Physician

PHYSICIAN, a term in its modern application denoting a person who has completed higher medical education. History. The designation of P. is found in the oldest Russian documents. Thus, for example, in the statute of Prince Vladimir, dating from 996, the words are found: "...monasteries and their baths, hospitals and their physicians." In the statute of Yaroslav, issued in 1016, almost the same expressions are repeated: "...monasteries and their baths and their physicians, hospitals and their physicians." In the ancient Russian chronicle (Nikonovskiy list, 1091) it is mentioned: "...and construction of bathhouses, and physicians, and hospitals for all who come to receive treatment free of charge." The designation of P. in these documents was assigned to persons who provided medical assistance at charitable institutions, "almshouses," usually located at monasteries. These "almshouses" were managed by clerks, stewards, bailiffs, and most often by the clergy—priests, who according to the Hundred Chapter Council were obligated to be "healers" and "physicians" and at the same time "to instruct and reprimand in fear of God." In Muscovite Russia, foreign physicians ("doctors, healers") began to appear. At the beginning of the 17th century, the Apothecary Order was established, under whose supervision the activities of foreign physicians were transferred. The first attempts to regulate physician activity also date to this time. By the end of the 17th century, P. faced the death penalty or exile to Siberia for poor treatment. In the 17th century, the first Russian students of foreign healers also appeared. The beginning of systematic medical education and regular medical legislation was laid in the 18th century. By decree of Peter I, in 1706, the first "surgical school" was opened at the Moscow "military hospital," and soon after, a second such school in Petersburg. Peter's decrees regulated medical activity in considerable detail, down to the personal conduct of P.: "So that a doctor in his practice has a good foundation and practice, he should maintain himself sober, moderate, and willing, and in necessary cases be able to perform his duty both at night and during the day" (Military Statute). Despite the fact that there were almost no P. who had received even elementary training, the decree of 1729 prescribed: "To strictly ensure that wandering and uneducated persons in the healing arts do not dare to treat the people, and especially the lower classes, under severe penalty and punishment." Pharmacies were ordered: "...to not release ointments and plasters without prescriptions, and internal medicines without proper doctor's and pharmacist's prescriptions." Along with this, "regimental physicians" were ordered "to shave the beards of colonels, lieutenant colonels, and majors and to arrange their wigs." Legislation regulating medical activity developed extremely slowly; it is sufficient to note that the Decree of 1789 "to all doctors, healers, and midwives" in some of its parts was considered valid until the 1917 revolution (See also History of Medicine and Military-Sanitary Affairs). Rights and obligations of P. According to Soviet legislation, the right to the medical title and work are held by: a) P. who have graduated from higher medical educational institutions in the USSR and received from them diplomas conferring the title of physician, and b) physicians who have graduated from foreign universities, received from them diplomas conferring the title of Doctor of Medicine, and passed the appropriate examination at one of the higher medical schools of the USSR. An exception to the latter rule is permitted in relation to those physicians who graduated abroad and who have scientific or practical experience. The latter are admitted to professional work without passing state examinations with the permission of the People's Commissariat of Health and the People's Commissariat of Education. Qualification of P. (medical diploma) is conferred in the RSFSR, ZSFSR (Georgia, Armenia, Azerbaijan), Uzbekistan and Turkmenistan to persons who have passed 10 semesters of medical university and passed state examinations; in the Ukrainian SSR and Byelorussian SSR, to obtain the title of P., it is mandatory to complete a year of practical internship after graduating from medical university and to submit a diploma paper (Ukrainian SSR). Each physician wishing to engage in professional work must register with the health department at their place of residence and receive a registration certificate. Registration is carried out by the health department on the basis of documents confirming the right of this person to the medical title. In the absence of documents or their questionable nature, the health department may set a period (in the RSFSR-6 months) for the medical worker to provide indisputable documents and may permit professional work for this period. If it is impossible to document the right of this person to the medical title, this person, upon providing references about previous work, may be admitted to state examinations and in this case restores the title by receiving a diploma from a medical university. P. who have not worked in the profession for more than five years, if they have a diploma, are admitted to professional work only after completing a probationary internship at clinics or large medical-sanitary institutions for a period of 1 to 6 months, depending on the length of the break and previous work experience. Health departments are granted the right, in case of discovering clearly insufficient knowledge in a physician, to oblige the latter to complete a probationary internship at a medical-sanitary institution for up to 1 year, and in these cases the registration certificate previously issued to the physician may be revoked by the health department in agreement with the Medsantrud trade union. Physicians registered with health departments are granted all rights with respect to medical practice and holding medical and administrative-medical positions. P. engaged in private practice are required to keep records of patients in special books, stitched and sealed by the health department. These books must be presented by P. upon the request of the health department, judicial or investigative authorities. In the books, in addition to general information about the patient (anamnesis, status, diagnosis), all prescription data, performed operations and certificates issued by P. are also noted. Physicians issue certificates about health status, birth, vaccination, death, and received bodily injuries. The procedure for issuance, in other cases and the form of certificates are regulated by special orders of health authorities. Each physician is obligated to notify the nearest health department within 24 hours of each case of acute infectious disease, poisoning, murder, infliction of serious bodily injury or suicide encountered in their practice. Mandatory notification also applies to cases of professional poisonings and most important professional diseases (no later than a week, and in case of mass poisoning-immediately). Each P., regardless of whether they are on service or are in private practice, may be summoned to examine persons called up to the Red Army and to conduct forensic medical examinations. Likewise, each P. engaged in practical medical activity is obligated to provide emergency medical assistance in cases requiring it. According to the Instruction of the NKZ, NKVD and NKT of the RSFSR and VTsSPS of March 11, 1926, cases requiring the provision of first emergency aid include severe traumatic injuries, poisonings, and sudden diseases threatening danger to life. In case of refusal to provide assistance, P. may be held criminally liable under Article 157 of the Criminal Code of the RSFSR, punishable by imprisonment for up to one year or a fine of up to one thousand rubles. The right of P. to perform operations is also regulated by law. Operations as a rule can only be performed by P. and only in medical institutions, with the exception of cases of emergency and urgent assistance and simplest operations, according to a special list issued by the NKZdr. Such operations include punctures, intravenous administration of medicinal substances, opening of abscesses, phlegmons, removal of easily accessible, superficially located skin and mucous membrane tumors, etc. Any surgical intervention can be performed by P. only with the consent of the patient, and with respect to persons under 16 years of age or mentally ill persons—with the consent of parents or guardian. Exception is permitted only in cases of urgent but necessary operations to save life or an important organ, if the patient is unconscious, or with respect to children and mentally ill persons when parents cannot be questioned without risk of delay. In these cases, the physician must decide on the necessity of the operation after consultation with another physician, and if this consultation involves a risk of delay, the decision on the necessity of the operation is left to the physician with notification of any such case to the health department within 24 hours. In addition to the general norms regulating the professional activity of all P., separate instructions and provisions provide for the rights and obligations of separate categories of P. both by the criterion of specialty (sanitary P., forensic medical experts, P.-social inspectors, inspectors of mother and child protection, etc.), and by the criterion of position held (chief physician, head of department, prosector, ordinators, etc.). In view of the specific working conditions, it is necessary to dwell on the rules regulating the work of the district P. (Instruction of NKZ, NKY. NKT of the RSFSR and VTsSPS of March 11, 1926)! The P. in charge of a district is the responsible person for the district, and all the personnel of the district are subordinate to him.

