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Video: Fortunately, There Are Not Many People In The Medical World Who Refuse To Share Their Knowledge
Fortunately, there are not many people in the medical world who refuse to share their knowledge
March is International Colon and Rectal Cancer Month. How Russian doctors master new surgical technologies and is it possible to meet the needs of the whole country in high-quality treatment of colorectal cancer, said the director of the Clinic of Coloproctology and Minimally Invasive Surgery, Head. Department of Surgery, MPF, First Moscow State Medical University. THEM. Sechenov, professor Peter Tsarkov.
Peter Tsar'kov. Photo: from personal archive /
March is the international month to fight colon and rectal cancer, one of the most common malignant tumors in developed countries. The Russian Society of Colorectal Surgeons (ROCS) will celebrate it by participating in six international professional forums and holding two master classes for regional surgeons. In total, this year, a cycle of 15 thematic master classes is planned in different parts of the country. How Russian doctors are mastering new technologies, what is changing in postgraduate education of doctors, and is it possible to meet the needs of the entire country in high-quality treatment of colorectal cancer, the director of the Clinic of Coloproctology and Minimally Invasive Surgery, head of the department told Mednovosti. Department of Surgery, MPF, First Moscow State Medical University. THEM. Sechenov, Honorary Member of the Serbian, Israeli and American Societies of Colorectal Surgeons,chairman of the ROKH, professor Petr Tsarkov.
In June, the project "Russian School of Colorectal Surgery" will celebrate its 10th anniversary, which has given Russian doctors the opportunity to directly adopt the best world experience. What has changed during this time in the postgraduate training of domestic coloproctologists?
- The traditionally inert system of Russian postgraduate education did not keep pace with the rapid development of the industry, and progressive methods did not reach ordinary hospitals for a long time. But now the situation is changing: we are switching to a new system in which a specialist can gain one part of educational points within the framework of the old training system, and the other part by participating in high-level “live” conferences. The specialist himself chooses the events he needs, where leaders in various fields of medicine share the most modern knowledge and conduct master classes, demonstrating new techniques with their own eyes. At the same time, people have a choice of where to study, and the opportunity to receive a variety of knowledge, not limited by the level of a particular department in their region.
Professional public organizations perform educational functions all over the world. In many European countries and in the United States, a doctor will not receive a diploma or certificate without passing an examination by a commission of experts respected in their field. Further, with a certain frequency, the same commissions confirm his qualifications. Our country has a different system, but today the Ministry of Health is ready to transfer part of its powers to public organizations that are familiar with the most current trends and technologies.
The Russian Society of Colorectal Surgeons was among the organizations that received the right to assign educational points for participation in its events. Now about 1.5 thousand specialists come to the annual "Russian School of Colorectal Surgery". But from our very first School, when there was no point retraining system yet, its events were always sold out - people from all over the country came to study in their free time.Fortunately, there are not many people in the medical world who refuse to make contact and share their knowledge. Over the years, among the speakers at the School were: the founder of colorectal oncosurgery, Bill Heald, the head of the Institute of Morphology in the UK, Philip Querk, the president of the US Colorectal Surgeons Society, Stephen D. Wexner, the director of the National Cancer Institute of Japan, Yoshiro Moriya, and many others.
But there are other problems: the geography of our country and the poverty of ordinary hospitals and the people working in them do not allow everyone to come to the Schools
- Indeed, not everyone can physically leave their workplace for a few days, we need both the material opportunity and the interest of the heads of institutions, who are often satisfied with everything. At the same time, information hunger remains in the country. It is not enough for people just what pharmaceutical companies impose on them in some of their advertising campaigns, and even what can be read in scientific journals. You need the opportunity to discuss topics of interest, ask questions, listen to different points of view and draw your own conclusions as a result. Therefore, between major events, we try to hold conferences on narrow issues and thematic master classes in the regions. But the requirements for their quality are no less.
During the master classes, operations are broadcast, which are performed “live” in clinics of this region by invited specialists. For example, at the end of last year, a two-day master class at the Arkhangelsk Cancer Center was conducted by a world-renowned specialist from Japan Tsuoshi Konishi.
Fortunately, today there is interest in master classes in almost all regions. Local ministries of health see such events as an opportunity for the development of their doctors and help in their organization. If we talk about numbers, then about 100 people gather at each master class in the regions - this is an average of about 1.5 thousand specialists per year. And plus the same number of people come to the Moscow conference. That is, three thousand Russian doctors annually take part in educational events of the ROCH. And we are proud that many of them have been able to improve their surgical technique and change treatment protocols in their clinics.
The agenda of the master class, held the other day in Ufa, was the question: "Surgery for those who are interested in the result of treatment, and not just compliance with standards." Does this not stand out from the current trend towards the standardization of medicine in our country, where a law was even passed on the compulsory nature of clinical recommendations?
- In world practice, standardization implies adherence to recommendations - a document reflecting the consensus opinion of representatives of a certain professional organization, based primarily on evidence. A high degree of recommendation is assigned to conclusions about the effectiveness of some treatment methods, which were obtained on the basis of large randomized studies with high scientific and practical value. Other recommendations are less reliable because either there is no research at all, or they are small and cannot be fully relied on on a national scale. The clinician must take into account the clinical guidelines, but they are not a 100% guide to action.
