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Medium severity medicine

Head of the Primorye Expert Council on Health Issues Elena Rusakova about the situation in the industry

The reason why doctors should go more often and invest more in the health sector is reflected in the Chairman of the Public Expert Council of the Primorsky Territory on Health, the Chief Dentist of the DFO and Primorsky Territory on Preventive Pediatric Dentistry, Vice President of the Dental Association of Russia, expert in the quality of medical care National Medical Chamber, Doctor of Medical Sciences, Professor Elena Rusakova.

Medium severity medicine
- Elena Yuryevna, people always go to doctors reluctantly. But sometimes it happens that with all the desire there is no one to go to: there are not enough doctors, a specialist or an examination can only be reached after a long wait. Does Primorye health care cope with the flow of patients? Maybe you should not pin too much hope on state medicine at all?

- Lack of personnel is a common problem for medicine. In the Primorsky Territory, it is also considerable - 1,5 thousand people. It is especially important to consider the solution of this issue in the pediatric service. Working with young children is, of course, difficult. But a doctor who has received a pediatrician diploma and works by profession has the opportunity to become a high-level professional, since a pediatrician provides medical care from the birth of a child until the age of 18, that is, when a person becomes an adult. Based on the accumulated knowledge in the field of pediatrics, the doctor knows how to treat both a child and an adult patient. In the Primorsky Territory, there is a need for other specialists: cardiologists, neurologists, oncologists, dentists and doctors of other specialties, but it is somewhat less.

And taking advantage of the opportunity to communicate with citizens through this publication, I must say: contact your doctors as soon as possible and do not self-medicate! We will solve the problems of personnel shortage, we will not leave anyone without medical care. But to treat a person with neglected diseases is much more complicated than one who came to the doctor with an early stage of the disease, while the process is reversible. Do not feel sorry for yourself - at least spare your own money: in terms of the financial component, prevention in 20 is cheaper than treatment.

The sooner the disease is detected, the greater the chance that it can be prevented. In medicine, there are the concepts of "mild disease", "disease of moderate severity" and "severe degree". It is important that medical help comes at the very first stage. Then, perhaps, it will not reach the second and third, the person will recover. The quality of life, about which so much is being said now, is precisely that.

- They just say that the quality of life is in direct proportion to the amount of money ... Is it possible to make free medicine to treat people as well as paid?

- The professional level of doctors working in public and private clinics is about the same. Moreover, it often happens that in the morning you can get a coupon to the same doctor in a free state clinic, and after lunch or on another day of the week, he also takes it in a private clinic. It is not prohibited. And it is clear that for only one budgetary salary in 25-40 thousand rubles, average in Primorye, the doctor will not feed his family.

But we must take into account the service component. We have good specialists and we are provided with medicines. But the service is such that many citizens have the feeling that "medicine itself is sick with something." For example, in order to get to a cardiologist or neurologist in a regular clinic, a person must first take a coupon to a therapist. Only he gives a referral to narrow specialists. Along the way, it turns out that some more examination is needed - again a coupon the next day, again waiting in line. We are blamed for the wrong scheme of medical care. But we are between two fires: on the one hand, there are dissatisfied patients, on the other, the need for a long time to fill out medical documents approved by the Ministry of Health.

The qualifications of doctors in the compulsory medical insurance and voluntary medical insurance systems sometimes differ slightly, but the intensity of the doctor's time and labor costs is incomparable. In state polyclinics, the doctor examines the patient and gives him recommendations for a maximum of 10-15 minutes, these are the standards. Continuous flow, like on a conveyor belt. In private clinics, a consultation can take an hour. Of course, this allows you to more closely study the features of the disease, select the necessary drugs. And not in vain, by the way, even Aristotle and Socrates said that “the word heals”. It is necessary to talk with the patient, question him in detail and carefully, answer his questions and dispel doubts. When a person is calm, in a good mood, and has a positive attitude, recovery is more successful.

