Antibiotics (Properties, Application, Interactions) - M.P. Cherenko 1999

Organization of surgical care in Ukraine. Training of surgical personnel

Organization of surgical Care

The provision of medical care, including surgical care, to citizens of Ukraine is grounded in their constitutionally guaranteed right to free state-sponsored medical care across all modalities (Article 49 of the Constitution of Ukraine). Surgical care is one of the most widespread forms of medical assistance. This high demand is driven, on the one hand, by the high prevalence of surgical diseases, congenital and acquired malformations, and injuries both in our country and globally in all industrialized nations, and on the other hand, by the vast advancements in surgery achieved since World War II in treating various pathologies, correcting malformations, and even replacing functionally compromised Organs (via organ transplantation and xenoprosthetics).

The massive scale of surgical care is evidenced by the hundreds of thousands of operations performed annually in Ukraine for diseases and injuries across various organs.

The foundation of the modern system of surgical care organization in Ukraine is still largely inherited from the former USSR. This care was structured according to a territorial principle and a tiered delivery model, featuring subordination from lower to higher tiers. This framework aims to bring general and surgical medical care as close as possible to the patient's place of residence, supported by appropriate, primarily territorial, medical institutions.

Ascending in scope, the organization of surgical care encompasses primary medical care, qualified surgical care, and specialized surgical care. Surgical care is subdivided into emergency (or urgent) care, required by patients with acute conditions and injuries, and elective care, provided to patients with chronic disorders.

Primary emergency medical care for patients with acute surgical conditions and injuries is provided in outpatient clinics, feldsher-midwife stations, and rural district hospitals in rural areas, and by outpatient surgeons, trauma centers, and predominantly specialized ambulance teams in cities and equivalent populated areas. For patients with minor acute injuries that do not require surgical intervention (or where Procedures can be successfully performed by practitioners at these initial stages) and those with acute conditions not requiring hospitalization, the primary care provided at this level is effectively qualified care, which concludes the Treatment pathway. The Role of primary medical care for surgical patients with acute conditions and injuries in rural outpatient clinics and district hospitals—as well as in urban polyclinics when a patient requires care exceeding the scope and duties of a general outpatient surgeon—consists of examining the patient using available resources (including those of the polyclinic surgeon) to establish a tentative or, at times, definitive Diagnosis, and referring the patient to the surgical department of a district or central district hospital, along with determining the appropriate mode of transport. In most cases, patients are transported by an ambulance team or the receiving district hospital's own ambulance. Less frequently, air transport (a helicopter or even an airplane) may be called upon if the patient's life is in imminent danger. Patients from urban polyclinic surgical offices are referred to the respective surgical departments of district or municipal hospitals, either via ambulance dispatch for acute internal organ diseases, or (infrequently) using public or private transport in cases of mild acute conditions and injuries.

In polyclinics across cities and towns equipped with surgical offices and departments, qualified surgical care is provided to patients with minor superficial injuries and straightforward acute conditions (such as small soft tissue wounds, localized Burns, furuncles, abscesses, and subcutaneous whitlow).

Qualified emergency and elective surgical care for the most common acute abdominal conditions (such as acute appendicitis, incarcerated hernia, acute cholecystitis, perforated gastric and duodenal ulcer, gastrointestinal bleeding, pancreatitis, and acute intestinal obstruction), abdominal injuries, soft tissue trauma, purulent processes, as well as chronic conditions of the Abdominal cavity AND certain other organs, is provided in general surgery departments of central district, municipal, and regional hospitals, and occasionally in district hospitals equipped with surgical departments and adequate facilities (highly skilled surgeons, advanced laboratory and instrumental diagnostic tools, and anesthetic support). In large cities, particularly regional centers, alongside district and municipal hospitals that provide qualified surgical care to urban residents, such care is also delivered by regional hospitals to patients referred from the district hospitals of the respective region.

The rapid advancement of surgery over the past half-century—which has left no organ in The Human Body inaccessible to a surgeon's hands and scalpel—has made it virtually impossible for a single surgeon to master the entire arsenal of modern diagnostic tools for surgical diseases and the complex techniques required for operations across all organs and anatomical regions.

This has necessitated the differentiation and division of surgery (alongside other broad medical fields) into distinct disciplines and subspecialties. Consequently, surgeon specialization in specific branches of surgery was initiated, leading to the establishment of specialized surgical institutions that provide specialized surgical care.

