Goodbye to Russia

Today I am leaving Moscow and returning to Chicago (Lufthansa via Frankfurt).  My hosts arranged a taxi from the hotel to the airport for about one-third of the regular price (1150 instead of 3400 rubles). I was able to communicate with the taxi driver using some basic Russian vocabulary that I learned this week, and ended up at the correct airport. Traffic was remarkably light on the Moscow roads at 4 am. Usually the roads are completely choked with bumper-to-bumper traffic and even a short trip can take 1-2 hours. Security at the airport is moderate to heavy - baggage X-rayed twice, bomb-sniffing dogs, etc).  

It has been an incredible honor to visit Endocrine Research Center as an Endocrine Society Ambassador. I learned that we have much in common with the Russians. Of course, there are many fascinating contrasts as well. I learned much from them and hope that I was able to teach them a few things in exchange. I greatly value the new friendships that I have made these past 2 weeks. I look forward to the second half of the exchange where we host our Russian friends in Chicago at Northwestern University.

Realities of life at энц and as a doctor in Russia

Endocrinologists start their day at 9 AM and work until about 5 PM. Diabetes clinic might go until 8 PM.  Surgeons come to work at 7:30 or 8 AM. Operations start at 9:30 am and 2 or 3 procedures are done in a day.  Most doctors work at multiple hospitals, including operating at multiple hospitals.

Patients are admitted 1-5 days before surgery for workup. During this time, imaging, labs, and cardiology tests are performed or repeated.

All patients get an EGD before big operations (adrenalectomy, pancreas resection, modified radical neck dissection in older patients) to screen for peptic ulcer disease. If ulcers are found the operation is delayed to treat the ulcers.  Peptic ulcer disease is still quite common in Russia.

The regular inpatient rooms consist of 4 beds with no privacy curtains. There is a sink in the room. There is a common washroom at the end of the hall.
The doctors do not perform formal team bedside rounds on a daily basis but rather on a weekly basis.

Nighttime coverage at Endocrine Research Center (энц) consists of 3 doctors, a surgeon, an internist and an anesthesiologist. There are no overnight emergency admissions or consultations at энц.  

In Russia, 95% of doctors are women. However, fewer than 10% of surgeons are women. When we give lectures here at энц greater than 95% of the audience is female.

Patients wait for hours in the hallway outside of the surgeon's office for results of their labs or biopsies, or perhaps just to speak with the surgeon. Most of these consultations are unofficial.
Signs have been created to help patients modify their behaviors towards a more healthy lifestyle.
  

There is an electronic medical record, but everything is printed also and there is a paper chart that is kept for 20+ years in storage. 

Today we were told that the Russian government announced that they will reduce salaries for federally employed physicians in Moscow by 30%. We were also told that currently physicians in Russia have salaries that are similar to elementary teachers and waitresses in Russia. Doctors can also work in private hospitals for wealthy patients where they get a fee-for-service payment structure. In private hospitals doctors make more money if they see more patients, and if the order more tests, x-rays etc. Because of this, there are an excessive number of tests ordered and procedures per patient in private hospitals.

Perioperative issues at ERC

A patient may wait for one year or more before getting approval from the government for surgery.  If there is no approval the patient can pay cash and have surgery at any time in a private hospital. 

Patients are admitted to the Endocrine Research Center 1-5 days before a planned operation. During this time the workup is finalized or repeated.  There is no patient transportation around the center, so most patients take the elevator or walk up and down the stairs to move around the hospital for testing.  We walked with a patient down 4 flights of stairs to bring her to the Ultrasound department.

Patients are taken to and from the operating room on a gurney just like in the US.

Cloth drapes and gowns are used for most operations. The surgeon washes with alcohol/chlorhexidine and dries with a sterile towel. An alcohol/chlorhexidine solution is then applied to the hands and arms and allowed to air dry. The scrub nurse hands the surgeon a gauze soaked in alcohol which is used to clean the hands a third time. The scrub nurse gowns the surgeon and ties the sleeves of the gown around the surgeon's wrists. They do not seme to care at this point if the I gloved hands come in contact with the surgeon's bare hands. After the surgeon is gloved, the gloves are cleaned with alcohol.  The patient is prepped with betadine and alcohol.

The patient's legs are wrapped with a compressive gauze to prevent deep venous thrombosis.

This is an example of a sterile pack for a thyroidectomy. 

Laparoscopic instruments are all reusable - never disposable.  Trocars are all metal - not plastic. 

Energy devices are reprocessed, re-sterilized and reused up to 20 times. Cloth drapes are used for most operations.  Paper drapes are used for patients with hepatitis or HIV, and energy devices are disposed of after operating on patients with hepatitis or HIV.  

This is an example of a device that is used for the retrieval of adrenal tumors.  It appears to be a large latex sheath.



Large single lumen drains are routinely used after laparoscopic adrenalectomy and chyle leak is commonly seen. Drains are routinely used after thyroidectomy, neck dissection and parathyroidectomy.

After a thyroidectomy the drains will be removed on the first or second postoperative day and the patient will be discharged on the third postoperative day.  The patients are all placed on levothyroxine the day after total thyroidectomy because they may not get radioiodine for up to 3 months.

First Medical University of Moscow

We are visiting the main clinical hospital of the First Moscow State Medical University.  Our host today is Valentin Fadeyev, head of the Dept of Endocrinology. The Endocrine Research Center is affiliated with First Medical Univ, and residents rotate at both institutions.

Today I gave a 90 minute lecture on the diagnosis and management of primary hyperparathyroidism in the US to residents, attendings, and medical students. Although most of the audience understood English, one of the Endocrinologists provided simultaneous translation. 

