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13Therefore, administration of cytoprotective drug Trimetazidine in a comprehensive treatment of patients with BC prevents the development of destructive processes in the nervous tissue.
Conclusions.
1. Brain concussion results in the development of hypoxic disorders, changes of the pro- and antioxidant balance, and as a result, appearance of neuron injury marker in the peripheral blood.
2. Administration of Trimetazidine in a comprehensive treatment of patients with brain concussion evidenced a pronounced anti-hypoxic, antioxidant and neuroprotective effects of the drug.
Further studies are stipulated by the necessity to investigate the effect of neuroprotective drugs in case of craniocerebral injuries - perspective and pathogeni-cally substantiated direction in treatment.
References
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2. Колб В.Г., Камышников В.С. Справочник по клинической химии. - Минск: Беларусь, 1982.290 с.
3. Королюк М.А., Иванова Л.И., Майорова И.Г. Метод определения активности каталазы //Лаб. дело. - 1998. - №1. - С. 16-19.
4. Ланкин В.З., Тихадзе А.К., Жарова Е.А., Беленков Ю.Н. Исследование антиоксидантных свойств цитопротекторного препарата триметази-дина //Кардиология. - 2001. - №3. - С. 21-28.
5. Мещишен 1.Ф., Григорьева Н.П. Метод шлькюного визначення HS-груп у кровi //Буковин-ський мед. вюник. - 2002. - Т.6, №2. - С. 190-192.
6. Мироненко Т.В., Панченко Е.Н. Применение продигиозана в комплексной терапии последствий лёгкой закрытой черепно-мозговой травмы //Шк. справа/Врач. дело. - 1999. - №5. - С.101-105.
7. Современные представления о патогенезе закрытой черепно-мозговой травмы / Под ред. Е.Г. Педаченко. - К.: ТОВ «Задруга», 1996. - 282 с.
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METHODOLOGY FOR TEACHING NERVOUS DISEASES TO MEDICAL STUDENTS
Kryvetska I.
Candidate of Medical Sciences, Associate Professor of the Department of Nervous Diseases, Psychiatry and Medical Psychology named after S.M. Savenko, Bukovynian State Medical University, Chernivtsi, Ukraine
Kryvetskyi I.
Candidate of Medical Sciences, Assistant of the Department of Clinical Anatomy and Operational Surgery,
Bukovynian State Medical University, Chernivtsi, Ukraine
ABSTRACT
The article deals with modern aspects of training a neurologist. The importance of studying basic disciplines in the process of training a neurologist is emphasized. The most frequent mistakes that may arise in practice due to overestimation of the results of paraclinical research methods, underestimation of the role of the treatment that the patient receives for other indications are analyzed. An extremely important component of the learning process is the formation of a clear life position of the doctor.
Keywords: ethics in neurology, fundamental neurosciences, system of values, humanistic traditions.
The training of a highly educated specialist in various fields of medicine is an extremely important task [1-3]. At the same time, one should not lose sight of the need to form the human qualities of a doctor. Almost every discovery in the field of neuroscience raises ethical questions [4]. In particular, brain death or a chronic vegetative state is a rather difficult ethical problem. Despite the existing criteria for brain death, in some states of the United States, for example, they may conflict with the religious beliefs of the patient's family [4]. It is no less difficult to reveal to the patient and his loved ones the true truth about a potentially incurable or genetically determined disease. There are no universal recipes, but there are recommendations in some cases to provide the patient and his family with this kind of information gradually. Note that ethical problems can arise not only in extreme situations, but also in the everyday work of a doctor [5], the relationship between business and medicine [4].