“Sometimes it is the time that hurries patients.” People can not wait for free ultrasound or CT scan for 3-4 weeks, are forced to do the procedure or examination for money. And we are sure: “this is all on purpose”, in order to force out patients into the sphere of paid medicine. They are right?

- Not on purpose. Forced. We are constantly talking about the need to increase the number of specialists and equipment in institutions that provide medical assistance under compulsory medical insurance. It is an abnormal situation when only one ultrasound machine functions in the clinic or only one doctor works on it. Do not forget that medicine is a field of activity where medical assistance is provided to all who apply, a doctor has no right to refuse a patient. However, it also happens that it is impossible to foresee a sudden increase in the number of patients. An enterovirus infection broke out, a flu epidemic began and, as a result, a queue arose for a blood test or X-ray ...

For the initial diagnosis and determination of the main indicators of human health (clinical blood test, urinalysis, cardiogram, visual acuity, hearing, etc.), our polyclinics are well equipped. When any special research methods are required (for example, PCR - polymerase chain reaction), patients are referred to specialized medical centers.

- You said that in the region there are many vacancies for physicians. But what they are going to attract here, if the salaries are only about 40 thousand, and the climate and conditions are harsh?

- At the meetings of our Expert Council on Healthcare, we, together with "Support of Russia", discussed how to change the situation and achieve an influx of doctors in Primorye. The main attraction factor is undoubtedly housing. If a young specialist is invited to the territory of the Primorsky Territory and given an apartment, then satisfactory conditions for life and work will be created, at the same time it will be possible to solve the demographic problem. We came up with a proposal to the governor of Primorsky Krai - to direct funds from the regional budget to support the mortgage program for health workers. We were answered with consent. The down payment will be paid from a special fund, the rate is minimal. The first 120 families have already received the right to such benefits and are entering into agreements with the regional administration.

The salary of doctors - yes, it is not enough. Labor in medicine is difficult in all respects, and especially in the emotional sphere. Financially, it is also very difficult for doctors to compare their earnings with the prices of food in the store, at the hairdresser, for extra classes for children, for housing and communal services. As a rule, doctors take additional rates in a public medical institution or work in private clinics, such circumstances lead to emotional and professional burnout.

- And how many residents of Primorsky Territory can now afford to be treated in those private clinics, where the "public" doctors earn extra money?

- Depending on what level of medical care we are talking about. If it is a blood test with the determination of the level of hemoglobin, erythrocytes or leukocytes - perhaps such a paid diagnosis is available to everyone. But the same is done in polyclinics at the expense of the compulsory medical insurance, that is, free of charge for the patient. It should be noted that due to the workload of laboratories, the analysis will be ready a little later than in a commercial clinic. For example, in a private clinic, you can donate blood at 12 noon, and in a public medical institution - only in the morning, you can receive test results by e-mail and much faster from a private clinic. And again - the level of service ... But - for some money.

- Many people because of difficulties with coupons and records in general do not go to the doctors. Pharmaceutical pharmacists become consultants for them. How do you feel about such self-treatment?

- Strongly negative. In my opinion, this is unacceptable. I control the level of my health, lead a healthy lifestyle and rarely visit pharmacies, however, on rare visits to the pharmacy, I have heard more than once how a person with a fever or cough asks the pharmacist how to "bring it down". And the pharmacist recommends the drug in an authoritative tone. Very often - the most expensive of the presented or "shock antibiotics". But the uncontrolled use of antibacterial drugs has an extremely negative effect on the human body, especially on the child's body. Yes, the symptoms of the disease (runny nose, cough) will disappear in about 5-10 days, and uncontrolled intake of antibiotics leads to consequences - the formation of microflora, which is already "resistant" to the action of the drug. If such a person ever has another disease or operation, then "antibiotics" will not be able to destroy the pathogenic microflora. There is no official ban on such "treatment in pharmacies". And no circulars will help the matter here. You just need to instill in people a culture of attitudes towards their health. Explain that a reasonable person will first visit a doctor who will assess his condition and only then will he prescribe the necessary medicine.

- What are the people in Primorye sick most often?

