Training young doctors in the modern environment

Nadezhda V. Agranovich; Агранович Надежда Владимировна; Anna B. Khodzhayan; Ходжаян Анна Борисовна; Svetlana A. Knyshova; Кнышова Светлана Александровна; Alyona S. Anopchenko; Анопченко Алёна Сергеевна; Margarita G. Gevandova; Гевандова Маргарита Грантиковна

doi:10.17816/socm634510

Training young doctors in the modern environment

Authors: Agranovich N.V.¹, Khodzhayan A.B.¹, Knyshova S.A.¹, Anopchenko A.S.¹, Gevandova M.G.¹
Affiliations:
1. Stavropol State Medical University
Issue: Vol 23, No 2 (2024)
Pages: 143-152
Section: SOCIOLOGY OF MEDICAL PROFESSION
URL: https://rjsocmed.com/1728-2810/article/view/634510
DOI: https://doi.org/10.17816/socm634510
ID: 634510

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Abstract

BACKGROUND: Over the past decade, reforming primary care in the Russian healthcare system has become a top priority for the state. The government is creating conditions to improve healthcare accessibility, as instructed by the President. A decision was made to expand the primary care development program in rural areas, small towns, and villages.

AIM: To analyze the training and challenges faced by young doctors in primary care practice following university graduation.

METHODS: To analyze the issues and omissions in the young doctor training system, a survey was conducted with general practitioners from the Young General Practitioner School who graduated from the General Medicine Department (as per Federal State Educational Standard-3) and started working immediately after graduation. The survey involved 128 general practitioners from the Stavropol Territory, who graduated from a medical school in 2018–2020.

RESULTS: The study identified the key challenges faced by early-career doctors. These include the lack of hands-on training before independent practice, lack of mentorship for most graduates, insufficient workplace equipment, limited computer access (especially in rural areas), shortage of nurses, and an excessive patient load for a general practitioner. The professional difficulties of graduates are associated with insufficient hands-on training in the 5^th/6^thyear at university and the cancellation of internships.

CONCLUSION: The analysis of the most common issues faced by graduates in primary care today showed challenges related to their transition to independent practice, and the need for better mentorship by more experienced peers.

Keywords

graduate, general practitioner, young general practitioner school

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BACKGROUND

Over the past decade, the reform of the primary care system in the Russian Federation has remained a key government priority. In accordance with presidential directives, the government continues to create conditions aimed at improving healthcare accessibility. A decision was made to expand the scope of the primary care development program in rural areas, urban-type settlements, and small towns across the country.^¹

The principles for modernizing the primary care system in the Russian Federation have been approved. These are based on the core principles of health protection as defined in Article 4 of the Federal Law On the Fundamentals of Health Protection of Citizens in the Russian Federation and include the following:

Ensuring the accessibility and quality of primary care and healthcare services provided in rural areas, urban-type settlements, and small towns with populations of up to 50,000;
Prioritizing patient interests in the delivery of healthcare, observing citizens’ rights in the provision of primary care, and ensuring the state guarantees associated with these rights;
Prioritizing preventive measures in the delivery of primary care;
Establishing the responsibility of government authorities, local self-government bodies, and officials of organizations for ensuring citizens’ rights in the organization of primary care.^²

The reform aims not only to improve treatment, disease prevention, and healthcare accessibility, but also to facilitate scientific research and ensure high-quality training of healthcare and pharmaceutical professionals. The initial stages of the reform focused on strengthening the practical healthcare framework: 1991–2009 (2010), functioning and ongoing transformation of the mandatory health insurance system; 2003, initial planning of healthcare reform; 2004, launch of the program Improving Structural Efficiency of the Healthcare Program for 2004–2010, which included the nationwide introduction of general medical practice and the autonomy of hospitals and outpatient clinics [1–4].

Since 2012, Russia has been undergoing large-scale reform of one of the key components of the healthcare system—university and postgraduate training of qualified specialists. These changes include the abolition of internship programs, the reform of residency and continuing medical education, the replacement of professional certification with accreditation, and the approval of new educational standards for future doctors. Competencies and learning outcomes are considered the main objectives in the implementation of the Federal State Educational Standards for Higher Professional Education and serve as the integrating elements of the graduate model [2, 5].

The education system at medical universities in Russia is currently undergoing reform. As a result, state educational standards continue to evolve, leading to changes in curricula, teaching formats, and instructional methods.