For example, the concept of "informed consent" was put forward more than 100 years ago as the right of every adult to decide what can be done with his body after death. The aging of the population makes the problems of cardiology, oncology, endocrinology, psychiatry, neurology more and more urgent - not only in the field of narrow specialties, but also their interconnection. Specialists are increasingly faced with multimorbid conditions, when knowledge and skills are required in several formally unrelated disciplines. Examples of such conditions are pain syndromes, fatigue syndrome, shortness of breath, etc. [6]. Patients should be aware of the dangers of drug abuse, side effects of drugs that adversely affect, for example, driving a car [7]. Drug abuse is often associated with chronic pain syndromes (pain in the neck, back, headache), especially in women. The introduction of neuroimaging methods into clinical practice has led to another ethical problem associated with identifying any changes in
MRI or CT in neurologically and mentally healthy individuals (in particular, those included in the control group during scientific research).
At the same time, despite the rather high percentage of changes revealed by neuroimaging methods (47%, or 71 cases out of 151 examined [8]), they are rarely serious - in this study they were detected only in 3 cases (cavernous angioma, arteriovenous malformations of various localization). In most cases, these changes could be interpreted as caused by aging, do not require special treatment and are characterized by a favorable prognosis. However, this required a qualified assessment of not only the results of MRI or CT, but also clinical data (history, assessment of neurological and mental status, taking into account the identified changes). Thus, when training specialists in the field of neurology and psychiatry (in this case, in the field of radiation diagnostics), it is necessary to pay special attention to the ability to correctly assess the results of paraclinical research methods. Otherwise, overdiagno-sis of certain neuropsychiatric diseases is possible, an insufficiently substantiated assumption about which may be a serious psychological trauma for the subjects or their relatives. Functional neuroimaging methods create even more problems of a similar nature [9].
Patients with severe neurological deficits and poor prognosis, for example, at a late stage of amyotrophic lateral sclerosis, are of particular attention not only in medical but also psychologically [10]. The management of this category of patients is extremely difficult, and the foundations of the approach to it should be laid even at the stage of university preparation. An important element in the formation of an integrated approach is the integration of various disciplines, when they are not opposed, but complement each other. This is one of the directions of the educational reform - the training of a clinician who is able not only to understand his narrow field, but also knows how to take a broader look at the patient's problems, if necessary, involving specialists of a narrower profile in the conduct.
It is important that the doctor does not forget to ask the patient about medications prescribed by other specialists, as well as taken on his own initiative [7]. This group, which the patient does not consider "medicinal", includes vitamins, aspirin and oral contraceptives. You can ask the patient to bring to the appointment a list of all drugs (indicating the doses) that he takes for various indications (by the way, the patient often does not consider the above drugs as drugs and, accordingly, does not include in the list). In patients with cognitive impairment, there is a danger of an overdose of the drugs they are taking.
An important role in university training is played by teaching the skills of communicating with the patient. Thus, in a conversation with a patient, one should take into account his educational level, cultural characteristics, language difficulties (if any), as well as traditions and religious status. It should be borne in mind that in a conversation with a patient with the help of an interpreter, a distortion of the meaning of what the patient wanted to say may involuntarily arise. Therefore, it is necessary to repeat once again the question, the answer to which caused difficulty. It is necessary to be
extremely careful when using phrases colored with humor, since they are perceived differently by the doctor and the patient [11]. Of course, both the patient and his relatives or those around him should have the opportunity to ask the doctor questions of interest. Only in this case will it be possible to achieve full contact with the patient. It is advisable to give recommendations in writing, especially if they relate to dose titration of the drug. You can ask the patient and his relatives to come back to the appointment if necessary (for example, from the point of view of a doctor of another specialty, reduce the dose or completely cancel the drug received).
Palliative medicine deserves special attention. Traditionally, it was limited only to cancer patients, leaving out of sight patients with other, primarily neurological, pathology. Specially trained psychologists could be of great help in the management of these patients. In any case, this problem remains and needs to be resolved. Note that different religions treat it differently [12].
The widespread use in practice of electronic medical records (and other tools based on computer programs) significantly reduces the likelihood of errors, for example, incorrect reading of the illegible name of a drug or incorrect decoding of an abbreviation [3]. In addition, some electronic systems already have built-in routines for checking the correctness of the appointment (including dosages) of certain drugs. All this significantly reduces the possibility of mis-prescribing drugs. Many errors will be avoided by the standardization of medical records (including the spelling of drug names) by computer network providers and medical institutions [7].