- In Russia, the top three causes of death are vascular diseases (heart attacks and strokes), oncology and so-called “external causes” (injuries, accidents, etc.). The same trend is observed in the Primorsky Territory. But there are also features due to regional climatic and geographical conditions. Primorye has a very high hydrodynamic regime - high humidity, strong wind (more than 10 m / s) at low temperatures. You can look in publications on geography and climatology: when the temperature is minus ten degrees, and the wind force exceeds 15 m / s - for the human body it feels like minus twenty-five. In fact, we spend half of the cold season in such extreme conditions. It is quite understandable that flu, ARVI and other diseases "come" to us. Every year we "fight" with them, and in the winter period of time we even repeatedly and, as a cause-and-effect relationship, a high load on immunity and the formation of chronic diseases. The incidence rate in Primorsky Krai is higher than in "dry", warm and sunny regions.

In the analysis of the dental health of the Far East, the indicators are worse than those of the Russians living in other territories. When studying this problem (in the work of my doctoral dissertation), we found out that the level of minerals in soil and water is 10 times lower than normal. And this creates an unfavorable background for the formation of dental diseases. Naturally, we carry out prevention. But, unfortunately, many people go to doctors too late, when the teeth are already decayed and dentists are forced to remove nerves and fill the canals. Realizing that sooner or later such a tooth will have to be removed.

Regional features cannot be discounted. Somewhere in Sochi or in the North Caucasus to live, who would argue, is much more comfortable. There are more trace elements in the water and soil. Sunny, much more vegetables, fruits, herbs ... And in our country they ripen only in summer, from about July to September. The rest of the time we eat mainly Chinese vegetables and fruits, there are not very many vitamins in them.

- Even in fresh, not canned?

- Sure. Vitamins are unstable substances. Here's an example. In the second year, in September, students of a medical university conduct experiments in biochemistry classes - they study the amount of vitamin C in lemon, kiwi, and sweet pepper. So, after three days of storage, this vitamin is destroyed and disappears. So if you drink tea with lemon in case of a cold, do not entertain the illusion that the virus will immediately "retreat". Sweet pepper, which students bring from their summer cottages, contains more vitamin C than lemon from the store. And also not for long.

Somewhat longer, the vitamins “live” in frozen berries. Therefore, compotes, fruit drinks, mashed currant berries will be useful. If we talk about vitamins that are sold in pharmacies, we must observe whether they are absorbed in the body. It depends on how the intestines work, whether a person has a metabolic disorder, etc. This can only tell a doctor, without special knowledge in such matters can not figure out.

- An area where specialists and the latest research methods are needed especially significantly is oncology. Do doctors in Primorye have the opportunity to fight cancer in regional clinics so that patients are not sent for treatment to Moscow, St. Petersburg, Tomsk or abroad - to Singapore or Korea? How long do you have to wait for quotas, are there enough medicines for cancer patients?

- Oncological diseases in our country, unfortunately, are widespread in the same way as throughout Russia. And the problems are the same. There is an oncological dispensary, but it is significantly busy, there are queues for oncologists. Soon we will solve this problem - the new building of the oncological dispensary is ready to receive patients. The premises are more spacious there, and more doctors work.

Not all neoplasms are cancer. But if the histological examination of tissues confirms that the person actually develops a malignant tumor, the treatment is carried out in Primorye, in the oncologic dispensary. When it is necessary to use any complex methods of radioactive diagnostics, patients can receive quotas for treatment in Moscow, St. Petersburg or Tomsk. For this, a referral from an oncologist is needed when verifying the diagnosis (the result of histological examination confirms the oncological process). After that, the Department of Health issues a quota. Quickly, without any queue.

