Dr. Pavel Brandt. Pavel Brand - about how anti-aging medicine profits from the lazy
Oksana Galkevich: So, friends, as we said, this week our colleague Sergei Leskov is on vacation. But we, nevertheless, decided not to waste this time, not to waste it, we invite various interesting people, specialists from various industries. We discuss with them those events that seem important and interesting to them, which they would like to discuss with you and with your participation. So, we introduce our interlocutor today. In the studio of the "Reflection" program, Pavel Brand is the chief physician, medical director of the Family Clinic network of medical centers. Hello, Pavel Yakovlevich.
Pavel Brand: Hello.
Petr Kuznetsov: Hello.
Oksana Galkevich: You know, since we began to talk in advance about the fact that at 19:30 we have such a half-hour, I quietly put off some SMS messages on your medical topic in general. And I must say that a whole pool of questions concerned the quality of doctors’ training. Basically, roughly speaking, they formulated it like this: there are a lot of half-educated doctors.
I don't know, maybe it's too harsh. But what do you say? Is there a personnel problem in our Russian medicine here and now?
Pavel Brand:There is a personnel problem, to put it briefly and simply. There is a personnel problem. The fact that there has become a lot was not enough before - this is not entirely true. The percentage is approximately the same. The problem is that over the past, I think, 10-15 years, the amount of information that a doctor needs to know in order to work as a doctor has changed somewhat. And this may be due to the fact that we have a certain lag behind world medicine. Due to the increase in information, it actually seems that doctors know less than before.
To make it clearer, there is such a thing as doubling of all medical information, which occurs at some point in time. In 1950, it took about 50 years to double all the medical information known to mankind. By 1980 it had already been 10 years. By 2003 it was 5 years. By 2010 – 3 years. It is believed that in 2020, all medical information known to mankind will double every 78 days.
Oksana Galkevich: Accordingly, should this challenge be met with some kind of change in medical education?
Pavel Brand:Yes. This is the problem, that the amount of information is progressively increasing, but medical education is not changing very quickly. That is, it is trying to keep up, but so far it is not very successful.
Oksana Galkevich: You said that our lag behind world medicine is significant. What did you mean?
Pavel Brand:Yes. We are behind conceptually. Therefore, everything here is quite simple and complex at the same time. The problem with the lag is that we basically train doctors in much the same way as we did 30 years ago. Nothing much has changed globally. Now there are some attempts at change, the introduction of a system of continuous medical education. These are literally the last year or two, and these are still more pilot projects than some real situation that is changing right before our eyes. In fact, this is also where the lag lies. That is, education is changing, we are not keeping up with it very well.
The main problem is that we have not accepted the concept of evidence-based medicine. I always talk about this. The fact that the whole world has finally switched to this concept. I can't say that she's downright brilliant. But no one has come up with anything better yet.
Oksana Galkevich: Explain to our audience, non-specialist people, non-professionals, that there is a concept of evidence-based medicine.
Pavel Brand:The concept of evidence in medicine is very simple. It is truly simple, understandable, and there is nothing complicated about it. And it was formulated back in 1993, although in fact it all started a little earlier. In 1993, a fairly clear definition was formulated, a fairly clear formula, which states that all medical interventions, be it treatment, prevention, rehabilitation, examination, must take into account the best available evidence. For such the highest quality evidence, a pyramid of evidence was built and various levels of evidence were accepted, the highest quality of which is randomized clinical trials. These are studies that are carried out by specialists, doctors, scientists according to certain rules. These rules are also quite simple. Speaking globally, any study of any medical intervention, rehabilitation, screening, whatever, must follow very simple rules. These are the rules. All patients must be randomized into groups. Randomized - that is, they must be distributed into these groups without any preferences, that is, in a free manner.
Randomization from word rnd , random distribution. All patients and doctors who treat these patients as part of the study should not know what kind of drug or method they are receiving. This is called double-blind. That is, the patient does not know which drug he is receiving, a drug or a placebo, and the doctor does not know whether the patient is receiving a drug or a placebo. Only some controller, the so-called monitor, knows what drug the patient is receiving. Sometimes there are triple-blind studies, when even the monitor does not know, but only in the center that processes the study results.
Moreover, the study should be conducted in many different centers, preferably in different countries, to avoid any conflicts of interest. These are the basic principles of conducting randomized clinical trials, which are accepted as the basis of evidence. Naturally, there should be samples of patients that are as representative as possible. An essential specific calculation formula that allows you to extrapolate or transfer data from a small group to the rest of the population. This is the basis of evidence-based medicine. Then there are simpler studies - prospective, cohort. This is a whole series of studies. The lowest level of evidence according to various classifications is considered to be either the opinion of an expert, that is, a doctor. If the doctor says: “I’ve been doing this all my life and I’m fine,” this is the weakest evidence.
Oksana Galkevich: Lower level.
Pavel Brand:Lower level. Even lower than this can only be studies on animals and bacterial cultures. That is, when we hear that someone has proven in animals that there is a new cure for something, we must understand that this means that this has not actually been proven, because such things cannot be extrapolated directly to people. They were doing this 50 years ago. Now this is no longer accepted.
Oksana Galkevich: Pavel Yakovlevich, but from what you just said about the concept of evidence-based medicine, as far as I understand, this requires a complete reconfiguration of domestic healthcare and its work.
Pavel Brand:Yes, this should have been done simply back then.
Oksana Galkevich: And another change may be in the minds of the professional community, as far as I understand, because this is a completely different approach.
Pavel Brand:This is a different approach, this is a different understanding. This is all somewhat more complicated than simply relying on evidence. Essentially, evidence-based medicine is a modification of what we have, because it includes three main pillars. This is truly the latest, most serious evidence, this is the personal clinical experience of the doctor and this is the desire of the patient and his relatives. Because in the Soviet or old Russian medical school, such things as evidence and the desire of the patient are usually not taken into account. Everything relies solely on the clinical experience of the doctor and the scientific school to which this doctor belongs. Unfortunately, a scientific school is not a very good support, because each scientific school has its own vision of the problem. The most classic example, truly a textbook one, is a stomach ulcer, when we had two schools in Russia, back in the Soviet Union, when one school said that the cause of a stomach ulcer is the influence of the vagus, the vagus nerve, the other school said that this is all Helicobacter, that is, the bacterial theory of ulcers. So they fought among themselves. Some patients were operated on, others were treated with antibiotics. Moreover, each stubbornly tried to prove that the other was wrong. In the end, it turned out that those who spoke about the Helicobacter theory were right after all. But, nevertheless, we can hardly imagine how many people were operated on during this time.
Although operations for ulcers that do not penetrate and do not manifest themselves in any way are, of course, not required. This is already an emergency situation. Therefore, this really requires a change in the so-called paradigm, but, unfortunately, not only a change in the paradigm itself. This requires enormous economic costs, because, for example, 99% of the drugs produced in Russia not under a foreign license, their own drugs, unfortunately, according to the criteria that I have outlined, they have not undergone any clinical trials.
Oksana Galkevich: You are now saying some very alarming things.
Pavel Brand:These are generally known things. This is completely open information. It is not disputed by anyone. There were animal trials, and there were non-randomized trials.
Oksana Galkevich: Which, as you say, is not serious evidence.
Pavel Brand:There is no serious evidence. Therefore, we will have to take the entire pharmaceutical industry of the country and destroy it in one fell swoop for the sake of some kind of evidence-based medicine. Evidence-based medicine has its drawbacks. This is a high level of involvement of researchers by pharmaceutical companies. It also has its own nuances. There are problems with the fact that drastic changes occur periodically depending on sample sizes. That is, yesterday it was believed that this medicine was good, but tomorrow it is already considered that it is not very good.
The most striking example is aspirin, a drug of acetylsalicylic acid, which for a long time was considered correct, and the study was that it is good to use it for the prevention of cardiovascular events, that is, all people after 55-60 years old should take aspirin, so that they do not develop had a heart attack or stroke.
Oksana Galkevich: It seems that many people still think so today.
