London GP Maria Naymark: The main difference between our doctors and British ones is ‘the attitude towards evidence-based medicine’.

Maria Naymark. Photo: Alyona Freyman
Maria Naymark. Photo: Alyona Freyman

It was only quite recently, during the pandemic, that doctors, who were working twenty-four-seven saving patients, were feted as heroes. Past services are quickly forgotten, however, and now it’s the done thing for patients, public figures and journalists to criticise the NHS. Complaints are made against the British healthcare system for the long waits to receive medical treatment and the shortage of qualified staff. Prescribing paracetamol as an initial treatment has long been a meme on social media, especially amongst immigrants accustomed to taking pills by the fistful. We decided to delve into the subject and take a look at the problem from the other point of view. In an interview with Kommersant UK, Maria Naymark, a GP and family doctor working both in the state and private sector, told us about the current working conditions of British medics and why Russian-speaking immigrants are not always satisfied with how they are received. 

What significant changes have there been to your work in recent years?  

In recent years, there has been a significant increase in the workload for all medical personnel, including family doctors. Pervasive problems in the National Health Service lie behind this, such as underfunding and the staff attrition provoked by the low salaries; junior doctors’ pay, for instance, has not been indexed for many years. The high number of patients continues to rise and the burden of paperwork is becoming ever more onerous. What’s more, the doctors feel pressure from the patients who are used to the freely available, high-tech treatment previously provided. It’s now becoming more difficult to refer people to certain specialists. Waiting lists for medical treatment can last for months and sometimes even years. The NHS has been getting a lot of flak from media commentators who write about inefficiencies in the system. In this acrimonious atmosphere, it’s very difficult to fulfil your duties, so doctors are leaving for private clinics. Still, not all doctors like private medicine, as it’s only affordable to the wealthy and those with insurance, which is very expensive in Britain. The noble idea behind the NHS is that it is fair and free for all. In theory, it is a very good system and in many ways, it remains so. Both the rich and those on low incomes can go to a state hospital for treatment. This can be literally life-changing for people who can’t afford to go to a private clinic. The current sad state of affairs means that many specialists are leaving the profession altogether. You see, doctors have many marketable skills which are in demand in other areas such as business; they solve emergencies every day, manage crises, make decisions rapidly in difficult situations, and have the habit of working a lot. Many medics are leaving to work in Middle Eastern countries, especially the Emirates, as well as New Zealand, Australia and Canada, where the healthcare systems are similar but less burdened.  

If a patient dies before they are seen by a specialist, who is responsible?  

Fortunately, there is a triage system which filters patients and identifies emergencies. Every doctor knows which symptoms indicate problems such as heart attacks, strokes and cancer that require emergency assistance; these cases are treated well and quickly. These symptoms are encountered in different fields of medicine; gynaecology, neurology, pulmonology oncology etc. Doctors know these so-called “red flags” well and, when they see them, they send patients along a faster route. For instance, there is a two-week wait rule. If signs of cancer are picked up, they go straight to the oncologist. If they present at casualty with a time-critical condition, a specialist will see them straight away. So, of course, if they’re experiencing acute symptoms, the patients won’t have to wait for an appointment with a specialist for several months. The waiting time drags on if the patient is suffering from a disease that won’t kill them. A classic case when it’s practically impossible to see a doctor is varicose veins; there are virtually no lethal cases but living with this disorder is hard. You can spend several hours (sometimes a day) in casualty with a broken finger, which, although not a fatal injury, is very inconvenient to live with. On the other hand, if you’re having a heart attack, you’ll be given medical attention straight away. 

What are the main advantages and disadvantages of the British system of doctors’ surgeries? 

A drawback of the British system of GPs’ surgeries is that, firstly, only ten minutes is allotted to each appointment, which is very little. In some surgeries, the management somehow pulls strings so that each appointment lasts 15 minutes, which makes a huge difference, it really is easier to breathe, for the doctor and the patient. Secondly, it can be hard to get an appointment. A strength of the system is that state-provided healthcare is absolutely free; everyone can receive expensive treatment irrespective of their social status or bank balance. It’s available in every part of Britain; high-tech medical centres are, at most, a two-hour drive from any location. They don’t transport difficult cases to London from the North as, both in Manchester and Liverpool, there are high-quality facilities. It always saddens me when I hear that people from all over Russia have to travel to a specialist in Moscow or that victims of an accident in Novosibirsk are sent to the capital by plane. Another strong point here is that there are a lot of good doctors; it’s impossible to become a consultant without being a highly qualified specialist with extensive experience; that’s how the system works.

