Development of personal competencies of a cardiologist

The article considers federal educational and professional standards for doctors’ training from a practical point of view. In contrast to algorithms, clinical guidelines and protocols for healthcare delivery, competence in the field of informing and communicating with a patient and legal representatives requires the humanitarian skills, that is, a fundamentally different methodological point of view. The ways to develop such skills in a general practitioner or a cardiologist during education are not clear. In many countries, research is being conducted on the need for doctors to master not just patient-centered skills, but specific communication skills for cardiology practice. Certain favorable results are evident, but such work is complicated by a completely different epistemological category of this kind of skills than the generally accepted biomedical one, which is usually called clinical.

The training of a future general practitioner, who has passed the initial accreditation, and then a cardiology resident, requires a young specialist to acquire some competencies. Federal state educational standards prescribe specific universal (UC) and general professional competencies (GPC), while professional standards provide an exhaustive list of labor functions (LF) and actions that must be implemented in educational programs of higher education. In this article, we will consider a number of special skills of a cardiologist, based on our experience in practical health care and teaching experience.
Obviously, in routine practice, a newly-minted doctor is faced not only with biomedical problems (etiology, pathogenesis, diagnosis and treatment of diseases), but also with problems of interaction with patients, their legal representatives, as well as with colleagues and institution authorities. This kind of interaction is an integral part of a doctor's work and requires psychological skills, cultural and ethical competence. These requirements are laid down in educational and professional standards.
The professional standard Сardiologist includes LFs related to informing patients, developing their healthy lifestyle skills, primary or secondary prevention, and health education [1]. These quite specific and brief requirements of the professional standard pose challenges, the implementation of which is essentially different from usual biomedical com petencies, such as medical examination, interpretation of diagnostic tests, documentation, prescribing a therapy and monitoring its effectiveness and safety. The difference between these tasks is that the doctor deals with a patient's cultural and psychological features -as a person living in society, having a social circle, plans, dreams, desires, etc. The biomedical component undoubtedly dominates, first of all, due to the specifics of evidence-based healthcare model.
The federal state educational standard of a General Medicine specialist suggests the following UC and GPC [2,3]: -ability to analyze and take into account the cultural diversity in the context of intercultural interaction (UC-5); -ability to form an intolerant attitude towards cor ruption (UC-11); -ability to implement moral and legal standards, ethical and deontological principles in professional activities (GPC-1).
Professional competencies are established by an educational organization based on a professional stan dard. The professional standard was approved by Order of the Ministry of Labor and Social Protection of the Russian Federation of March 21, 2017 № 293n, which includes, among other things, the following labor actions and skills (A.02/7): -personalized patient treatment, including pregnant women, elderly and senile patients, asses sment of treatment effectiveness and safety; -ability to collect complaints, history of a patient and analyze the information received; -knowledge of the regularities of healthy body functioning and the mechanisms of ensuring health in the context of the theory of functional systems; features of the regulation of body functional systems in pathological processes.
The above requirements for doctor qualifications indicate the need for future specialists to develop communication skills, ethical subjectivity, ethical decision-making, the ability to analyze the patient's words, and the skills of internal psychological work. And besides, it is important to take into account the goal-setting of health care provision -preservation of health, which raises the question of health concept. Let's take a look at these categories in order.
Health. The concept of positive health goes back to the definition of the World Health Organization and is also contained in Russian legislation. Article 2 of the Federal Law On the Basics of Health Protection of Citizens in the Russian Federation dated November 21, 2011 indicates that health is a state of physical, mental and social well-being of a person, when there are no diseases, as well as organ and body system dysfunction. Obviously, health cannot be defined in terms of denial of pathology or disorders. A positive definition of health assumes full physical adaptation of the body to environment, when its widest possible changes will not significantly violate the body's function. In the same way, you can designate the psychological and social levels. And given the integrity of these levels, their interaction should also be healthy [4].
Ethical decision-making. This category is parti cularly difficult, since outside the bounds of legal regulation, ambiguous ethical issues require a large amount of data for an optimal solution. Risk and benefit assessment is a classic example of this decision kind, and in addition to biomedical risks, the patient's goal-setting, his attitude to the situation and the risk/benefit understanding are taken into account in the decision-making process. In this sense, for example, antithrombotic therapy is always a compromise between the prevention of thrombosis and an increase of bleeding risk [5].
Ethical burden as such (as opposed to medical risks) appears in this situation, when the result and effectiveness of therapy depends on the patient's adherence, and adherence depends on the patient's attitude to treatment and other recommendations, on the financial component, as well as on his overall trust in doctors and health care system [6]. This raises the question of full communication.