Pavel Brand:Yes. But not so long ago it was proven that this is wrong. Aspirin can be taken only for secondary prevention, when an event has already happened, because it has certain disadvantages that do not allow it to be given to everyone.
Petr Kuznetsov:Marat from Kazan asks you via SMS: “Literally today I had an appointment with a therapist. The doctor says: “An ultrasound is only for October.” Is this coercion for a paid examination?”
Pavel Brand:Good question. I think there is nothing strange about this. We’ve just gotten a little used to this very social system of medicine over 70 years. Not even for 70, but probably for the last 50 years of social medicine. This is a problem all over the world: if nothing acute happens to a person, then research occurs rather delayed. Why? Because there are few truly specialized specialists everywhere. There are probably no such number of doctors as in Russia anywhere in the world. Maybe only in China and India. But in civilized countries there are quite a few doctors, and there studies after 3-4 months are the norm. And the question is always about the stages of medical care. If it is an emergency, medical assistance must be provided within minutes or hours. If it is an emergency, then within hours and days. If this is a delayed situation, it is days and weeks. If planned, then months and years.
That is, there must be a clear understanding here. Unfortunately, health officials do not communicate very well with the population and cannot explain that there are things that should really be examined and treated immediately, and there are things that are in no hurry. If a person needs to have a scheduled ultrasound, it should not be done tomorrow or in a week.
Oksana Galkevich: But here they like to demand that it be tomorrow.
Pavel Brand:Probably, in this vein - if you want, you don’t have medical indications, but you want to do it tomorrow, paid medicine gives you this opportunity. Please.
Petr Kuznetsov:There is a question about another form that has just appeared - telemedicine. There are a lot of questions. What do you think about it? What can this solve?
Pavel Brand:Telemedicine is a very interesting story. Telemedicine has, if I'm not mistaken, 24 forms.
Petr Kuznetsov:24 forms of telemedicine?
Pavel Brand:Yes. 24 options for what can be called telemedicine. Because talking to a doctor on the phone is also telemedicine. A conversation between two doctors on the phone is again telemedicine. The doctor can view the tests sent via Whatsapp – this is also telemedicine. If I'm not confusing anything, there are 24 or 25 shapes that stand out. Therefore, to talk about what I think about telemedicine, we need to analyze each form.
Globally, I believe that it is effectively worth talking about one form of telemedicine, which is the worst from the point of view of its real application and the most interesting from the point of view of monetization. That's why everyone wants her so much. This is the medicine of the primary connection between doctor and patient, when the doctor and patient are directly connected without seeing each other in real life. Unfortunately, this kind of telemedicine is not very good. It has certain nuances, you can formalize it, make certain standards, introduce certain restrictions, and then everything will be more or less, although also with its own nuances. Unfortunately, in the form of simply conducting “let’s now have doctors contact primary patients directly and try to make a diagnosis via Skype, telephone or the Internet” - this is not very healthy. Because there are huge risks of missing a disease, prescribing the wrong treatment, not seeing something, not asking, not smelling it. Usually, flamboyant opponents give the example of the smell of diabetic acetone, which you will never feel by communicating by phone or on the Internet.
On the other hand, there are a huge number of benefits to telemedicine. This is, for example, a doctor-to-doctor connection, when a doctor in a remote region, a non-specialized general practitioner, can contact a highly specialized specialist from the federal center, who will interpret the information that the doctor has collected. And he will be able to somehow structure it, suggest whether an operation is needed, whether some additional examination is possible, and so on. Communication between the patient and the surgeon before the operation, when the patient is examined by the doctor and wants to clarify some nuances with the surgeon before flying to him across the country, again, to federal centers.
More than that, what are the active proponents of telemedicine talking about? The fact that every doctor practices telemedicine to one degree or another every day. Acquaintances, acquaintances of acquaintances, friends, relatives call him and ask the question: “Listen, my back hurts - what should I do?” And here a dilemma arises. On the one hand, yes, this is happening. Everyone understands that it exists. But everyone really wants to monetize it. Because how can that be? Money is passing by. Usually no one pays anything for this. We came up with a form with our comrades, doctors, that we don’t want to monetize it directly, we monetize it, for example, so that we launched such a small flash mob on Facebook, doctors help, what kind of consultation does a person call me and say: “I want to know , what should I treat or which doctor should I go to and which hospital.” I tell him. - “Oh, how can I thank you?” I say: “Transfer the money to some charitable foundation.”
In my opinion, in this form this monetization is understandable. As soon as this begins to be monetized through some direct patient-doctor money, many additional temptations immediately arise, in addition to what is already present. But there are doctors who actually make money from this and who can work like this. For example, many radiologists do work remotely. They look at the photo, give a description, and get paid for it. Oncologists can check the prescribed treatment regimen in this way, give some kind of preliminary conclusion, and invite the patient for a consultation. There are possible options here. Therefore, it is impossible to say unequivocally that telemedicine is good or bad. It has its own nuances. This needs to be very clearly, very carefully prescribed by law, so that there are no questions later: who is responsible, who pays, who makes the appointments, what appointments, can diagnoses be made or can only a preliminary conclusion be made, is it necessary to send this patient to a doctor or just watch him on Skype or even talk to him on the phone. There are a lot of questions. They are very complex indeed.
Oksana Galkevich: Pavel Yakovlevich, you spoke about the concept of evidence-based medicine due to the fact that we are somewhat behind (I am softening the wording) from world health care, from world medicine. Tell me, is there some kind of movement to the side, perhaps the adoption of this concept, the reconfiguration of some new mechanisms. The backlog needs to be eliminated somehow, it needs to be caught up. And does it exist, or is this understanding not there?
Pavel Brand:There is movement. We even have entire specialties, in fact, which to one degree or another are very close to the world level, to world evidence-based medicine, because they are quite narrow, and these specialties were suddenly headed by people who support the principles of evidence-based medicine, and it turned out that that everything is quite simple, it is enough to write the correct recommendations, approve them in the Ministry of Health, and in principle, if we do not enter evidence-based medicine, then at least we will participate in some of its aspects: this is primarily cardiology. In fact, especially in Moscow, we have a very pronounced movement towards evidence-based medicine. Although there are, of course, retrogrades. But there's no escape here. These are reproductive technologies. In Russia they are generally very highly developed. This is endocrinology in many ways, which is really narrow enough to follow global trends. To some extent, urology is now starting to move, gynecology is starting to move slowly, that is, there is some progress. But therapy, neurology and pediatrics are still before the moon.
Oksana Galkevich: And why did I let you down by bringing you back to this topic? Due to the fact that there are things that are very actively discussed even in your professional sphere, and we certainly cannot understand whether this is pseudoscience or whether it is still worth taking seriously. Homeopathy, osteopathy.
Petr Kuznetsov:I recently came across this.
Oksana Galkevich: Petya has experience in communication.
Petr Kuznetsov: With an osteopath.
Pavel Brand:Not in the subway, I hope?
Petr Kuznetsov:The baby was probably a month old. They took me to an osteopath. In general, the appointment lasted about 40 minutes. It consisted of probing some points. After which... "doctor" probably shouldn't be said just yet?
Pavel Brand:Why? This is an official medical specialty recognized by the Ministry of Health now.
Petr Kuznetsov: Oh, it’s recognized, right?
Pavel Brand: Yes.
Petr Kuznetsov:The doctor says: “Okay, that’s it, I’ve stabilized something here. That’s what you have to charge.”
Pavel Brand:Yes, a very successful story. I like it too.
Petr Kuznetsov:Sometimes you don't quite understand what you're paying for.
Pavel Brand:In medicine, you don’t always understand what you’re paying for, even if it’s real medicine. Look, pseudoscience is more of a formulation. It’s just that neither homeopathy nor osteopathy can be explained by the methods of modern science - no chemistry, no biology, no physics, no mathematics, nothing. Therefore, it was somehow formulated precisely as pseudoscience. Although we, of course, have negative examples when genetics or cybernetics were recognized as pseudoscience. But here this is precisely a kind of milestone indicating that at this stage we do not understand what it is, and most likely we will never understand it, because the depth of immersion in science is quite serious now, more serious than 80 years ago, when we discussed this story about genetics or cybernetics. But, nevertheless, we do not see any evidence that homeopathy or osteopathy has any meaning other than the placebo effect.
