Industry-sponsored postgraduate medical education: Russian

experience

Boleslav LichtermanInstitute for the History of Medicine, Russian

Academy of Medical Sciences, Moscow, Russia

lichterman@hotmail.com

Outline of presentation

• A system of postgraduate medical education in Russia, its benefits and pitfalls.

• A case of Russian Postgraduate Medical Academy.

• Suggested reforms and introduction of credit system.

• The impact of industry on continuing medical education and clinical practice.

Higher Medical Education in Russia

• six years at medical school (medical, paediatric or sanitary faculty of medical university)

• internatura - specialization for one year in a big hospital in one of three major fields: internal medicine, surgery or obstetrics and gynecology

• and/or ordinatura – a two year subspecialization ( in neurology, cardiac surgery, ophthalmology etc.) (optional)

• followed by aspirantura - a three year PhD program, academic degree (kandidat meditsynskikh nauk) after completion kandidatskaya dissertation (optional)

• doctorantura – a program for completion of second doctorskaya dissertation for getting highest academic degree (doctor meditsynskikh nauk) and becoming a professor

СТРУКТУРА МЕДИЦИНСКОГО ОБРАЗОВАНИЯ В РФ

БАЗОВОЕ ОБРАЗОВАНИЕ (6 ЛЕТ)

КУРСЫ ПОВЫШЕНИЯ КВАЛИФИКАЦИИ – 1 РАЗ

В 5 ЛЕТ ~ 144 ЧАСОВ

КУРСЫ ПЕРЕПОДГОТОВКИ> 500 ЧАСОВ

ИНТЕРНАТУРА – 1 ГОД (ПЕРВИЧНАЯ ПОСЛЕВУЗОВСКАЯ ПОДГОТОВКА)

ИЛИ ОРДИНАТУРА – 2 ГОДАИЛИ АСПИРАНТУРА – 3 ГОДА

МЕДИЦИНСКОЕ ОБРАЗОВАНИЕ В РФ

ОБЯЗАТЕЛЬНОЕ ПОСЛЕВУЗОВСКОЕ ОБРАЗОВАНИЕ

ДОПОЛНИТЕЛЬНОЕ ОБРАЗОВАНИЕ

ПОСЛЕДИПЛОМНОЕ (ПОСЛЕВУЗОВСКОЕ) ОБРАЗОВАНИЕ

Russian/Soviet system of postgraduate medical education is

• highly centralized • unified • state-controlled • state-sponsored

Refreshment courses (1-2 months, min. 144 hours) every five years at an institute (academy, faculty) of postgraduate medical education.

A Historical Outline• 1885 - Imperatorsky Klinichesky Institut (The Imperial

Clinical Institute) of the Grand Duchess Elena Pavlovna was founded in St.Petersburg

• 1920s - 16 postgraduate medical institutes were opened in former USSR

• 1930 – Central Postgraduate Medical Institute was established in Moscow ( now Russian Postgraduate Medical Academy)

• Currently there are more than 70 institutes and faculties for postgraduate medical education in Russia. 161.300 physicians studied there in 2000. The overall number of physicians in Russia is about 700.000.

Russian Postgraduate Medical Academy

• seven faculties • 112 chairs (departments)• research centre• publishing house, • three hostels • more than 2000 employees • the annual number of specialists who

refresh their knowledge exceeds 30.000.

Problems of postgraduate medical education

• standards of education are non-existent • the number of medical specialties (92 in

Russia (33 main and 59 additional specialties) vs 52 in Western Europe) is excessive

• qualification criteria are blurred • certificates are given automatically • postgraduate medical institutions do not

have their clinics

How to achieve the goals of CME?How to achieve the goals of CME?

Modernize normative base:- modernization of federal education standards, programs and tests- introduction of system CME credits- credits should be taken into consideration for certification of a specialist- and for licensing of healthcare institutions- regulation of CME procedures

Provide material base:— at medical universities (modern technical equipment and libraries, infrastructure for distance learning)— at healthcare institutions (access to modern sources of information, computerization, electronic libraries, internet etc.)

What is necessary for practical What is necessary for practical implementation of CME?implementation of CME?

