G. Komarov. Fundamental principles of cooperation between medical specialists and society
(Discussion points to the question of the priority national project concerning Public Health).
Introduction: Social development is closely connected and depends on the health state of the country’s population, on each of its citizens, on the cultural level of its people and on their common wealth, on the juridical support, providing conditions for maintaining good health and working ability, on the development and successful functioning of the Public Health system.
The experience of the successfully and steady developing countries shows that there are several ways to achieve it: through scientific, technical progress and improvements in industry, but these are not the major factors. What is more important is solution of the social problems and providing people with the full value life conditions, so that they maintain health and high working potential, that is keep their basic right – their right for life and health, for getting timely and effective medical help.
In spite of the perfect in contents declarations on maintaining and improving people’s health in this country, in reality, regression was taking place in many sphere, life, labor conditions became worse, as well as nutrition, the national health was deteriorating, reproductive potential was decreasing while sickness and death rate were increasing. Since the early 90s the death and birth diagrams crossed for the first time within several centuries, which reflects the increasing depopulation. Today the death rate is higher than the birth rate by 700-800 thousand people. If the trend continues, then Russia annually may come to loose 4 million people per year and more by 2020. These facts force to take actions in changing state social policy and reform the system of Public Health in Russia.
The state reforms in the Public Health will be based on the structural modernization which will increase the level of the medical help and partially on the technological modernization. 15 center of the high quality medical help are expected to be open during the next 2 years, nothing is said about overall modernization of the 13 000 medical prophylactic centers in this country.
Unfortunately, there is little information about the Public Health Priority project, which is being developed by the President and Government. It is expected to involve large investments. But medical society is not informed about the ways of its development, its principles, priorities, concrete measures. That causes doubts in the society, loosing its trust towards the government, which discredits itself in mass corruption, lack of professionalism and its indifference towards citizens’ views and interests.
Lets’ go to the roots of the problem. The first attempts of democratization and at the same time formalization of the relationships within the “Public Health molecule” – interaction between doctors and patients, doctors and the society – belong to our predecessors, to the Pirogov’s medical movement. These were our colleagues, delegates and participants of the16 all Russian medical conferences, who also witnessed the Great Social October Revolution.
We can see their appeal to refuse Soviet Government in cooperation in different perspectives. We have to see this forced decision in the context of the events, first of all – “red terror”. It will be a mistake to evaluate the reaction to the events without strong evaluation of the events themselves, as they were destroying the intellectual potential of the society, undermine its humanitarian base, which Russian Medical School was so proud of.
It is not up to us to judge our colleagues and those who beheaded the Pirogov medical movement, stopped its activity back in 1918.
Our task is easier in theory and more difficult in its realization. On the one hand, we stand on the “shoulders” of our predecessors and can use their experience, on the other hand, for the last decades, influenced by the double standard policy and humanitarian values devaluation, moral foundations of the professional medicine were destroyed. In the society captured by the consumer boom, medical specialization is now treated as an original way of profit, as a commodity, having its own price, which is being sold and bought together with other goods. It gave rise to the ugly in its essence and immoral phenomenon – paid medical services in the state medical establishments – that gave birth to the so-called shadow sector of the Public Health, that is patients pay money directly to the medical staff. The principle “first money, then medical help” has become an every day reality and its scope can be compared to the Public Health budget.
The problem is not that “live” money in the realm of doctor-patient cooperation decrease the level of mutual trust, which is essential in the prophylactic, treatment of the diseases, not in that it undermined people’s trust towards medical recommendations and not in the degradation of the professional morals of the medical staff that led to the decrease of their rating. The problem is that high quality timely medical help has become unavailable for the majority of the population, especially to those who need it most – children, women, disabled, pensioners, people of scanty means.
The abnormality of this situation was evident to the Russian Medical Association. In 1997 at the II (XVII) All Russian Pirogov Conference, for the first time within 2 thousand years, since Hyppocratus vow, it set the task one side medical agreement with the society and three sided agreement between doctors, patients and state – “Medical-Social Charter of Russian Federation”.
