They are looking forward to the service of new pediatricians who should come to work next year, studying at the TSMU in the target direction. According to Irina Ermolenko, the law “on education” must be strictly observed here. If the state has given the opportunity to study free of charge as a doctor, it is necessary for the newly-made specialist to pay his debt to the state healthcare system. Moreover, today the village is quite attractive for a career start. For example, in Mikhailovka, a young specialist will receive both housing and a million rubles, lifting under the Zemsky Doctor program. The young specialist “will be taken under the wing”, they will help to get through becoming in the profession. Experienced doctors will share their work experience.
Governor of the Voronezh region Alexander Gusev.
Within the framework of the national project, the primary link, that is, the clinic, will be modernized. Let's set a task for 2019: transfer all children's clinics to work according to the “lean clinics” scheme. This is not only electronic registration, but also separate flows of patients, the absence of queues. ”
At the expense of the regional budget, 20 children's clinics and children's outpatient departments are being repaired to create organizational and planning solutions for internal spaces that ensure the comfort of children. The preventive direction of the pediatric service was further developed.
With the aim of early diagnosis of diseases of the reproductive organs in children aged 15-17 years, screening of minors is carried out. In the first half of the year, 69.3% of boys and 58.6% of girls from the total number of adolescents to be examined were examined. A large educational work is being conducted in the youth environment on the benefits of a healthy lifestyle.
By 2020, at least 95% of children's clinics and outpatient departments will be equipped with medical devices. In order to improve reproductive health, it is planned to organize the work of the offices of pediatric obstetricians-gynecologists and children's urologists andrologists. The plans are to increase bed capacity and equip the rehabilitation department for children of the Liskinsky district hospital. To increase the availability of medical care to children in remote areas, a mobile diagnostic module will be purchased.
For 2020–2022, it is planned to build a new oncohematological building for 100 beds in the regional children's hospital. The construction cost is about 2.2 billion rubles. At the expense of the regional budget, design documentation has been prepared. An application for federal funding was sent to the Ministry of Health of the Russian Federation and was supported at a meeting of the interagency group.
Chernozem regions in the program for the development of children's health
IN Belgorod region, according to the press service of the regional government, as part of the project, retrofitting of children's clinics with medical products will be carried out, a modern material and technical base will be created, equipment will be purchased, specialist doctors trained, and comfortable planning decisions will be implemented. Due to co-financing from the regional budget for medical organizations of the region, 1,496 units of equipment will be purchased in the amount of 27.4 million rubles.
As of July 1, 2019, the Department of Health and Social Protection concluded contracts for the supply of equipment for a total amount of 75.59 million rubles. 136.29 million rubles will be allocated for the reconstruction of the rehabilitation department of the Children's Regional Clinical Hospital from the federal and 63.44 million rubles. from the regional budgets. In the current year, 438.74 million rubles were allocated for repairs in hospitals.
This year, in the simulation center of the FSBI "Ivanovo Research Institute of Motherhood and Childhood named after V.N. Gorodkova ”trained ten obstetrician-gynecologists, neonatologists, resuscitation anesthetists, and until the end of the year, 76 more specialist doctors of the above specialties will be trained at the simulation center of the Belgorod State Medical University NIU.
Photo: Oleg Kharseev, Kommersant
One of the main directions of the regional program is to increase the coverage of dispensary care for minors, the development of a preventive focus in pediatrics.
“The main indicator of the regional project of children's health care is the percentage of preterm births at the period of 22-37 weeks of pregnancy in perinatal centers, approved by the Ministry of Health of the Russian Federation for 2019 - 75% (women at the age of 22-37 weeks of birth should give birth in third-level obstetric institutions in 75% cases). According to the results of the second quarter, 85% of women in early pregnancy were delivered at the perinatal center of OGBIH “Belgorod Regional Clinical Hospital of St. Joasaph”, ”the press service of the regional government emphasized.
IN Kursk region 739.099 million rubles were allocated for the implementation of the program for the development of children's healthcare. According to the Health Department, in 2019 it is planned to re-equip with medical devices and create comfortable living conditions in six city and district clinics, and later in other children's clinics in the region. Within the framework of the project, it is planned to build a new multidisciplinary regional children's hospital.
“The program focuses on the early diagnosis and prevention of diseases of the reproductive sphere, as well as diseases of the cardiovascular, endocrine, musculoskeletal, digestive systems and organs of vision,” the health committee explained.
404.24 million rubles are allocated for the implementation of a similar regional program in the Lipetsk region until 2024. According to the press service of the regional administration, in 2019 it is planned to introduce the principles of lean production in 12 children's clinics.
In addition, it is planned to build a new clinic, which in terms of medical care will unite two clinics located in adapted rooms on the ground floors of residential buildings. It is also planned to erect a new surgical building for the regional children's hospital.