The pandemic changed how healthcare works around the world. The range of medical services offered remotely was significantly increased. Doctors started to make diagnoses and prescribe treatment to patients by telephone and online. In your view, how effective, or otherwise, are remote methods of diagnosis compared to seeing a doctor in person? Is it maybe better than languishing in queues for weeks waiting for an appointment with the right specialist? 

Remote consultation is a tremendous tool if used in the right way. Firstly, a significant proportion of people come to appointments for administrative reasons, such as to make a letter for their employer or receive a prescription for an analogue of a previously prescribed drug. It’s very convenient to be able to do this remotely, most of all for the patient. Secondly, for those who already have a treatment plan, remote appointments are convenient for repeat examinations and further monitoring of the condition to discuss test results, blood pressure readings etc. Thirdly, this format is a good way of identifying urgent cases (triage). For instance, someone might call and say they are experiencing heart pain. This type of patient is sent straight to casualty, skipping an appointment with their GP, as they need urgent tests and monitoring which a GP can’t provide. A face-to-face appointment is likely to be unhelpful or even dangerous, as it puts off the trip to casualty. In the overwhelming majority of cases, however, new patients should of course be seen in person. Doctors try to see children under ten in person (and especially infants in their first year). In rare cases, if a child is already known to a physician and there is an established treatment plan, a follow-up appointment can be done remotely. In answer to your question of whether it’s better to wait for weeks for an appointment in person, I don’t think so, because a remote appointment is better than nothing.

Maria Naymark. Photo: Alyona Freyman

What kind of patients are the most difficult? 

There are a range of conditions we call “medically unexplained symptoms”, which do not fit the clinical description of any known disease. Analysis and test results are normal, yet the patient is still suffering. Often these ailments have a psychosomatic and post-traumatic nature. What’s more, the symptoms can be very diverse; weakness, shortness of breath, pain in any part of the body, or dizziness. In short, any subjective symptoms imaginable. For the patient, they are all completely real. It’s very rare to be able to prescribe symptoms to psychosomatic causes immediately. So tests and analysis are prescribed. It’s a gradual approach to the identification of the problem. Sometimes, the patient goes to several specialists; a neurologist, cardiologist and rheumatologist, that’s the classic triad. Then they go back to their family doctor and say that everything is normal but, all the same, their head is still spinning. While this process is going on, you begin to realise that the problem isn’t quite somatic, or physical. To confirm this, trust is needed between the doctor and the patient, because the doctor may already suspect that the case is psychosomatic, but if there is no trust, it is difficult to study the symptoms in greater depth and detail. And trust is established gradually, by the way that you ask questions and listen to the patient. Of course, it’s easier to do it in person, but it’s also possible by videolink, it all depends on the doctor’s professionalism.  

Are there many patients like this currently, with post-traumatic syndromes and psychosomatic problems? 

There’s never a shortage of cases of psychosomatic problems and PTSD, because lots of unpleasant things happen in the world. Britain has always welcomed people who have been forced to leave their homes because of military action or political repression. These people arrive with their own traumatic baggage. On top of this, personal worries and childhood traumas can lead to the emergence of psychosomatic disorders. 

Often your colleagues check the symptoms of illnesses and the dosage of medicines in front of the patient by looking on the internet. For Russian-speaking immigrants, this looks absurd. Can you comment on this practice? 

Except for the commonest medicines which I prescribe every day, I always check the dosage in the special handbook, the British National Formulary (BNF). This has long been in an online format. I have a look at the recommendations for the treatment of various illnesses; this is normal. If all you have in your medical arsenal are metamizole and brilliant green (a painkiller and a disinfectant, both widely prescribed in the former Soviet Union, where they are known as analgin and zelyonka respectively), you probably don't have to check the dosage, but in the BNF the are 70,000 medicines and each year some new ones are added and some are removed. The recommended treatments for various diseases are constantly being revised. For instance, at the moment serious changes are taking place in the treatment of ailments such as diabetes, hypertension and renal deficiency. The medicines have different dosage programmes depending on the individual characteristics of the patient, their age, renal function etc. So, actually, contrary to the concerns of some patients, it would be strange if the doctor prescribed the dosage without checking online to make sure that the decision they have taken is safe. I remember when I started working as a doctor in Moscow, there was a handbook of prescribable medicines called Vidal, and it also seemed strange to some patients that doctors were always referring to it to check information. But, for a doctor, it’s important to measure your work seven times before cutting anything off.  