Two projects of this document (by prof. D. Venediktov and G. Komarov) were first presented to the delegates of the III (XIX) All Russia Pirogov Conference in 1999. In 2001 it was accepted in the Komarov’s variant. This document was sent to the president, to both chambers of the Parliament, to the Government, to the leaders of the large political parties and public organizations, to the heads of the large religious confessions, to the Ministry of Public Health and other structures that correlate with health (of Defense, MIA, Education etc), to the WHO, World Medical Association, to the world and Russian medical associations, to the Universities and scientific research establishments, to the health management structures throughout all of the Russian regions, to the largest Informative Agencies and Mass Media. The Charter survived three re-productions and edition came to 65 000 samples.
The Charter was approved by the WHO European Bureau, along with more that 30 000 Russian medical workers (personal signatures and conference protocols are available).
Nonetheless, despite regular reminding, the document was never considered in the State Duma, nor in the RF Government.
In 2004 the V (XXI) All Russia Pirogov Conference considered “RF Convention on the doctors’ rights and responsibilities” and the project of the Federal law on the “Patients rights” suggested by the Russian Medical Association (based on Komarov, Sarkisyan and Pidde projects). After being approved the document were sent to more than 3000 medical-prophylactic establishments in Russia to be regarded by the medical staff. This may contribute to the next step in realization of the major points of the earlier adopted documents – “RF Medical Social Charter” and “RF Convention on the Medical workers’ Rights and Responsibilities”.
Seven major principles of the cooperation between doctors and the society/ Doctors are part of the society, its considerable part which now constitutes in Russia 2,33% of all population (607 600 people). Due to the peculiarities of the profession, doctors can not be opposed to the social interests.
Moreover, the system of the Public Health appeared and still functions as an institutes and structure of social service. The most important constitute, the quintessence of the system is the “molecule” – micro-system “doctor-patient”. Theoretically, it is possible to remove any part out of the system and it will continue its function. Of course, it will affect this or that sphere but it will be functioning until its molecule – “doctor-patient” is destroyed. It is like the sea – one can get and remove everything living in its waters, but the sea will be there. But the sea will disappear the moment there is no oxygen and hydrogen.
The same is true of the Public Health system. If we remove the patient, forget about his interests and needs, then the system will loose its meaning. If the doctor is removed (his interests are forgotten), the system won’t be able to carry out its functions and will become unnecessary.
Seven fundamental principles of the cooperation between doctors and the society.
|Realm of cooperation||Society||Doctors|
|1. Achievements of the high level professional medical knowledge.||Creates the conditions for education and its continuation. ||Get education, store, replenish it, exchange and educate. |
|2. Application of the professional medical knowledge for the well being of the people. ||Acknowledges the right of the doctors to apply it and contributes to that. ||Apply and control the results of this application. |
|3. Full and timely information||Creates channels and provide for its work.||Create information product and distribute it.|
|4. Influence on the factors decreasing the health level and threatening by the disease development and spread. ||Acknowledge and accepts recommendations, eliminates. ||Carry out research, give timely warning and control the elimination. |
|5. Prevention and decrease of the morbidity, creation of the best conditions for recovery of the distorted health. ||Provides for the harmonious physical and spiritual development of the people, healthy way of life, health working conditions and the conditions for the timely and effective cooperation with the doctors. ||Professionally and timely forecast, recognize and eliminate health dangers, carry out diagnosis, treatments diseases at early stages of their development. |
|6. Counteracting evil and harmful phenomena.||Defines evil as everything harmful to the people’s development, contributing to the diseases and eliminates according to the doctors’ recommendations. ||Carry out research, estimation of harm, develop measures for elimination and prevent, participate in the elimination, control the quality of the dangers’ elimination. |
|7. Fight against death, life prolongation, continuation of the human kind.||Provides for the conditions for the longevity, reproduction and safety of human life||Forecast the life dangers, carry out reanimation, alleviate the suffering of the dying. |
There is a need to create the code of the principles of the doctors and society cooperation.