It is planned to eliminate the personnel shortage of primary care medical workers providing medical assistance to children. To overcome the personnel shortage of doctors and paramedical staff, a set of measures of social support for health workers was strengthened. A law has been enacted to increase the availability of rental housing for physicians: the amount of monthly monetary compensation for renting premises for doctors of state medical organizations in the region has been increased.
Photo: Oleg Kharseev, Kommersant
IN Tambov region the regional program was a logical continuation of the departmental target program "Development of the material and technical base of children's clinics and children's outpatient departments." According to the press service of the regional administration, the organizational and planning decisions and the principles of lean production in 2019 should be implemented in four institutions: in the regional children's clinical hospital, children's clinic No. 1 of the city hospital named after Archbishop Luke, Children's Clinic of City Hospital No. 4 and City Children's Clinic named after V. Koval. Up to 2021, the project provides for the modernization of 13 children's clinics.
In 2019, it is planned to purchase 19 units of medical equipment in the amount of 70.4 million rubles. Also, the reconstruction of structural units of the children's regional hospital will be carried out. A state contract was concluded for the development of design documentation for the reconstruction of its building for 27 million rubles.
IN Oryol region 62.3 million rubles will be allocated for the regional program for the development of children's health within the framework of the national project “Health” in 2019 The main task of all the transformations was to increase the percentage of visits by children to medical facilities to preventive purposes up to 55%.
According to the passport of the Oryol Oblast program “Development of children's health care ...”, 124.6 million rubles were planned for the development of the material and technical base of children's polyclinics and children's polyclinic departments of medical organizations until 2024.
The program focuses on early enrollment in children with the first established diagnoses of the most common, including “school-caused” pathology. This will allow for timely treatment and rehabilitation measures and reduce the likelihood of chronic disease, officials say.
According to the developers of the program, "strengthening the material and technical base of the BUZ of the Oryol region" Scientific and clinical multidisciplinary center for medical care for mothers and children to them. Z.I. Round "will expand the possibilities of providing specialized, including high-tech, medical care to children, ensure the introduction of innovative technologies in pediatric practice, and create comfortable conditions for children. It is planned to purchase mobile diagnostic mobile complexes, which will ensure the maximum availability of medical care for the children living in remote rural areas.
As a result of the implementation of regional programs in all regions, it is planned to reduce child and infant mortality. In general, the first steps taken at the regional level to implement the program for the development of children's health care, to create a new model of medical care for children, provide the basis for optimistic forecasts, we are confident in the relevant departments of the Chernozem region.
As the head of the National Medical Chamber, Leonid Roshal, told Vademecum, attempts to replace pediatrics with general medical practice were also made in the 90s. “Young people came along with Yeltsin, who said:“ We will do everything as we do abroad. Let's close the clinics, introduce general practitioners, and they will treat the children. ” Then not only me, but also academician Alexander Baranov, head of the Scientific Center for Children's Health. “Vademecum and other pediatricians defended the specialty and firmly declared that we were not going to go back to Africa,” recalls Academician Roshal. “We managed to defend our position, but periodically someone returns to this issue again.” The academician could not clarify which industry leader was the conductor of the concept of general practice in children's healthcare.
According to Konstantinov from the Russian Children's Clinical Hospital, such an idea was expressed by Yuri Shevchenko, who served as Minister of Health of Russia from 1999 to 2004: “I was then the head of health care in the Krasnoyarsk Territory. We were required to report how many such specialists work in the field. But this campaign quickly came to naught. ” According to Leonid Roshal, the proposal to replace pediatricians with general practitioners came from foreign experts: "We argued with representatives of the World Bank in Russia and the WHO, and then the position in WHO was not quite right." The third attempt to replace pediatricians with general practitioners was made in the mid-2000s, when Mikhail Zurabov was the head of the Ministry of Health and Social Development, but she also did not lead to visible results.
Nevertheless, the reformers managed to disrupt the previous system of training pediatricians. “Until today, the trends that have arisen during the discussion of the situation with family doctors, when the pediatrics course was as saturated as possible with third-party profiles — this included obstetrics, otorhinolaryngology and other areas, have been preserved. This has led to the fact that the basic specialty is now taught very narrowly. In addition, much attention is paid to outpatient pediatrics, a maximum of hours is given to it. And this, in essence, is patient routing training. That is, we, giving hours to how a pediatrician should draw up documents, reduce attention to basic disciplines that teach to treat, ”says Petr Shumilov from RNIMU.