As for the new law, there is still a lot of work to be done before its implementation, and it is still difficult to say how it will all look. If the recommendations are based on evidence-based medicine data and are of a recommendatory nature, then this should help the doctor. When a patient comes to him with a clinical situation described in the recommendations, he will confidently apply the method of treatment indicated there. This standardization of care is good for small mid-level clinics. And clinics of the expert level, or as we call them, the third level, for the most part have to deal with non-standard patients and select for their treatment either a combination of some standard methods, or generally unique approaches. On the other hand, a non-standard clinical situation can arise anywhereand the team of the clinic is fully entitled to follow its own path and treat the patient as it sees fit.
At a master class in Ufa, we discussed surgical methods for treating colorectal cancer, which are not very common even in large Western countries and are not included in their clinical guidelines. However, this specific surgical technique is effectively used in Japan, from which it was adopted by other eastern countries - South Korea, China. Western surgeons are also paying more and more attention to this technique, and now the issue of trying to use it on Western-type patients, including Russians, is being discussed. At the upcoming School in June, we plan, in cooperation with the European Society of Coloproctologists, to hold a special master class to train Russian and European surgeons in one of these oriental techniques.Having realized how effective it is in our population, in the future it will be possible to introduce the Eastern method into Russian and Western treatment standards.
But this probably also requires technical capabilities. The modernization of healthcare in our country has been very uneven, and many regional clinics cannot use not only some unique, but also minimally invasive techniques that have already become routine
- In the course of modernization, equipment was also purchased for performing laparoscopic operations. Of course, the country's needs are not 100% satisfied, but there are a lot of clinics in which such technologies have become possible. At the same time, specialists with extensive experience in their master classes try to convey to the audience that access - laparoscopic, robotic or open - is only access for performing the operation, and its very meaning remains the same. Imagine a room that you can enter in several ways: through a door, window or balcony. But what and how you will do there does not depend on it.
In the promotion and implementation of laparoscopic technologies, there is a share of what is called surgical egoism. A number of surveys of doctors and patients have been published in specialized journals about what result of operations performed for colorectal cancer is especially important for them. Doctors prioritized a small incision, less pain after surgery, and early discharge. And for the patient, the main thing was to get rid of the tumor, and after that he lived happily ever after. And whether he spends three days or two weeks in the hospital is not so important. Of course, if there is such a possibility, then with the skillful use of laparoscopic technologies there is a certain advantage for the patient, but it is not that which is decisive, but the quality of the surgeon's work.
Is it possible to talk about quality at all in conditions when a general surgical hospital needs only one doctor's diploma to obtain a license for cancer treatment, and many cancer patients instead of specialized institutions end up in regional hospitals?
- In our opinion, it is possible to license a medical institution when the entire multidisciplinary team working within it has been trained in an integrated approach to treating a particular disease. For colorectal cancer, such a set of specialists should consist of surgeons specializing in CT and MRI of the colon, radiation diagnostician, radiation therapist, chemotherapist, pathologist. By the way, only in such a team is it possible to informally fulfill the order of the Ministry of Health, which regulates the conduct of an oncological consultation before the start of treatment for each cancer patient.
The Nordic countries have chosen this path, and today in Sweden, Norway, Denmark, the Netherlands, colorectal cancer treatment is carried out only in a few specially accredited clinics. Only after the colorectal surgeon and the entire team together with him undergo specialized training, receives an identification number and registers its right to treat this disease, does the institution receive the right to receive such patients. And this practice gives very good results: if our survival rate barely crossed 50%, then in Sweden it is close to 70%.
The trend towards centralization of treatment is observed around the world, but not all countries can afford it. It is difficult to talk about this in Russia as well, but we also have positive examples of some regions where such centralization has practically been achieved. For example, in Ryazan, a pilot project has been underway since the end of last year, in which the regional hospital is defined as the main center for the treatment of various coloproctological diseases. Almost all patients in the Ryazan region who have colorectal cancer are operated on in a large specialized department of the regional clinical hospital. And only those patients who require radiation therapy are referred to the regional oncological dispensary.
We hope that the positive experience of such regions will become a trigger for the development of a large-scale program at the national level. This could improve disease-free survival rates for colon cancer by 15-20%, and not in federal centers, where they still achieve good results, but throughout Russia.
How many specialized teams are required for the whole country, and what is needed to train them?
“To meet the country's needs for high-quality colorectal cancer treatment, it is enough to train about 200 multidisciplinary teams. (In 60 million Great Britain, 100 brigades were trained in this way). The main thing is that the qualifications of the surgeon and other specialists from the "team" are supported by practice all the time. This means that, for example, in the Moscow region, in addition to the regional oncologic dispensary, it is enough to license 2-3 more regional departments in this profile. It takes about two years to raise the level of 200 teams based on one specialized center, and the cost of the entire training program (including travel and accommodation) is comparable to the cost of purchasing and installing two CT scanners.