All that is happening today in the sphere of health protection is caused by the fact that health is not priority, not in the public consciousness, not in the State management, not in the policy of the development and reformation of the public health system, not in the economical modernization of the country.
Actually, the essence of everything that is carried out and produced by the society is aimed at one goal – to create proper conditions for normal development, successful application of physical and intellectual abilities, to meet their natural biological and social needs, their ability to propagate and continue human kind. All the rest is supposed to support the main aim: material and intellectual resources, food, technologies, means, measures, money, etc.
Considering the above mentioned, it is clear that health is the focus center, which concentrates everything produced by each person, state and society.
In this case, the 7 formulated principles are the concentrated expression of the fundamental tasks, which solution with the help of medical service and society can increase the production potential of the country, its progress, successful sustained development and state well being.
Actually these principles are the continuation of the main statements of the “RF Medico-social Charter”. They do not contradict to common sense, logic, historical experience and do not seem to need any explanation. But the fact that the it has been refused for the last 5 years shows that its articles were either invented, or badly formulated, were not timely, and were not understood by doctors, nor by patients, nor by the officials.
Principle 1. Medical knowledge and professionalism.
Doctors acquire necessary knowledge getting Higher Medical education. The quality of higher education is not just a personal business of specialists but one of the major tasks of the state, which is proved by the fact that today in the successful and economically developed countries the education is provided by the government. In Germany for instance, more than 92% of all students study free of charge. In France – more than 80%. In Russia this number comes to 53% for now.
The huge problem is small student and aspirant scholarships that are enough just to pay for a couple of lunches. That makes students look for another sources of income, which decreases the possibilities of getting the necessary knowledge.
Incomes of the professors and teachers in the European Medical Universities are higher than in Russia by 15-25 times. European Universities are provided with better equipment. But it is necessary to mention that the level of higher education is still high enough in our country. It is maintained due to the scientists and teachers’ enthusiasm and understanding of their duty.
The situation is worse with the continuing after graduate and additional medical education. According to various estimations, almost half the medical workers do not take the necessary after graduate education or take it very rarely.
The fact that contributes to that is the system of after graduate professional education licensing, which gives the license not to the doctor himself, but to the place he works at. This decreases the level of medical professional responsibility and the quality of the medical service.
All the above mentioned and other things are conditions, made by the government and society, to provide for the medical professionalism. Besides that, it is one of the reason of the frequent collisions that end up in the court, when patients doubt the full range and quality of the medical service they get.
The task for the doctors is to store enough knowledge to correspond to the modern standards and for the high quality professional medical activity. It is possible only under the condition of the periodical after graduate education and continuous self study of the scientific and practical medical literature. Today distant education and Internet play an important role. But the polls carried among doctors show that less 1% have PC, providing for the access to the Internet, only 4,2% have a collective possibility to use PC in the health service establishments from time to time.
So, the realization of the first principle involves lot of unsettled and heard to settle problems for the society, government and doctors.
Maybe the expected increase in the state investments into the system of the Public Health since the beginning of 2006, will change the abnormal situation.
Principle 2. Application of the professional and medical knowledge for people’s well-being.
Society and government, as well as individuals “de facto” acknowledge doctors’ right to carry out prophylactic works, diagnostics, treatment and rehabilitation measures, along with expertise of the incapacity for work, and death reasons applying the latest medical knowledge, technologies, medicines and technical means (special equipment and instruments). The lawful base for carrying out medical service is the Federal Law “RF Medical Legislation Foundations”.
Up to now, there is now bills on the lawful regulation of medical activity: “Bill on doctors’ rights”, “On professional Medical Activity”, “On Medical Mistake”, “On Professional Medical responsibility”, “On the Insurance of the professional risk in medical activity”, “On Patients’ rights”, etc. This is the case that motivated the development of the “RF Medico-social Charter” – to develop and discuss “RF Convention on the doctors’ rights and responsibilities” at the high level professional medical Forum – All Russia Pirogov Conference.