The dominant trend in higher education has also influenced medical universities: the traditional necessary knowledge approach is being replaced by a competency-based model [6–8]. However, the concept of professional knowledge remains relevant, that is, knowledge allowing specialists to perform their duties efficiently. Professional knowledge includes the following components: propositional knowledge (gained from private and public sources, personal theories, and memories); the process of cognition (acquisition of information, behavioral models, etc.); personal knowledge (pre-propositional knowledge that motivates the desire to learn something new); and moral principles or knowledge (reflected in literature and the arts) [7–12].

The essence of these changes lies in standardization. According to the prospective ideas of the Ministry of Health of the Russian Federation, all aspects of medicine—education, postgraduate training, specialization, continuing professional development, treatment, and rehabilitation—should comply with specially developed standards. For this purpose, in 2014, the Ministry of Economic Development of Russia issued Order No. 326 On Approval of the Accreditation Criteria, the List of Documents Confirming Compliance of the Applicant and Accredited Entity with the Accreditation Criteria, and the List of Standardization Documents, Compliance with Which Ensures Fulfillment of the Accreditation Criteria, dated May 30, 2014 (as amended August 19, 2019).^³ This order regulated the transition to a standardized system of doctors’ education and was intended to serve as the foundation for the Federal State Educational Standards of higher medical education.

In 2016, Order No. 127n On Approval of the Timeline and Stages of Specialist Accreditation, as well as the Categories of Individuals with Medical, Pharmaceutical, or Other Education Subject to Specialist Accreditation,^⁴ dated February 25, 2016, was adopted. According to this order, the internship program was gradually phased out starting in 2016: first for pharmacists and dentists, then for physician specialties, and finally for surgeons. Today, medical university graduates have to obtain an accreditation certificate instead of a qualification certificate upon graduation. This document grants the right to independent practice, including providing outpatient care as a general practitioner or pediatrician, immediately after graduation. All graduates must undergo accreditation; without it, healthcare practice is not permitted. This was the key innovation in the postgraduate training system. The new approach aimed to address the shortage of general practitioners in the primary care system [2, 7].

At the same time, graduates have gained the opportunity to enter a residency program in a narrow specialty immediately after completing their medical degree, with specialist accreditation test results accepted as entrance examinations for clinical residency programs [2]. A narrow specialization may also be pursued by those who already hold accreditation and have at least 1 year of experience working as a district pediatrician, general practitioner, dentist, or pharmacist.

As a result, the traditional format of higher professional education was fully abolished in September 2017, and in 2018, a comprehensive reform of postgraduate education was launched [1, 2, 6].

Thus, medical education in the Russian Federation has undergone significant changes in recent years: internship programs have been abolished, residency has become less accessible to recent graduates, and specialist accreditation now plays a central role [3–5, 13, 14].

The specifics of training students in the specialist degree program have also changed: the number of hours allocated to hands-on training and lecture-based classes in professional disciplines has been reduced, and instead, approximately 40% of the training volume has been reallocated to self-directed learning [2, 3, 7]. Final-year students now gain practical experience independently, without supervision or support from experienced mentors in healthcare organizations—an element previously ensured through the internship system as a form of bedside clinical training. This change disrupted a crucial theoretical-practical continuum in the transfer of knowledge from experienced colleagues to young doctors [13, 14].

To revive the tradition of mentorship and improve the competence of young doctors starting their professional careers immediately after receiving their higher education diploma as a district general practitioner and passing accreditation, the Ministry of Health of the Stavropol Territory, in collaboration with the Department of Outpatient Therapy at Stavropol State Medical University, initiated the Young General Practitioner School (Letter of the Ministry of Health of the Stavropol Territory No. 01-13/1993,^⁵ dated March 16, 2018). This became the first regional initiative in Russia aimed at providing practical support to young doctors graduating after 2017 without having completed an internship.

The Young General Practitioner School involves heads of healthcare organizations, the faculty of the Department of Outpatient Therapy and related departments of Stavropol State Medical University, leading external experts of the Ministry of Health, and experienced physicians from primary care organizations.

The topics of the Young General Practitioner School sessions were developed based on suggestions from the young doctors, graduates of 2017–2019 working in the Stavropol Territory. According to a conducted survey, the main issues of concern that young doctors wish to address include cancer vigilance in general practice, medical documentation (particularly referrals for medical and social assessment), the specifics of emergency care in outpatient settings, and the diagnosis and treatment of specific diseases (urinary tract disorders, respiratory diseases, visceral diseases during pregnancy, and comorbidities in elderly patients, among others) within the framework of general practice.

AIM

To analyze the training and challenges faced by young doctors during their independent clinical practice at the primary care level following graduation from medical university.

