НЕПРЕРЫВНОЕ МЕДИЦИНСКОЕ ОБРАЗОВАНИЕ: НЕОБХОДИМОСТЬ ПЕРЕМЕН

Семелева Е.В.¹, Селезнева Н.М.²

¹ORCID:  0000-0001-6692-4968, кандидат медицинских наук, доцент, ²ORCID: 0000-0002-3004-2063, кандидат медицинских наук, доцент, Национальный Исследовательский Мордовский Государственный Университет им. Н.П. Огарева, медицинский институт

НЕПРЕРЫВНОЕ МЕДИЦИНСКОЕ ОБРАЗОВАНИЕ: НЕОБХОДИМОСТЬ ПЕРЕМЕН

Аннотация

Введение: в статье рассматривается проблема формирования непрерывного медицинского образования (НМО) в современных изменяющихся условиях, выявляются характерные особенности и механизмы функционирования НМО. Цель статьи – выявление и изучение наиболее актуальных вопросов в сфере НМО для их систематизации и дальнейшего внесения изменений в существующий процесс врачебной подготовки.

Материалы и методы: методологией исследования является обобщающий анализ проблем НМО, его направленности и содержания на различных уровнях современной образовательной системы, который позволяет исследовать НМО прежде всего как постоянное совершенствование профессиональных компетенций.

Результаты исследования: авторами статьи рассмотрены вопросы и проблемы НМО  в Российской Федерации (РФ), подчеркнута важность Государственных программ  развития здравоохранения РФ для повышения квалификации и переподготовки врачей. Отмечается, что в зарубежной исследовательской литературе также уделяется существенное внимание разнообразным подходам к определению понятий в сфере НМО: «образование на протяжении всей жизни», «процесс приобретения новых знаний и профессиональных навыков». На основе анализа данных исследования определяется значение НМО в развитии социально-экономической системы РФ.

Обсуждение и заключение: в заключении статьи авторами исследования делаются выводы, раскрывающие специфику происходящих изменений, отражающихся в процессе функционирования НМО. Авторами подчеркивается, что современному медицинскому работнику необходимо постоянно поддерживать и пополнять свои знания.

Ключевые слова: непрерывное медицинское образование; образование на протяжении всей жизни; образовательные технологии.

Semeleva E.V.¹, Selezneva N.M.²

¹ORCID:0000-0001-6692-4968, MD, Associate Professor, ²ORCID:0000-0002-3004-2063, MD, Associate Professor, Mordovia N. P. Ogarev National Research State University, Institute of Medicine

CONTINUING MEDICAL EDUCATION: THE NEED FOR CHANGE

Abstract

Introduction: the article considers the problem of continuing medical education (CME) formation in today's changing environment, identifies characteristics and functioning of CME mechanisms. The purpose of the article is the identification and study of the most topical issues in the field of CME for their systematization and further changes of the existing process of medical training.

Materials and Methods: the methodology of the study is a comprehensive analysis of CME problems, its orientation and contents at different levels of the modern educational system, which allows exploring CME primarily as the continuous improvement of professional skills.

Results of the study: the authors of the article have considered the questions and problems of CME in the Russian Federation (RF), stressed the importance of the state health development programs for refresher training and retraining of doctors. It is noted that in the foreign research literature considerable attention is also paid to a variety of approaches to the definition of concepts in the field of CME: "education throughout life", "the process of acquiring new knowledge and skills." Based on the analysis of the study data the significance of CME in the development of the socio-economic system of RF is determined.

Discussion and conclusion: at the end of the article the authors of the study make conclusions that reveal the specifics of the ongoing changes reflected in CME functioning. The authors emphasize that a modern medical professional must constantly maintain and improve their knowledge.

Keywords: continuing medical education; education throughout life; educational technology.

Introduction. High qualification and a sufficient level of competence of health professionals are the most important factors designed to improve the quality of medical care. Modern healthcare requires competent specialists who possess the necessary knowledge, skills and abilities and who are able to substantiate their actions and decisions from the standpoint of evidence-based medicine. Only constant, continuous professional development of a health professional provides the basis for high efficiency of his/ her daily work. In contrast to developed countries where health workers are required to have their knowledge certified annually and use modern guidance in the workplace daily, Russian doctors have a refresher course every 5 years, and often lack access to modern sources of information in the workplace. However, about 15% of doctors do not take even these courses within the time frame. The situation is compounded by the fact that refresher training often has a formal nature and contents of educational programs do not meet the needs of practical health care.