It is the task of the government and the society to development and adopt the laws providing for the lawful regulation of the medical professional activity and responsibility. Besides, it should be kept in mind that these laws stand more for the patients’ rights. The absence of the direct laws decreases the level of the medical professional responsibility and gives rise to conflict situations, judicial mistakes in defining doctors’ guilt, negatively affects the quality of the medical service, results in the discontentment on the part of patients as well as doctors.
But full value medical legislation is an important, even main but far not the only duty of the government and society. What is also important is to provide for the special conditions in which medical experts could fully applied acquired knowledge and medical technologies. SO the government has to provide for the edifices, equipment, transport, working clothes, means of communication, free and unrestricted access to the professional information, to the data base (within Russia and outside of the country), as well as to provide for the specially trained personnel.
When the conditions are created, medicine employers can apply fully their knowledge and technologies and have to take the responsibility, provided by law, for the cases of not full or not timely application of their professional medical knowledge and the government and society provided conditions. Applying their knowledge, doctors have to strive to commit less mistakes.
This approach can regulate the effective application of the intellectual and professional potential of the medicine specialist and provide for the new quality and volumes of the medical service.
Principle 3. Full and timely information.
The decisions of every Pirogov Medical Conference – I (XVII) in 1995, II (XVIII) in 1997, III (XIX) in 1999, IV (XX) in 2001 and V (XXI) in 2004 – contain points on giving information to both doctors and patients. Moreover, in 2001 Russian Medical Association worked out the project “RF Doctrine of Public Health System Informational Security”, which was presented to the Ministry of Health but was never considered.
The RF Ministry of Health worked out and approved of the project of Medical Publishing House, which was registered in 2004 but its work was never launched because of the lack of funds.
Russian Medical Association suggested creation of the Federal newspaper which will popularize healthy way of living, help to achieve high level of sanitary culture with population, will spread medical knowledge on disease prevention, patients’ participation in the treatments and rehabilitation process, will contribute to counterpropaganda against doubtful and dangerous for the society methods of healing and sorcery, etc.
It was also suggested to create another newspaper – “Narcodrom” for the people who have this problem and for the risk groups. The idea of the newspaper was aimed at the counterpropaganda of drugs, warning about the dangers of taking drugs in the zone of high trust to the experts in narcology, publication of the recommendation of how to reduce taking of the heavy drugs, to ease the abstinent syndrome, etc. This suggestion was not considered either.
Russian Medical Association worked out the project of the special “Medical Newspaper” for medical specialists. It was regularly published from 1999 till 2005, it was also available in the Internet. The project was supported by the Financial support group of the RF Ministry of Health.
During the time of its publishing, regional departments of Russian Medical Association created a number of supplements to the Federal issue: “Medical Newspaper of Kuzbass”, Novosibirsk Medical Newspaper”, etc. There was an idea to create information Russian network of the Medical Newspaper which would provide for the free of charge Federal and regional issues, first to the hospitals and medical establishments , then to their branches and with the increase in the circulation, to each medical specialist.
After the Ministry of Health was reorganized into the RF Ministry of Health and Social Development, RMA was refused the further support and finance for the project.
It is one of the Government’s tasks to create and provide for the functioning for the inner channels that collect and analyze statistic data and manage the system of Health Protection, as well as provide information to the medical specialist and patients. As it is seen from the above mentioned, now there is no understanding of the information policy in the sphere of health protection and no information available to the medical specialist and patients. Without that, no need in healthy way of living can be created.
It is the duty of the doctor to prepare information on the population’s need in the healthy way of living, explanations of the dangers of various factors and conditions, on the measures preventing various diseases, on the early stage recognition of the developing disease, on he patients v\behavior in the families, collectives, in the society, on the number of forms of patient’s participation in treatment and rehabilitation, for the adaptation of those suffering from chronicle disease, and present this information in a special Mass Media. It is also the duty of the medical specialist, to inform the society about the known violations of the medical legislation, citizens’ right for health and its protection.
Principle 4. Influencing the factors, decreasing the health level and threatening by the development of diseases.