One should take into account the increasing medical literacy of patients from year to year. This is facilitated by a large number of medical and paramedical publications, and, of course, the introduction of the Internet into life. Unfortunately, a significant part of them expresses very superficially very serious issues, and some are simply harmful to the patient. Therefore, the task of a doctor, regardless of specialization, is to combat the dissemination of inaccurate information.
The above can be illustrated by comparing two disciplines - neurology and oncology, and the results turn out to be in no way in favor of the former. Less attention is paid to neurological diseases in society; they remain, as it were, in the shadow of such a problem as oncology [6]. The attention of society to the problems of tumor diseases is manifested both in the number of specialists employed in this area of oncology (about 200 times more than in neurology) and in the number of scientific symposia devoted to them [6]. To a large extent, this is due to the fear of a tumor, which is characteristic of modern civilization. It is strange to hear that patients with multiple or amyotrophic lateral sclerosis (diseases with very unfavorable consequences) in a private conversation with the attending physician express satisfaction that they have found this or that disease, and not a "tumor" [6].
One of the reasons for such differences in approach is that in oncology doctors specialize in the organ (specialists in lung and bladder tumors, etc.), while in neurology crystallization occurs in various directions
associated with nosological forms (Parkinson's disease, multiple sclerosis, etc.). Therefore, the funds allocated for scientific research in the field of oncology, studying the problem of damage to one or another organ, is several times higher than for relatively narrow neurological areas (according to rough estimates, about 5 times) [6]. At the same time, scientific progress in the field of neurology can be seen only when the disease has already developed with all the complications, while in oncology it is possible to suspend the development of the disease until the appearance of clinical manifestations that significantly affect the quality of life of patients. This is facilitated by really impressive successes in the field of oncology and the fact that information about them is spreading rather quickly in society through the mass media. Much less is known in the population about the success (especially in European countries, but not in the United States) in the treatment of stroke, epilepsy, and some neurodegenerative diseases, although they are quite impressive [6].
Considering this problem, it should be borne in mind that for society, the "war on tumors" seems to be something common, not causing rejection. At the same time, the problems of neurological diseases, which are widespread and characterized by a complex prognosis, are less likely to come into view. A striking example is stroke: every year 16 million new, new-onset cases of stroke are registered in the world [13], and about 1/3 of patients die within 1 year from the onset of the disease [14]. From 25 to 74% (about 50 million in the world) of stroke survivors require partial assistance or remain completely dependent on outside care [15, 16]. Even after intensive rehabilitation measures, moderate or severe disability remains in 25-50% of patients [15]. In the eyes of society, the efforts of neurologists look much less successful than the work of an oncologist. At the same time, even a small success of oncologists is often perceived as a huge step forward [17]. To a large extent, this is due to the attitude of society (and even doctors who are not neurologists) to neurological diseases as potentially incurable.
Due to the fact that neurological diseases remain outside the close attention of society, in most cases the entire burden of treating and managing patients falls mainly on their relatives and friends. Cancer is a different matter - public concern about this problem is understandable, but it is still largely fueled by the activities of pharmaceutical companies that produce anticancer drugs. These companies are willing to invest heavily in research, marketing, training, etc. with the expectation of getting profit in the future - quickly and in large volumes. In the field of neurology, in the decade, at best, several truly innovative drugs have been developed, and the funds allocated for their promotion on the pharmaceutical market are incomparable with those spent in the field of oncology.
Teaching ethical aspects of neurology begins at the stage of basic training, when students study fundamental disciplines. Thus, the Department of Human Anatomy is the first to accept students for training in medical sciences. Starting from the first lessons, it is advisable to explain the moral standards that must be followed when working with cadaveric material. They
proceed from the main principle of medicine - humanism, ethics and respect for human dignity. At the same time, it is necessary to respect historical traditions in anatomy, to follow the continuity of generations. A student in a lesson in the anatomical hall should know and remember that cadaveric material is the remains of a person who once lived, felt, created. Respect for the parts of the human body in the anatomical room will help educate the future doctor and form his relationship with patients. Teachers should remember that the formation of moral and ethical norms in the mind of the student will allow in the future to exclude possible moral mistakes of the doctor.