The main reason why the changes in medical education have become so necessary is the poor quality of care and patient dissatisfaction. Thus, according to the Ministry of Health of the Russian Federation (RF), the total percentage of patients satisfied with the quality of care in our country is no more than 36% [1].   Most of our citizens want quality medical care and a respectful attitude towards them. It may be argued that patients’ opinion is a subjective indicator. However, the objective indicators of medical care quality are also not very comforting. According to the Federal Mandatory Medical Insurance Fund, in 2012 the proportion of irregularities in patients’ treatment, identified during the examination of the medical care quality, was more than 30% of all examinations [1]. And for several years this figure has been almost unchanged. In addition to this, the comparison of objective indicators of the quality and safety of health care shows that they are much worse in our country than in developed countries. Thus, in-hospital mortality rate of patients with myocardial infarction in the RF  is 2-3 times higher than in the EU on average (18% and 5% respectively), infectious complications in hospitals occur twice as often as in the EU (8% and 4% respectively) [1]. Of course, there are organizational reasons for that, but the main one is the qualification of doctors.

Another important reason is lack of medical staff. Today the prestige of the medical profession of a doctor, a nurse, a medical assistant, a researcher, as health workers estimated themselves, is one of the lowest in the entire history of health care in our country. The low prestige of the profession and a weak motivation for quality work of health workers are due to extremely low salaries, which do not correspond to their high responsibility and hard and unsafe work. The low salaries of health workers in the past 20 years led the Russian health care system to decline.

One more problem is overloaded doctors. In the public health system there is an extremely non-optimal ratio between primary care physicians and medical specialists. The low supply of skilled workers in Russia is aggravated by hospitals being understaffed with family doctors and general practitioners; high coefficient of having more than one job; document management overload and participation in the implementation of the additional drug supply program. All of these lead to long queues in outpatient clinics, reduced access to primary health care for the population of the Russian Federation and to the deterioration of the patient care quality.

Apart from the mentioned problems it should be noted that in the last 20 years the requirements for the level of qualification of the doctor have been raised significantly and, hence, for the system of his education. Modern physicians must be able to use sophisticated new diagnostic and treatment techniques, which are often, though highly effective, not safe for the patient. He should be able to assess the risks of their use properly in every case. All of the above means that the existing system of continuing medical education in the country is failing and needs a major upgrade. Since 2012 the formation of the most important normative instruments for structural changes in health care in general and medical education in particular has begun.

Literature Review. Modern society is in conditions of constantly changing and increasing demands for professionalism and competence of specialists at all levels, in circumstances where it is necessary to create new educational programs, use modern learning technology, conduct special training for teachers for the implementation of innovative industrial programs. In the context of the transition to a market economy, which resulted in population’s increased need for quality health care, the problem of health care staffing has aggravated. The situation is exacerbated by the constant brain drain of personnel from public health institutions, the lack of a necessary influx of young professionals, which lead to aging contingent of medical workers.

In the studies of the last decade the need for the study of a professional and personal image of the medical worker is substantiated, the analysis of satisfaction with employees’ work opens up for the head the possibility of choosing optimal management models and, in particular, the possibility of strategic planning of human resources development in an organization. Experience in the implementation of continuing medical education (CME) in 18 European countries shows that in 17 of them CME is considered necessary; in 6 countries it is regulated by the law and in 13 countries it is provided by professional medical societies. Currently, in many countries, the term "continuing medical education" is not the only one that is used; there is also the term "continuing professional development" which includes, in addition to improving the professional knowledge and skills in your specialty, receiving additional competencies: in managing health care quality, developing clinical guidelines, managing a department, etc.[4]. Thus, it is a continuous process of professional development which aims at improving patients’ treatment outcomes and increasing medical care safety. The expected result of large-scale plans for national health care restructuring in the interests of social and industrial development can be achieved not only through the proposed activities, but using the human factor, the basic foundations of which are the satisfaction of a doctor with his professional activities, seeing the prospects, understanding of the goals and objectives of the medical organization.

Minister of Health of the Russian Federation V.I. Skvorcova has repeatedly stressed that health development is impossible without highly qualified personnel and that the "quality of medical care depends on the qualifications of health care workers". The rapid development of medical science and public health practices, the need for improving medical care quality, education modernization were the basis for the scientific substantiation and introduction of CME system, in which persons, who have followed the specialist accreditation procedure since 2016, will be gradually included. According to the Federal Law of 12.29.12, "About Education in the Russian Federation» №273-FL, continuing medical education is the additional professional education, which is carried out through the implementation of training and retraining programs [2]. Maintaining the qualification at the appropriate level throughout a career is today’s practical public health requirement. Therefore, throughout the career a health worker should increase his/ her competence which is determined by practical necessity in the workplace.