But we must not forget that homeopathy and osteopathy themselves are not terrible. People are generally inclined to one or another method of influence that helps them quickly and beautifully get rid of their own illness, especially if this illness is caused not by physiology, but by psychology. In this regard, homeopathy and osteopathy help many people very well. We know that a huge number of people are committed to homeopathy and osteopathy. And they feel good. God bless. We shouldn't waste medicine on these people. We do not in any way treat them for what they do not have. On the one hand, it was so simple: a man came, he had nothing, he told him to go. But he doesn't feel well. What's the problem? Psychological and psychiatric care is poorly developed in the country. In fact... It's just beginning. Now modern centers have just appeared, again, with a certain level of evidence. The country has a huge history of these pseudo-charlatan methods. There is a medical catastrophe in the country, which does not provide people with real treatment. That is, the problem is really at the level of a doctor who cannot give normal pills, but gives some so-called bullshit, which do not work, do not help, and, perhaps, harm something. And the homeopath gives balls, which seem to definitely not harm anything, but can only cause diabetes if you eat a lot of them.
In fact, they are just sugar balls. And it becomes easier for the person. What's bad about it? There are several bad things about this. While we recognize this history on a par with medicine, we are not developing medicine. It is very difficult for us to move towards evidence when we recognize methods that 200 years ago did not show very good validity. This simply slows down the development of normal medicine. This is often simply a scam because it is impossible to verify.
Petr Kuznetsov:Space for manipulation.
Pavel Brand:The scope for manipulation is colossal. There is no evidence. A man came, gave me a ball and said... Everything is based on trust. This is a type of trust fraud. It became easier - thank God. If it doesn’t, then go to a regular doctor, he will help you.
Petr Kuznetsov: To the surgeon.
Pavel Brand:To the surgeon. And the third point is when these doctors, as they are called now, nothing can be done, actually delay the start of normal treatment by applying their methods. And when they understand very well the boundaries (unfortunately, there are very few of them), where they understand that this is not fatal, that this is psychology. Let me give you an example to make it clear, very simple. For example, back pain. Something that happens to everyone. What everyone knows, everyone has met. And why do osteopaths work most often?
There is one problem. Back pain, this is a proven fact, in 90% of cases it completely goes away on its own without any treatment within a month. Accordingly, we take any doctor, not a doctor, anyone, and say: “OK, 15 sessions in 2 days - and in 15 sessions everything will go away for you.” That is, with a 90% probability this will be exactly the case, because it will go away on its own - without any pills, without any physiotherapy, without homeopathy, without anything. It’s just that if you don’t touch a person at all, everything will go away. But since back pain is not only local pain, it is also psychological discomfort, a person is uncomfortable, it is difficult for him to get up, go to work, perform some of his usual functions, then naturally, when he comes to the doctor, who 40 minutes holds his hands on him and says that he moves his sacred rhythm in one direction or another, then, probably, this somehow creates for him the effect of treatment, the placebo effect.
It must be said right away that the main objections of supporters of homeopathy, osteopathy and other urine therapies are that placebos do not work on children and animals. It has long been proven that this is not the case. Placebos work great on animals through their owners and on children through their parents. That is, there are studies that have shown this very well. Therefore, again, there is probably nothing wrong with the placebo effect. The only thing that I would really like is for those who use placebos, including doctors who deal with placebo therapy and prescribe all kinds of nootropics and vascular drugs, to warn the patient that, you know, we are giving you a placebo, we are we give you a pacifier, but we give it to you, and it will still be easier for you. Because it has been proven that even if the patient knows about the placebo, the placebo still works.
Oksana Galkevich: Pavel Yakovlevich, I would like to turn to some kind of information agenda. We have now discussed more general topics. For example, this week we raised the issue of reforming the work of our clinics and outpatient departments. They are going to make them faster, higher, stronger, to reduce queues, not to delay people, to shorten the recording time, to increase the time of communication with the patient. What do you think needs to be done here? And if you have become acquainted with these plans in some form, how well do you think they are drawn up?
Pavel Brand:I'll tell you honestly. I have not become familiar with these plans, since now I am not particularly concerned with public health care. And I have enough work...
Oksana Galkevich: You just probably know one way or another...
Pavel Brand:Yes. But roughly I imagine this project “Lean Clinic”.
Oksana Galkevich: Yes, right. That's right. "Lean Clinic", yes.
Pavel Brand:Outpatient centers. Look, any work aimed at strengthening the outpatient department is very good. We have a colossal surplus of beds in the country. Despite the fact that everyone is trying to tell us that our...
Oksana Galkevich: Scold optimization. That's it, right?
Pavel Brand:Yes, criticize optimization and so on. The problem with optimization is not reducing the number of beds, but reducing without providing an alternative. It’s precisely the development of the outpatient department, truly high-quality development, that would make it possible to reduce these ineffective beds and do everything well, everything right. But we start from the end. Therefore, in our country it’s just such a scourge - to start everything from the end. It seems like everything was thought out correctly, everything was said correctly. But they started exactly on the other side. They began to reduce beds, but the clinics did not change. Doctors were not trained. And in the end we got what we got.
Oksana Galkevich: The first step was to cut costs.
Pavel Brand:Yes, to cut down castes, as they say now in the information agenda. The main problem is that you can build a very beautiful building, you can completely fill it with the most modern equipment. But someone has to work on it. This someone must be properly trained and well motivated. This is where we have big problems. We have problems with both learning and motivation. Training a good doctor is expensive. Self-education of a doctor is also expensive. And no one is trying to compensate him for his costs of self-education. Thus, we get a stalemate in which we can seem to do a lot of good things, but at the same time we run into this very doctor who is bothering us.
Oksana Galkevich: With dull eyes.
Pavel Brand:Doctors burn out, they are often poorly trained, quickly burn out, do not have the financial opportunity for self-development, are forced to work two jobs, and so on, in order to feed their families. This is not conducive to improving medicine in this context. Although the focus on the outpatient department itself is absolutely correct. It would also be nice if there was some movement towards licensing doctors. But we’re still as far away from that, I’m afraid, as we are from the moon.
Oksana Galkevich: How does everything that is happening around our country affect you and your work - sanctions pressure, our response, the movement towards some kind of closedness, perhaps isolation, self-isolation?
Pavel Brand:Retaliatory sanctions affect naturopaths the most. They love to treat with products.
Oksana Galkevich: Do you mean import substitution?
Pavel Brand:No. Which they like to treat with foods, diets, and a high content of feijoa. But in a global sense, naturally, there are problems associated... The biggest problems are related to the fact that the exchange rate of the dollar and the euro has changed. And these problems are long-standing, they are big. And if earlier you could buy an ultrasound machine for 3 million rubles, now it costs, relatively speaking, 6 million rubles. And this is a really serious problem, because it is simply physically impossible to raise prices in healthcare in the same way (for example, in private healthcare) as the dollar exchange rate has changed.
Oksana Galkevich: 2 times.
Pavel Brand:Therefore, it has become more difficult to update equipment, and it has become more difficult to purchase quality equipment. There is, of course, a problem with this. But, nevertheless, new markets are opening. Korean equipment is very high quality. The Chinese have learned to make high-quality equipment.
Oksana Galkevich: What about ours? Sorry.
