Upskilling of medical personnel amid the annual doubling of medical knowledge and the digital transformation of healthcare

UPSKILLING OF MEDICAL PERSONNEL AMID THE ANNUAL DOUBLING OF MEDICAL KNOWLEDGE AND THE DIGITAL TRANSFORMATION OF HEALTHCARE

Table of Contents

1. Summary

2. Relevance

3. Underqualified Medical Personnel in the Russian Federation

4. Reasons for Underqualified Medical Personnel

5. Modern Ways of Personnel Upskilling Abroad

6. Prerequisites for Fulfilment of the Russian President’s Instruction on Personnel Development in the Healthcare Sector

7. Proposals to Improve the Qualifications of Staff in the Healthcare Sector

8. Expected Results

References

 

1.    SUMMARY

Russian President Vladimir V. Putin has set the task of improving the skills of personnel in all sectors of the economy, in particular, by creating modern digital knowledge centers (professional libraries) in Russian provinces together with educational institutions (Instruction No. Pr-616, dated March 30, 2024, paragraph 27) [1]. In healthcare, it is extremely important to create such centers both to address the significant increase in the volume of medical information and to upskill medical personnel. These issues are evident fr om the results of expert examinations of the quality of medical care, which reveal violations in 25% of cases annually and the numerous appeals from patients to the Investigative Committee—there are more than 4,400 annually. The main reasons for underqualified medical personnel are as follows: teaching being no longer a prestigious profession it used to be so the training of medical personnel at higher education institutions and colleges is not as strong; high workload of doctors; additional professional education courses being a formality; lack of requirements and conditions for continuous improvement of medical personnel skills in medical institutions, including the lack of professional libraries in them. In addition, all medical care quality control measures involve doctors strictly following only the requirements of standards and clinical practice guidelines (guidelines), although these instructional documents do not cover all diseases (500 out of 2,000) and are applicable in typical cases only. This is how doctors develop a formal approach to treating patients; they are less motivated to develop clinical thinking, and they question whether it is really necessary for them to learn other up-to-date sources of knowledge and to undertake additional professional education courses. They need to know guidelines, but the knowledge itself is not enough for effective decision-making. A doctor is expected to know the boundaries of application of these documents in relation to a particular patient, accordingly, to possess a wide range of up-to-date medical knowledge. Developed countries are addressing the gap between available medical information and its practical application by introducing special government programs and providing doctors with access to digital knowledge platforms (databases).

Today, the Russian healthcare sector has created the necessary conditions for fulfilling the President's Instruction on the organization of digital knowledge centers and professional development of medical personnel. Leading specialists from national research institutes and medical universities have developed a large-scale project called MedBaseGeotar+II, the first Russian digital medical knowledge platform. It contains a huge intellectual arsenal of up-to-date information sources (more than 180 thousand), which is upd ated by 25% annually. In order to accelerate the transfer of new knowledge to the country's health professionals, it is proposed to introduce a requirement for a professional library into the standard of equipment of a medical organization. Investments in providing doctors with up-to-date knowledge through improving patient outcomes have a high ROI: up to 5 rubles for every ruble invested, according to foreign research.

2.    RELEVANCE

Today, the country's leadership has se t the task of improving the qualifications of personnel in all economic sectors. Russian President Vladimir V. Putin delivered a speech at the St Petersburg International Economic Forum in June 2024, wh ere he said, “Now brains are the main means of production. We need to develop technology, build universities, and train personnel accordingly.”^[1] This task was reflected in his Instruction No. Pr-616, dated March 30, 2024 (par. 27 and 5), which states to create modern digital knowledge centers (professional libraries) in Russian provinces together with educational organizations and to bring this knowledge to users [1]. Mikhail V. Mishustin, Prime Minister of the Russian Federation, when addressing a strategic session held to discuss the new national Personnel project, said, “Qualified specialists are the backbone of enterprises in all sectors of the economy, even the most innovative, the most technologically advanced, of any social organization. Competent workers are always in demand, especially now, when the President has set the task of strengthening industrial, technological, financial and economic sovereignty.^[2]”

In healthcare, skills development and knowledge centers are highly relevant, both because of underqualified healthcare personnel and the dramatic increase in the volume of medical information. In the 80s, medical information doubled every 7 years; in early 2010 this period was reduced to 3.5 years, and in 2020 it went fr om 1 year to 2.5 months [2]. It follows that students, teachers at medical universities, colleges and practitioners are expected to have enough time to update their knowledge; non-standard information and educational technologies are required to deliver and assimilate such a large amount of new information.