Thus, traumatology and orthopedics, oncology, urology, and neurosurgery branched off from general surgery long ago to become independent disciplines. Ophthalmology, otorhinolaryngology, and dentistry became independent fields even earlier. In the post-war period, surgery underwent further, deeper differentiation. Pulmonary and bronchial surgery, esophageal surgery, cardiac surgery, vascular surgery, proctology (colorectal surgery), gastroenterology, and surgical endocrinology emerged as separate disciplines. This process of surgical differentiation continues today. For instance, herniology and other specialized clinical departments already exist. Practically all regional and large municipal hospitals feature surgical departments covering major surgical subspecialties (thoracic, neurosurgical, surgical gastroenterology, maxillofacial, otorhinolaryngological, ophthalmological, burn care, vascular, or even cardiovascular, etc.), providing specialized surgical care to both rural and urban residents.

A major role in delivering qualified and specialized care to the population is played by the surgical clinics of medical universities and academies in Ukraine, which operate on the bases of general surgery departments in municipal and regional hospitals within university cities. Highly qualified teams of surgeon-educators (professors, associate professors, assistants) deliver a high volume of specialized care for various pathologies. Many of these clinics serve as municipal centers for specialized surgical care (encompassing hepatobiliary and pancreatic surgery; gastric and intestinal surgery; surgical management of hemorrhages; pulmonary surgery; endocrine surgery; colorectal surgery; esophageal surgery, etc.).

Specialized care is provided to citizens of Ukraine regardless of their place of residence by surgical research institutes, which function as scientific-methodological and organizational centers for the development and Structure/175.html">Implementation of advanced diagnostic, therapeutic, and preventive Methods for diseases and injuries of specific systems, organs, or anatomical regions. These include the Kyiv Research Institute of Experimental and Clinical Surgery of the AMS of Ukraine, the Kharkiv Research Institute of General and Emergency Surgery of the MoH of Ukraine, the Romodanov Kyiv Neurosurgical Research Institute of the AMS of Ukraine, the Kyiv Research Institute of Cardiac Surgery of the AMS of Ukraine, the Kyiv Research Institute of Otorhinolaryngology, the Kyiv Research Institute of Endocrinology and METABOLISM of the AMS of Ukraine, the Filatov Institute of Eye Diseases and Tissue Therapy in Odesa, the Dnipropetrovsk Research Institute of Gastroenterology, the Kyiv Research Institute of Hematology and Blood Transfusion, and the Kyiv Research Institute of Tuberculosis and Pulmonary Surgery, among others.

Alongside these institutes, there are A number of specialized republican-level centers focusing on specific surgical fields (such as burn centers, proctology centers, and thyroid surgery centers).

Over the past two decades in Ukraine's megacities and major industrial centers (Kyiv, Kharkiv, Donetsk, Dnipro, Zaporizhzhia, Odesa, Lviv, Kryvyi Rih, Kherson, etc.), specialized emergency surgery hospitals have been established. Their structure includes departments covering major surgical specialties (neurosurgery, vascular surgery, gastroenterology, Polytrauma, etc.), ensuring effective specialized care for patients with acute conditions and critical states (gastrointestinal bleeding, perforated ulcers, acute pancreatitis). The creation of emergency hospitals and the concentration of diverse surgical specialists (both narrow and broad profiles) within them has mitigated the negative consequences of hyper-specialization among surgeons.

Specialized traumatological (Bone and joint trauma) and orthopedic care is provided by urban trauma centers, specialized departments in central district, municipal, and regional hospitals, and scientific-methodological centers such as research institutes of traumatology and orthopedics (in Kyiv, Kharkiv, and Donetsk).

Oncological care is provided to patients by municipal and regional oncology dispensaries and Cancer centers, working in conjunction with the departments of oncology at medical universities and academies based within these dispensaries, as well as oncological research institutes—notably the Kyiv Radio-Rontgen-Oncology Institute, with its numerous multidisciplinary clinics (thoracic, gastroenterological, gynecological, proctological, maxillofacial, and breast tumor clinics, among others).

A crucial role in advancing emergency surgical care and achieving significant success in this field is played by municipal, regional, and republican emergency medical stations (formed through the merger of emergency and urgent medical service stations) and the establishment within them of specialized teams dedicated to specific areas of emergency surgery (Shock management, thromboembolic care, toxicology, etc.).

As a result, medical assistance is delivered to victims swiftly and expertly right at the site of the injury or onset of illness.

Alongside the state territorial healthcare system—specifically public surgical care subordinate to the Ministry of Health—Ukraine possesses a fairly extensive network of departmental hospitals under the jurisdiction of various other ministries and organizations. These include the Ministry of Social Policy (the Republican Hospital for Inpatients of the Great Patriotic War and other wars, local war veteran hospitals, and hospitals serving certain other categories of pensioners), the Ministry of Transport, the Ministry of Coal Industry, the Ministry of Internal Affairs and the Security Service of Ukraine (SSU), the Medical and Health Management Department under the Cabinet of Ministers of Ukraine, and many others. These hospitals, clinics, and medical units of major enterprises feature surgical departments that provide comprehensive qualified and specialized surgical care to employees of these enterprises and services, funded through the budgetary allocations of these institutions. Departmental medical facilities comprise inpatient units, polyclinic departments with surgical offices, and their own dedicated ambulances.