Why do they often simply prescribe paracetamol in Britain, while in Russia and Ukraine leaving a physician without a list of medicines to take is nonsense? 

Yes, here they usually advise people to drink plenty of water or raspberry tea and take a paracetamol, because, as well as being a safe medicine, it’s also a kind of test; if the patient's condition improves after paracetamol, it’s unlikely to have been anything serious. If paracetamol brings the temperature down, that’s great, and if it doesn’t, that’s a sign that the situation requires a more serious approach. So it’s useful to try paracetamol first. In Britain, as in other Western countries, evidence-based medicine is practised; only medicines with proven effectiveness are used. All these immunity boosters and bio-additives which are so popular in the former USSR have no clinical basis. Also, the unrestricted use of antibiotics is not encouraged here, as it can lead to the appearance of superbugs, which is to say infections which are resistant to all forms of antibiotic treatment.

Nowadays, evidence-based medicine is slowly spreading across the former USSR and far from every doctor over there will prescribe a patient a sack of medicines to take home. Actually, the topic of handing out sacks of medicines (often entirely useless ones) is a very interesting subject in the former USSR. Even 20 years ago, when I was doing my internship, doctors didn’t really believe in all these health supplements and immunity boosters, but, under the influence of advertising, the patients were demanding them, so the doctor prescribed them. Both parties became accustomed to this. Actually, patients often come in with some form of anxiety disguised as a symptom and instead of getting to the bottom of things, the doctor just prescribes them some tablet, which, thanks to the placebo effect, will actually have a temporary beneficial effect. I think that the habit of prescribing and taking fistfuls of pills comes from the Soviet past when doctors had a brusque approach to patients and often didn’t take the time to pick out the psychosomatic problems from the array of presented complaints. Conversely, it wasn't done for patients to worry about their mental health, practice mindfulness, go to psychotherapy or do fitness. These days, patients don’t make a fuss when doctors suggest problems might be psychosomatic or caused by anxiety and recommend solving them by going to a psychotherapist rather than a chemist. Of course, before this dialogue is possible, a certain level of trust is needed between the doctor and the patient, which is why it’s important to find a doctor with whom you can have honest and open therapeutic interaction.  

Why do foreigners and Brits of foreign origin prefer to undergo medical tests and treatment in their home countries? 

People seek treatment in their home countries because their healthcare systems are familiar to them and they know what to expect. Also, the cultural context and being able to speak in your native language are very important. Research has shown that patient outcomes are better when doctors belong to the same social and ethnic groups as their patients as it leads to more mutual understanding. For example, in Britain, GPs do gynaecological examinations and this shocks foreigners. It’s very comforting for people when reality meets their expectations. The financial component is also important; in Britain, private medical services are significantly more expensive than, for example, in Eastern Europe (in Poland, Russia and Bulgaria). Many foreigners (and Brits as well, by the way), go to Portugal or Spain for medical treatment, as in these countries, medical care is significantly cheaper.  

To what degree are treatment methods different in Britain and Eastern European countries? 

The main difference is the attitude towards evidence-based medicine. Western medicine regards the achievements of science with respect, whilst also evaluating them critically. Before any new treatment method is approved for use, it goes through multistage clinical scrutiny, including review by independent experts (this is important) and it undergoes criticism. In Russia, by contrast, anyone can come up with some new remedy and administer it with absolutely no empirical evidence. It’s impossible to do this in Britain. The issue here is not even effectiveness; it’s about safety. 

Was it difficult for you to go through retraining to become a qualified UK doctor? Has your experience of working in another country helped you?

At first, it seemed that the most difficult step would be getting my degree recognised, but it turned out that was the easy part. Now I work as a General Medical Council (GMC) examiner and I administer PLAB exams for doctors with foreign qualifications. I sat this exam myself many years ago. This is the first test you need to pass to receive GMC registration. After that, there were many other exams. It’s not easy being a doctor here, but it’s very interesting. I’m lucky that, at the very start of my career, when I was still in Moscow, I went to Sechenov Medical University where the cardiologist LA Syrkin was the head of the faculty. They practised evidence-based medicine there. Everything they taught me is useful here.  

 If you became the British Health Secretary, what would you put right first of all?  

First of all, I would index doctors’ wages. Next, I'd increase appointment times to 20 minutes. After that, I'd hire more doctors, both GPs and specialists. 

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