Materials and Methods. Continuing medical education for medical workers today is mandatory continuing education for professional development that starts after receiving a degree and lasts throughout their professional career. The main goal of CME is providing Russian citizens with a guarantee for safe high quality medical care in medical institutions in accordance with international indicators.

On January 1, 2016 article 69 of the Federal Law of 21.11.11 "About the bases of public health protection in the Russian Federation» №323-FL came into effect, according to which the right to undertake medical work in the Russian Federation belongs to persons who have received medical or other education in the Russian Federation in accordance with federal state educational standards and have a certificate of specialist accreditation [3]. Transition to the procedure for the accreditation of experts will be carried out in stages from January 1, 2016 to December 31, 2025 inclusive. Every health care worker should accumulate at least 50 credits for a year (50 hours of educational activity), and 250 credits for 5 years.     The project is being implemented according to the principles of CME: lifelong learning; use of e-learning and distance learning technologies; taking into account the most urgent practical public health problems in the programs formation; networking interaction of educational and professional public health organizations. The main principle of CME in the Russian Federation is education must be based on partnership between state budgetary educational institutions and professional societies, and the existing system of postgraduate education should be developed.

The system of training in the framework of CME includes:

1) full-time postgraduate training (on the basis of educational institutions): university training (workshops, lectures, seminars and discussions, face to face exams) and distance learning (remote lectures, webinars, training modules with the final tests for control);

 2) learning in the workplace and self-learning: discussions with colleagues, auditing, analyses of complex cases, attending conferences and seminars, writing research papers, reading medical journals and national guidelines followed by testing.

Since 2016 within the framework of the implementation of the basic CME principles specialists with higher medical education have been also offered to undergo an additional professional training program consisting of at least 144 hours on a voluntary basis: for not less than 108 hours – studying the program of the educational organization and for at least 36 hours – having training sessions using educational materials. The introduction of CME system and the use of modern educational technologies will be the basis for the gradual introduction of the 2021 accreditation of medical professionals on the basis of CME as the system that allows undertaking medical work. Health workers, being the most valuable and significant health care resources, have a decisive influence on the process of the implementation of any changes in the field of public health. At present, the domestic health system entered a period of institutional reforms aimed at increasing the quality of health care services by improving the supply of resources and development of staff capacity in health care organizations [5]. In conditions of the increasing flow of information, continuous introduction of new drugs into clinical practice and new methods of diagnostics and therapies, the doctor finds himself in a situation where he is keenly aware of the need for continuous professional development.

Results. Despite the effectiveness of actions taken by the public health administration and the Russian government, it is obvious that it is not possible to improve the educational system without analyzing the views of health professionals who are directly involved in this process. In this context, the aim of our study was to investigate the views of physicians to identify the most pressing issues in the field of CME for their systematization and further changes in the existing process of medical training.

A specially designed for this purpose “anonymous sociological questionnaire” was used as a tool for the collection of statistical material. The survey was carried out with the help of a mass processing technique among health care workers in Saransk city. 200 questionnaires were filled and statistically processed. The results of the survey showed that 74.0% of the respondents "were in favor of CME program, they are willing to maintain their skills at the appropriate level for all professional activities"; 10.5% of the respondents consider it unnecessary to introduce CME system: "it makes no difference", "salaries will not be higher", "it is just wasting of our time" and 15.5% of health workers were undecided. To the question "How do you feel about e-learning and distance learning technologies?" in 86% of the cases we received a positive response. 48.5% of the respondents are successfully registered in CME system, and about 43.0% of the participants stated that "they have difficulty working with an electronic portfolio," although they evaluated their computer skills as "good". The average age of the medical workers who participated in the survey was 40.2 years old.

The main difficulty of the implementation and accreditation of CME is associated with the fact that not all health professionals are able to follow their individual learning plan. First of all, these are workers in rural health centers and pharmacies; they cannot leave their place of work for a long time to complete an additional education program or to participate in a seminar or congress; not all villages have a trouble-free access to the Internet (and it is a prerequisite for participation in continuing medical education); representatives of Soviet medical school mainly work in rural health centers and pharmacies, and it is very difficult for them to move to a new format of their qualification training / confirmation.     Another problem is the fact that today in CME system there are not all training seminars, conferences and congresses, which allow gaining points. Points are awarded only for participation in accredited educational activities about which experts often just do not know. At the same time today congresses and summits are actively advertised and that attracts specialists; advertisements say that they allegedly give points. And CME participants are not able to check physically whether a training event will really allow them to get the points or it is just a publicity stunt of unscrupulous organizers.