METHODS

To assess problems and deficiencies in the young doctor training system, a survey was conducted among general practitioners participating in the Young General Practitioner School who had studied at the General Medicine Department under the Federal State Educational Standards-3 curriculum and began practicing immediately after graduation. The survey included 128 general practitioners who graduated from medical university between 2018 and 2020. All participants provided informed consent to take part in the study and for the use of data for scientific purposes. The mean age of participants was 25 ± 1.3 years. Among them, 82 (64%) were women, and 46 (36%) were men. All doctors completed a questionnaire developed by the authors. The questionnaire included items related to issues and difficulties encountered during their university education and at the onset of independent professional activity, quality of office equipment, mentorship, availability of consultations with other specialists in regional healthcare organizations, and other relevant issues (Table 1).

Table 1. Questionnaire for the Young General Practitioner School students

Age
Sex	Male	Female
Where do you work?	Village	Town
Do you have a mentor?	Yes	No
Please specify the number of people registered in your district
Do you have a nurse?	Yes	No
Do you have a computer at your workplace?	Yes	No
Does your healthcare organization have an intranet?	Yes	No
Do you use electronic medical records?	Yes	No
Do you do personal home visits on a daily basis?	Yes	No
Do you have appointments?	Yes	No
Do preventive care offices or departments participate in the preventive medical examination of certain adult population groups?	Yes	No
Please specify the equipment you have in your office:
Blood glucose mete	Yes	No
Scales with a height meter	Yes	No
Blood pressure monitor	Yes (I use my own device)	No
Peak flow meter	Yes	No
First aid kit	Yes	No
Measuring tape	Yes	No
Hand lens	Yes	No
Pulse oximeter	Yes	No
Do you face any challenges at work? If yes, please specify?	Yes	No	My mentor supports me
Do you think one needs to have an internship before their independent practice?	Yes	No
What needs to be changed in the senior (5^th–6^th) year training at a university?
What issues would you like to discuss (i.e. what challenges you face in your independent practice) at the Young General Practitioner School classes?

The statistical analysis of the data was performed using Microsoft Excel statistical tools. To assess the significance of differences between two groups based on a single variable, the Mann–Whitney U test was used. The χ² (chi-square) test was applied to compare relative values. A value of p ≤ 0.05 was considered statistically significant.

RESULTS

Survey results indicated that the majority (61%) of Young General Practitioner School participants work in rural areas of the Stavropol Territory. Thirty-nine percent are employed in urban primary care facilities.

The analysis of questionnaire responses revealed the main problems faced by young specialists during university training and upon entering the workforce:

Insufficient time for hands-on training in healthcare facilities during the fifth and sixth years of study;
The abolition of the internship program;
The absence of an assigned mentor for each young specialist;
Insufficient workplace equipment (e.g., pulse oximeters, digital blood pressure monitors);
Partial lack of computer access, especially in rural areas;
Frequent absence of nursing staff in the assigned practice area;
Excessive patient load per general practitioner, exceeding normative levels.

Based on their own, albeit limited, independent clinical experience, in response to the question, “What would you change in the sixth-year training curriculum of a medical university?” most young doctors expressed a desire to increase the hands-on training in clinical settings (69%) and to allocate more time to the discussion of primary medical documentation in outpatient practice (73%) (Fig. 1).

Fig. 1. What needs to be changed in the senior (5^th–6^th) year training at a university?

The most significant challenges encountered by young doctors at the start of their independent clinical practice are presented in Fig. 2 (multiple responses were allowed).

Fig. 2. Do you face any challenges at work? If yes, please specify.

Nearly all respondents associated negative experiences with an increased number of patients assigned to a single general practitioner. In urban outpatient clinics, the average patient panel was approximately 1,800 individuals, whereas in rural areas this number reached 2,500 or more.

Responses to the question regarding the presence of an experienced mentor indicated that 63% of young doctors in urban healthcare organizations had a tutor, in rural areas a mentor was absent in 57% of cases.

Most young doctors, both in urban and rural settings, reported the presence of a nurse working on their therapeutic site. Only 21% of respondents answered negatively to this question.

Regarding computer access, the vast majority of young doctors in both urban and rural areas responded positively. However, urban healthcare organizations were significantly better equipped with office technology (Fig. 3).

Fig. 3. Do you have a computer at your workplace? (p ≤ 0.05).

The availability of office equipment in doctor offices in urban and rural outpatient clinics varied and was incomplete: in urban healthcare organizations providing primary care, 92% of the respondents reported a fully equipped workstation, whereas in district outpatient clinics and outpatient departments this figure was only 77%.

The distribution of responses regarding office equipment from 78 general practitioners in the city of Stavropol and 50 general practitioners from districts of Stavropol Territory is presented (Fig. 4).

Fig. 4. Please specify the equipment you have in your office (p ≤ 0.05).