The Physician is the administrator of credits allocated for the maintenance of the district. In terms of providing medical care to the population, the Physician is obligated to conduct daily outpatient consultations, excluding weekends and holidays, with the consultation time not exceeding 5 hours for a physician not managing a hospital and 4 hours if, in addition to the outpatient clinic, the Physician also has hospital beds. The hours for patient registration and consultation are determined by agreement between the head Physician and the district executive committee. Patient admission and discharge are at the discretion of the head Physician; if the hospital has several departments for different specialties, patient admission and discharge are conducted by the head of the department. The district Physician is obligated to make house calls to provide assistance to patients only in cases requiring emergency intervention when the patient cannot be transported to a medical institution without danger to life or obvious harm to health. Such cases include: a) pathological births, b) poisonings, c) life-threatening hemorrhages, d) severe injuries, e) occurrence of epidemic diseases. When called to provide assistance at home, the Physician must be provided with transportation. Forensic medical examinations and autopsies must be conducted by the district Physician only in the absence of a forensic medical expert, with the day and hour of the forensic medical examination being determined by agreement between the investigative authorities and the Physician. For each house call for a forensic medical examination, the district Physician must receive the established remuneration. Number of physicians and their distribution. By the end of 1913, there were 24,031 civilian physicians on the territory of the Russian Empire, including 21,709 (90.3%) men and 2,322 (9.7%) women. Of the total number of physicians, 71% lived in cities and 29% in non-urban settlements. When calculated for the territory now occupied by the USSR, this number should be reduced due to the reduction in territory (provinces of former Poland, Baltic territories, etc.). In 1914, there were 18,320 physicians on the territory without these provinces. After 1917, the number of physicians begins to grow rapidly due to the significant increase in admission standards to medical universities, caused by the acute need for physicians, and the opening of a number of new higher medical schools (Moscow, Smolensk, Krasnodar, Simferopol, Omsk, Nizhny Novgorod, Samara, Dnepropetrovsk). In 1928, there were already 57,500 physicians in the USSR, of which 42,500 were in the RSFSR and 10,700 in the Ukrainian SSR. The gender composition has changed significantly. The percentage of women physicians increases each year and reaches 38. According to 1926 data, for the RSFSR, 74% lived in cities, 21.3% in rural areas, and 4.7% were not precisely specified. Thus, in percentage terms, the gap between urban and rural areas has widened even further. However, this discrepancy does not indicate a deterioration in the provision of medical care to the rural population and is explained mainly by the rapid growth of specialized types of medical-sanitary assistance in cities. According to the report of the Chief Medical Inspector for 1913, there was one physician (calculated for the entire population) per 6,900 inhabitants, in cities per 1,400 inhabitants, and in rural areas per 20,300. If we take for comparison the data for the RSFSR "73 For 1926 and consider only those serving in health care institutions, we have 4,037 people of population per one physician. In cities in 1926 in the RSFSR, there were 829 people per physician in the European part of the RSFSR and 2,409 in the Asian part; in rural areas, 11,131 and 35,516 respectively. The distribution is also extremely uneven between individual districts. According to health department data for 1928, the average coefficient of provision of the population with medical care was 2.8 per 10,000 population. The best-provided districts are Crimea (8.7), Leningrad Oblast (7.2), Central Black Earth Oblast (5.0), and North Caucasus (3.7) per 10,000. Below average are the districts: Vyatka (1.3), Central Black Earth Oblast (1.6), Siberian Krai (1.6), Middle Volga (1.9). In last place are Kazakhstan (0.7) and Kirgizia (0.8). In terms of the number of physicians, the USSR occupies one of the first places among other countries, as can be seen from the following table provided by Deichman ("Preventive Medicine", 1926, X, 7-8): Table 1. Countries Number of physicians U.S.A.............'.