The clinical neurology course at the medical school is designed to train general practitioners, not neuropathologists. Nevertheless, the teaching of neurology should occupy an important place in the education system, especially for pediatricians, due to the importance of the nervous system in the genesis of various diseases and in the normal functioning of the body. The objectives of the course of nervous diseases are: 1) development of practical skills for neurological examination of the patient, the ability to assess, on the basis of the revealed pathological signs, their semiological significance for determining the localization of the process; 2) training in the use and correct interpretation of data obtained using additional research methods (elec-trophysiological, radiological, biochemical, immuno-logical, etc.); 3) the development of clinical thinking as a method of cognition based on a dialectical understanding of the processes occurring in the body, based on modern scientific achievements: recognition of the most common diseases of the nervous system, which is the basis for the appointment of adequate therapy, prevention and determination of working capacity.
Improving the quality of training graduates of a medical university in the field of neurology is largely determined by the improvement of educational and methodological work at the department. Further development should be given to such teaching methods as lectures, practical exercises, student work at the patient's bedside, student independent work with a textbook and additional literature (monographs, special journals, etc.). Knowledge of this important clinical subject largely depends on the professional skill and erudition of the teacher, the high-quality conduct of the practical lesson, equipping it with modern visual aids and technical means. The main requirements for a student at the end of the course today are possession of practical skills in the prevention, diagnosis and treatment of diseases, the ability to theoretically expand and substantiate the etiology, pathogenesis of lesions of the nervous system, high stability of the knowledge gained.
Optimization of the educational process at the department covers all links, including its leading link -lectures. At the lectures, students are given at a high scientific level information about the state of problems of neurology, the prospects for its development, they get acquainted with its latest achievements and the contribution of domestic scientists, they develop the ability of scientific and clinical thinking, a deep understanding of various aspects of the disease process. Much atten-
tion is paid to the content, methodological and educational orientation of the lectures. The department carried out the unification of the content of lectures at all faculties, taking into account their specifics. Creative individuality, each teacher's own style of presenting the material is not excluded, but it is assumed that the lecture contains definitions, classifications, etc. that are the same for all faculties.
In the process of teaching neurology, it is necessary to teach the student to distinguish the form and content of the disease, to understand the dialectical inconsistency of the processes occurring in the body, to separate the essential, necessary from the accidental, to see the basis of the disease of the nervous system and make the right decision when making a diagnosis and choosing treatment tactics, to strive to develop the student's skills the application of the basic provisions of neuroscience to specific life situations, to use these provisions not according to a template, but creatively. The student is given ideas about the deontological aspects of neurology, about the problems of modern diagnostics in neurology, objective and subjective reasons for diagnostic errors.
The object of the teacher's close attention should be the formation of students' cognitive interest in the study of neurology, which undoubtedly affects the quality of acquired knowledge, abilities, skills and is one of the reserves of the productivity of the educational process. It is important to give students an idea of the importance of neurology in the future professional activity of a doctor, to show its role in solving scientific and practical problems of other disciplines. The formation of students' cognitive interest in neurology includes the following aspects: 1) to present the role of neurology as a necessary discipline in mastering the profession of a doctor; 2) show the relevance of neurology as a specific area of scientific knowledge; 3) to reveal the substantive aspects of clinical neurology in the profession of a doctor.
We attach great importance in improving the educational process to the creation of modern teaching aids. The department for medical faculties published such works as "Epilepsy and other paroxysmal disorders of consciousness", "Cerebral palsy", "Methodological developments in neurology for students of the medical faculty", "Manual on neurology and neurosurgery (educational guidelines for students of the medical faculty)," Features of teaching neurology and neurosurgery at the Faculty of Medicine (methodological guide for teachers)", "Organization of medical rehabilitation of children with perinatal lesions of the nervous system", "Collection of test questions and answers in the discipline "Neurology" (test control, practical skills and questions for module lessons)", etc.