The audience was surprised to hear that calcium is part of the routine chemistry panel in the US. In Russia patients are usually diagnosed with PHPT only when symptomatic for this reason.  There continues to be much interest in parathyroid localization studies.  Despite the costs, it sounds like cinacalcet is used for patients with primary hyperparathyroidism in Russia. Patients bear the financial burden for this medication. 

New Maiden Monastery

Many famous Russians are buried here including Boris Yeltsin. 

The most famous Russian doctors of the 19th century are in this cemetery.

If you want to take pictures of them it will cost 100 rubles per picture.

Medications in Russia

Most medications do not require prescriptions and can be purchased by any adult at any pharmacy without prescription.  Many patients purchase and take endocrine drugs over the counter including levothyroxine, oral contraceptives, glucocorticoids, and androgens. The drugs that require prescriptions include anti-seizure drugs, psychotropics, narcotics, and most benzodiazepines.  Drugs that are considered "life-saving" are usually free of charge in government pharmacies, such as regular insulin for diabetics, basic anti-hypertensives, and glucocorticoids for adrenal insufficiency. Most medications are paid for by the patient and not reimbursed by the government.  Exceptions are chemotherapy, IV fluids, anesthetics. 

"Apothecary"

Families will bring things to inpatients that they might need such as medications. The doctors might even buy medications for their patients who are in distress. I heard stories of doctors leaving the hospital to find and purchase IV calcium and IV dextrose for their patients with acute severe hypocalcemia or hypoglycemia.

FNA biopsy clinic

FNA biopsy of the thyroid at Endocrine Research Center

These patients are waiting for a fine-needle aspiration biopsy.

This is the performance of an FNA biopsy at ERC.  The radiologist holds the ultrasound probe and the surgeon performs the biopsy.  The surgeon prepares the slides.  Only air dried slides are prepared (for Romanowsky stain).  On-site adequacy is not performed. This is very high volume, high throughput clinic.  Only a few moments are required with each patient.

The first journal club at Endocrine Research Center (энц)

Max has given the first Journal Club talk ever at Endocrine Research Center. Journal Club is not a standard part of residency training here. He reviewed an article by Yeh et al, Incidence and prevalence of primary hyperparathyroidism in a racially mixed population. J Clin Endocrinol Metab. 2013 Mar;98(3):1122-9. 18 trainees attended the meeting. Max translated the slides into Russian. Our Russian friends tell us that Google Translate improperly translated "men and women" into "mankind and girls".  For example "46% of the population was mankind and 54% were girls".  Below are some of the slides with the translations.

Tips for visitors to Russia, and some of my favorite conversations

These are transcriptions of real conversations that I have had with people in Russia this week.

1. "Do not take pictures at the palace or the old women who guard each room will beat you with a fan and tell you to stop taking pictures."

2. "If a police officer points at you while you are driving, you are to pull over immediately and show him your papers (proof of insurance, registration, and drivers license). If your papers are somehow not acceptable, he may remove the license plates from your car, which you must retrieve from the police station after paying a fine. If you want to bribe the officer you say "is there something that can be done?" If there are no cameras recording the event, they will usually accept a bribe of between 100-1000 Rubles. A bargaining session determines the amount of the bribe."

3. Read with a Russian accent: "If I operate on this person without positive biopsy they will send me to Collective Farm for one year.  Do you have this Collective Farm in America, yes?   OK, this is joke.  I will not go to collective farm because I will tell them that Dr. Sturgeon told me to operate."

4. Conversation with tour guide:
--- "Have you heard of this man who was poisoned, shot 4 times, beaten, rolled up in a curtain, and then thrown in the river to drown?  That is how we treat our enemies."
     --- "You mean Rasputin?  You're talking about Rasputin, right?"
--- "Oh, you know this man?"
     --- "No, I don't know him.  He is not my friend."

5. "Never dip bread into soup- very bad manners. Never in my life have I see this."

6. In central Moscow, parking is strictly regulated with a 3000 ruble fine for illegal parking.  Everywhere else in Moscow you park wherever you can. Everyone parks on the sidewalks.

7. Never give an even number of flowers to somebody. This is very bad luck. An even number of flowers are only used in funerals. 

8. Never shake hands or give something to a Russian  across a doorway. It is considered bad luck.

Uniquely Russian

Russian delicacy: Crucian Carp. The live fish swims in milk all day at the restaurant. At the end of the day you take your cup, and dip it in, and drink the milk. We were not brave enough to try this.

Our hosts tell us to beware of pickpockets everywhere, especially at museums and in crowds.  Never put your wallet in your front or back pants pockets. Inside coat pocket is better, but also not completely safe. In case you cannot remember their advice, signs remind you of this danger. 

Borsch is the traditional soup of Russia.  First the carrot and onion are sautéed in butter, then add cabbage and potato. At the end, beets are added to give it the red color. The base is chicken bouillon. Herbs, especially dill and onion, are used as garnish. Some borsch is vegetarian, and some contain beef or chicken.

Russian dining.  Breakfast is large and eaten between 8 and 10 am. Porridge, sausages, cold fish, and cheese are common breakfast items. Milk is usually served warm. Some breakfasts may be 3 courses.  Lunch is eaten between 2 and 3 PM and is called "dinner".  Soup is the most common dinner item.  Russian pies can be savory or sweet and may be eaten as an additional meal between breakfast and dinner (photo below) called "lunch". Bread is commonly served at breakfast lunch and dinner, but never with butter.  Supper is served between 8 and 10 pm and is usually one course consisting of either fish or meat.