Pavel Brand:It's more difficult with ours. We have good ideas, but they are often poorly implemented. That is, this is a big problem. Again, do you understand what the problem is? We have such a colossal history in our country where everyone wants to earn money quickly and instantly. Therefore, now, for example, huge amounts of money are being invested in telemedicine, forgetting that it would be nice for us to learn how to make normal ultrasound machines to begin with. And only then we can talk about telemedicine. Because, again, there will be telemedicine, but there will be no equipment to support this telemedicine. That is, we come in from behind again, from the end. And, unfortunately, we are going the same way in education. That is, we are changing postgraduate education without affecting simply higher education. In my understanding (I always give this example) this is an attempt to fasten the pedals to the horse. That is, it is not possible to transfer from a bicycle to a rocket without passing a car, a ship, and so on. You can't do that. And this leads to the fact that we really do not have our own normal cardiographs, tomographs, or ultrasound machines, but we are ahead of the rest in the development of telemedicine. It's great to immediately try to jump into XXIII century But I’m afraid it won’t work without crutches.
Oksana Galkevich: Thank you very much. It was very interesting. We have touched on a wide range of topics today. Dear friends, Pavel Brand, chief physician and medical director of the Family Clinic network of medical centers, was in the studio of the “Reflection” program today. We are not saying goodbye to you, we will literally take a break for three minutes and return to you. We'll have a big topic coming up. Stay with us. We will talk about microfinance organizations, about loans, about who can and cannot issue loans to the population. Stay with us.
Pavel Brand: Thank you.
Oksana Galkevich: Thank you.
Pavel Brand:
The program “On Nervous Grounds” and I, its presenter, Pavel Brand, neurologist, candidate of medical sciences, medical director of the network of family clinics “Family Clinic”. With me is my co-host Marianna Mirzoyan, editor of the Namochi Mantu Instagram channel, medical journalist. Today our guest is a gastroenterologist, candidate of medical sciences, director and managing partner of the Rassvet clinic in Moscow, Alexey Paramonov.
Today we have an unusual, non-neurological topic: “Stomach pain.” It also has something in common with neurology. Rather, not even with neurology, but with elements of psychosomatics. The topic is huge. Alexey, I think that the very first problem that we will discuss is epigastric pain, gastritis.
What problems are associated with this pain? Someone’s stomach hurts so much that the person cannot bear the pain at all. He runs to a gastroenterologist, drinks antacids in packs, eats all sorts of Rennies and so on, nothing helps him. They do a gastroscopy and find superficial gastritis with minimal changes. Another person with a huge ulcer lives and does not blow his mustache, something aches. What is the problem, what is the reason? How to deal with this?
Alexey Paramonov:
For the patient, the problem, first of all, is that the correct diagnosis is rarely made, unfortunately. You said “superficial gastritis”. This is what, indeed, we write in almost every first gastroscopy. In fact, there is no such thing in the nomenclature of diseases. This is an endoscopic phenomenon. But the paradox, indeed, is present that the changes are minimal or not at all during endoscopy, but it can hurt. At the same time, in some situations, for example, with diabetes, a large ulcer does not cause any pain. This paradox is resolved in such a way that not everything that we usually call gastritis is gastritis.
In fact, gastritis is more of a histological concept. It can be reliably diagnosed only by taking a piece of the mucous membrane and looking under a microscope. At the same time, he may get sick, he may not get sick, these are completely parallel processes. The fact that, in percentage terms, the most common cause of epigastric pain is functional dyspepsia syndrome. Our patients often mistake this syndrome for gastritis in everyday life. In fact, most of them have functional dyspepsia. This is a condition when the same processes are present as with gastritis. There, too, the acid affects the stomach wall and irritates it.
But this is not the main feature. The main feature in the individual settings of the gastric mucosa is the sensitivity of its nervous system. There are people who are hypersensitive to acid; they perceive it as pain. There are other people whose sensitivity is normal or reduced; they do not even perceive a more gross process as pain. These settings, in turn, are very closely tied to psychological phenomena. It has been proven that such disorders occur in people who have anxiety and who have depression. Sometimes these psychological phenomena do not lie on the surface; the patient may not be aware of them. His attending physician, a general practitioner, or a gastroenterologist may also not be aware of them. They can sometimes only be identified by special tests from a specialist.
Gastritis can only be reliably diagnosed by taking a piece of mucous membrane and looking under a microscope.
Marianna Mirzoyan:
What tests are used for this and how to understand that your gastritis is not actually gastritis?
Alexey Paramonov:
As for tests, there are many of them. There are such popular ones as the Beck Scale and the Hospital Anxiety and Depression Scale. But these are all auxiliary tools for a gastroenterologist, a reason to understand that a person has a psychological problem and refer him to a psychotherapist. We, as gastroenterologists, understand that there is a problem of this kind, based on the duration of the disease, the persistence of this pain and the insufficient effect of standard drugs, proton pump inhibitors. Omeprazole, esomeprazole, Nexium, Pariet - these drugs are well known to our patients. With a classic ulcer, with classic gastritis, they relieve pain, if not with the first tablet, then certainly the next day. And here we will hear a story - either it helps or not. Or I took it for three days - it helped, but on the fourth day it stopped helping. In such cases, we already begin to look for functional dyspepsia.
Pavel Brand:
It turns out that practically our entire population, starting from a young age, is ill with something other than what is usually considered. In our country, it is believed that the main cause of gastritis is associated with poor nutrition at school, with violations of the diet of office employees who eat dry food or do not eat regularly. Because of this, problems develop with the gastric mucosa, all kinds of ulcerations and erosions occur, which themselves hurt. It turns out that all this is not true. That, in fact, premorbidly, we are somehow already prepared for our psychological state to affect our pain sensations. That is, it is psychosomatics. Even with minimal changes, with normal nutrition, we can have a pain syndrome that will annoy us, bother us, and so on.
Alexey Paramonov:
Without a doubt. Gastritis really exists, there is such a disease. But it occurs several times less often than the diagnosis itself is given to patients. You have now brilliantly outlined the theory that you formulated back in the late 19th century, and it dominated until the early 2000s, the 21st century. It still remains dominant in the minds of some of our doctors.
In fact, nutrition does not play a significant role in either gastritis or functional dyspepsia. All 15 tables according to Pevzner and their variations have no meaning. The real, most common cause of gastritis, true gastritis, is Helicobacter, a well-known microbe that causes chronic inflammation in the stomach. But this is not always parallel to pain. The most common cause of pain is functional dyspepsia, where two main factors play a role. I'm simplifying greatly, but the first factor is the acid in the stomach, the second factor is a psychological state that changes the settings for the perception of pain. Hence the impact. A patient often tells us: “I get pain when I’m nervous. I’m going on vacation, and everything went away in one day, I returned to work and got sick on the same day.” Here, a daily routine, sufficient sleep, good rest, mood, hobbies - this is a wonderful treatment. If this does not help, we block the second factor - acid with the same proton pump inhibitor, which does not work as well as for gastritis, but still works. On the second floor there is already specialized medical care. This could be psychotherapy, it could be anti-anxiety medications, it could be antidepressants.
Nutrition does not play a significant role in either gastritis or functional dyspepsia..
Pavel Brand:
We have not discussed gastritis caused, for example, by taking medications. Yes, this is a separate category, gastritis caused by intake. Most often in our life we encounter non-steroidal anti-inflammatory drugs, aspirin-associated gastritis, or NSAID-associated gastritis, this is, after all, a different pathology.
Alexey Paramonov:
Yes, now called NSAID gastropathy. Indeed, these drugs very actively affect the gastric mucosa, disrupt its protective mucus, remove the protective barrier, and it is easily damaged by acid. Therefore, there should be a policy to limit non-steroidal pain medications. The patient should think before swallowing the tablet. If he takes these pills for a sufficiently long time, or if he belongs to a risk group, he once had an ulcer, or is an elderly person with concomitant diseases, the painkiller should be taken together with a proton pump inhibitor, to prevent, first of all, gastric bleeding.
You said good things about aspirin. Yes, we once fought for it to be prescribed for the prevention of cardiovascular diseases, and now we are fighting for it not to be prescribed so often. Cardiologists tell us that it should be prescribed in a limited number of cases - after a heart attack, after a stroke. Our patient now began to thin his blood from a hypothetical position at the age of 40, and apart from bleeding and an increase in mortality, nothing better happens from this.
