General practitioner: who is he? General medical practice (family medicine)
When we find out that our new acquaintance is a doctor by profession, we always ask: what specialty is the doctor? And when we hear the answer: general practitioner, we are perplexed as to what kind of doctor he is, who he treats, what he knows, what he can do, whether this is good or bad. At the same time, the general medical practice in the last 20 years, it has taken its place in Russia and has become a common practice, at least using the name - family medicine. Is it imported into our medical culture? Where did its origins come from? These questions are answered by the history of medicine, in which the practice of a family doctor has its roots in deep and not so ancient times.
In fact, the ancestors modern medicine, like real Russian medical researchers who laid the foundations of Russian medical science and practice - S.P. Botkin, G.A. Zakharyin, N.I. Pirogov, were a prototype of a general practitioner. This is a doctor who sees the patient completely, and not in parts, who is able to assess the degree of involvement of each organ and part of the human body and identify the leading problem or problems. The relevance of this approach to the treatment process explains the widespread and high demand for general medical practice throughout the world. However, general medical practice, widespread in pre-revolutionary Russia in the form of the institute of zemstvo doctor, which continued in the first decades of the USSR, was lost by the 1970s. And if back in 1950, any graduate of a medical school could work as both a therapist and a surgeon and conduct an examination of ENT organs and eyes, later the concept of specialization won, which, on the one hand, improved the quality of care in certain areas, but contributed, on the other hand, to The loss of the doctor's vision of the patient as a whole gave rise to "specialists in the little toe on the left foot."
Over the last century, medicine has been filled with a colossal amount of information and is updated daily. “One doctor cannot know everything equally well,” you say. Absolutely spot on. But a doctor now has a large number of sources of information that do not replace knowledge and experience, but provide the opportunity to be a highly informed specialist. At the same time, without good basic professional training and experience in daily medical practice, it is impossible to understand the flow of information about new medicines and treatment methods. In addition, communication between specialists, colleagues of various specialties, joint management of a patient, sometimes with a diverse and complex pathology, is the basis of the daily activities of a general practitioner. Such a doctor does not work like a dispatcher and does not “refer” his patient to another specialist, but bears full responsibility for him. Such a doctor strongly recommends returning to him after consulting a specialist or reporting the results of examinations, as this is required healing process. Such a doctor is not afraid to admit that he doubts his diagnosis, that he wants to get more information, additional consultation. With the rapid development of medical science, this quality of a doctor gives an advantage to the patient.
Due to the fact that the tradition of general medical practice in Russia was interrupted and resumed only in the 1990s, the class of general practitioners is very heterogeneous in origin and possession of practical skills. Many doctors acquired this specialty after being retrained as therapists, surgeons, pediatricians, and gynecologists. And this leaves an imprint on their daily work. However, every year the number of doctors who have completed residency at the departments of family medicine/general practice is growing, which provides an optimal balance of knowledge and skills. But in practice, one can still see that there are doctors who are ready and able to deal with patients of all ages, from diapers to old age. There are general practitioners who, in parallel with their main activities, specialize more deeply in some field (for example, in surgery or pediatrics, or certain areas of internal medicine - gastroenterology, cardiology, etc.). The level of qualification of a doctor certainly depends on his experience. Many general practitioners easily and highly professionally cope with most of the problems of their patients, such as: acute moderate viral otitis, manifestations of congestive heart failure, chronic gastritis or purulent inflammation finger - panaritium. All these and many other conditions do not require a highly specialized approach; they can be successfully treated by the same person - your attending physician. And he will also determine the indications for consultation with highly specialized colleagues: if the diagnosis is unclear, the disease takes an unusual course, or a problem is identified that requires highly specialized high-tech help.
Thus, a general practitioner is your attending physician who treats and prevents diseases in all family members: parents, their children, elderly family members, advises during pregnancy and breastfeeding. Such a doctor inevitably knows your personal characteristics, drug tolerance, and family history. Will help with most of the most common medical situations and will optimally determine the time when it is worth contacting a specialist.
One of the fundamental principles of the functioning of the health care system is the optimization of primary health care. Typically, people in need of medical care turn to local doctors for help. In most cases, a local doctor involves several specialists to diagnose and treat a patient. Sometimes visiting specialized specialists is not justified.
Thus, visiting a local therapist leads to loss large quantity time. Ultimately, the local doctor turns into a dispatcher for the distribution of patients to specialized specialists, which leads to the loss of his functional responsibilities. At the same time, there is practically no preventive work and medical examination. Experience in foreign countries has shown that 50% of patients who visit a local doctor are referred to specialists. But with the introduction of the position of general practitioner, 80% of patients begin and complete diagnosis and treatment in outpatient clinics. In modern healthcare, this is the main support for the development of out-of-hospital care to the population.