Special attention at the department is paid to the control of students' knowledge, which ensures the systematic nature of their work, the possibility of the teacher's correction of the acquired knowledge. For this purpose, various types of control are used: 1) routine daily check, including programmed control (various types of tests) and oral questioning; 2) testing after working through an entire section of the course; 3) writing a detailed history of the nosological form; 4) control
during the examination of the patient; 5) test: checking the practical skills of students at the patient's bedside, programmed test computer control in anatomy, physiology and semiotics of lesions of the nervous system, oral interviews in private neurology, treatment and prevention, clinical and situational tasks. To unify the assessment of the quality of knowledge gained by students during preparation and in the classroom, as well as to solve them in the classroom in the case when educational work with thematic patients becomes difficult (severe and rare diseases, complex, methods of diagnosis and treatment, insufficiently full representation in classes of the studied forms of the disease, etc.), we have proposed a collection of test questions and answers in the discipline "Neurology" (test control, practical skills and questions for molar lessons). The training manual includes questions and sets of clinical (sit-uational) tasks on all the topics under consideration, which can be used not only for intermediate and final control of knowledge, but also for self-control of the student. Tasks are models of clinical situations, the questions to them usually correspond to the questions arising in medical practice: to make a detailed diagnosis, to decide with which diseases a given disease should be differentiated.
Conclusions and offers. Thus, the course of neurology broadens the student's medical horizons, contributes to the formation of the logic of clinical thinking, a deep understanding of the role of the nervous system in the physiological and pathological reactions of the body. This ideological role of the course of nervous diseases, its importance in the formation of a medical doctor, takes clinical neurology beyond the framework of the so-called narrow disciplines. The course of clinical neurology is of great importance for the formation of the clinical thinking of a modern doctor.
References
1. McQuillen MP. Pearls and pitfalls of ethical issues in neurology. Seminars in Neurology. 2001;21(4):353-358. http://dx.doi.org/10.1055/s-2001-19406
2. Pandya SK. Medical ethics in the Neurosciences. Neurology India. 2003;51:317-322.
3. Cardy P. Crossing the line — from neurology to cancer. Practical Neurology. 2004;4(6):318-321. http://dx.doi.org/10.1111/j. 1474-7766.2004.00260.x
4. DePolder Holler A, Doyle Lee J, Schulmal EA, Schafer JA, Flippen C. In- vited article: Improving safety for the neurological patient: Evaluation medications, literacy, and abuse. Neurology. 2010;75:742-746. http://dx.doi.org/10.1212/wnl.0b013e3181eee480
5. Illes J, Rosen AC, Huang L, Goldstein RA, Raffin TA, Swan G, Atlas SW. Ethical consideration of incidental findings on adult brain MRI in research. Neurology. 2004;62(6): 888-890. http://dx.doi.org/10.1212/01.wnl.000011853L9 0 418.89
6. Illes J. Neuroethics in a new era of neuroim-aging. American Journal of Neu- roradiology. 2003;24:1739-1741.
7. Ringel SP. Locked in or locked out? Neurology. 2004;62(9):1650-1652.
http://dx.doi.org/10.1212/01.wnl.0000123087.06540.3 d
8. Granek-Catarivas M, Goldstein-Ferber S, Az-uri Y, Vinker S, Kahan E. Use of humour in primary care: different perceptions among patients and physicians. Postgraduate Medical Journal. 2005;81(952):126-130.
http://dx.doi.org/10.1136/pgmj.200 4.019 40 6
9. Дамулин И.В., Шурупова Р.В. Проблемы и перспективы обучения неврологии в современных условиях. Журнал неврологии и психиатрии им. С.С. Корсакова. 2014;114(11):84-87. [Damulin IV, Shurupova RV. Problems and perspectives of teaching neurology to today's medical stu- dents. Zhurnal nevrologii i psikhiatrii im. S.S. Korsakova. 2014;114(11):84-87. (In Russ.)].