3.    UNDERQUALIFIED MEDICAL PERSONNEL IN THE RUSSIAN FEDERATION

Today, doctors are seriously underqualified, so they are in need of upskilling. This is evidenced by the following facts:

-      according to the results of independent testing conducted in Moscow, more than 20% of candidates fail the exam the first time[3];

-      every year, based on the results of medical care quality assessment in the Compulsory Health Insurance system, errors (defects) are detected in 25% of cases, which causes serious damage to both patients and medical organizations, with the latter having to pay fines of more than 11 billion rubles[4];

-      numerous complaints from patients have resulted in the Investigative Committee organizing a medical expertise department, and more than 170 criminal cases are brought to court every year (and 10 times more are initiated)^[5];

-      there are tens of times more healthcare-associated infections (i.e., that tend to be contracted in hospital during medical interventions) than are detected; consequently, they are not addressed. For example, in the Russian Federation, their level is 28 times lower than in the USA, with the same number of hospitalizations, according to Rospotrebnadzor, with about 10% of these cases resulting in death^[6];

-      one third of the surveyed population of the Russian Federation believes that it is necessary to raise the professional level of doctors and introduce personal responsibility of the chief doctor and attending doctor for the quality of treatment (Russian Public Opinion Research Center (VCIOM), 2019)^[7].

According to international research, up to 250,000 patient deaths occur annually in the USA due to incorrect actions of medical staff, which is 10% of the total number of deaths, and half of them can be prevented through organizational efforts and doctor upskilling (2016) [3]. In the United States, about 800,000 patients die or suffer various types of injuries every year due to misdiagnosis and treatment, with the majority of cases occurring in 5 common diseases: stroke, sepsis, pneumonia, deep vein thrombosis, and lung cancer (2023) [4]. The Russian Federation does not have research like that, but due to shorter training periods for doctors than in developed countries and their overload, the results may be worse. As a consequence, from the position of the current level of medical development, the efficacy of medical care is reduced.

4.    REASONS FOR UNDERQUALIFIED MEDICAL PERSONNEL

     The level of doctors' qualification is influenced by three main components: 1) the quality of their training in higher education institutions; 2) the system of additional professional education (upskilling); 3) independent and continuous improvement of professional skills. There are problems related to each component.

1)    Training in medical higher education institutions and colleges. Most importantly, it is no longer prestigious to become a higher education institution or college teacher. In the Russian Federation, the remuneration of teachers at medical higher education institutions is equal to that of practitioners. In comparable terms, it is 2.5 times lower than in Soviet times and 2 times lower than in developed countries [5]. Statistics by provinces make the situation worse: they can differ by a factor of two or more. In Russia, compared to most developed countries, there is no internship; students are admitted to practice in primary care immediately after graduation, while in developed countries it happens after a minimum of 2 years of residency. Russia also has the shortest duration of training in residency programs: 2 years. The provision of higher education institutions of the Ministry of Health of Russia with educational resources (printed and electronic publications) is 900 rubles per student per year, which is 2.5 times lower than the similar provision for high school students in the Russian Federation and 18 times lower than in university libraries of developed countries (in comparable terms). In medical universities of the system of the Ministry of Education of Russia this provision is 1.5 times lower than in the system of the Ministry of Health. In medical colleges, the situation is even worse: teachers get paid on average just as much as practicing nurses, i.e. 2 times lower than in higher education institutions, whereas in Soviet times this difference was only 1.2 times. In all educational organizations, teachers' workload is increasing due to the rising number of employer-sponsored and commercial admission cases. In addition: today, the work of a university teacher is evaluated not by the results of student training, but by their entrepreneurial activity: development of medical devices, drugs and publications in scientific journals.

2)    The system of additional professional education. In addition to the problems outlined above (paragraph 1), in a number of cases, upskilling courses can be completed formally to extend the right to a job. This is because some additional professional education organizations provide an upskilling certificate without the person actually completing the course. It can even be a pure formality. Thus, the Explanatory Note to the draft law “On Amendments to the Federal Law ‘On Education in the Russian Federation’ ” states that there are cases of receiving both basic and additional professional education in organizations that do not have the necessary educational infrastructure, clinical facilities and qualified staff^[8].