Pavel Brand:
As I understand it, NSAIDs, after all, do not stand still, and more modern options have appeared, like Sibs, which reduce the effect of non-steroidal anti-inflammatory drugs on the stomach.
Alexey Paramonov:
Yes it is. They are improving, but there is also a limit to perfection here. When one of the first such selective drugs, meloxicam, appeared, indeed, its incidence of damage was lower than that of the classic ortofen, diclofenac. But, when we continued to develop further, it turned out that in order to achieve an equivalent analgesic effect, we need to increase the dose, and when we increase the dose, selectivity begins to be lost and the stomach is damaged in exactly the same way. Coxibs are more selective, but they have other problems. There regarding thrombosis. Therefore, this problem cannot be said to be solved by selective NSAIDs. The solution to the problem is, rather, in combination with a proton pump inhibitor.
Pavel Brand:
One way or another, everything should be according to testimony and, if possible, then undercover. For some reason, doctors also like to call it a cover-up with proton pump inhibitors and acidity regulators.
Let's move on to the next problem, which, in my opinion, is no less common, and sometimes much more disturbing, disturbing to patients - the problem of heartburn. Heartburn is not only a problem of the stomach, but also a problem of the esophagus, often even the throat. This point is not obvious to the majority of the population of our country, or our patients. Moreover, the worst thing is that this is not obvious to most doctors. For example, a cough caused by gastroesophageal reflux is often the last thing a therapist in a clinic thinks about.
Heartburn is not always reflux disease.
Alexey Paramonov:
Yes you are right. Reflux disease has many manifestations. In addition to the classic ones - heartburn, belching, this is what you named. This is a sore throat, this is chronic tonsillitis, chronic pharyngitis. When it gets into the larynx and respiratory tract, it is both bronchitis and laryngitis. There are purely gastroenterological symptoms, but relatively rare ones, such as esophagospasm, when intense chest pain occurs. Such a patient may be brought to the hospital with a suspected heart attack. Reflux disease has many manifestations. Some people know them better, some people know them worse.
The situation is much worse with the awareness of doctors and patients that heartburn is not always a reflux disease. In addition to the fact that heartburn is a reflux disease, it is also the same functional dyspepsia that we talked about. There is a formulation, a terminological trap, perhaps - it is also called functional heartburn. The mechanics here are similar to what we talked about earlier - reflux occurs. In a healthy person, refluxes also occur, but a healthy person does not feel them, but in a patient with functional heartburn, there is a hyperperception of pain and he feels refluxes, they torment him. Subjectively, this heartburn may be more severe than with equivalent reflux disease. Proton pump inhibitors also do not help such patients completely, unlike classic reflux disease, where they almost always eliminate heartburn; other symptoms may not be controlled, but heartburn is eliminated. Here, first of all, a differential diagnosis is important to help the patient. With functional heartburn, sooner or later we will apply the techniques that were discussed - psychotherapy, antidepressants, changing the daily routine, lifestyle. Enough rest, less stress, even up to changing jobs if your boss is a rude and dangerous person. Change your boss, your health is more important.
For patients whose symptoms last a long time, the question arises: is antireflux surgery necessary? This question is not idle. The fact is that in some situations we cannot cure reflux disease otherwise. We can eliminate many symptoms with proton pump inhibitors, but we cannot eliminate reflux itself. We make it less dangerous, less acidic. Then only antireflux surgery can help. Now these operations have become effective, safe, and can be done laparoscopically in a short time. But they still require a qualified specialist. Not everywhere it is done professionally. The fundamental pitfall is that the operation is sometimes performed on a patient with functional heartburn, which not only does not help him, but in principle cannot help him, and leads to additional problems. The patient begins to suffer from everything that was before the operation, plus bloating, distension of the stomach during aerophagia and other troubles are added here. Careful selection is important here. When a patient is taken for surgery, at a minimum, daily pH measurements should be done. It must be proven that it is reflux disease and not functional heartburn. Even with the proof of pH-metry, it would be nice to think about this patient further, because no one forbids the patient to have both reflux disease and a functional component. The doctor’s task is to understand what is more and predict the effect of the operation.
Pavel Brand:
Alexey, everything about heartburn is thorough and clear. Briefly, as I understand it, we are talking about laparoscopic fundoplication surgery, which is called anti-reflux surgery.
The second symptom that usually worries our patients is belching. Surgery won't help much here. A person has eaten, is at a social event, and then suddenly - belching. What to do?
Alexey Paramonov:
Belching can also be a manifestation of reflux disease. But, you correctly focused on this symptom. Very often its cause is not gastroenterology, it is aerophagia. Aerophagia is already a psychological phenomenon. This is a condition in which the patient, without realizing it, swallows a lot of air. We all swallow air, this is normal, we have a gas bubble in our stomach. Swallowing air occurs during eating, drinking and talking, especially emotional talk. But for some people this happens in small quantities, and then belching occurs or some of the air is generally released in a different way. In people who are in a state of anxiety, or with other psychological problems, swallowing can be very massive and then massive belching occurs. It torments the patient and causes anxiety; he feels uncomfortable being in society. On the first visit of such patients to a gastroenterologist, it is necessary to understand whether there is reflux disease. But most often, again, a psychotherapist is needed, and sometimes the solution here is treatment with an antidepressant.
Very often the cause of belching is aerophagia, swallowing air..
Pavel Brand:
It turns out that all our major illnesses, ladies and gentlemen, are caused by nerves. That’s why we continue everything in the “On Nervous Grounds” program.
Alexey, let’s not dwell further on the stomach; probably, everything is more or less clear with the stomach. The next item in our order is the gallbladder if we go down. Let's probably discuss the gallbladder and pancreas in one complex. Yes, these are two, practically opposite, located organs that are in some kind of symbiosis. I'd like to understand why this is important. Firstly, there is the problem of gallstones, which is acute - this is often a surgical pathology. I think that in our country there is both overdiagnosis of gallstone disease and underdiagnosis in terms of the need for surgery. Plus, operations and treatment of the gallbladder in general, one way or another, affects a person’s entire life, because it greatly limits what he or she can eat for the future. It is classically believed that you should stop eating spicy, fried, hot, salty and, in general, everything. At the same time, the pancreas is extremely unpleasant because it causes very bad conditions in the form of acute pancreatitis, severe stabbing pain in the abdomen, which practically cannot be relieved by anything. It’s bad, terrible, even to the point of pancononecrosis, which is absolutely sad. What do we know about this?
Gallstone disease is not always a reason to remove the gallbladder.
Alexey Paramonov:
You concluded with a good question. We know little about this. We know little why acute pancreatitis occurs. As for the relationship between the gallbladder and the pancreas - yes, it is very close, and anatomically close. In most people, the pancreatic duct and bile duct open side by side, or even merge into one duct before opening, and the problem goes back from there.
As for cholelithiasis, an important thesis here is that treatment should not be worse than the disease itself. Many patients can carry stones within themselves and live happily ever after; the stones will never show themselves. Statistics have shown that performing a cholecystectomy and removing the gallbladder for everyone with stones was not justified. Even if there are not very large risks associated with this operation, the operation is small and well-developed. But the risks accompany any operation; they turned out to be higher than the risks of doing nothing. Yes, when cholelithiasis is detected, it happens that patients are scared that the stone may pass into the duct - jaundice will occur, there may be suppuration of the gallbladder and other problems. But the likelihood of this in most cases is small; there is a greater likelihood of problems during surgery.
When is surgery really necessary? In the presence of biliary pain. Biliary pain is pain in the center, or right hypochondrium, that occurs shortly after eating. The pain is cramping and wave-like in nature. If such an attack occurs at least once, this is an indication for surgery. Having happened once, it will happen again and again and end in complications. Another indication for surgery is a very large stone, 25 millimeters or more. It was also the surgeons who decided to operate. In other cases, surgery is not always necessary; you can abstain.
