Ethics of time management in the conditions of modern domestic health care system

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The health care system in modern conditions of its reforming, the interaction of practical medicine and science, education, business, and government authorities requires effective management. Time management is actively developing - an interdisciplinary section of science and practice that studies techniques and techniques that allow rational distribution of time at the personal, team and corporate levels. One of the most important tasks of time management is the desire to improve their own efficiency, to achieve their goals as quickly as possible, ensuring career growth. However, today, due to the lack of attention to the best historical traditions of Russian medicine and medical education, there has been a tendency to devalue the spiritual component of healing. In this connection require special attention comprehension of ethical issues of time management, which are the consequence of the desire to save time at the expense of the interests of the patient, that is embodied in a mechanistic approach to treatment, lack of understanding of the characteristics of his personality, ignoring the moral values. In modern domestic and foreign scientific and methodological literature in the works of G.A. Arkhan-gelsky, S.M. Kalinin, S.V. Bekhterev, M.A. Lukashenko, T.V. Telegina, E.S. Glukhova, F. Gilbert, P.F. Drucker, S. Covey, D. Allen, T. Ferris and etc. described how to effectively time planning on a personal, team and corporate level, as well as methods for achieving personal effectiveness in the field of time management. 19 20 ФЕДЕРАЛЬНЫЙ НАУЧНО-ПРАКТИЧЕСКИЙ ЖУРНАЛ 2 (24) 2019 In the literature of the soviet period, A.K. Gastev, P.M. Kerzhentsev, emphasized that personal effectiveness becomes a method of thinking that makes it possible to manage time, while various techniques and techniques are considered tools of thinking. Meanwhile, the time as a philosophical and general scientific category is studied in the humanities -philosophy, sociology, psychology, history. However, in the scientific and methodological literature, in our opinion, issues of interaction between time management and humanitarian knowledge, the ethical aspects of time management, the importance of the highest moral values understanding in organizing activities aimed at improving personal effectiveness are insufficiently covered. Ethical views of prominent doctors, scientists, health care organizers, public figures - N.I. Pirogov, I.M. Sechenov, V.F. Voyno-Yasenetsky, A.L. Myasnikov, N.M. Amosov, S.N. Fedorov, F.G. Uglov, E.I. Chazov and others, along with their original proposals in the field of time management, are presented in one of the areas of journalistic literature - memoiristics. In published historical sources (autobiographies, letters, diaries, memoirs, memoirs) consistently reflected the process of the formation of their fundamental ideas. Formation of domestic time management belongs to the beginning of the twentieth century, however, in early cultural and historical epoch interest in time management arose in various fields of activity. One of the features of the medical activity is the need for timely and prompt provision of medical care, often in difficult conditions. The creative activity of many prominent domestic doctors was aimed at finding new ways to optimize time spending in an effort to alleviate the condition of a suffering person. In the aspect of studying the ethical aspects of time management in the history of domestic medicine, in order to identify the socio-cultural and historical conditionality of its development, we see it appropriate to distinguish the following periods: • From the middle of the XVIII cent. before the beginning of the ХХ cent. The beginning of this period is associated with the struggle of advanced doctors of Russia for the independent development of domestic medicine. The emergence of higher medical education, the approval of national personnel in scientific, educational and administrative institutions were happened. Research work was developed. University clinics were created, world-famous clinical schools, the first medical scientific societies were appeared. Public medicine, zemstvo medicine, experimental hygiene were developed. Under these conditions, in medicine - in the field of management, organization, medical activity, science - the experience of organization, planning, rational use of time was accumulated. • Since the beginning of the XX cent. until the end of the XX cent. This is the period of Soviet health care. The emergence of time management occurred in the 20s of the XX cent. conditions of rapid development of the economy and scientific organization of labor. The task of fighting for time on the scale of society and the state was set for the first time. The development of time management was initially limited by the production sphere, and since the 1970s in society the idea of budgeting time, as well as a system for managing personal time were widely spread. Further development of time management in medicine continued within the framework of the state policy of the USSR in the field of healthcare, the