To conduct radiation treatment, the clinic must have a special license. We have relatively few patients who need such help, there is no point in creating such medical facilities from scratch. The Nuclear Medicine Center on Russky Island will now expand. There, for example, in the medical center of FGAOU VO FEFU, it is already possible to do positron emission tomography (PET CT). This type of diagnosis allows you to see the presence of metastases in the body and adjust the treatment regimen. To carry out this type of research, special sanitary and technical conditions are required in the clinic itself, because the material used in the work is radioactive glucose (18F-fluorodeoxyglucose), its half-life is 110 minutes. This means that after 20 hours the drug is completely destroyed and excreted by the urinary system. However, such a "short" period of the life of radioactive glucose dictates special conditions for the transportation and storage of this substance. We must be able to deliver it on time and accurately, according to the number of patients in need. It is impossible to "stock up" this drug in advance, and the drug is placed in a special storage facility. There is a queue for PET CT, but within reasonable limits. The time of work with a radioactive preparation is calculated accurately. Previously, I would have had to go to Korea to undergo this procedure, now it is being carried out in Vladivostok.

“But even now many cancer patients are seeking treatment there too.” Or to Singapore, China, Israel or Germany. Are we really so far behind these countries?

- The situation here is the same as in other medical fields, just a disease - much worse than “normal” colds or fractures. Cancer treatment regimens in Russia and abroad are the same. The question is all in the same level and quality of service. You can understand a person who is told that he has an oncological disease. This is a shock. He is trying to enroll to an oncologist - and the reception must still wait. Even a few days of such expectation - the patient experiences horror and fear. And the patient travels, for example, to Korea, where the consultation costs 200 dollars, but without a queue. This is his right to choose.

There are other reasons. For example, after chemotherapy, drugs may be prescribed to relieve the serious consequences of intoxication. Or drugs that allow you to not lose hair. Or something else that affects the comfort and well-being of a person after surgery or radiation therapy. In our program, which is paid for by the OMS, only basic drugs can be administered, the rest is not enough money. It is clear that people choose if they have at least some financial capabilities.

Still, the main thing in oncology is not “where is the best treatment available,” but how early the disease was detected. If it was diagnosed already at the third or fourth stage, the patient's life expectancy, unfortunately, decreases. When the tumor was found and removed at the very beginning, the prognosis is quite optimistic. Much also depends on which organ is affected, metastases have formed or not. I highly recommend that you periodically take a blood test for tumor markers, such studies are carried out both in Russia and in other countries. The sooner problems are revealed, the easier it will be to solve them.

- You are the chief dentist of the Far Eastern Federal District and Primorsky Krai, a well-known specialist in preventive and pediatric dentistry. Tell me, will our compatriots ever be able not to be ashamed of their smile, or is it necessary to move to Hollywood for this?

- Dentistry is developing very quickly and intensively, new technologies appear almost every year. Clinics in Primorye do not lag behind those in Moscow, and sometimes even surpass. There are clinics where the level of dental care is comparable to the level of care in Europe and America. Often it is necessary to redo dentures made in Singapore, Korea, China. Patients, thinking that the level of dental care abroad will be better, receive dental care abroad, but the patient can only evaluate the service component, and “learn” about the quality of work when he has already left the country, and the doctor of a foreign state is responsible for the work done foreigner-patient does not bear.

And the technologies in our dental clinic are used well-known all over the world - even in America, even in Europe, even in the developed countries of Asia.

Today, it is primarily methods aimed at preserving teeth and preventing their diseases. Earlier, in Soviet times, they did not hesitate for a long time - they turned teeth and set gold crowns. Many crowns are a rich man, living in luxury ... Now there are other times. People care about health and naturalness, not chic and shine. To restore the teeth, zirconium oxide is used. It is better than heavy metal ceramics, under which a significant part of the tooth has to be turned.

Another direction in dentistry is restoration. This term does not only refer to antique furniture. There are many materials that allow you to perfectly restore the color, shape of the tooth, and even light on artificial enamel will be refracted in the same way as on natural. A smile is the envy of Hollywood.