Provide sufficient funding:— from federal sources (computerization of healthcare institutions, creation of National electronic medical library, equipment for university libraries, probation at foreign centers)— from regional sources ( creation of regional libraries, financing of conferences and seminars etc.)— from local sources (money for postgraduate training of healthcare providers, probations, participation in conferences, introduction of standards, creation of medical libraries)Motivate healthcare providers:—CME should have an impact on salary— compilation and publication of ratings ( of physicians and of HMO)— quality control of medical care

SuggestionsSuggestions

Healthcare providers should continuously improve their qualification and annually report their acquired creditsPrograms of postgraduate education should be updated according to modern requirements (distance learning, modern methods of education, good content, tests etc. )Overall volume of education activity should increase from 144 hours to 216 (288?) hours due to independent learning of healthcare providers (including learning at workplaces) and evenly distributed within 5 year period

In search of a compromise• “Introduction of Western model of postgraduate

medical education is unacceptable in Russian realities because it would destroy our system of education” (Romanyuk PF, 2004).

• How to accumulate credits? 2/3 might be provided by on-site education at

postgraduate medical institutions and 1/3 - by extramural education (attending conferences and seminars, writing of scientific papers, reading of medical journals and manuals followed by testing etc.).

In search of funding

• federal funding for CME is insufficient• education facilities are outdated• teachers’ salaries are low

Industry-sponsored postgraduate medical education

• At conferences and symposia• Via medical representatives• Sponsoring lecturers and opinion leaders• Conflicts of interest are often ignored

Problems• How many Russian physicians join international

meetings?• How often an ordinary physician purchase

medical literature or subscribe a specialized periodical?

• Are there many Russian physicians who have an access to reliable sources of information, systematic reviews and meta-analyses

• Do they have chances to use electronic databases or internet?

Russian pharmaceutical market

• Ca.17.000 different drugs are registered• More than half of then are imported• More than 90% of Russian drugs are simple pharmaceuticals or

generics• More than 400 pharma companies are working in Russia• Each medical representative has 1200 information contacts annually• Physicians put visits of medical representatives as the third

information source (after reference manuals and specialized medical periodicals) (a sample of 1298 physicians)

“Medical representative is fighting not for a market share but for the place in physician’s mind” (Budarina TN,2008)

Positive effects of relationship between physicians and pharmaceutical business

• Doctors are informed about the newest drugs

• Facilitation of getting these drugs• Possibility of additional professional

advancement and active participation in the life of scientific community

Negative possibilities of relationship between physicians and pharmaceutical

business

• Prescription of unnecessary drugs• Prescription of more expensive drugs• Possible mistrust of patients

“None of these normative documents [Russian laws and instructions] regulate relationship between a physician and medical representative of a pharmaceutical company. Interestingly, it cannot be the case because such regulation would contradict principles of the market economy” [Budarina TN, 2008]

A case of “Pfizer”

• In 2005 “Pfizer” was concerned by decrease of sales of Diflucan in Volgograd region. For promotion this drug local company representatives organized a boat trip on Volga river for medical doctors. The program included a round table discussion, dinner, handing drug samples to the participants (400 were invited, 600 arrived). After the event 6-month stock of Diflucan in pharmacies of the city and the region was sold within one week. (Budarina TN, 2008)

Johnson & Johnson education centers worldwide

Country USA Germany China (2 centers)

India(3 centers)

Russia and CIS

Year of foundation 1992 1991 2005 2005 2008

Territory (sq.m.) 4600 5000 5000 3000 3 000

Annual number of trained specialists

6000 14 000 10 000 10 000 3 000

Kazan Teaching Center of High Medical Technologies

Launched by the Ministry of Health in 2008with support of Tatarstan government and Johnson & Johnson company

Aim: to train qualified physicians for increasing availability of modern medical technologies for Russian population

Up to 3000 physicians might be trained annuallyTraining course lasts for 9 days (72 hours)

On course completion an official certificate is given

The lack of trained specialists in Russia

700

Orthopedic surgeons implanting joints

Endoscopic surgeons

Interventional neuroradiologists

220

1 100

3 000

2 400

13 500

Needed number

in RussiaSpecialists

Number of specialists

using high-tech methods

5 000 30 000Physicians 600.000

Surgeons 90.000

Education activitySince 2008 specialists are trained in:

Endoscopic surgery

Interventional radiology

Starting from 2009 training in:

electrophysiology

oncology

hematology

pharmacoeconomics

healthcare organization

Johnson & Jonhson plans to invest 10 million USD within a five year period for purchase of training equipment ( phantoms etc.) and teaching programs

Facilities of the Kazan CenterTerritory: 3 000 м2

Facilities:

• Seminar rooms with live translations from operative theatres in Russia and abroad

• Reading hall equipped with PC’s with access to internet

• Laboratories for training on stimulators • Operating room (dry-lab) for work on live

tissues • Conference-hall for 250 seats

“The problem is not in opinionated specialists but in the lack of common ethical space”

(Budarina TN, 2008)