basic principles of which were: the state nature of healthcare; preventive focus; public participation in health; unity of science and practice of public health. • Since the end of the XX cent. until now. This period began with the collapse of the USSR, when in Russia in difficult socio-economic conditions transition to a market economy and decentralization of management were carried out, a new strategy was developed to improve healthcare management, and its reform began. Today time management is developing in a market economy, when along with the state, paid medicine is developing, the development of science and technology expands the possibilities of diagnosis and treatment. One of the most important tasks of time management is finding of ways to effectively time planing at the personal, team and corporate levels, as well as ways to achieve personal effectiveness and career growth. The founder of national clinical medicine M.Ya. Mudrov (1776-1831), developing the doctrine of the unity and integrity of the body, argued: «I will tell you briefly and clearly: healing consists in treating the patient himself...». His system of clinical examination of the patient and an individual approach to treatment, the implementation of complex therapy (diet therapy, hydrotherapy, hemorrhage, psycho-and occupational therapy) were first in Russia reflected in recorded medical histories carefully kept in a personal archive [5]. G.A. Zakharyin (1829-1897) - the founder of a large clinical school, a follower of M.Ya. Mudrov, improved the method of questioning the patient. Such work on compiling and improving the medical history from the point of view of modern time management made it possible to optimize the doctor’s work, rationally use the time and improve the quality of treatment. N.I. Pirogov (1810-1881) - an outstanding Russian surgeon, scientist, teacher, public figure, creator of topographic anatomy and the experimental direction in surgery, one of the founders of military field surgery. In his multifaceted activities, he attached particular importance to issues of management and organization of time. In 1847, he first applied ether anesthesia in droves in the conditions of military operations in Dagestan with the help of the apparatus he developed for delivering anesthesia. During the Crimean War in the besieged Sevastopol in 1854-1855 years the using of ether anesthesia made it possible to operate 2 (24) 2019 ФЕДЕРАЛЬНЫЙ НАУЧНО-ПРАКТИЧЕСКИЙ ЖУРНАЛ simultaneously on three tables of 80-100 patients per day. N.I. Pirogov wrote: «You can end 10 large amputations, even with the help of not very experienced hands, in 1 hour and 45 minutes. If you simultaneously operate on three tables and with 15 doctors, then at 6 hours and 15 minutes it can be done 90 amputations, and therefore 100 amputations with a short time at 7 o'clock» [6, p. 184]. The practical conclusions, formulated by N.I. Pirogov in the conditions of hostilities, laid the foundation for the organizational, tactical and methodological principles of military medicine. He argued: «Not medicine, but administration plays a major role in helping the wounded and sick at the theater of war». The success and timeliness of medical support for troops depends on the organizational structure of medical institutions, their subordination, appointment, mobility and interaction between them and is determined by the nature of the war, methods of warfare, but also the achievements of healthcare practice. For the sake of streamlining the work of dressing points, rational use of forces and time, N.I. Pirogov first used the sorting of the wounded, which formed the basis for further medical-evacuation support for the wounded. The proposed organization for sorting the wounded was subsequently used in many armies around the world. From 1864 to 1917 zemstvo medicine was a new, special form of health-medical care for the rural population in Russia, its unique experience enriched the further development of domestic and world health. Until 1864 organized medical care for the rural population in Russia did not exist. The basis for the organization of medical care in the zemstvo was district medicine. Zemstvo plots were allocated in the county structure. A traveling medical care system has been created: the zemstvo doctor on the established days moved around the villages, accepting patients at exit points. A serious drawback of such an organization system was the irrational use of time, especially taking into account our climatic conditions and - traditionally -the state of Russian roads. In the middle of 1870s, a stationary medical care organization system was introduced, which significantly optimized time costs. The doctor worked in a local hospital, conducted outpatient visits, in emergency cases he went to seriously ill patients, for epidemics, for vaccinations. County and provincial hospitals were created in zemstvo provinces. Under the conditions of zemstvo medicine, assistance was also provided in obstetric care, the fight against infectious diseases, sanitary supervision and practical sanitary measures, the spread of hygienic knowledge, and care for the situation of medical personnel in zemstvos. Zemstvo doctors demanded free medical assistance