Caries also gives people a lot of trouble. This, as you know, is a defect in tooth tissues, when they gradually become soft, literally - like a rotten rotten stump. The bark is still there, but there is emptiness inside. Taking this opportunity, I would like to address our dear fellow citizens. Please, come to the doctor not when the tooth already hurts or a hole (cavity) is found in it, but twice a year, at least for the prevention of dental diseases. In the arsenal of the dentist there are drugs that are painlessly applied with a brush to the teeth and conditions are created to ensure that the teeth do not deteriorate. This applies to both adults and children. Diseases in people of different ages have their own: a child's problem - caries, an adult - periodontitis and periodontal disease, inflammation of the gums and their bleeding. In advanced cases, a seemingly healthy tooth can be simply removed from such a gum with two fingers. And many of our patients for a long time simply do not pay attention to halitosis, pain when brushing their teeth, loose gums ...

This is the alphabet, but it has to be interpreted all the time by modern, intelligent, educated people. Teeth should be cleaned at least twice a day, after eating. 2 generations of bacteria manage to form within 24 hours, their life cycle is 12 hours. So that they do not multiply, it is necessary to remove the remnants of food from the oral cavity and not to leave bacteria to the nutrient medium.

- Advertising various "family toothpastes" except from the iron now does not sound. What to look for when choosing?

- First of all, the fact that there is no "family" pasta and cannot be. Some pastes are recommended for children, others - for adults. A child needs to protect teeth from caries, and the older generation needs to eliminate, for example, bleeding gums or bleach enamel (in general, whitening procedures are safer to carry out at the dentist). So it's best not to fall for the tricks of the marketers. And, of course, do not forget about the visits to the doctor. Especially with children. By itself, brushing your teeth from their diseases does not protect, only under the guidance of a doctor can you achieve a state of good dental health.

Let me remind you that there is an order of the Ministry of Health, which obliges dentists to examine a child up to 18 years every year. Parents should be especially attentive when the child is from 6 to 12 years, that is, during the period of changing milk teeth to permanent ones. There may be the most unexpected unpleasant surprises - for example, if the lateral tooth does not fall out by itself, and the roots of permanent teeth that erupt at the same place begin to go at random, sometimes even to the maxillary sinus in the maxilla or in the mandibular canal.

- What a horror ...

- We deal with such cases more often than we would like. Given that, to the extremes of the process it would be quite possible not to bring it. I write it off not only on the eternal fear of dentists, although they have been treated for a long time with anesthesia. Rather - the general illiteracy and carelessness.

These are also elementary truths - but to my surprise, not everyone knows them. Caries can be stopped as long as the tooth tissue is not damaged, that is, a cavity has not yet formed in the tooth. It begins with the appearance of white chalky spots on the enamel. The doctor sees them when they shine the light of a bright lamp on the surface of the tooth. In some clinics, the patient is shown these illuminated spots using a small video camera. So, while this is just a stain, a remineralizing preparation can be rubbed into the surface of the tooth with a special brush. After that, the chalky spot disappears, the threat of caries too. Children are now applying sealants to the recesses of the teeth - preparations that "seal" problem areas that are difficult for a child to clean with a brush. The effect is excellent.

Why is it important? In children 20 milk teeth, this is the so-called "temporary bite". The first permanent tooth appears at about six years old, it is located behind all others and its appearance, as a rule, passes unnoticed. Another chewing tooth is cut through years in 12-13. If a child doesn’t clean teeth effectively, these teeth deteriorate and must be removed. And we have a few chewing teeth, so take care of them. Especially since the eighth in the series - “wisdom teeth” —n’t all people have been mortgaged now, so evolution has disposed.

- Preparations against caries, which you mentioned - mostly imported? Is it possible in dentistry import substitution, which is now talked about so much?

- Yes, for the most part foreign medicines, materials and equipment are used. The percentage of Russian products is very small, mainly products for canal disinfection or enamel remineralization. In Soviet times, we had good pharmaceutical factories, they produced excellent preparations for dental treatment, but many have already been closed. Now in Russia there are production facilities, whose products meet international standards. But there is also a question of brand, reputation. For example, I have been working as a dentist for almost 25 years. During this time, we all were able to assess the reliability of the companies we deal with. And we cannot experiment on humans, empirically check whether a new filling of an unknown manufacturer is deformed in a day, whether the color, structure and plasticity of the prosthesis will change. Apparently, over time, it will become clear that domestic developments stand the test honestly. But so far the situation is the same as, for example, with a good perfume. Most likely, you will not buy a perfume from an unknown manufacturer in a closed form.