3)    Continuous improvement of one's professional skills. This is the exact statement given in the Oath of a Russian doctor, which they take after completing education or upskilling (“Law on the Fundamentals of Health Protection of Citizens”, Article 74). There are the following challenges in this regard:

-      The workload of health workers, many of whom have to work full time and a half or even more, which means they are less motivated to acquire new knowledge. As a result, according to surveys conducted in 2023, no more than 20% of doctors read professional literature on the regular;

-      The vast majority of medical organizations have not created conditions to accelerate the transfer of new knowledge to doctors—there are no professional libraries (neither printed nor digital);

-      The regulatory framework (namely: Regulations on the Organization of Medical Care, Procedures for the Provision of Medical Care, Including Standards of Equipment of Medical Organizations, and Recommendations of the Roszdravnadzor Quality Institute) does not provide for modern digital (printed) professional libraries in medical organizations [6].

-      All control activities in the systems of Roszdravnadzor, MHIF[9] and Investigative Committee are conducted formally according to procedures, standards, and guidelines. As a consequence, doctors, worried about inspections, patient complaints, and punitive measures, are forced to formally fulfil the requirements of these documents. As a result, patient care suffers. Moreover, this approach implies that, apart from guidelines, a doctor does not need other medical knowledge and does not need to take an additional professional education course. It is, however, important to note that guidelines are basically limited instructions, which are often insufficient to make informed decisions, especially in complex and non-standard situations (besides, there are only 440 of them for 2,000 diseases).Of course, a doctor needs to know guidelines, but the knowledge itself is not enough for effective decision-making. A doctor is expected to know the boundaries of application of these documents in relation to a particular patient, accordingly, to possess a wide range of up-to-date medical knowledge and critical thinking skills.

-      Chief doctors of medical organizations and opinion leaders do not tell doctors to develop their critical thinking skills, question their decisions, and check them by looking them up in up-to-date knowledge sources. Typically, today, they only tell them to follow standards and guidelines, conduct telemedicine consultations, and use artificial intelligence (AI) prompts. Guidelines, as noted above, are only instructions; telemedicine consultations are time-consuming, and AI prompts require highly qualified specialists to assess their applicability to a particular patient.

-      Pathological anatomical conferences have in many cases lost their educational value and independence, as the pathologist reports to the head of the medical organization. The latter, in turn, is not interested in identifying defects as they are worried about punitive measures from regulatory authorities and patient complaints. For the same reason, they conceal cases of healthcare-associated infections.

Thus, there are a number of reasons why medical personnel is getting more and more underqualified. These reasons require a systemic solution and additional financial investments (an increase in the remuneration of teachers and practitioners). At this stage, a relatively quick, low-cost, and effective solution to this problem could be to provide doctors with permanent access to modern digital platforms (databases) of medical knowledge, especially since the prerequisites for this have been created in the Russian Federation (see paragraph 6). An approach like that has proven to be highly effective in developed countries; it is being widely used today.

5.    MODERN WAYS OF PERSONNEL UPSKILLING ABROAD

In developed countries, healthcare managers understand the link between the quality of medical care and the provision of doctors with a wide range of new knowledge. So they adopt special programs and create all conditions to ensure that health professionals have up-to-date information at arm's length, digital and printed. This is a mandatory standard for every medical organization. For example, international accreditation standards (Joint Commission International) contain a requirement for an organization to support education and new knowledge (MCI.21)[10].

The concept of a learning health system is being introduced state-wide, wh ere, in order to improve patient outcomes, high-quality knowledge is actively integrated into all processes: education of medical students, provision of medical care, and managerial decision-making in the field of public health. All possible means (science, medical education, information technology) are involved in this process at all levels, from the national Ministry of Health to specific organizations, and a new regulatory framework is being developed.

There has been an expansion and strengthening of the role of libraries in medical schools and practical healthcare. For example, in the UK, the National Health Service, in conjunction with library services (NLS), runs the Knowledge for Healthcare program, sponsored by the Health Education England. In the USA, the Agency for Healthcare Research and Quality, the National Library of Medicine and the Medical Libraries Association are rolling out the Learning Health System program [7, 8].

All practitioners have access to digital platforms and medical knowledgebases that are procured by the government or medical organizations, so they are available free of charge to health professionals. These include: 5 Minute Consult, UpToDate, BMJ Best Practice (Clinical Evidence), Clinical Key (First Consult), Dynamed, EBM Guidelines, Online Books & Journals Platform within Thieme Connect[11], etc.

6.    PREREQUISITES FOR FULFILMENT OF THE RUSSIAN PRESIDENT’S INSTRUCTION ON PERSONNEL DEVELOPMENT IN THE HEALTHCARE SECTOR

Today's digital technologies facilitate the process of creating and broadcasting new medical information from research through authors to consumers. They enable accelerated processing of large amounts of data and turn it into new knowledge. The form of information provision is changing: there are now digital medical knowledgebases, digital library systems, clinical decision support systems. With this new form of knowledge, it can be updated more quickly, disseminated instantly over the Internet, used remotely, become interactive and have additional usability features such as quick search.