to the rural population and were able to achieve by the beginning of the twentieth cent. cancellation of inpatient care fees in 215 counties out of 359. Payment for the treatment reduced the uptake of medical care, the consequence of which would be to increase the risk of the spread of dangerous, including infectious diseases. In addition, sanitary statistics were carried out, which made it possible to evaluate the effectiveness of the activity and help to find ways to optimize it, including making it easier to find ways to reduce inefficient time costs. During this period, a special type of Zemstvo doctors formed, incorporating the best traditions of Russian public medicine. In Russian literature in the works of prominent medical writers - A.P. Chekhov, V.V. Veresaev, M.A. Bulgakov hard work, service to the people, and ethical ideals are chanted. The image of the Zemstvo doctor was formed in certain cultural and historical conditions. In the XIX - early XX cent. -the heyday of Russian philosophy, one of its characteristic features was a special interest in historical and ethical issues. In the philosophical-historical and social-philosophical sphere, one of the central issues was the choice of the further path of Russia and the Russian people. The ideas of Russian philosophy were developed in the whole context of culture: in science, in a living, figurative word in Russian fiction, in painting, music, and theater. People’s liberation ideas, «humanity and concern for human life», as N.G. Chernyshevsky wrote, were covered in all areas of culture and had a decisive influence on the fate of many prominent figures of that time. Intelligent Russian youth of the late nineteenth century were looking for a direct way to serve the people: to alleviate the suffering of peasants, to teach their children in rural schools. So, recalling the circumstances of the choice of his professional activity, V.F. Voino-Yasenetsky (1877-1961) - a domestic humanist, an outstanding surgeon, doctor of medicine, professor, spiritual writer, bishop of the Russian Orthodox Church, archbishop of Simferopol and Crimean, wrote: «... I once went to the director of public schools of the Kiev school district with a request to arrange me in one of the schools. The director turned out to be an intelligent and insightful person: he appreciated my populist aspirations well, but very energetically dissuaded me from what I was up to and urged me to enter the medical faculty. This was consistent with my desire to be useful for peasants who were so poorly provided with medical care» [1, p. 15-16]. In 1898, Voino-Yasenetsky entered the medical faculty of Kiev University. At this time a system of ethical principles was formed, embodied in the activities of the best representatives of zemstvo medicine: • do not what you want to do, but what is useful for a sick person; • do your job competently, accurately, carefully; • help the suffering always and everywhere, regardless of the circumstances; • comprehend medical work - analyze, identify the most characteristic, summarize, draw conclusions, determine prospects; • transfer their knowledge and experience to the younger generation - medical pedagogy as a facet of creativity; 71 ФЕДЕРАЛЬНЫЙ НАУЧНО-ПРАКТИЧЕСКИЙ ЖУРНАЛ 2 (24) 2019 22 • contribute to the improvement of the domestic health care system [4]. In the history of domestic and western medicine before the development of zemstvo medicine, there were no examples of creating a system of public organization for providing the rural population with modern scientific medical care. The lack of the possibility of understanding historical experience stimulated the search for new solutions in the creation of such a system, including in the field of management. At the same time, the solution to the problems of optimizing time costs was originally intended to alleviate the suffering of the patient and was based on traditional, historically established features of domestic medicine and medical education, which presuppose a holistic vision of the patient, individualization of treatment, and complex therapy. The sciences of health, treatment, disease prevention and the art of healing have developed in unity with the unshakable moral principles of like-minded people brought up in the humanitarian environment of the medical faculties of Russian universities. The situation of the first years of Soviet power -civil war, devastation, famine, the spread of epidemics -required the organizational unity of healthcare, the development of the state healthcare system. A state network of hospitals and pharmacies was created, and training was organized. For the first time, the legacy of many great thinkers - Hippocrate, Ibn Sina, I.P. Frank, N.I. Pirogov and others, who foreshadowed the future of preventive medicine, was embodied in the principles of state policy. The state nature of health care provided for the centralization of management, state funding, state planning of health programs. The entire population of the country was provided with free and accessible medical care. The preventive direction of health care in the USSR as a principle in the organization of medical business is today adopted in many countries of the world. Sanitary