There is a constant practical and scientific research of the factors badly influencing people’s health and contributing to the development of various diseases. These factors are natural-climatic, ecological, social, organizational, industrial, family, etc. They are studied and new ways, technologies of dealing with them, reducing or eliminating their pathogenic effect are developed.
According to the results, the medical specialists inform people, health protection structures, as well as executive and legislative structures through various means about the endangering factors and recommend the ways to decrease the danger or eliminate it.
They participate in the activities decreasing the influence of the pathogenic factors, if their participation is necessary. They monitor the measures taken against these factors and estimate their effectiveness.
State (society), the government, structures of executive and legislative power, people acknowledge doctors’ right for the research (if necessary on animals or even volunteers, with the risk minimized). They take their recommendations, follow them in the most effective ways and if necessary apply for medical help. Alone or together with medical workers estimate the effectiveness of the measures taken. They develop special technologies for the further instant and effective application if the dangers reappear.
Principle 5. Prevention and reduction of the morbidity, creation of the better conditions for recovery and restoration of health.
State and the society create all the necessary and attainable conditions for the harmonious physical and spiritual development, help to formulate the need in the healthy way of living since the childhood, propagate the healthy way of living, teach the ways to maintain health, prevent it dysfunction and disease.
They take the measures to protect the human habitat, to restore it after natural and ecological (man caused) catastrophes and pollutions. Take actions to produce harmless products, material and safe technologies.
They reduce the number of the polluting energy sources, chemical and radioactive means, that were hardly investigated on the point of its influence on people’s health, rationally reduce the number of the mass annihilation weapon storage, as well as the industrial, cattle breading and populated territories’ waste products.
They take a number of measures increasing people’s resistance towards infectious diseases (if necessary – vaccination with the help of the medical workers).
They create the safe working conditions for all the categories of the population and carry out strict government control over the labur legislation (concerning the protection of the working population health) in the nongovernmental production sector.
They create the necessary conditions (premises, equipment, transport, communication connections, etc) for the ambulance and policlinic medical specialists, for the family doctors, for the stationary treatment of the patients, so that they are offered first aid in the common and emergency situations.
They create the necessary conditions for the usage of the natural-climatic and balneal factors for rehabilitation and j\health restoration.
They take measures to organize and provide for the process of the cooperation between doctors and patients with the latest technologies, and for the patients to follow medical prescriptions – available for people medicines and medical products.
They carry out the social and labor adaptation of people with evident, unavoidable health dysfunctions and invalidity.
Estimate and award work of the medical specialist and their assistants, promote the high level of social respect to the medical profession.
The medical specialists timely and professionally carry out preventive work against health dysfunction and decrease the probability of the disease development. Discovering the factors that may negatively influence the health state and cause different diseases, doctors warn the person, relatives, health protection structures, structures of executive, if necessary legislative power. They recommend to take preventive and protective measures to decrease its effect or remove those dangers, no matter what resources or organizational means are required.
In case of the disease, doctors apply all their professional knowledge, available and necessary technical means, medical technologies to carry out early stage diagnostics and adequate treatment. In case of difficulties, using the latest means of telecommunication, they timely ask their colleagues, who have the necessary knowledge or know better how to apply some technology, for help, no matter how far those specialists maybe.
After the treatment is finished, the doctors keep supervision over the effectiveness of the rehabilitation program until the patient is fully recovered, no matter how long this period maybe and what expenses it may require.
Principle 6. Counteraction against evil and harmful phenomena.
The factors, negatively influencing people’s health, maybe caused by the unpredictable natural-climatic phenomena, catastrophes, by unpremeditated mistakes that lead to the environmental problems, by the genetic mutations, by pathogenic organisms. But there are also ill-intentioned factors and actions that may bring harm health, further development of diseases in case of individuals, groups and populations.
It is doctors’ duty to discover those factors and actions at early stages, no matter who initiates them (one person, group of people, religious fanatics and sects, entrepreneurs and officials, immoral managers of various ranks, etc).