With pancreatitis, there is the concept of acute pancreatitis and chronic pancreatitis. Acute pancreatitis is the most serious disease that you mentioned, sometimes ending in death. The course is difficult and requires many months of hospitalization. It's difficult to predict. Diet probably plays some role. Our medical observations indicate this. But, at the same time, large studies have not shown a connection with diet. There is a clear connection with smoking, oddly enough, and a clear connection with high triglycerides in the blood. Triglycerides are common fats. Their number is determined, on the one hand, genetically, and on the other hand, depends on nutrition. If you eat a lot of fat, they will rise.
I can’t say how to prevent acute pancreatitis; hardly anyone can. With chronic pancreatitis, pain and nausea, pain in the left hypochondrium, and girdle pain occur from time to time. This kind of pain is not too dependent on food. Periods of exacerbations occur - sometimes there is pain for two weeks, but there is no pain for two months. There must be evidence that pancreatitis is occurring. Such evidence includes an increase in blood amylase, an increase in blood lipase, an increase in C-reactive protein, an inflammatory marker, inflammatory changes in a clinical blood test - an increase in leukocytes, ESR. Ultrasound and computed tomography should reveal reliable abnormalities - this is a thickening of the duct of the gastric gland, this is the formation of a cyst and its swelling, fluid around it.
Every first patient with superficial gastritis receives an ultrasound examination with the following conclusion: “diffuse changes in the pancreas; pancreatitis cannot be excluded.” This has nothing to do with pancreatitis. In 99% of cases, these diffuse changes are, on the one hand, a fantasy, and on the other hand, the patient came for a study and it is inconvenient to write that he is healthy. We see many patients who have been walking around for years with complaints of abdominal pain, girdle pain, have the title of pancreatitis, and have these same diffuse changes. At the same time, they have no evidence of the presence of inflammation in the pancreas. Such patients require study and understanding of what is wrong with them. The reason for the pain is completely different. This cause may also be dysfunction of the sphincter of Oddi, the muscle at the exit of the bile duct, which can spasm and cause pain. Often this is the same psychosomatics that we talked about. Pain is associated with depression, anxiety and something else. Patients are treated for pancreatitis for years, instead of a single course of antidepressant treatment.
Pavel Brand:
Let's move on to a broader, more interesting and completely psychosomatic topic, in my opinion, in the form of irritable bowel syndrome. A problem that affects a large number of people. I know about a hundred people with the problem of irritable bowel syndrome - diffuse pain throughout the abdomen, a constant urge to go to the toilet at the most unexpected time, in the most unexpected place, intensifying, indeed, with all sorts of emotional stress. Here the connection with emotions is clearly visible. But at the same time, there are people who are completely calm and suffer from the same problems. That means there's something inside.
Alexey Paramonov:
In such people, you need to understand whether they have irritable bowel syndrome, first of all. For this, there is an algorithm that applies to the entire gastrointestinal tract: we first exclude the presence of organic diseases, then we confirm that we are talking about irritable bowel syndrome. Depending on the group to which the patient belongs, a patient with a risk factor, young or elderly, whether he has lost weight or has an increase in temperature, a change in tests, we come to the conclusion whether he needs a colonoscopy. Colonoscopy answers these questions in a significant proportion of cases. A colonoscopy with biopsy is almost always required. We have another problem, sometimes they even did a colonoscopy and they said: there was nothing to take a biopsy from, there is no ulcer, no tumor. You should always take it. Because there is such a disease - microscopic colitis, which cannot be seen in any other way except by looking through a microscope. There will be massive infiltration of lymphocytes, amyloidosis too. There are diseases that cannot be excluded without a biopsy.
According to the frequency of the disease, in any case, above 80% will end up with a functional disorder. I can say that irritable bowel syndrome is functional dyspepsia on the floor below. All the same laws, but there is no acid in the intestines. But the basic basis - anxiety, depression - plays a very significant role. Yes, there are studies that show: irritable bowel syndrome occurs after infections, for example. One way or another, in the long term, when it exists for months and years, without an emotional basis, it won’t work anyway.
Marianna Mirzoyan:
The question immediately arises, what can a gastroenterologist do in this case? Firstly, is it possible to refer people to psychotherapists, do people get there? Second point, can you prescribe anti-anxiety drugs and antidepressants yourself to help the patient?
Alexey Paramonov:
Yes, this is a fundamental point. Indeed, our Russian patient does not like psychotherapy, and “psychiatrist” sounds threatening to him. Although these people do not always treat those who are “chased by aliens.” Ordinary city stress sometimes also requires the help of such a specialist. In our purely gastroenterological guidelines, the same Roman criteria, a consensus for gastroenterologists, they contain recommendations for prescribing antidepressants. There are antidepressants that have been proven effective for the same irritable bowel syndrome. We can appoint them ourselves. We do not prescribe them for the purpose of treating depression or other things - gastroenterologists do not have enough classification to do this. We prescribe it to treat irritable bowel syndrome. We know this is highly likely to help. If a patient comes to a psychotherapist, it will be wonderful.
Pavel Brand:
Great, Alexey! There remains a very important point to discuss, the final, beautiful one - taking antibiotics. The most important topic, in my opinion. We all know, our mothers told us since childhood: an antibiotic, which means we need nystatin or some kind of Diflucan. Nystatin is a real disaster. We always have the theory that an antibiotic kills not only the bad flora in the intestines, but also the good one. When good flora dies, mushrooms begin to grow, they must be killed with an antifungal drug. Then there was a new trend: introducing probiotics and eubiotics, which could improve the situation. Even after taking an antibiotic for 3-4 days, you must immediately take an antifungal drug and a probiotic so that life immediately improves. Is it so?
Alexey Paramonov:
This is so very partial. It is simply dangerous to prescribe an antifungal drug for every reason; they are quite toxic. Their benefits have not been proven. The main danger from taking antibiotics is antibiotic-associated diarrhea. In its severe form, it is pseudomembranous colitis, when the clostridium difficile present in the intestines multiplies. Antibiotics create conditions for its reproduction. It can cause quite severe diarrhea, bloody diarrhea, and in severe cases, a generalized severe infection. These situations can be prevented. On the one hand, here is the well-known domestic concept of dysbiosis, although it is completely wild, this is understandable. This concept has compromised probiotics as a class of drugs. It is completely wrong to give up probiotics completely. There are some types of probiotics, the effectiveness of which has been proven and recognized, and is included in leading consensuses and guides, in particular, in the prevention of antibiotic-associated diarrhea. If we prescribe certain types of pribiotics at the time of antibiotic treatment, the likelihood of complications is reduced.
It is dangerous to prescribe an antifungal drug for every reason; they are quite toxic.
Pavel Brand:
Alexey, where can I get magic probiotics? In a store or in a pharmacy?
Alexey Paramonov:
The optimal ones are some strains of lactobacilli, the so-called LGG, the drug of which is not registered in Russia. They are present on our market in the form of food additives, food additives also mixed with vitamins. Those that are sold in pharmacies as probiotics contain completely different strains. The only thing we have in pharmacies is Saccharomycetes, the drug Enterol. It is the same all over the world. As for the most effective lactobacilli, they have to be purchased abroad for now.
Pavel Brand:
It's clear. Then, a clarifying point: how long do you need to take antibiotics to cause antibiotic-associated diarrhea, pseudomembranous colitis. Why am I asking? Relatively speaking, treatment of purulent sinusitis is either three, five, seven or ten days of antibiotics, or serious therapy with monthly courses of antibiotics.
Alexey Paramonov:
Naturally, if you take an antibiotic for a long time and also change antibiotics, the risk increases.
Pavel Brand:
“A lot” - how much? For some, “a lot” is three days. I know people for whom three days of antibiotics are already like death.
Alexey Paramonov:
The standard course, after all, is seven days for most types of antibiotics, give or take something. The fundamental point is that even one antibiotic tablet in a predisposed person can cause all these serious disorders. Therefore, first of all, do not take an antibiotic without clear indications. ARVI cannot be treated with antibiotics. The next point: the risk increases significantly in older people, in people after major operations - joint replacement, similar major operations. The risk increases significantly. For such patients, if a course of antibiotics is prescribed, and they are often prescribed, it is imperative to simultaneously prescribe at least Saccharomycetes, Enterol, which is available to us. If minimal signs of diarrhea occur, a stool test for clostridium toxin is needed. Moreover, this toxin during diarrhea must be determined four times in a row. A one-time analysis gives nothing. This requires caution on the part of doctors to prevent severe forms of this disease.