» 980

o 1,500

» 1,600

» 2,000

» 2,200

» 3,200

» 4,100

» 4,700

» With the overall, quite sufficient for saturating the network, number of Physicians, their uneven distribution leads to the fact that, despite a significant number of unemployed Physicians in large university centers (Moscow, Leningrad, Kharkov, Rostov-on-Don), on the periphery, especially in the rural network and in national republics and regions, there is a large number of unfilled medical vacancies. Furthermore, even in cities, there are significant difficulties in filling positions with specialist Physicians due to their shortage, caused by the rapid growth of specialized institutions. The need for qualified specialists in some fields (otorhinolaryngologists, radiologists, prosectors, etc.) is not met even in large centers, which leads to significant development of concurrent employment. Measures aimed at the proper provision of the medical-sanitary network with Physicians can be divided into the following main categories: a) measures for conducting internships, advanced training of Physicians, and planned training of specialists; b) measures for the compulsory direction to the periphery of 'state-obligated' Physicians—state scholarship holders in medical universities, interns, clinical ordinators, and interns who received support (scholarships) from the state or local authorities during their studies, internship, or specialization; c) measures for establishing benefits for various categories of Physicians. Measures of the first type aim to prepare workers in those areas of practical work where there is an especially acute need. This goal is primarily served by the internship institute for young Physicians. During a one-year internship, in conditions as close as possible to those in which the young Physician will have to work in the future, he acquires practical skills that the school did not provide him with; training of specialists is carried out through one-year internships (Physicians of Okhmatdet, Health Departments, sanitary Physicians, venereologists for rural venereal points and venereal detachments, etc.), through clinical ordinature and three-year postgraduate studies. The widely developed network of advanced training courses in recent years has enabled a significant number of Physicians (more than 4,000 in the RSFSR alone) to improve their qualifications. Measures of the second category consist of a series of laws obliging Physicians who received state scholarships to work in the designated area by the People's Commissariat of Health or its local authorities. This obligation applies to state scholarship students who, upon graduation, are directed by health authorities to serve compulsorily, to regular clinical ordinators, Physicians who have completed a paid internship, and interns who have completed a three-year specialization with a scholarship. The term of service for a scholarship is set at one year for each year of scholarship received, but in the RSFSR it cannot exceed three years in total. State scholarship holders who evade compulsory service or are exempted from it for any reason are obliged to reimburse the state not only the scholarship they received but also the average cost of training in a medical university for the entire period they received the scholarship. The third group of measures—benefits provided to certain categories of Physicians—aims to create an incentive for filling those medical positions where working conditions are particularly difficult. These include medical positions on the outskirts, positions of rural district and sanitary Physicians, forensic medical experts, psychiatrists, and workers in epidemic organizations. The law establishes for the aforementioned categories of Physicians a number of benefits, which mainly boil down to the following. For workers being sent (even at their personal request) to serve in remote areas, if the distance between their original place of residence and the new workplace exceeds 1,000 km by railway or 500 km by other means of communication, the following benefits are established (resolution of the CEC and Sovnarkom of the USSR of May 11, 1927): moving expenses are paid of not less than one month's salary (but not more than double) for the person being sent and not less than one-quarter of the salary for each family member, and daily allowances for the duration of the journey. Upon dismissal of workers, the cost of return travel is paid. While serving in the first zone of remote areas, workers receive a percentage supplement to their salary of 10% after each year, and in the second zone, supplements are given for every three years of work until reaching 100% of the salary. For every 3 years of work in the first zone and 5 years in the second, a three-month additional leave is provided; after 5 years of work, a scientific business trip is granted for a period of up to 6 months; children of workers sent to remote areas enjoy the right to enroll in educational institutions on the same terms as manual workers. For medical workers being sent to the periphery and rural areas, the following benefits are established: payment of moving expenses in the amount of one month's salary and 1/4 of the salary for each family member; payment of travel and baggage, daily allowances for the duration of the journey and additionally for 6 days. For Physicians sent to the periphery, the right to residential space in their former place of residence is preserved for 6 months; Physicians working in rural areas are granted a one-month leave with the right to accumulate leave for 3 years (resolution of the CEC and Sovnarkom of the RSFSR of July 9, 1928). For district Physicians, sanitary Physicians serving the rural population, Physicians of psychiatric institutions, forensic medical experts, and Physicians of anti-plague organizations, three periodic supplements to the salary are