Despite the fact that the position of general practitioner was introduced recently, this principle of providing medical care in Russia was known even before the middle of the last century. At that time they were called “zemstvo doctors.” The general practitioner decides much big problems than a local doctor can do. Functional responsibilities General practitioners are multifaceted: diagnosis, treatment, prevention, rehabilitation of patients, organizational measures, etc.
"IN Soviet time we followed the European path and began to produce highly specialized specialists. This is not entirely correct. A general practitioner is, in fact, a therapist who at the same time can look at the nose, throat, eyes... We hope that they will soon replace local therapists. But we are not destroying pediatrics - it is a heritage Russian medicine, so the treatment of children remains a separate item. Besides, a pediatrician is a general practitioner, only for children,” Pechatnikov explained.
How does this change benefit the patient? The fact that a general practitioner, after completing the appropriate training and assigning this qualification, will be able to carry out, for example, an examination of the fundus of the eye and take cardiogram readings in one step. Of course, those patients who require deeper specialized research, will be redirected to highly specialized specialists.
In 2016, at the State Budgetary Healthcare Institution “GP No. 69 DZM”, they were trained in vocational training“General Practitioner” 20 therapists, this year it is planned to train 10 more doctors, as well as all newly hired therapists. All GP offices are equipped with new equipment, including the purchase of otorhinolaryngophthalmoscopes, which will allow doctors to carry out full inspection patient. The appointment time has also been increased to 20 minutes, this will allow a full examination, assessment of the patient’s condition, and recommendations to be made without haste.
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General doctor
1. Organization of primary health care according to the principle of a general practitioner (family doctor).Forms of organization of general medical practice.
General doctor ( family doctor) - a doctor who has undergone special multidisciplinary training in providing primary health care to family members, regardless of their gender and age.
A specialist who has completed the training program in accordance with the qualification requirements and received a certificate is appointed to the position of GP. A general practitioner (GP) provides outpatient appointments and home visits, providing emergency care, carrying out a complex of prevention, treatment, diagnostic and rehabilitation measures, assistance in solving medical and social problems of the family.
On a contractual basis, GPs (GPs) can be assigned hospital beds. He also organizes hospital at home, day hospital.
The procedure for carrying out the activities of a general practitioner (family doctor) is established by the federal executive body in the field of health care, bodies executive power subjects of the Russian Federation. ( Art.59. “Fundamentals of legislation on protecting the health of citizens, ed. Federal Law dated August 22, 2004 No. 122-FZ).
A general practitioner must have knowledge both in the field of medicine and in other related specialties - psychology, sociology, social medicine, health economics, prevention, etc. His main task is to protect the health of the families he serves, provide primary health care, and treat patients independently depending on their age and type of disease.
The main function of a general practitioner is to provide multidisciplinary outpatient care to the population in accordance with the requirements of the qualification characteristics and the received certificate.
A general practitioner must have a basic therapeutic education, but since the scope of his activities is significantly expanding, he must have knowledge in related specialties and possess practical skills to implement various diagnostic and treatment methods currently performed by narrow specialists in outpatient clinics.
One of essential functions A general practitioner is the early detection of latent forms of the disease, the implementation of dynamic monitoring of the health status of patients with the necessary therapeutic and recreational measures and the involvement of specialists from various medical institutions for this purpose.
An important section of the activity of a general practitioner is conducting an examination of temporary disability, rational employment, and if there are signs of permanent disability, timely referral to medical examination.
In the activities of a general practitioner, a significant role should be given to the prevention of diseases, the organization of medical and social assistance to the lonely, elderly, disabled, and chronically ill (together with social protection authorities, charitable organizations, and mercy services). General practitioners must know the current legislation on social protection of these groups.
Among the main functions of a general practitioner, it is also necessary to note the provision of advisory assistance family on issues of feeding, raising children, immunoprophylaxis, family planning, ethics and mental hygiene of family life.
An integral part of the work of a family doctor is maintaining approved records and reporting documentation.
Forms of organization of general medical practice: Solo practice and group practice.
Solo practice It is advisable to use mainly in rural areas.
Group practice the most appropriate form should be considered in cities (guidelines developed by the NGO Medsotsekonominform and approved by the Ministry of Health of the Russian Federation). It makes it possible to organize a doctor’s work more rationally and more fully satisfy the population’s needs for medical care. In this case, general practitioners work in a territorial clinic. They receive patients, use the services of specialist consultants, treatment and diagnostic rooms of the clinic (laboratory, x-ray, functional diagnostic rooms, physiotherapy rooms, etc.).