10. McQuillen MP. Pearls and pitfalls of ethical issues in neurology. Seminars in Neurology. 2001;21(4):353-358. http://dx.doi.org/10.1055/s-2001-19406
11. Pandya SK. Medical ethics in the Neurosciences. Neurology India. 2003;51:317-322.
12. Cardy P. Crossing the line — from neurology to cancer. Practical Neurology. 2004;4(6):318-321. http://dx.doi.org/10.1111/j.1474-7766.2004.00260.x
13. DePolder Holler A, Doyle Lee J, Schulmal EA, Schafer JA, Flippen C. In- vited article: Improving safety for the neurological patient: Evaluation medications, literacy, and abuse. Neurology. 2010;75:742-746. http://dx.doi.org/10.1212/wnl.0b013e3181eee480
14. Illes J, Rosen AC, Huang L, Goldstein RA, Raffin TA, Swan G, Atlas SW. Ethical consideration of incidental findings on adult brain MRI in research. Neurology. 2004;62(6): 888-890. http://dx.doi.org/10.1212/01.wnl.000011853L9 0 418.89
15. Illes J. Neuroethics in a new era of neuroim-aging. American Journal of Neu- roradiology. 2003;24:1739-1741.
16. Ringel SP. Locked in or locked out? Neurology. 2004;62(9):1650-1652. http://dx.doi.org/10.1212/01.wnl.0000123087.06540.3 d
17. Granek-Catarivas M, Goldstein-Ferber S, Az-uri Y, Vinker S, Kahan E. Use of humour in primary care: different perceptions among patients and physicians. Postgraduate Medical Journal. 2005;81(952):126-130.
http://dx.doi.org/10.1136/pgmj.200 4.019 40 6
EDUCATIONAL AND METHODICAL SUPPORT IN TEACHING THE DISCIPLINE "NEUROLOGY" IN HIGHER EDUCATION INSTITUTIONS
Kryvetska I.
Candidate of Medical Sciences, Associate Professor of the Department of Nervous Diseases, Psychiatry and Medical Psychology named after S. M. Savenko, Bukovynian State Medical University, Chernivtsi, Ukraine
Kryvetskyi V.
Doctor of Medical Sciences, Professor, Head of the Department of Human Anatomy named after M.G. Tur-
kevich, Bukovynian State Medical University, Chernivtsi, Ukraine
Kryvetskyi I.
Candidate of Medical Sciences, Assistant of the Department of Clinical Anatomy and Operational Surgery,
Bukovynian State Medical University, Chernivtsi, Ukraine
ABSTRACT
The article reveals the main methodological approaches to teaching clinical neurology at the medical faculties of Bukovina State Medical University, aimed at improving the educational process, its optimization and intensification in order to improve the quality of training university graduates in the field of neurology. Keywords: teaching methods, neurology.
Further development of higher education and medicine, in particular, is impossible without a creative search for new ways and methods of improving the educational process, its optimization and intensification.
The clinical neurology course at the medical school is designed to train general practitioners, not neuropathologists. Nevertheless, the teaching of neurology should occupy an important place in the education system, especially for pediatricians, due to the importance of the nervous system in the genesis of various diseases and in the normal functioning of the body [16].
At the Department of Nervous Diseases, Psychiatry and Medical Psychology, the names of S.N. Sav-enko uses technical teaching aids: negatoscopes, film cameras, epidiascopes, graph projectors, multimedia
projectors, computers. There are lecture halls, radio and cinematographic, with projection devices. A training room for pediatric groups was allocated on the basis of the neurological department of the children's hospital, equipped with visual aids (tables, diagrams, X-rays, drugs, transparencies). The educational process is facilitated by equipping the department with computers, the presence of diagnostic rooms (electro- and rheo-en-cephalography, ultrasound methods, etc.), as well as the fact that the department has a children's neurological department (for 40 beds), an intensive care and resuscitation department, medical rooms (Exercise therapy, IRT).
Practical classes are of decisive importance, since students are faced with real medical activities in them, which makes them pay special attention to them when