established for every three years of service in the amount of 20% of the salary (for Physicians of anti-plague organizations—30%), favorable conditions for children's admission to educational institutions, free education in them, and preferential right to scholarships on par with workers; scientific business trips every 5 years with preservation of salary and issuance of scholarships. District Physicians and Physicians of psychiatric treatment institutions are provided with free apartments with heating and lighting. Physicians sent to combat epidemics are paid daily allowances at an increased rate. Physicians who have lost their ability to work due to contracting infectious diseases, or the families of Physicians who died from infectious diseases, are paid an increased pension in the manner and amount established for persons who lost their ability to work or died due to industrial injuries. In case of death or disability resulting from infection during work on plague, Physicians or their families are assigned a personal pension as persons having exceptional services to the republic. Military Physician, see Military-sanitary affairs. Sanitary Physician, see Sanitary physician. Choice of medical profession, see Professional selection. Qualification and advanced training of physicians, see Medical education. Detrimental aspects of medical professions, see Medical personnel. Professional organization of physicians, see Medsantrud.

Physicians as carriers of infectious diseases. With the observance of necessary precautionary measures, physicians, as a rule, should not be carriers of infectious diseases. These measures are reduced to the following: firstly, a physician should not have contact with other patients if he himself feels unwell. In life, there is usually no case where a physician, knowingly ill with some infectious disease, comes into contact with his patients, but on the other hand, the possibility is not excluded that he, having an elevated temperature caused by influenza, mild tonsillitis, or another as yet undetermined disease, goes to perform his professional work. This should not take place. The pathogens of both influenza and tonsillitis can be transmitted to other persons via droplet infection (talking, coughing, sneezing). Very often, a minor tonsillitis is caused by the diphtheria bacillus, and the physician, until the true nature of his illness is clarified, will in this case spread diphtheria pathogens. The same applies to scarlet fever. Not infrequently, scarlet fever produces relatively late rashes or proceeds entirely without a rash, and only an affection of the throat is its initial symptom. Naturally, in this case, a physician who does not pay attention to his malaise and inflammatory phenomena in the throat may become a carrier of the scarlet fever disease. This is illustrated by a precisely established fact described in the literature regarding the development of a scarlet fever epidemic in the village of Lommedalen, near Christiania, caused by the fact that one young woman, who was caring for a scarlet fever patient and had herself fallen ill in Christiania with a mild tonsillitis, upon arriving in Lommedalen, infected not only her own household with scarlet fever there, but subsequently a number of other families in the village as well. Physicians working for the first time in scarlet fever wards, even if they had scarlet fever in childhood, very often fall ill with tonsillitis. Such tonsillitis must be considered dangerous for those around them. In view of all this, a physician who has any kind of throat affection has no right to perform his professional work. If there are as yet no precisely established facts of the transmission of scarlet fever, measles, rubella, whooping cough, mumps, smallpox, and chickenpox through third healthy persons, then no one denies the possibility of mechanical transmission of the infectious agent of these diseases through the carrying of contaminated objects or contaminated clothing. Therefore, it is clear that a physician should not, in the same suit, without a gown, touch diverse patients, i.e., move in his clothing from a measles patient to a scarlet fever patient, then to a therapeutic patient, a diphtheria patient, or, finally, to healthy people, etc. General hygienic measures (washing hands, face, and disinfecting one's instruments, etc.) must be observed especially carefully each time. It is known that perfectly healthy people can be carriers of diphtheria bacilli. Therefore, a physician working in diphtheria wards is obliged to periodically check the flora of his mouth and nose through bacteriological examination. In the case of detecting virulent diphtheria bacilli in himself, he is obliged to refrain from contact with other patients for the duration of this carriage. Transmission of an intestinal infection by a physician to anyone is usually not encountered. The pathogens of cholera, typhoid fever, paratyphoid, and dysentery are found, mainly, in the excretions of the patient, and therefore the application by a physician dealing with such patients of ordinary hygienic measures and the protection of his clothing and footwear from contamination are sufficient to avoid mechanically introducing the infectious agent to other persons. Diseases transmitted through the blood by parasitic means, such as typhus and relapsing fever, a physician can transmit to others by carrying infected parasites (lice) on himself from a patient to a healthy person. Such facts could have taken place during the typhus pandemic that occurred here during the Civil War period, given the extreme lousiness of the population. Under normal conditions, this is not observed. Transmission of erysipelas, anthrax, and other infections is possible only by mechanical means during a gross violation of hygienic rules (contamination of hands, instruments, etc., with infectious material).