If in Russia pediatrics as a separate medical specialty and the corresponding education system was saved, then some countries in the post-Soviet space accepted the idea of abandoning pediatricians in favor of general practitioners. For example, in 2006, the Ministry of Health of Kazakhstan approved the concept “On the Elimination of the Faculty of Pediatrics”. Since the beginning of the 2007 school year, pediatricians began to be trained according to the European system, which includes five years of undergraduate and two years of internship, during which the principles of general medicine were studied. After such training, the student became a general practitioner. If he wanted to become a pediatrician, then he had to unlearn three more years in the residency. In 2012, the latest pediatricians were graduated from Kazakh universities. And in November last year, the Prime Minister of the Republic of Kazakhstan Bakytzhan Sagintayev announced the restoration of pediatrics in his rights.
Vice-rector for Academic Affairs of the Kazakh National Medical University. S.D. Asfendiyarova Maksut Kamaliev told Vademecum that it is planned to open a pediatric faculty this year only at their university, the rest will continue to train pediatricians in the previous mode: “Nobody wants to take risks and experiment. We were chosen as a pilot site, and further we will transfer experience to other universities. In the first year we will take 150 people. During this time, we not so much gained as we lost. We have lost pediatricians both quantitatively and qualitatively. ” Despite the fact that a radical elimination of the country's pediatric services did not happen, the shortage of pediatric doctors in Russia is obvious. According to a study by the Health Foundation, in 2016, 25.8 thousand pediatricians accounted for 31.4 thousand district rates at state polyclinics. The head physician of the Domodedovo Central City Hospital Andrei Osipov explains that, despite a decent salary, doctors do not want to be district pediatricians, including because of the high workload of paperwork: “The staffing of district Domodedovo district pediatricians is approximately 50%, that is, in two outpatient clinics and outpatient departments and 11 outpatient clinics, which are part of the hospital, lack half of these doctors. ”
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Loan of mistrust
The transfer of the specialty that began in 2017 to a new system for admitting doctors to professional activities, that is, to accreditation, at first glance, opens up a new career opportunity for graduates of the pediatric faculty. They can start practice on the site even before residency. The main idea of the reform is to fill the lack of personnel in the primary care. But let's use a simple example to analyze the viability of this venture.
For example, Saratov State Medical University. IN AND. Razumovsky released 187 pediatricians in 2017; as early as this year, 45 interns will complete training in the "pediatrics" profile. According to the estimates of Peter Shumilov from RNIMU, 2/3 of graduates of the faculty of pediatrics usually continue to study further under the programs of "adult" medicine. At the same time, according to the staff of the faculty of additional professional education of RNIMU, graduates of the pediatric faculty make up 10% of students in retraining programs specializing in general practitioner (family doctor). Following this formula, it can be assumed that 77 more doctors will join the 329 district pediatricians who are currently working in Saratov polyclinics.
But will these theoretical calculations be confirmed in practice? The position of the local doctor does not attract all yesterday's pediatric students.Andrei Osipov says that the graduates of 2017 turn to the Domodedovo hospital mainly for referrals to the target residency, only one graduate will come to work as a rural doctor under the program "Country Doctor". In the clinic she will be given a mentor who will supervise her (although, according to the order of the Ministry of Labor No. 306n “On the approval of the professional standard“ Pediatrician district, ”a graduate of the faculty of pediatrics only needs an accreditation document to work in primary care).
Representatives of private medical centers agree with colleagues from the public sector: graduates need to be retrained. Voronezh Children's Doctor, according to the director of this clinic, Irina Mukha, is ready to accept a graduate to work “under supervision”. A graduate pediatrician will not be able to get into EMC at all: the head physician of the EMC Children's Clinic Rosanna Gardashnik says that even before the reform they did not consider the resumes of yesterday’s students. That is, even if a graduate goes to work as a precinct in a children's clinic, this will not solve the personnel problem, instead of full-fledged doctors, assistants will take bets.
Another consequence of the educational reform for pediatrics may be an increase in the time frame for receiving specialized care. Not all clinics will be able to provide a precinct recruit with a mentor, and a doctor without experience is unlikely to accurately and confidently determine that a narrow specialist should treat the patient. Moreover, the assistant will not succeed in gaining knowledge during work: according to Peter Shumilov, it is impossible to teach the definition of complex diseases in the clinic. So where will the specialized specialists necessary for working with children come from tomorrow?
About the number of pediatric otolaryngologists, surgeons, neurologists and representatives of several other medical specialties, experts interviewed by Vademecum say without panic: "There is no catastrophe yet." According to the TsNIIOIZ, in 2015, 21.3 thousand doctors were engaged in special medical care for children. Nevertheless, in five to eight years, the industry will probably feel a shortage of such specialists. According to Andrei Osipov from the Domodedovo Central City Hospital, the failure will be especially noticeable for doctors who need longer clinical practice, such as neurosurgeons, to qualify.