and anti-epidemic measures were carried out, protection of motherhood and infancy, health education, development of physical education, sanitary protection of water, air, soil, food, catering, housing, public places, the basis of medical examination was developed. The participation of the population in health care - the establishment of this principle took place in the first years of Soviet power with a lack of medical personnel. Commissions were formed to improve labor and everyday life, mass sporting events were organized to promote a healthy lifestyle, etc. The principle of the unity of medical science and healthcare practice is directly related to its state character. Research institutes, the Academy of Medical Sciences were created, theoretical, clinical, preventive medicine was actively developed. In the Soviet period the ideas of time management in medicine developed under the conditions of the state healthcare system, the dominance of Marxist-Leninist ideology. In a socialist society, health was seen as a social function, which was provided not only by the individual, but to a greater extent, by the whole society. In this situation, the tasks of increasing one's own effectiveness and career advancement in the conditions of official ideology have not been developed. Today, in the process of rapidly developing globalization, one of the consequences of which was the spread of uniform standards throughout the world, a number of negative phenomena are also revealed in medicine. The greatest concern is the leveling of human characteristics, due to the diversity of historically developed cultures and life. Today, in the process of rapidly developing globalization, one of the consequences of which was the spread of uniform standards throughout the world, a number of negative phenomena are also revealed in medicine. The greatest concern is the leveling of human characteristics, due to the diversity of historically developed cultures and life. All this destroys the thought and takes time, not allowing thoughtful work with the patient. A paradox occurs: the doctor doe s not have time for healing. The main semantic component of medicine - humanitarian - is washed out. The essential feature of modern medicine in all its forms (treatment, science, professional education, healthcare) is its interdisciplinary nature, and the consistent expansion of interdisciplinary ties. This phenomenon is highly progressive, because its purpose is to preserve and improve by all means the main value of society - human health. However, intersectoral and interdisciplinary interaction raises problems that had no analogues in the past, and therefore have no algorithms. To solve them, approaches are required, which should be based on philosophical reflection in value-targeted, systemic, procedural, and productive aspects. One of these problems is that the widespread development of the technical capabilities of diagnostics and treatment, the variety of pharmaceuticals, experiments in the organization of healthcare have created a situation somewhat similar to the enthusiasm for technicalism in industry: a person with his distinctive identities subjective features has fallen into the background behind an array of diverse innovations. The doctor has become part of a system that would seem to be aimed at curing people, but not taking into account the individual characteristics of the person (both the patient and the doctor), a system in the development of which such essential components that have developed over the centuries as the art of healing, ethical principles of the physician are emasculated. The sign of our time was the coexistence, on the one hand, of such large-scale phenomena as the construction of large clinics, perinatal centers, dispensaries, and other medical institutions equipped with modern equipment and instrumentation. On the other 2 (24) 2019 ФЕДЕРАЛЬНЫЙ НАУЧНО-ПРАКТИЧЕСКИЙ ЖУРНАЛ hand, there is a reduction in emergency care centers in rural areas and small towns, a number of doctors refusing to help patients with reference to existing or invented administrative restrictions. Finally, the disgusting wrong side of paid medicine: tearful requests to collect money «Many a little makes a mickle» for life-supporting operations, which are possible, but they (it’s a shame to say when it comes to human health) are expensive. In all this, oblivion of the ethical principles and professional duty of a doctor is seen as a disease of the modern domestic healthcare system. Today the problems of bioethics are exacerbating. Broadcasting a certain lifestyle in the context of globalization leads to an inversion of values, which causes concern when the public comprehends many ethical problems, one of which, for example, is associated with the achievements of genetic engineering, the possibilities of using stem cells, reproductive technologies, clinical transplantology and others. So, for the treatment of diabetes, strokes, spinal cord injuries, hepatitis, cirrhosis, tumors, leukemia and other diseases, embryonic stem cells obtained from aborted embryos can be used. Obviously, according to the predicted increase in the incidence rate, the need for this biological material will also grow, which