In order to make medical care more accessible to the population in certain areas, it is possible for polyclinics to organize separate offices for general practitioners. It should be considered preferable if the physician resides within the service area.
A general practitioner can be a private practitioner and serve the assigned population under an agreement with a medical institution.
2. Rights, duties and responsibilities of GPs.
Rights of a general practitioner:
Monitoring the work of employees subordinate to him;
Based on the terms of the agreement (contract), the acquisition, ownership and disposal of real estate;
Concluding contracts for the provision of medical services within the framework of compulsory and voluntary health insurance programs with any organizations, enterprises, institutions, insurance companies in the prescribed manner;
Receiving payment for medical services not provided for by the terms of the contract, on the basis of an additional agreement;
Use of medical institutions to improve one’s qualifications under the terms of a contract with payment, both at the expense of the employer and at one’s own expense;
Conducting an examination of the quality of medical care provided to the patient by other specialists.
Responsibilities of a general practitioner:
Providing primary health care to the population in accordance with the received certificate;
Sanitary education work (propaganda healthy image life);
Preventive work (timely detection of early and latent forms of diseases, risk groups);
Dynamic observation;
Rendering urgent help in emergency and acute conditions;
Timely consultation and hospitalization in accordance with the established procedure;
Medicinal and rehabilitation work in accordance with the qualification characteristics;
Conducting an examination of temporary disability in accordance with the Instruction “On the procedure for issuing certificates of incapacity for work and referral to medical examination”;
Organization of medical, social and household assistance together with social protection authorities and charity services for the lonely, elderly, disabled, and chronically ill;
Providing advisory assistance to families on issues of immunoprophylaxis, feeding, raising children, preparing them for preschool institutions, school, career guidance, family planning, ethics, psychology, hygiene, social and medical-sexual aspects family life;
Maintaining approved forms of accounting and reporting documentation.
The general practitioner is responsible within the limits of your rights:
For an independently made decision;
For illegal actions or inactions that resulted in damage to the health or death of the patient, in accordance with the procedure established by law.
3. Qualification requirements for a general practitioner. The general practitioner must:
Know the basics of legislation on protecting public health, the structure and basic principles of healthcare, rights, duties, responsibilities, be able to plan and analyze your work, know the principles of cooperation with other specialists and services (social service, insurance company, doctors’ association, etc.) ;
Know and comply with the principles of medical ethics and medical deontology;
Master the following types of activities and their corresponding personal tasks: prevention, diagnosis, treatment of the most common diseases and rehabilitation of patients; provision of emergency and emergency medical care; performing medical procedures; organizational work.
When carrying out prevention, diagnosis, treatment of diseases and rehabilitation of patients , the general practitioner must be able to independently examine and evaluate physical examination data of patients; draw up a plan for laboratory and instrumental examinations; master the principles and methods of prevention and treatment of the most common diseases and rehabilitation of patients; timely organize further examination, consultation and hospitalization, etc.
A general practitioner monitors a patient for the following diseases : internal diseases, surgical diseases, diseases of the female genital organs, infectious diseases, tuberculosis, diseases nervous system, mental illnesses, skin and venereal diseases, diseases of the ENT organs, eye diseases, allergic pathology.
When providing emergency (emergency) medical care, A general practitioner must be able to independently diagnose and provide emergency (emergency) care at the prehospital stage in the following cases: emergency conditions: shock, fainting, collapse, coma, acute respiratory failure, heart failure, laryngeal edema, false croup, status asthmaticus, hypertensive crisis, bleeding, appendicitis, drowning, fractures, etc.
When performing medical procedures, a general practitioner must be able to perform all types of injections independently; carrying out intradermal tests; determination of blood group; conducting and ECG interpretation; spirometry; manipulations to provide emergency care (intracardiac administration of drugs, artificial respiration, aspiration methods, indirect massage hearts); surgical manipulations (biopsy, punctures, probing, anesthesia, primary treatment of wounds, burn surfaces, application of bandages, immobilization, opening of abscesses, etc. in all specialties).