In number of cases, medical workers maybe the first ones to discover ill-intentioned activity by defining its effects in case of one person (those actions maybe: violence, psychological mockery, social behavior modification, creation of the dangerous pathogen organisms, faking food, beverages, medicine, cosmetics, chemical substances, application of the toxic substances in farming, illegal drug circulation, violent narcotization, illegal weapon circulation, production and selling of the harmful goods, spreading of he false information on those goods’ safety).
The number of these real and extremely spread factors is large, but there is no need to list all of them. Timely inform people and government structures, the society – is another preventive activity of the medical specialists, their professional duty, protection of the patients rights and interests.
After discovering endangering factors, medical specialist inform as many people as they can, the whole society, as well as suggest the ways and technologies to remove or at least reduce the effects of those factors, and (if necessary), take part in the activities. After its elimination, medical specialists estimate the effectiveness of the measures take for the consequences elimination.
Society and state have to trust the information given by the medical workers, even in cases when their predications are not proved. Even in these cases, the medical “hypo diagnostics” aimed at the health protection, provide for constitutional right for life safety and development. Society and state have to encourage doctors for the timely discovery of the harmful factors and for the timely information on them.
Principle 7. Fight against death, life prolongation and continuation of the human kind.
One of the most important duty of a doctor is counteract death and maintain people’s lives. There are many life endangering factors, only few of them depend on diseases, most of them connected to the natural-climatic, ecological, social, organizational, industrial, criminal and other factors. It is not necessary to list all these factors, what is important for the present point is the realization of the three sided duty of the medical service: 1) timely prognosis, 2) operational information, 3) offering adequate professional help.
Doctors start to help people who are under death danger, no matter what reasons caused this situation, in spite of the place, whether they have or not the necessary equipment and conditions, in spite of the physical and psychological state, no matter how dangerous it is for them.
Respecting the law of their country or any other territory on which the doctors render first aid, in cases of high probability of death, meaning the consequent lawful responsibility, doctors are guided only by the patient and injured person’s interests and have the right to apply all of the resources, technologies, materials and means available, no matter who they belong to and how much they cost.
Doctors struggle for patients life until their knowledge, objective data and experience does not let them verify biological death.
In the period of inevitable dying, doctors facilitate the suffering of the dying ones, with all the available means but without resorting to death lethal injection.
If the dying person whishes confession and there is no priest, doctors have to accept, listen to that confession promising to keep it as medical secrecy and realize the promise strictly as given. Difference of religious confession between doctor and patient is of no importance in this case. This is inevitable moral imperative of the medical profession.
Medical specialists take all the necessary measures to maintain reproductive function of the patient, in spite any factors and conditions, as reproductive function is a biological imperative which higher than social one.
Society and State acknowledge medical rights defined in the above mentioned paragraphs.
Society and State that do not create necessary conditions for the medical professional activities, do not form the respectful and lawful status of the medical service, do not pay worthy for its work are doomed to pay high prices for someone else’s medicines.
As I see it, reformation of the health protection system does not have to start from the technological modernization of the health protection system, though it is important, but from the different economic supply for another public attitude towards health – as the highest value, source of State and Society progress and development. Maybe with the consideration of the cited or differently formulated and edited principles so that that are clear for the whole population and medical specialists.
That society is badly ill, where doctors refuse to examine and treat the patient who is not able to pay, smell alcohol and covered with sewage.
That society is immoral where militia man will not let doctor to the injured by the explosion, dying of bleeding person until the judicial photographer comes for documentation of the position of the yet alive body…
That society is immoral, where the drivers pass by the doctor standing in the middle of the highway with the hand raised, because the drivers are afraid to stain their back seats with the blood of a man, dying at the roadside.
That society is immoral where one death is considered better or less than hundred deaths.
Immoral is the society which thinks that Hyppocratis Vow does not need to supplemented by the three side agreement between patients, doctors and society (State)…
Author – Georgy A. Komarov.
Moscow State Medico-Stomatological University, Public Health and Health Protection Department, (head of the department – Doctor of Medicine, Prof. G.A. Komarov).