under certain conditions can become a commodity or a type of resource. It can be assumed that in the economic interest in satisfying demand, there is a threat of an implanted lifestyle that contributes to an increase in the number of abortions. What consequences can this lead to? Is it possible in the context of globalization to create a universal system of values that is acceptable both for developed countries initiating globalization processes and for countries and peoples that are at risk of economic decline, poverty and oblivion of national cultures? Obviously, this problem requires deep understanding in the future and at present cannot be solved. In the general context of the problems in the field of ethics that exist in the modern domestic health care system, in the development of time management, a number of problems are also identified, both in the field of medical care organization and in the relationship between the doctor and the patient, the unresolvedness of which ultimately reduces the quality of treatment. So, in order to increase personal effectiveness, in accordance with the principles of time management, a health manager, in order to save time, resorts to the delegation method - reassignment of emerging operational tasks (usually unplanned), which are usually not included in the list of employee functional duties (in the job description), to his subordinates. The manager is guided by formal (providing the technical side of the work) and informal (psychological) rules, and situations of manipulation often arise here. Moreover, he meets with the resistance of subordinates, arising for many reasons: passivity; fear of criticism, punishment; lack of information, knowledge and experience; overwork with work, duties, assignments; fear of responsibility; low level of labor motivation and etc. This attitude towards delegation can be an indicator of serious systemic organizational problems. But it can also have local causes related to the human factor. Therefore, the approaches to their solution should be based on orientation to a system of higher moral values: freedom, justice, equality, love. Moreover, equality in professional and business communication should imply equality of human dignity of all subjects of communication, maintaining honor and dignity, trust, goodwill, respect for another subject and his needs, interests. The ethics of business communication requires the manager to have an attitude towards employees, involving the free disclosure and implementation of their personality; guarantee of social and professional rights of an individual; nondiscrimination and respect for equality on national, age, gender and other grounds, etc. One of the most important problems in the work of a doctor is the limited time spent working with the patient. Examination capabilities are expanding, the doctor must comprehend a large flow of information. Often, in conditions of time pressure, the use of wide technical capabilities of diagnostics replaces communication with the patient, his questioning. The patient is depersonalized. Under these conditions, the desire to optimize the time spent can be dangerous for the patient and, as a result, ends with the extra time spent by the patient for additional examination, clarification, clarification, coordination, solving bureaucratic issues, wasting time in queues, and most importantly - losing health. Obviously, the solution to this problem cannot be limited only by the application of effective methods of time management. In the context of the implementation of the digitalization of medicine projects, of course, unprecedented opportunities for diagnosis and treatment, reduction in the organizational costs of time for both the doctor and the patient are opened. But the development of new digital technologies will fall on the shoulders of doctors who are apparently not prepared in advance, and there is a risk that with an ill-conceived organization there will be even greater time costs, to the detriment of the time necessary for the patient. A special place is occupied by ethical problems of time management in the conditions of paid medicine. As noted above, one of the most important tasks of time management at the present stage of its development is the search for ways to effectively plan time on a personal, team and corporate levels, as well as ways to achieve personal effectiveness and career growth. In terms of paid medicine, time management, assuming care for the time of the doctor and patient, is also intended to ensure profit. Here the formula «time is money» begins to work, and in many cases ethical issues, for obvious reasons, recede into the background. 