrinologist working for the entire city is, unfortunately, still real for modern Russia.
Federal legislation defines the recommended (this is important!) number of narrowly focused specialists per 1,000 people of the population. As a result, in one region, the number of doctors per 1,000 people may be higher than the recommended number, and in another, on the contrary, lower
How do we control doctors?
Speaking about the early detection of diseases, I will note such an aspect as quality control of diagnosis and treatment. I think that now it is quite utilitarian in nature. The examination by insurance companies is carried out on the fact of performed medical manipulations.
As a result, the focus is not on preventing medical errors, but on identifying those that have already been made. Ahead-of-the-curve work is not so common. Besides, it is no secret that insurance companies have a financial interest in increasing fines, not in increasing the quality of medical care.
I believe that the way out can be a reform of the system of examination of the quality of medical care and, most importantly, prevention. For example, we can evaluate whether a doctor was able to convince a patient to quit smoking, eat less salt and sugar, and start a healthy lifestyle. There can be developed a lot of criteria.
In the meantime, this assessment system does not have a huge amount of data — for example, we never know how many patients reach the target cholesterol level (and therefore managed to “escape” from atherosclerosis). Therefore, I consider it necessary to review the quality criteria for prevention within the framework of the state guarantee programme.
How are we treated, and most importantly, who pay for treatement?
In many developed countries of the world, there is a system of drug insurance and secondary prevention. It makes it possible to increase the availability of drugs for patients, which means that it improves the effectiveness of treatment and preserves the health and lives of people.
In Russia, so far, preferential drug provision is available only for certain categories of patients, in particular for people with disabilities. But they do not always get what they are prescribed, in the right amount and at the right time. There are enough failures with provision.
It has long been necessary to think about providing free medicines not only to people with disabilities and beneficiaries, but also to other patients
But work is underway in this direction. It has long been necessary to think about providing free medicines not only to people with disabilities and beneficiaries, but also to other patients. For example, a special programe of drug provision for Russians with heart and vascular problems was launched last year. It involves the provision of free medicines for the rehabilitation of people who have suffered acute cerebrovascular accident, myocardial infarction, coronary artery bypass grafting, angioplasty with stenting, and catheter ablation. In 2021 alone, 10 billion rubles have been allocated to the regions under this programme. Accordingly, patients will have the opportunity to get the medicines they need for free — and continue to be treated at home. I believe that this is a really important step that will prolong people's lives.
I would like to note that these are only my assumptions about how one of the points of the Russian president's address should be implemented. In the near future, the ministries will submit their documents, and we will already have a clear understanding. But then we will need to carefully monitor how well the relevant regulations are developed and how they are implemented. Because, among other things, our feedback affects how accurate, targeted, high-quality and timely medical care will be in our country.