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UI project brings new family medicine clinic to Russia

IOWA CITY, Iowa -- More than a year after launching a collaborative project with Russian physicians, University of Iowa faculty members have seen the results of their work -- a new Russian clinic that they hope will be a model for American-style family practice medicine.

Drs. Elizabeth Swanson and Gerald Jogerst, principal investigators for the project, and Gayle Nelson, nurse manager, visited the clinic in October 1996. In early 1995, they and colleagues from the UI and the St. Petersburg Medical Academy of Post-Graduate Studies (MAPS) in Russia initiated an effort to teach Russian physicians the principles of family practice and to establish a clinic to serve patients and prepare new generations of family doctors. The project is funded by the U.S. Agency for International Development.

"It is rewarding to see the people we've taught actually putting into practice what they've been trained to do," says Jogerst, assistant professor of family practice at the UI College of Medicine. "That includes seeing patients in the clinic as well as teaching their first class of interns in family medicine."

Five Russian doctors spent six months in the United States being trained by counterparts at the UI and in community clinics across Iowa. They returned home having learned a type of medicine much different than prevailing Russian models.

"The Russian polyclinic system has a large number of specialists, and patients move from doctor to doctor within clinics that resemble mini-hospitals," explains Swanson, associate vice president for health professions education at the UI. Family medicine can help provide a less expensive and more efficient approach by training doctors to diagnose and treat a range of relatively common health problems.

"The family physician can fill in to provide 90 percent of the care needed by the general patient population," Jogerst says. When necessary, family physicians can refer patients to hospitals or polyclinics, much like in the United States.

Establishing a model family practice clinic required educating staff and patients about a new style of medicine. In training the clinic's nurses, Nelson helped teach them to take a more active role in patient care.

"Some of these women left stable positions to take a shot at this new idea," she says. "Russian nurses are truly the handmaidens of the physicians and don't have much independent decision-making capabilities. We worked with them and the physicians to promote a team concept."

Though the clinic had only been open 10 days when the UI visitors arrived, it was already busy treating patients, many of whom seemed to realize that they were receiving a different kind of care.

"One of the interns studying with the physicians we trained brought her own child to the clinic because she wanted the child to receive that level of care," Swanson says. Physicians who treat both children and adults are rare in the specialized Russian system, so the idea of a clinic serving whole families is another departure from the Russian norm.

Models of family medicine are spreading in Russia, although they often adopt many of the practices and expectations common to their culture. For example, clinic staff treat about half of their patients in "house calls" to nearby apartment buildings. Standard Russian medicine also incorporates many treatments considered alternative in the United States, including massage and herbal therapies.

"We really encourage them not to abandon their whole way of practice," Nelson says. "We hope that they will take the best of both ways and come up with a high-quality system accepted by patients and physicians."

The MAPS clinic and Russian family medicine in general could face a challenging future in an changing environment with scarce resources. Health care financing is a complex blend of state stipends and subsidies, private insurance, and fee-for-service care. Success may depend as much on business acumen as quality of care.

"I think the entrepreneurial spirit is going to help," Nelson says. "Those who establish new types of clinics will have to learn how to do business as well as practice good medicine." She adds that the Russian physicians learned marketing strategies as part of their training.

Jogerst notes, however, that many of the dilemmas confronting Russian health care are not unfamiliar. "Their problems may be larger in certain areas, but we have the same problems. Maybe we can learn to apply some of their solutions," he says.

Indeed, the project has underscored similarities much more than differences for its investigators. "All three of us grew up in the Sputnik era with a distrust of Russia. Through this, we've learned that the Russian people are very hard-working, gracious and committed," Swanson says.

Swanson, Jogerst and Nelson will return to Russia in March to conduct a family medicine conference with MAPS faculty and complete the project. Through their visits and regular e-mail communication with Russian colleagues, they have found friends as well as business partners. "This has been a life-changing experience in its depth of friendship and the chance to work in a different cultural environment," Nelson says.