Today, the Russian healthcare sector has created the serious basis for fulfilling the President's Instruction: professors from national research institutes and medical universities have developed a large-scale project led by Higher School of Healthcare Organization and Management and GEOTAR-Media, a major medical publishing house of Russia. The project is called MedBaseGeotar+II, the first Russian digital medical knowledge platform. It contains a huge intellectual arsenal—more than 180 thousand sources, including: National Guidelines for more than 100 medical specialities; more than 25 best world editions of the Golden Series; Library of Military Medic, an encyclopedic dictionary with 120 thousand medical terms; more than 5 thousand clinical recommendations approved by the Council of the Russian Ministry of Health, Russian and foreign professional societies; reference book of medicines, including a module on drug-drug interactions. The platform is designed to take into account the achievements of modern digital technologies, integrates with the IIA, and can be accessed from any digital device. MedBaseGeotar is similar in content and user properties to English-language information resources. The system is AI-enabled to facilitate search and CV writing.

7.    PROPOSALS TO IMPROVE THE QUALIFICATIONS OF STAFF IN THE HEALTHCARE SECTOR

     Based on the above analysis, it is appropriate to consider the following proposals:

1)    In terms of higher and additional professional education.

In order to address the shortage of teaching staff, it is necessary to increase their remuneration and to establish maximum norms of labor load, as it was in Soviet times—10 students per one teacher. The basic salary of the teaching staff should be 5–8 minimum living wages for medical universities and research institutes and 4–6 minimum living wages for colleges. In order to increase teachers' motivation to create modern teaching and methodological literature, it is necessary to define this activity as a key criterion in the system of their labor evaluation. First and foremost, teachers are expected to provide quality education to students, which cannot be done without modern learning resources.

In order to provide the educational process with enough modern professional learning resources for students, it is necessary to establish norms of expenditures for their provision:

-      at least 5 thousand rubles (at 2023 values) per year per student of a medical university and faculty, i.e. 2 times more than today's high school students. Then the average share of expenditures on this item in a medical school will be 1.2% of its budget, the way it is in developed countries today;

-      at least 3.8 thousand rubles (at 2023 values) per year per medical college student, i.e. 1.5 times more than today's high school students;

-      educational publications contained in libraries and Federal State Education Standard literature lists should be 3 years old or younger (today many of them are more than 10 years old), and there should be one textbook and/or one access to the electronic library system  for each student, as in schools.

2)    In terms of practical healthcare:

-      Procedures for the Provision of Medical Care and Regulations on the Organization of Medical Care, approved by Order of the Ministry of Health of Russia, should include a requirement for a professional library (printed and/or digital) in a medical organization, with current, up-to-date content. Consequently, Roszdravnadzor should ensure that this requirement is met when licensing medical activities^[12].

-      The Federal Law “On Basic Public Health Protection in the Russian Federation” should be supplemented in Article 10 (Part 2) to state that the quality of medical care is ensured by “by the application of medical care procedures, clinical recommendations and standards of medical care, as well as in non-standard and complex cases in which these documents cannot be used, by applying other methods of diagnosis and treatment, rehabilitation methods permitted in the Russian Federation that are the best for a given patient, recommended by professional non-profit organizations”.

-      Wide range of current medical knowledge should be the base when it comes to the training and work of experts in the quality of medical care, of members of medical commissions and deputy chief doctors in clinical and expert work in medical organizations, the Compulsory Health Insurance system, Roszdravnadzor, and the Investigative Committee.

-      The chain of command of chief external experts from the National Medical Research Center to a central hospital (or a central hospital in a territory (republic, region, district) in Russia^[13] should become the core of the dissemination of current knowledge among doctors. It is fundamentally important that ministers of health, chief doctors, and leading Russian opinion leaders tell practitioners to develop clinical thinking and check their decisions, looking them up using a wide range of Russian and global sources of knowledge. It is also advisable to develop and implement a departmental project “Strategy of Medical Knowledge Transmission in the Russian Federation”, which would include a section on the development of medical libraries in medical and educational organizations, as prescribed by President's Instruction No. Pr-616, dated March 30, 2024, and accepted today in developed countries.

8.    EXPECTED RESULTS

Investments in providing doctors with access to new knowledge have a very good ROI: according to foreign studies, for each additional ruble, the ROI averages 5 rubles [9, 10].

