An outfit of American cardiac surgery experts finished a weeklong trip to St. Petersburg on Saturday for the Healthy Heart Foundation, formerly the Almazov Foundation for the Development of Medical Science and Education.
The medical professionals, including Drs. Al Haddadin, Jamie Gerber and Michael Dewar, along with PAs Michael Lalaonde and Tim Dutton and RN Zuzana Svitek took part in the foundation’s 15th annual exchange, this year providing medical assistance at the St. Petersburg State University I.P. Pavlov Medical Center.
This, however, was no ordinary humanitarian trip.
While the medical team assisted in performing much-needed procedures —four coronary artery bypass surgeries and one complex mitral valve repair — the ultimate goal of the foundation is to promote self-sustaining cardiac surgery expertise in northwest Russia. Through their example, they hope to change what they believe is a fundamentally flawed model of the “medical mission.”
According to 15-year foundation veteran Dewar, what often happens is that a group of western doctors will travel to a developing nation to perform surgeries for a week while the local doctors stand back and watch, if anything. When the foreign experts go home, the area is left no more capable of caring for its needs than when they came.
Making matters worse, if a developing country is incapable of training its professionals domestically, the best and the brightest are often sent to the West to receive medical training. Once abroad, Dewar says, only about five percent will ever return home for work.
Russia is no stranger to this brain drain. Commenting last week on two expatriate Russian physicists winning the Nobel Prize in Physics, President Dmitry Medvedev said that “[Russia] does not have a normal system to stimulate our young specialists, talented people, so that they stay to work in this country.”
According to the Healthy Heart Foundation web site, “The key problem is to educate specialists without causing them to emigrate from their home countries which need their services so badly. In short, we provide education without causing emigration.”
To accomplish this goal, the foundation provides young Russian doctors with “short-term, focused” training sessions at Yale-New Haven Medical Center in New Haven, Connecticut, where they learn the latest techniques of the field and earn real experience, performing surgery under the guidance of senior surgeons.
With these short-term programs, the Russian doctors are less likely to anchor themselves in America than if they received a full medical training there.
Following these training sessions, the American doctors make annual visits to northwest Russia for a week to “operate, intervene, lecture and monitor the adoption of the advanced techniques in the trainee’s home environment.” According to the team, they try to keep the former to a minimum, running the annual follow-up visits as hands-off as possible, providing mostly assistance and advice and performing surgery only when absolutely necessary.
So far the approach seems to be working. Of the 22 young doctors from northwest Russia who have participated in the one to two-month training programs at Yale University, only one has left the Russian Federation. He wound up at Yale.
In St. Petersburg, the group has also been able to establish self-sustainability on a local level. In the past, the group has worked with the Federal Almazov Heart, Blood and Endocrinology Center, but was able to move on now that former program participants Drs. Mikhail Gardeyev and Andrei Kutin are performing international level heart surgery and even transplants on their own there.
Despite these successes, the group remains modest, noting that it is only a small drop in the bucket of cultural inertia needed to overhaul Russia’s medical system.
While this system boasts 44 physicians per 10,000 people, besting the Organization for Economic Co-operation and Development average of 31, Russia’s physicians are severely underpaid and do not command the same level of respect as in western nations. According to a 2007 Radio Free Europe/Radio Liberty report, “Health workers earn between $70 and $175 a month, while surgeons can hope for a monthly salary of about $400.”
In the U.S., cardiac surgeons averaged $425,000 a year over the same period.
To say that the system has a particular problem in training advanced specialists would be a gross understatement. According to Dewar, northwest Russia (population 14 million) has only enough cardiac surgeons by U.S. standards to service New Haven County in Connecticut (population 800,000).
The problem is even more acute in the sub-specialties. When the team came to Russia last summer, former participant Dr. James Heim told The St. Petersburg Times, “For the whole of the St. Petersburg region there’s only one experienced specialist in this field (pediatric congenital heart defects) — Dr. Vadim Lyubomudrov. He does a great job, but one surgeon is not enough.”
Dr. Lybomudrov is now working in Dubai, leaving the whole of northwest Russia without a qualified specialist in this field.
The problem, Dewar believes, stems from a lack of formalized, rigorous training standards and top-level assessment of needs. All the while Dr. Lybomudrov was the only sub-specialist in the region, no real attempt was made at a higher level to meet this urgent need, which has now become a tragedy. It’s a system, he says, that’s “so disorganized it doesn’t make sense.”
In the U.S., cardiac surgeons can spend over a decade in training after medical school, completing a five-year general surgery residency followed by a multi-year cardiac surgery fellowship, with further training required for sub-specialties such as pediatric cardiac surgery and cardiac transplants.
Along the way, there are rigorous board certification exams with detailed surgery requirements that ensure the proper, uniform training of each specialist.
In Russia, Dewar says, training is closer to the medieval guild model. If a young doctor finds himself working under a disinterested or unqualified senior, he may never receive proper training. Nonetheless, he may eventually find himself in a full surgery position at a regional hospital.
The lack of any concerted attempts at reform on a national level may simply be a matter of diminishing marginal returns: In a country with a life expectancy of 66 years, the world’s 13th highest HIV/AIDS death rate, and where the leading causes of death are alcohol and smoking related, highly specialized surgery for rare congenital defects may not be the most cost-effective target.
According to Dewar, however, it’s a problem of awareness and effort rather than a financial issue: “The Russians have money, and it’s easy to stock a heart center.” Total expenditure on healthcare as a percentage of GDP is 5.4 percent in Russia, compared to over 15 in the United States.
While the program has been working so far by using an inside-out model of social progress, expansion plans include lobbying higher-level officials for change. In February, local program director Dr. Maria Prokudina will speak at a regional governors’ meeting about challenges facing the Healthy Heart Foundation and the medical system as a whole.
Despite the considerable adversity, the American doctors have found the spirit of the local medical community to be alive and well. Dewar referred to the Russian doctors as “brilliant,” praising their resourcefulness and ad-hoc solutions to problems: “It’s always like a conversation, you learn from them too.”
Source - The St. Petersburg Times (October 12, 2010 Issue # 1617)