Pavel Brand:
Today we tried to analyze the main points associated with abdominal pain. We didn’t have time to discuss a huge number of problems; we will have to meet with Alexey again. I would like to make one last point on a very important point that we just discussed. I have met a lot of patients, especially after major operations, by the way, after joint replacement, who developed bloody diarrhea during antibiotic therapy. All these patients were treated by traumatologists and orthopedists as patients with an acquired infection - with a virus, with something else, with symptoms of an infectious lesion. They were almost isolated in separate boxed wards. Also elderly patients with long-term problems, which then developed into big problems with activation and so on, with dehydration. Doctors need to be educated, doctors need to know certain points that allow them to better manage patients, otherwise there will be problems. Unfortunately, we have a lot of such problems. We will continue to educate people, we need to do something useful.
Thank you very much Alexey! I think we’ll meet again in our program, because this is a very interesting topic.
Passed away on June 12, 2018 Yakov Beniaminovich Brand- famous cardiac surgeon, head of the department of emergency coronary surgery at the Research Institute of Emergency Medicine named after. N.V. Sklifosovsky, TV presenter of the programs “Without a Prescription” and “Coma”.
As part of a team of cardiac surgeons in 1996, he performed coronary bypass surgery on the first president of Russia, Boris Yeltsin.
Yakov Brand knew how to talk with patients (he could discuss the upcoming operation with a patient for two hours), he could tell the truth to his boss in unprintable words, and in general he wanted to become an artist, but it didn’t work out, and he went to medical school.
In medicine - doubt, in life - do not give in
— What did you learn from your father as a doctor and a person?
“It seems to me that it would be correct to separate the doctor and the person here.” As a doctor, I remember well one phrase that my father once said: “A doctor must always think and doubt!” This principle still helps me a lot in medical practice. Unfortunately, our doctors usually don’t think or doubt.
Peremptory actions of doctors are the scourge of our country, which results in not very good consequences for patients.
As a person, what I respected most about my father was his integrity. It was absolutely impossible for him to compromise with his own conscience. If he thought something was wrong, he did not do it under any circumstances.
By the way, he suffered repeatedly for his integrity. For example, about fifteen years ago my father was offered to buy one medical device, writing down in the documents an amount twice as large as it cost. The father refused in a harsh manner, after which he was sent away by one of the heads of the Department of Health. His father looked at him and asked: “Is this for work or friendship? If it's for work, then I'll go. If it was out of friendship, wouldn’t you go yourself?”
Of course, he could not prevent all the evil in the world, but he considered participation in gray-black schemes absolutely unacceptable for himself. It was a taboo for him in medicine.
Surgeon and teledoctor
Jacob Brand in one of the programs. Screenshot from youtube.com
— Dr. Brand hosted television programs for many years. How realistic is it to present such a complex thing as medicine in television format? It seems that treatment is an individual action.
— It all arose quite by accident. After Boris Nikolayevich Yeltsin’s operation in 1996, the film “Yeltsin’s Heart” was made, where my father, as one of the surgeons who operated, gave an interview. The TV people really liked him as a colorful person, and when the idea of a TV show that would be hosted by a doctor arose, he was invited, and for ten years he became a TV presenter.
This combined with the life of an operating surgeon: the program ran on a weekly basis, and once a month on Sunday, four programs were filmed at once for a month in advance. So, having spent one day off a month on filming, the rest of the days my father continued to operate on a regular schedule.
I don’t think that the television format “demeans” medicine. One of the main tasks of a doctor is education, when information is conveyed to the population, the wider the better.
Now we have educational doctors who write books and host television shows. People have a lot of topics, questions, and bewilderments. And it’s good if an authoritative specialist answers them.
The process of television work itself was very close to my father. After all, at one time he really wanted to become an actor. I think this desire, to some extent, pushed him to TV.
- Why didn’t Yakov Benyaminovich go to the theater?
- He went. I came to some theater university, went to the dean of the faculty and said from the doorway: “Hello!” with a characteristic Odessa accent. The dean immediately said: “Goodbye!”
After which he had no choice but to follow in his family footsteps into medicine.
Patients want treatment and comfort in a 50/50 ratio
— Russians have an archetype of a good doctor, an aibolit, who not only heals, but who is kind. Talks to you, consoles you, invigorates you, and so on. You wrote about your father that he knew how to talk with people and considered this skill absolutely necessary for a doctor.
“I don’t know how it was at the beginning of his medical career, but in recent years long conversations with patients were the norm for my father. Those seventeen years that he headed the department of emergency cardiac surgery at the Research Institute of Emergency Medicine named after. N.V. Sklifosovsky, he could communicate with patients and their relatives for several hours. He talked about the prospects for treatment, about the possible consequences of certain medical procedures - this was completely normal for him. He then continued to communicate with many patients and became friends.
— But how to combine such communication with the current purely medical workload of a doctor?
“The fact is that my father was never an ordinary doctor, he never worked in a clinic - he did not conduct outpatient visits. This was communication regarding the specific operations of his patients.
Nowadays, Soviet medicine is often idealized - but in fact, in the Soviet years everything was the same as today - communication with the patient at an outpatient appointment was never a priority for doctors.
But serious specialists did not limit the time for such communication. If necessary, the father could communicate with patients for two or three hours. There was always someone sitting under his office who needed attention, and he found time to explain everything to the person, and simply discuss something with him.
— From your current medical practice, do you think that patients expect to be communicated with?
- All people are different. Someone needs to quickly, just get information. Someone needs to ask clarifying questions and talk to the doctor. But still, people want to get as much information as possible, so now I myself don’t hold meetings for less than one and a half to two hours.
As a rule, this time is occupied 50/50 - with information and reassurance, giving the patient some kind of comfort. My father performed quite serious operations, I can assume that his patients also needed reassurance.
The Myth of a Respected Profession
S.M. Fedotov, “Doctors” (1970s)
— You mentioned the idealization of Soviet medicine, when “doctors were more responsible and knew more.” Do you think this is nostalgia, an illusion? What then are its reasons?
— The fact is that trees are always big in childhood. The high quality of Soviet medicine is not just an illusion, it is a very harmful illusion. There really wasn't anything particularly good there. But when any system changes, there will always be people who say: “It was better before.”
Yes, there were probably more doctors then. But the doctors also received pennies. There were no normal medications. The country did not carry out high-tech operations that were already being done all over the world. Being behind the Iron Curtain, we were forced to come up with some of our own theories, which had already been tested and rejected all over the world.
By and large, we are now dismantling the legacy of Soviet times - an isolated healthcare system.
But the trouble is that nothing has yet replaced Soviet medicine.
Another huge problem: people begin to think about their health only when they get sick. This approach is now changing around the world - doctors, patients, and governments are trying to think more about prevention. For now, we only think about how to live well and beautifully, and we will deal with the disease when it comes.
“Maybe that’s why we used to respect doctors so much: a person was “suddenly” overcome by illness and there was only one hope - for the doctor as a rescuer!
— Excessive respect for doctors in Soviet times is, again, I’m afraid, a beautiful fairy tale. I think the attitude towards the doctor was not a matter of respect - it was a matter of personal necessity.
When your pipe bursts, you also run to the plumber shouting: “We will do whatever you say!” Is this a sign of respect?
True respect is shown not when something has happened, and not when it is a matter of profession or specialty. Respect should be shown for the fact that a person studies all his life, and then works very hard.
About three years ago I visited Sweden. They measure the “trust rating of a doctor.” That is, how many patients, after listening to the doctor’s recommendations, will unquestioningly follow them and will not go to another specialist for a second opinion. The trust rating of Swedish doctors is 96%. For us it’s good if it’s 4%. That's it, respect.