When carrying out organizational work , the general practitioner must know the demographic and medical-social characteristics of the assigned contingent. Promote a healthy lifestyle, conduct hygienic training, anti-alcohol propaganda, etc.; give recommendations on feeding, hardening, preparing children for preschool institutions, career guidance, etc.; provide consultations on family planning, ethics, medical and sexual aspects of family life, etc.; carry out anti-epidemic and therapeutic measures; carry out work to identify early and latent forms of diseases and risk factors; organize the entire range of diagnostic, treatment, health and rehabilitation measures; diagnose pregnancy and monitor the course of pregnancy, treat extragenital diseases, identify contraindications to pregnancy, refer for termination of pregnancy, know the management of the postpartum period.
Together with authorities social security and mercy services, carry out work to organize assistance to the lonely, elderly, disabled and chronically ill, incl. for care, placement in boarding homes, etc.
Conduct an examination of temporary disability, refer to MSE, transfer to light work; be able to analyze the health of the assigned contingent, and correctly maintain accounting and reporting documentation.
Zhanna Valentinovna Dorosh, Candidate of Medical Sciences, Associate Professor of the Department of Therapy and Family Medicine of the Russian National Research Medical University named after. N.I. Pirogova, chief physician 2 clinical department"Medicine" clinics.
What does a family doctor do? How is he different from a therapist?
A family doctor or general practitioner provides outpatient medical care. This is a polyclinic, the primary link that a person who applies for medical care. The main difference between a family doctor and a therapist is the amount of what he can do with his hands. Manipulation is within his competence.
If the therapist has two weapons - a phonendoscope and a tonometer, then the general practitioner has otoscopy, rhinoscopy, and laryngoscopy. That is, he can look at the ear, throat, nose, and can look at the fundus of the eye. Some kind of diagnostic minimum for narrow specialists he carries out. He can register and decipher an electrocardiogram, maybe, if we are talking about the outback, and not major cities, do primary processing wounds, apply plaster.
What education should a family doctor receive?
For a family doctor there is a basic education - medical school or a university where everyone who graduates receives a diploma, no matter whether it is a general practitioner or a pediatrician. After this there must be either a residency in internal medicine or therapy, or pediatrics, or internship, if the education was received some time ago. Then the doctor can undergo initial retraining in the specialty “General Medical Practice (Family Medicine).” Another option is to go immediately after completing basic education at the institute to a residency in this specialty.
How many family doctors are there in Russia?
If we talk about how many family doctors there are in Russia now, this figure will be close to the number of general practitioners. There is a retraining program under which therapists who provide primary outpatient care in Moscow and surrounding regions are now being retrained and transferred to the positions of general practitioners and family doctors, depending on where they will work. This figure is constantly changing, the number of such specialists is growing.
How does a family doctor work?
The area assigned to the general practitioner is somewhat smaller than the area of the therapist. Depending on where the family doctor works, this is no more than 1800 attached. If we are talking about Moscow, then here the doctor does not see children, they remain under the supervision of pediatricians, so only adults are assigned to the general practitioner. The observation system remains the same as that of a local therapist. If the doctor is on vacation, then his place is taken by a part-time doctor who, during the vacation of your immediate supervisor, is responsible for what happens in his area.
The duration of leave for a family doctor is the same as for a general practitioner. The system for calling a family doctor to your home is also no different from the system for a local therapist. Home visits are carried out by the doctor on duty, not a therapist or general practitioner, who works on site and, if there is no operational need for this, he may not attend the call. If there is a need to visit a patient at home, then he can go on call during non-working hours after the end of the appointment.
What to do if your family doctor cannot make a diagnosis or you need to consult a specialist doctor?
This is a matter of competence of the general practitioner. You should always understand that the higher the level of professionalism of a family doctor, the less he will need consultations from other specialists. And only if highly professional questions arise, the patient will be referred to medical institution which provides specialized assistance.
For example, if a patient arterial hypertension or hypertonic disease, then these nosological units can be treated by both cardiologists and therapists. There are practically no indications for a patient to be referred to a cardiologist with such a diagnosis. Good Family doctor can carry out this level of examination and manipulation.
If the patient has, then at some stage when he needs surgical intervention, of course, the general practitioner will send the patient to see a specialist. If the family doctor feels that he cannot cope with the clinical situation, then the treatment he provides is ineffective, he can ask for help from a specialist and send the patient for consultation. This right remains, and general practitioners exercise it.
If a family doctor looks at the fundus of the eye and sees pathology there, he is obliged to send the patient to a specialist. If a doctor sees a pathology during otoscopy, he is obliged to assess how critical it is for the patient. He will leave some patients under his supervision in accordance with his competence, and send some to a specialist.
The level of competence of a general practitioner is prescribed regulatory documents. These documents are in a state of constant development and are being discussed. They are directly related to what a doctor can do with his hands and see with his eyes.
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