D. Galtsov. The physician as a cause of disease. In recent years, a number of major studies have appeared that have strongly advanced the old question of the influence of the psyche on various physiological and pathological processes in the human organism. A collective work edited by Oswald Schwarz provided a monographic treatment of everything known about the psychogenesis of various symptoms from the cardiovascular apparatus, respiratory organs, digestive, sexual, and a whole series of other functions. In the named work, the studies of Schilder, Bauer, Braun, Heyer, Straudberg, and Mayer received detailed coverage, finally clarifying that the cerebral cortex, by the mechanism of conditioned reflexes, exerts an unexpectedly strong influence on the most distant regions of the body. Thereby, various examples of suggestion and autosuggestion, the influence of affects, psychic traumas, etc., received full interpretation and explanation. In connection with this, and in accordance with the continuously growing interest in the methodology of the psychic treatment of neuroses (hypnosis, rationalistic psychotherapy, Freud's psychoanalysis, Adler's individual psychology, occupational therapy), the question naturally arose about the possibility of completely involuntary negative psychotherapy, expressed in the fact that the physician often acts depressingly on the patient, traumatizes him, deepening existing disorders and even causing new ones. Over the course of a number of years following the Imperialist War, some German psychiatrists—Kretschmer, Gruhle, Bumke—quite independently of one another, began to speak about iatrogenic diseases, pointing out how often careless remarks by a physician, hopeless diagnoses, unnecessary explanations on the topic of heredity, etc., cause in patients a state of anxious expectation and prolonged worry, as a result of which the tone of the tissues is lowered and a disorder of functions appears. This is especially felt in individuals with increased suggestibility. In the very recent past, this question has served as the topic of works by several Russian authors—internists, gynecologists, psychiatrists. In these works, examples are cited of reactive-depressive states caused by diagnoses: "myocarditis," "arteriosclerosis," "small heart," "aortic dilation," "angina pectoris," and even "uterine retroflexion," "chronic catarrh of the uterus," etc. Of the psychiatric diagnoses, psychasthenia often has a depressing effect, with its first syllable "psych," which in the eyes of the patient is an irrefutable indication of a mental illness—psychosis; in some cases, "schizophrenia" caused a deep affect of melancholy and despair, "cerebrasthenia" instilled the thought of a weakening of the brain, "degenerative hysteria" forced one to give up and abandon successfully started treatment, "cerebral sclerosis" sharply lowered previously satisfactory working capacity (Kannabikh). These terms act especially strongly when the patient sees them on forms with an official seal. It must be thought that, just as certificates stating that a patient has cancer or an initial form of progressive paralysis are not given to the patient, so too should certificates not be issued regarding schizophrenia and many other incurable conditions, especially in those cases where the disease is only slightly indicated and fully compensated, thanks to the preservation of general vital tone. Iatrogenic lowering of this tone can cause decompensation not only in nervous diseases but also in many other diseases.