 

 

REFERENCES

1.         Russian President's Instruction No. Pr-616, dated March 30, 2024 “List of Instructions for the Implementation of the President's Address to the Federal Assembly”.

2.         Densen P. Challenges and opportunities facing medical education // Trans. Am. Clin. Climatol. Assoc. 2011. Vol. 122.P. 48–58. PMID: 21686208/PMCID: PMC3116346.

3.         Makary M.A., Daniel M. Medical error — the third leading cause of death in the US // BMJ. 2016. Vol. 353. P. i2139. DOI: 10.1136/bmj.i2139.PMID: 27143499.

4.         Harris E. Misdiagnosis Might Harm up to 800 000 US Patients Annually // JAMA Network. 2023. July 26. doi:10.1001/jama.2023.13135. https://jamanetwork.com/journals/jama/fullarticle/2807896

5.         Personnel and Information Support of Medical Education and Practical Healthcare in Russia: How to Ensure Effective Knowledge Transfer to Students, Teachers, and Practicing Healthcare Professionals. / G. E. Ulumbekova, E. А. Gaponova, I. Yu. Khudova; ed. by G. E. Ulumbekova. - Moscow : GEOTAR-Media, 2023. - 96 p. : ill. - DOI: 10.33029/9704-8216-2-HR-2023-1-96.

6.         Proposals (Practical Recommendations) for Organizing Internal Control over the Quality and Safety of Medical Activities / Federal State Budget-Funded University National Institute of Quality of Roszdravnadzor [Electronic resource]. - URL: https://nqi-russia.ru/activities/internal-control/otdel-uk-i-omd/

7.         Foley T., Vale L. A Framework for Understanding, Designing, Developing and Evaluating Learning Health Systems // Learn. Health Syst. 2022. Vol. 7, N. 1. P. e10315. DOI: 10.1002/lrh2.10315

8.         Menear M., Blanchette M.A., Demers-Payette O., Roy D. A Framework for Value-Creating Learning Health Systems // Health Res. Policy. Syst. 2019. Vol. 17, N. 1. P. 79. DOI: https://doi.org/10.1186/s12961-019-0477-3

9.         NHS Library and Knowledge Value Proposition: The Gift of Time. Electronic access: https://www.hee.nhs.uk/sites/default/files/HEE%20-%20Library%20and%20Knowledge%20Services%20Value%20...

10.     Murphy J. Global Trends Health Science Libraries: Part 1 //Health Info Libr J. 2021. Vol. 38 (4). Р. 319–324. DOI: https://doi.org/10.1111/hir.12408

 

 

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[1] http://www.kremlin.ru/events/president/news/74234

[2] http://government.ru/news/52489/

[3] https://medvestnik.ru/content/news/Pri-prieme-na-rabotu-v-meduchrejdeniya-Moskvy-na-ekzamenah-proval...

[4] “Information on the results of control over the volume, timing, quality and conditions of medical care provided to insured persons in 2021.”

[5] https://argumenti.ru/crime/2023/07/842350 ; https://medvestnik.ru/content/news/Kolichestvo-ugolovnyh-del-protiv-medrabotnikov-vyroslo-v-2023-god...

[6] Rospotrebnadzor, report “On the State of Public Health in Russia in 2022”, 2023. 368 pages. ISBN 978-5-7508-2012-2; CDC website https://www.cdc.gov/hai/pdfs/progress-report/2021-Progress-Report-Executive-Summary-H.pdf

[7] https://wciom.ru/analytical-reviews/analiticheskii-obzor/kachestvo-mediczinskikh-uslug-zapros-na-zhestkij-kontrol

[8] https://sozd.duma.gov.ru/bill/656009-8?ysclid=m2a233p4j0523326316

[9] see Order of the Federal Compulsory Medical Insurance Fund No. 36, dated February 28, 2019.

[10] https://www.jointcommission.org/who-we-are/joint-commission-international/

[11] https://5minuteconsult.com, http://www.uptodate.com, http://bestpractice.bmj.com, https://www.clinicalkey.com, https://dynamed.ebscohost.com, https://www.essentialevidenceplus.com, https://www.thieme-connect.com/products/all/home.html

[12] https://www.consultant.ru/document/cons_doc_LAW_385633/0c7bf8d00f19dbae8d6d2053e9f9971b0b4f9a31/

[13] Order of the Ministry of Health of the Russian Federation No. 19n, dated January 21, 2022, “On Approval of the Model Provisions for a Hospital in a Territory (Republic, Region, District) in Russia”.