Finally, in response to the question “Is it necessary to bring back internship training?” 86% of young doctors gave a positive answer.

During the lectures of the Young General Practitioner School, the surveyed doctors expressed interest in the following topics:

Outpatient management of chronic obstructive pulmonary disease;
Management of patients with chronic coronary artery disease;
Protocol for periodic health evaluations;
Cancer alertness in the practice of a general practitioner;
Maintaining medical records in outpatient practice;
Differential diagnosis of upper respiratory tract infections.

DISCUSSION

The results of the conducted study demonstrate that unresolved issues remain in the training of young doctors for work in the primary care system. First, the time allocated for independent hands-on training in the educational process is insufficient. Second, doctor workspaces in outpatient clinics and departments are not fully equipped with computer hardware; internet access is limited, and there is a lack of knowledge and skills in using remote access resources, especially in rural areas.

The personal example and support of an experienced colleague (mentor) play an important role in the formation and professional development of a young doctor. As this study showed, mentorship is not fully implemented in district-level primary care organizations, likely due to workforce shortage in rural areas.

Therefore, the reintroduction of internship training—a form of postgraduate medical education supported by more than 85% of young doctors—would be justified and could play a significant role in improving the quality of young doctor training.

CONCLUSION

Thus, the analysis of the most common problems and challenges faced by young specialists working in the primary care system demonstrated that addressing staffing shortage in this sector cannot be achieved solely through the influx of recent graduates. It is at the primary care level that key decisions regarding population health are made: the foundation for healthy lifestyle behaviors is established, diseases and risk factors are identified early, and timely treatment is initiated. Therefore, doctors who start their career without adequate real-world clinical experience are often ineffective and poorly motivated, which contributes to the attrition of young doctors from primary care.

To resolve the current challenges in training primary care professionals and to support their successful transition into clinical practice after graduation, we consider it necessary to:

Increase the number of hours of hands-on training for fifth- and sixth-year medical students at healthcare facilities;
Introduce additional hands-on training sessions on relevant topics identified through the survey of young doctors;
Enhance the workplace mentorship program;
Equip the offices of general practitioners with all necessary medical instruments and tools;
Ensure that each general practitioner’s office is staffed with a nurse;
Achieve 100% computerization of workspaces with improved access to information systems;
Consider reinstating internship training for graduates of medical universities.

ADDITIONAL INFORMATION

Funding source. The publication had no sponsorship.

Competing interests. The authors claim that there is no conflict of interest in the article.

Authors’ contribution. All authors confirm compliance of their authorship with the international ICMJE criteria. The largest contribution is distributed as follows: N.V. Agranovich, A.B. Khodzhayan — the concept of the work; S.A. Knyshova, A.S. Anopchenko, M.G. Grantovna — analytical review of the literature, writing the text of the manuscript and editing the text.

Ethics approval. The present study protocol was approved by the local Ethics Committee of Stavropol State Medical University (No. 128 by 19.06.2024).

¹ Resolution of the Government of the Russian Federation No. 2226 On Amendments to Resolution of the Government of the Russian Federation No. 1304, dated October 9, 2019, dated December 21, 2023. Available at: http://publication.pravo.gov.ru/document/0001202312250115 Accessed July 9, 2024.

² Federal Law No. 323-FZ On the Fundamentals of Health Protection of Citizens in the Russian Federation, dated November 21, 2011. Available at: http://pravo.gov.ru/proxy/ips/?docbody=&nd=102152259&ysclid=m14rvf9d4w699291921 Accessed July 9, 2024.

³ Order of the Ministry of Economic Development of the Russian Federation No. 326 On Approval of the Accreditation Criteria, the List of Documents Confirming Compliance of the Applicant or Accredited Entity with the Accreditation Criteria, and the List of Standardization Documents, Compliance with Which Ensures Fulfillment of the Accreditation Criteria, May 30, 2014 (rev. August 19, 2019). Available at: https://normativ.kontur.ru/document?moduleId=1&documentId=329510&ysclid=m14sizbs75771745843 Accessed July 15, 2024.

⁴ Order of the Ministry of Health of the Russian Federation No. 127n On Approval of the Terms and Stages of Specialist Accreditation, as well as the Categories of Persons with Medical, Pharmaceutical, or Other Education Subject to Specialist Accreditation, dated February 25, 2016. Available at: https://base.garant.ru/71351836/?ysclid=m14srsralu790247288 Accessed July 15, 2024.

⁵ Letter of the Ministry of Health of the Stavropol Krai No. 01–13/1993 On the Activities of the Young General Practitioner School, dated March 16, 2018. Available at: Accessed July 8, 2024.