Driven by technological progress, the advent of television-video equipment, computers, and specifically laparoscopic instrumentation, recent years have witnessed The Emergence of novel, non-traditional surgical techniques performed endoscopically (such as laparoscopic resection of intra-abdominal organs for chronic conditions—Gallbladder, Appendix, fallopian tubes, bowel segments, etc., and plastic repair of abdominal hernias) or endovascularly (balloon and laser dilation of narrowed coronary and peripheral leg Arteries, etc.).

These types of specialized surgical care are currently provided primarily in surgical research institutes and select medical university clinics.

While highly effective, surgical care is also extremely complex and costly. Achieving a high standard of care cannot be sustained solely through state funding in any country globally, even the most economically developed ones. The significant lag in certain surgical subspecialties in the former USSR (particularly transplantology and laparoscopy) inherited by the former union republics—now independent states, including Ukraine—is primarily attributable to funding deficits resulting from a single, state-exclusive, and therefore inadequate source of healthcare financing.

Consequently, in sovereign Ukraine today—amid political restructuring and the reform of economic relations—alternative forms of healthcare financing are being developed and implemented pursuant to government resolutions, alongside the primary state budget. First and foremost, medical institutions are permitted to provide a range of paid surgical services based on patients' voluntary consent. This applies to technologically advanced procedures such as endoscopic (laparoscopic) abdominal operations. After all, acquiring the necessary equipment and providing specialized training for surgeons already skilled in traditional, open surgical techniques requires substantial financial investment.

Economic reforms are currently underway in Ukraine in connection with the legislative (constitutional) entrenchment of Various Forms of ownership (state, private, and collective). This will also impact the ORGANIZATION OF THE medical and surgical care system for Ukrainian citizens. Although a definitive conceptual model for healthcare organization has not yet been finalized, significant changes are already taking shape. In the future, alongside state-funded budgetary healthcare, health insurance is expected to play a prominent role, with services financed through enterprise funds, insurance companies, joint-stock companies, social security funds, and patients' out-of-pocket payments.

Training of Personnel for Surgery

The training system for surgeons in Ukraine has undergone and continues to undergo significant changes and reforms. Until recently, surgical training began at the medical institute level through sub-internships. Today, with primary specialization in surgery at institutes (universities and academies) abolished, surgeons are trained through a 1.5-year internship in general surgery. This program takes place in the surgical departments of city and district hospitals, as well as in the clinics of relevant medical university departments, utilizing a blended learning format (half the time spent on-site at the department and the other half working in the surgical departments where they will eventually be employed, concluding with a graduation exam). In addition, departments of surgery train personnel for academic and teaching careers through Master's and PhD (postgraduate) programs. Honor students are eligible to enter the Master's program upon graduation, while admission to the PhD program requires at least three years of clinical practice as a surgeon.

The professional development of surgeons—including continuing education and primary specialization in emerging surgical fields—is conducted through institutes and faculties for advanced medical training, the National Medical Academy of Postgraduate Education, research institutes, and relevant departments of medical universities. Specialists who have completed their internship master narrow surgical subspecialties in specialized institutions such as research institutes, hospitals, and academic departments under the guidance of leading experts. Special emphasis must be placed on the role of clinical departments of surgery at medical universities and academies in training and mentoring surgical personnel. Worldwide, universities serve as the primary hubs for science and academic training. It is within these university clinics that renowned Ukrainian surgical schools were established or pioneered, including those founded by S.P. Krymov, M.S. Kolomiichenko, H.H. Karavanov, M.M. Amosov, O.M. Avilova, O.O. Shalimov, K.T. Ovnatanian, O.K. Horchakov, H.M. Matiashyn, M.M. Kovalyov, V.D. Bratus, M.P. Pavlovsky, and others.

Beyond formal continuing education, the surgical profession demands lifelong self-improvement through The Study of medical literature, participation in conferences and surgical congresses, attendance at meetings of surgical and other professional societies, and more. Today, thanks to greater openness in the state and its political system, Ukrainian surgeons have the opportunity to travel abroad to observe the state of surgery and advance their professional skills in Western Europe, the United States, and Canada. Ukrainian surgeons receive state support, backing from Ukrainian medical diaspora societies in the US, Canada, and Australia, assistance from individual figures in the international Ukrainian diaspora, as well as support from domestic charitable foundations and organizations.