Heads of medical institutions themselves are also reluctant to let the doctors visit even one day conferences. It is important for an employer to understand that a trained specialist is a guarantee of quality medical care in an institution, but for this it is necessary to create certain conditions for a doctor. Since "patient satisfaction with the quality of medical care" is one of the criteria for evaluating the effectiveness of health care, it will, along with other indicators, influence the level of remuneration of both executives and employees in the near future. Everybody who works in the industry understands that patient treatment outcomes should be improved and indicators of care quality and safety in our country must not be worse than average European indicators. Only then you can get a real job satisfaction and regain the trust of patients.

Discussion and Conclusions.  In modern society increase of knowledge value enhances the role of man as a generator and new knowledge bearer, makes him a decisive factor of a social progress and at the same time its main result. In this context, the place and the role of education in the life of the whole society and each individual are changing. Continuing education can be characterized as an educational process which ensures the development of individual’s educational potential throughout his life. A special feature of the continuing education system is the fact that a person has the opportunity to study at various levels throughout his life, "enter" the system as a trainee and "exit" it as a trained person. For each person continuing education should be a process of formation and meeting his cognitive requests, spiritual needs, developing abilities with the help of different types and forms of education, as well as through self-education.

Problems of improving the quality of medical education have retained their relevance and importance over the years. Russian High School has a developed infrastructure, highly qualified scientific and pedagogical potential, historical traditions of training doctors. However, the industry retains quite a low level of quality of medical training and qualification. Further training for health care professionals throughout their career is mandatory. To implement this task, Russia launched a program of continuing medical education. CME is intended to replace the system of cyclical training of doctors gradually. The system of continuing medical education is distinguished, first of all, by the relevance (relevance to current educational needs and the presence of medical specialists’ request), the continuity, the use of innovative technologies (remote, electronic and simulation technologies also provide the accessibility and convenience for acquiring new knowledge and skills).

Improving the health care system is one of the fundamental conditions for the successful implementation of the strategy of socio-economic development of Russia, and the health state of the population is the most important goal of this development. Modernization of the health system is aimed primarily at providing affordable and quality health care for the general population. The volume of medical knowledge is constantly increasing. There are new methods of diagnostics, prevention and treatment. New drugs are being developed and become available, the experience of using known drugs is expanding and their side effects are being identified. A modern doctor, a doctor of the XXI century, needs to maintain and improve his/ her knowledge constantly.

Список литературы / References

1. Алтайская Е. Контрольная для здравоохранения. Чему научит непрерывное медобразование? URL:https://goo.gl/6kioqn (дата обращения 05.10.2016 г.)
2. Федеральный закон от 29.12.12 г. «Об образовании в Российской Федерации» №273-ФЗ.
3. Федеральный закон от 21.11.11 г. «Об основах охраны здоровья граждан в Российской Федерации» №323-ФЗ.
4. Jankovskaja L.V., Misjuk L.F., Sit’ko I.M. Continuing medical education as potential for self-improvement of a therapist / L.V. Jankovskaja, L.F. Misjuk, I.M. Sit’ko // Medical news. - 2016. -№ 11 (266). - P. 67-70.
5. Semeleva E.V. Public health service sociocultural modernization in Russia/ Сборники конференций НИЦ Социосфера.- 2016.- № 8. - С. 92-93.

Список литературы на английском языке / References in English

1. Altaijskaja E. Kontrolnaja dlja zdravooxranenija. Chemu nauchit nepreryvnoe medobrazovanie? [Test for health protection. What will continuous medical education teach?] URL:https://goo.gl/6kioqn (accessed 05.10.2016) [in Russian]
2. Federal'nyj zakon ot 29.12.12 g. «Ob obrazovanii v Rossijskoj Federacii» №273-FZ [Russian Federation. Laws. About education in the Russian Federation: federal law: (accepted by State Duma on December 21, 2012: approved by the Federation Council on December 26, 2012). №273-Federal Law]. [in Russian]
3. Federal'nyj zakon ot 21.11.11 g. «Ob osnovah ohrany zdorov'ya grazhdan v Rossijskoj Federacii» №323-FZ. [Russian Federation. Laws. About the bases of public health protection in the Russian Federation: federal law: (accepted by State Duma on November 1, 2011: approved by the Federation Council on November 9, 2011). №323-Federal Law]. [in Russian]
4. Jankovskaja L.V., Misjuk L.F., Sit’ko I.M. Continuing medical education as potential for self-improvement of a therapist / L.V. Jankovskaja, L.F. Misjuk, I.M. Sit’ko // Medical news. - 2016. -№ 11 (266). - P. 67-70.
5. Semeleva E.V. Public health service sociocultural modernization in Russia/ Sborniki konferencij NIC Sociosfera [Public health service sociocultural modernization in Russia / Conferences collections of NIC Sociosphere]. - 2016.- № 8. - S. 92-93.  [in Russian]