- Is smoking dangerous for your teeth?

- The fact that the teeth of tobacco lovers turn yellow and their enamel is destroyed is still half the problem. In smoking patients, we often diagnose oncological diseases in the oral cavity. Let me explain why. A man holds a cigarette with his lips, her temperature is above normal for the human body. The thin mucous membrane on the inside of the lips sticks to the cigarette, and so many times a day. There is a chronic focus of irritation, detachment of the mucous membrane, microtrauma. All this creates the conditions for the onset of oncological processes. Smokers quite often have cancer of the lips, salivary glands.

The possibilities of early detection of cancer in dentistry are quite large, they are well known in Russia and widely used. Light methods are particularly relevant - for the simple reason that they are carried out quickly, they do not require histological examination (that is, clipping a piece of tissue). If the dentist noticed something suspicious, he immediately sends the patient to a fellow oncologist.

- Recently there have been several cases when a patient died right in the dentist’s chair at some small clinic. Anaesthesiologists and resuscitators there simply did not provide for staffing. Do you think it is necessary to transfer all private clinics or offices “under the wing” of large medical centers to avoid such tragedies?

- Each tragic case is individual, it is always necessary to understand and draw conclusions in its causes. Small cabinets within walking distance, on the first floors of residential buildings, are unlikely to be able to obtain a license for such types of medical activities as anesthesiology and resuscitation. For this you need a room of at least 54 square. meters, appropriate equipment to control breathing, heart and brain work, qualified personnel. Apparently, they simply close. But I do not think this is a good way. Rather - reinsurance, let's call things by their names.

I remember the examination of expertise in the professional community in several such cases that occurred on the territory of Russia, with a fatal outcome. When they found out in detail the reasons for one of them, it turned out that the patient did not consider it necessary to warn the dental surgeon about a heart attack two weeks ago. The doctor introduced him to a standard drug approved for use, did all the necessary manipulations. The patient left the clinic, and he became ill at home, and he died. If the surgeon knew about the recent heart attack, he would use another medicine in another dose for pain relief. The cause of death of the patient was precisely a heart attack in history, rather than poor treatment. But ... the information is late, and you will not return the person.

- A lot depends on the qualifications of the doctor too. Do medical professionals in Primorye, especially young ones, have the opportunity for professional growth?

- We understand that a doctor should always study, and not “improve his qualifications” every five years. Now doctors of all medical specialties will be accredited. The system of continuing medical education provides that for each year a doctor must attend a certain number of lectures and practical classes - a total of 50 hours. For five years, in his personal account on the portal of the Ministry of Health, these data are entered by an individual code. It is immediately clear how many master classes or lectures the doctor attended, how much his professional level has grown.

To begin such studies, the doctor is tested, takes an exam on the application of practical skills on special simulation simulators, dummies, very similar to a real person. True, mannequins, they are "phantoms" - are just simulators. When a young doctor comes to the clinic, he is sometimes surprised to find that the patient has saliva or bleeding and must be blocked, that the patient is nervous and has to be persuaded. The child does not want to sit in a chair and turns around so that you can hardly hold the instruments ... Therefore, theory is theory, and the main, final stage is work in a clinic with a real patient.

Speaking of dentists, graduates of dental faculties of medical universities have a certain set of competencies. A general dentist can work as a dental surgeon, orthopedic surgeon (that is, perform prosthetics), be a pediatric doctor or an adult therapist. Specialties such as orthodontics and oral and maxillofacial surgery require training in clinical residency. But by attending one or another training program, our doctor can later acquire a new specialization or enroll in a residency (this requires 3 years of practical work). I think that the system of continuous medical education will, nevertheless, create conditions for doctors not to stop in their professional development.

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