The chance for a graduate of the pediatric faculty to go to residency is now low. Firstly, this year, not only they, but also the “last” interns are applying for places in the residency. Secondly, according to the order of the Ministry of Health of Russia dated May 11, 2017 No. 212n, in order to enter the residency, a graduate must not only pass accreditation, but also gain a certain number of points for achievements during his studies - for example, earn a scholarship or a grant from the president and government , get a red diploma, engage in scientific activities and so on. In addition, Shumilov notes, there are already fewer residency places: “If last year only 20 residents could enter my department, then this year the Second Honey for all departments received 14 budget places in pediatrics.” In 2017, 281 places were opened at SPbSPMU in residency programs, 152 - paid (training, for example, in the specialty "Neurology", will cost 110 thousand a year).
Graduates from the evening departments of pediatric faculties who completed their studies in January 2017 will also be entering the residency this year. This category of future specialists was in a difficult situation: they had to receive a doctor’s certificate after an internship, in a separate spring stream, but the internship was canceled, and now residency is the only option for admission to work. “Pediatricians will simply leave the profession. My forecast: as a result of these new implementations of postgraduate training, a significant percentage of graduates of pediatric faculties will not reach practical health care, ”Kirill Konstantinov from the Russian Children's Clinical Hospital summarizes.
Over the past two years, in accordance with the law of Ukraine No. 3612VI, the Vinnitsa region has been pilot in the reform of public health in the introduction of a system of general practitioners - family medicine. In principle, any reform should be aimed at improving the existing system. Now we need to conduct an objective assessment of the effectiveness of the reform regarding such a specialty as pediatrics. For such an assessment, it is necessary to take an excursion into the past and recall what the system of training pediatricians was in Ukraine and in other republics of the former Soviet Union. We were visited from other countries to take over the experience of children's clinics.
After graduating from the faculty of medicine, I had the great happiness in life to become a pediatrician, doctor of medical sciences, professor, devote my life to my favorite business (62 years of medical experience). Therefore, I consider it my moral duty and the right to express an opinion on the reform of general practice - family medicine, which is being introduced into pediatrics practice.
At the faculty of pediatrics, students studied pediatrics for four years! In the third year, the propaedeutics of childhood diseases was studied, that is, the introduction: indicators of the development of children, feeding rules, structural features of organs and systems, symptoms (semiotics) of diseases, examination methods. At the end of the school year there was a rigorous examination with an assessment of practical skills. In the fourth and fifth courses (2 years!), Students studied faculty pediatrics, that is, the main diseases of young and old children, also with an exam and subsequent practical training in children's medical institutions.
In the sixth year, that is, in the subordinate, knowledge was consolidated in all sections of pediatrics in accordance with the plan. The training ended with a state exam with an assessment of theoretical knowledge and practical skills.
One of the important forms of training in the subordinate was the participation of students in clinical rounds, councils, and medical conferences. These forms of work were accompanied by training in the principles of medical ethics and deontology.
Most pediatricians of the city and region were graduates of our university; they did not break off contacts with their teachers at a professional level. I believe that such training at the university provided satisfactory health indicators. For many years, our region was characterized as one of the best in Ukraine in terms of basic indicators of children's health. In general, such a system of organizing medical and preventive care for children was recognized by WHO experts as an exemplary one.
At present, the system of general practitioners - family medicine has leveled off all of the above factors in the training of family doctors in pediatrics.
So, in the training courses for family doctors lasting 4 months, only 1 month is assigned to pediatrics. Personally, I had to teach pediatrics to family doctors for the past 8 years. My cadets were mainly medical therapists, who in pediatrics had very poor knowledge, were afraid of children and felt very unprofessional. To fill the knowledge gaps in pediatrics for family doctors, we prepared training manuals at their request, realizing, however, that such manuals can in no way fill the deficit of practical and theoretical knowledge that a specialist who has received education in the pediatric faculty receives. The gaps in the knowledge of family doctors on monitoring a healthy and sick child, disease prevention, medical examination, feeding, vaccination, treatment at the prehospital stage were especially large.
In children's clinics there were separate entrances for healthy and sick children, rooms for raising a healthy child worked. Doctors were taken separately from therapists. Mixing the flows of adults and children, especially patients, was unacceptable.
In the long term, reform can lead to a deterioration in health indicators, an increase in child mortality, and chronic diseases, with all the ensuing consequences. It is expected that the pediatrician will become only a consultant, and not a specialist, who must observe the child from birth and at least 7 years old, helping the family grow him healthy.
Now more and more often wealthy parents are looking for help for sick children in private hospitals or at private practicing pediatricians. Free medicine is paid. Most of the children, given the complexity of the social problems of society, are left without qualified pediatric treatment and preventive care. This situation in the country is contrary to the constitution of Ukraine.
The conclusion is clear and comes down to the fact that pediatrics should be improved and preserved as one of the priority medical professions in the interests of future generations and the nation as a whole.