Is the doctor responsible for the patient's health?
—What is the ethical credo of today’s doctors? The “Hippocratic Oath” was abolished a long time ago.
— At one time at the institute, I took a so-called course in bioethics and deontology. It was, in my opinion, the fifth year, the lectures were in the evening in the most mossy auditorium of the most mossy building. At most half of the students made it to those classes, and even those during the lectures, as a rule, slept or played cards. These were the lectures.
The Russian doctor has no concept of ethics, because he was not taught this in principle.
That is, everyone knows this word, but everyone is terribly far from fulfilling it. For example, many people here have little idea of what medical confidentiality is. It is normal for us to inform the patient’s relative of his diagnosis, even the patient did not ask for this and did not give consent to it.
We will discuss the patient's condition with his relatives and colleagues. We have a huge problem with allowing relatives into intensive care, while throughout the world this is considered the norm, and it does not harm anyone, but only helps.
It’s completely normal for us to come to a doctor’s appointment with another doctor’s prescription to hear the phrase: “What idiot prescribed this to you?”
Yes, there was an oath between Soviet and Russian doctors. But by the way, when I was studying, even this oath was no longer mandatory, but voluntary. And I very much doubt that it has legal force.
In my opinion, it is much more promising to adhere to the classical principles in medicine - “do no harm”, “act in the interests of the patient”, and the same medical ethics. The doctor must give the patient the most complete information, educate, and try to do everything possible to cure him, even if the patient actively resists.
And only if the patient very actively and informedly resists (in full consciousness signs the appropriate documents refusing treatment), the doctor, respecting his free decision, should not treat him.
Most doctors in Russia act either in the interests of the medical system, or in their own interests, or in the interests of the private clinic that they represent.
At the same time, in the patient’s mind, the doctor is for some reason a unique being who has unique knowledge. In fact, doctors are also people, just like everyone else, with their own shortcomings and advantages.
Moreover, in our country, a doctor’s knowledge, as a rule, is twenty-five years out of date, and he is no longer an expert in his field. Of course, there are doctors who maintain a high level of medical literacy, work in the paradigm of evidence-based medicine and act solely in the interests of the patient, but there are catastrophically few of them - according to my estimates, no more than 5%.
A special problem in Russia is that the group of doctors 40+, which is especially significant in terms of age all over the world and is at the peak of its career, is practically absent here.
We have people from forty to fifty, those who studied in the nineties either did not go into medicine or left the profession. In addition, the quality of treatment is greatly hampered by our programs and plans to create some kind of national medicine instead of integrating into the global system.
Patients need to become partners
— What should a patient do in such conditions?
- Look for your doctor, there are no other options.
You must understand that 80 percent of exacerbations of chronic diseases go away on their own over time and do not require any medical intervention. In the same 20% of cases when intensive treatment is needed, the patient will have to largely take responsibility, delve into the specifics of his own illness, try to look for some nuances that the doctor may not know, may not be able to, or may not understand.
It's good when this happens at a therapist's appointment. Being unconscious on the operating table, a person can hardly advise the surgeon what to cut and what to sew. But you can read in advance about the methods that are used in treatment and study existing statistics.
At the same time, you need to understand: a patient cannot become a professional in his own disease; to do this, he needs to learn to filter information, and this is difficult to do even for doctors who have special education. But the patient will be able to become an accomplice in the treatment process. And this is no longer enough...
Jacob Brand. Photo: Alexey Nikolsky / RIA Novosti
Yakov Beniaminovich Brand(1955-2018) – Doctor of Medical Sciences, professor, since October 2001 he served as head of the department of emergency coronary surgery at the Research Institute of Emergency Medicine named after. N.V. Sklifosovsky.Hereditary doctor. Father Beniamin Volfovich is a surgeon, mother Anna Yakovlevna is a dermatovenerologist, sister Margarita is an infertologist and a specialist in female infertility.
He was involved in charity work and organized his own photo exhibitions in support of seriously ill children.
He was a member of the board of trustees of the Life Line Foundation, the founder of the Golden Hearts charity foundation, and also the chairman of the organizing committee of the Golden Heart Award.
On November 5, 1996, as part of a team of cardiac surgeons, he performed coronary bypass surgery on the first President of Russia, Boris Yeltsin.
In 1999-2010, he was the author and host of the television program “Without a Prescription” on the NTV channel. In 2001-2003, he was the host of the program about drug addiction “Coma” on NTV, paired with musician Sergei Galanin.
On his Facebook page about the magical thinking of people, the desire to remain forever young without doing anything, as well as the development on this basis of a new direction in medicine - anti-aging.
Since the beginning of time, man has wanted to live as long as possible while remaining young and healthy. Previously, they resorted to magical methods for this: they drank the blood of virgins, brewed an elixir of immortality, looked for the philosopher's stone or a sip of living water.
Over time, people came to understand that eternal life is impossible, but the desire to live as long as possible remained. Various magical rituals did not produce a significant effect, so science replaced magic. With the help of medicine and ecology, man has managed to more than double his life expectancy. It would seem, what else is needed? But a person is always missing something! Now he wanted not just to live long, but to live long and at the same time remain young and full of strength.
Realizing the impossibility of immortality, they sought to preserve youth. This is how legends about rejuvenating apples, the fountain of eternal youth, the humpbacked horse and other equally interesting ways of prolonging youth appeared.
The development of science seems to have put an end to the hope for a miracle cure for aging, but people are not at all so simple as to give up without a fight, because if Medicine could prolong life, why not prolong youth?
Since people, regardless of their standard of living and education, are characterized by magical thinking (yes, homeopathy, osteopathy and other magical healing methods are popular precisely because of it), as well as incredible laziness (I don’t want to do anything, I want a pill for all diseases), they with a tenacity worthy of better use, they believed in the possibility of inventing a means of preserving youth with the help of the latest achievements of science and technology. The demand for such a medicine would be simply enormous, and as you know, demand creates supply! This is how a whole direction of medicine appeared, which was called the fashionable English word anti-aging!
Over the past 20 years, anti-aging medicine has begun to aggressively gain its place in the market. The number of new “medicines” and devices for rejuvenation is incalculable, and more and more new ones appear. Vitamins and coenzymes, antioxidants and dietary supplements, hormone therapy and stem cells, placenta preparations and extracts from various parts of the body of cattle... This is not a complete list of what a person is ready to shove into himself for the sake of youth and beauty. The main thing is not to do anything, but to sit somewhere on the beach, eating a hamburger with fries, drinking a glass of whiskey and smoking 15-20 cigarettes a day. No, but what? Let the scientists worry about it. They invent something all the time, come up with something. So let them work for the benefit of our youth and beauty...
The most interesting thing is that belief in all these antioxidants and stem cells is that same magical thinking. It hasn't gone anywhere. It still forces seemingly smart and quite wealthy people to spend a lot of money on modern rejuvenating apples. Scientists have never been able to find a cure for old age. Over the past 50 years, there have been no significant studies with positive results regarding slowing down aging. No, there are certainly some successes. But, again, they concern life expectancy, and not prolongation of youth.
But the demand hasn't gone away. And where there is demand, there is supply. Those who realized in time that people are willing to pay and pay a lot for anti-aging therapy happily sell dietary supplements, oak bark extracts and other pieces of placenta to gullible ordinary people, promising eternal youth and pristine beauty.
In fact, the secret of active longevity is quite simple. You just need to not drink, not smoke, spend less time in the open sun (debatable, by the way), eat a balanced diet, regularly have sex and exercise, monitor your iron levels, blood pressure, blood sugar, cholesterol and consult a competent doctor to correct them, undergo timely screening for curable cancer diseases. All! No magic pills or miracle injections...
It would seem that it is not at all difficult, and most importantly, not at all as expensive as anti-aging medicine... But it requires effort and even, damn it, giving up some very pleasant joys of life. Whether to follow this lifestyle or not, everyone decides for themselves. But it’s time to get rid of magical thinking... The 21st century is just around the corner...