23 ФЕДЕРАЛЬНЫЙ НАУЧНО-ПРАКТИЧЕСКИЙ ЖУРНАЛ 2 (24) 2019 24 The solution of these problems requires their philosophical reflection in the desire to revive the moral and ethical traditions of Russian healing. It is necessary to restore the humanization of the profession. Approaches to this are seen in changing the organization and content of higher professional education. The restoration of the art of healing is associated with a number of pressing problems, among which the following can be distinguished. Firstly, the range of problems associated with insufficient training of applicants and the difficulties of professional selection. Secondly, the interaction of the humanitarian and natural science components. Thirdly, the problems associated with the specifics of medical education and the need for continuous self-improvement, the ability to navigate in an increasing flow of information. Separately, problems in the field of bioethics should be identified. The art of healing, first of all, provides for the presence of individual psychological characteristics of a person in a doctor that ensure success in treating a patient, the development of which occurs in the process of education and upbringing throughout life. Many scientific works of domestic and foreign researchers are devoted to the study and description of the abilities of musical, mathematical, literary and other. This allows you to look for effective ways of professional selection at all levels of education. The experience of domestic specialized general education, mathematics, music, art, sports schools is invaluable. But such issues in the aspect of training future medical workers are not covered in the literature. The situation is complicated by the fact that the profession of a doctor requires a combination of several groups of abilities. This makes their identification at an early age and development difficult. Perhaps that is why there are no specialized schools for the training of future medical workers. In most cases, a young man can only consciously choose the profession of a doctor by the end of school. But the level of training of applicants to medical universities is determined by the results of entrance examinations in biology, chemistry, physics, and the Russian language. Since exams are conducted in the form of testing within the framework of the USE, it is impossible to get an idea of the personality of the future doctor, his abilities, the ability to think and state, and communication skills. In addition, the overload of the school curriculum, the strengthening of the natural science block of disciplines and the shortage of students' time result in a decrease in attention to humanitarian disciplines. Interest in history, the Russian language and literature, reading in general, fine art, and classical music is being lost. All this limits the possibilities of assimilation of socio-historical experience. As a result, the educational function of the education system itself, which is also realized in shaping the personality of the future doctor, is weakened. It is impossible to identify the abilities of applicants and to conduct a high-quality professional selection, and those who later entered the university are not prepared for the assimilation and use of the flow of information. A number of sciences are taught in medical universities, the object of knowledge of which is a person, each of them is divided into narrow areas having specific terminology and problems. This creates the conditions for the growth of special knowledge. However, the predominance of the process of differentiation of the human health sciences with respect to their integration does not give the student a holistic view of the human body in the anatomical, physiological and psychosomatic aspects, leading to an underestimation of the influence of environmental factors on health. In this situation, mastery of humanitarian disciplines will help to understand the essence of man, the unity of the biological and social in him, his psychology, the diversity of relations with the outside world, which in the future will allow «to cure not the disease, but the patient». Thus, the need to study philosophy, history, foreign languages, psychology and other humanitarian disciplines is obvious. The World Health Organization defines the concept of health as a state of complete physical, mental, social well-being, and not just the absence of an illness. As you can see, mental wellbeing stands out. Therefore, the doctor needs knowledge of the psychology of communication, which may be needed already from the first minutes of communication with the patient, sometimes conflictology, ethics. But today, only a small part of the time in the first year is allocated to the cycle of studying the humanities. One of the real dangers arising in the context of modern medicine is a violation of the holistic view of a person, his internal harmonious unity. There is a tendency to understand the disease based on mechanistic representations at the level of an organ or organ system. In these conditions, the need is ripening, in the light of the current trends in medicine, to seek new ways to integrate knowledge based on a philosophical understanding of the essence of a person, his health, and approaches to complex treatment. It is clear that the embodiment of this approach in practical medicine requires changes in the field of medical education, because the formation of the worldview of a future doctor, his ability to think widely and use the knowledge gained at a university depends on the level of humanitarian training.

About the authors

I. E. Ditkovskaia

Siberian Federal University

Email: i.gailis@mail.ru
PhD, associate professor Humanities Institute

References

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