Communication skills. Requirements for the communicative competence of a doctor are laid down in deontological imperatives, such as a doctor's oath and codes of ethics. The doctor is required to have skills for conflict resolution, motivating to follow recommendations, and increasing adherence to therapy. The doctor must inform the patient and his legal representatives (if necessary) about the legal aspects of health provision, and also answer the questions that are asked. The ability to accept the patient as he is is considered an important skill for the practitioner. And although in general such skills can be taught separately, at a more abstract level all these requirements regard a professional personality.
Internal work skills. In the psychological sense, internal work should be understood primarily as reflection, i.e. the ability to give an account of one's emotional state, its causes, external factors that have influenced and damaged one's own personality. Internal work should be a habit. However, in case of emotional burnout signs of course, a psychologist should be visited. To prevent burnout, it is important to timely reflect on the personal routine problems [7].
The listed basic cultural and psychological competences are generally included in a doctor's qualifications. In cardiology practice, this is of parti cular importance, since the overwhelming part of cardiovascular diseases refers to the so-called noncommunicable diseases, or rather, to pathology associated with psychosocial risk factors. It is on the outcome of a doctor's interaction with a patient that the picture of situation/disease depends, which determines the motivation of a patient. Training the healthcare professional in the right kind of communication skills is a necessary part of education.
The characteristics of cardiologist training in terms of communication are given the attention of researchers. Gigon F, et al. (2015) address the issue of so-called advance directive -a document that a person can draw up in case he loses the ability to make decisions on his own, which indicates his wishes regarding possible medical interventions. The authors note that few such documents are produced and this could be influenced by a physician working with patients. As a result of studying the questionnaire survey of doctors, the following conclusion is made. In general, doctors have a fairly high level of communication skills, but it drops sharply when it comes to death and related aspects, including the advance directive. The competence of physicians in discussing end-of-life, death, and care during these periods should be enhanced [8]. Another study of complex communication situations in cardiology practice was carried out by Berlacher K, et al. (2017). As a prerequisite, the authors note that in some cases, cardiologists need to make a choice of therapy for severe patients, and this choice should take into account the goals of treatment of the patients themselves. The interviewed doctors (89%) noted that they received training in communication skills, but it was not enough. The authors propose a learning system, called CardioTalk, that would help cardiologists improve their ability to talk to patients about difficult issues. CardioTalk is a two-day master class for physicians held at a major clinical center and includes trainings on the communication difficulties with critically ill people. It is based on the VitalTalk training designed for oncologists, nephrologists and geriatricians [9]. Another study by Cuevas AG, et al. (2019) focused on the impact of patientcentered communication on patient confidence in decision-making. Doctors were asked to watch video sketches, where a physician demonstrating a high or low level of patient centeredness informs a patient with exertional angina and three-vessel involvement about the need for coronary artery bypass grafting. Subsequent questioning of doctors (n=231) found that the distrust in the doctor and healthcare in general negatively affects the result of communication with the patient and decisionmaking, which subsequently affects the outcomes. The authors note that the actual training of patientcentered communication can be the ways to increase the effectiveness of interaction. Attention should be paid to what the patient is more concerned about, his priorities [10]. Psychological features of cardiology care for cancer patients is considered in study by Lestuzzi C, et al. (2020). The authors note that patients transferred from oncology departments differ from those familiar to cardiologists. Each of the situations (newly diagnosed cancer, side effects of chemotherapy or radiotherapy, etc.) is unique, including from a communicative point of view. The authors offer practical recommendations for the interaction of a cardiologist with a cancer patient [11]. Finally, the study by Svavarsdóttir MH, et al. (2016) focused on the knowledge and skills of health professionals need to educate patients with coronary artery disease. The authors assumed that additional skills beyond medical knowledge are required to effectively educate newly diagnosed patients. Interviews were conducted with cardiologists, nurses and physiotherapists, and the following presentation was obtained. An advanced theoretical and clinical knowledge is needed along with high-quality communication skills to effectively educate a patient. In particular, the clinician needs to be able to establish interpersonal relationships with patients, to understand their need for specific knowledge, to facilitate effective dialogue and to provide personalized health education. In general, it was noted that communicative and pedagogical skills are needed, which patients do not have [12].

Conclusion
The above studies, along with the presented arguments, raise very specific questions for higher education institutions and clinical facilities involved in cardiologist training. By themselves, communication skills can be conditionally divided into two levels: more practical, instrumental, and more general, holistic. Instrumental skills training is possible in the form of trainings and master classes, which are popular today. On a more general level, training as such poses rather great difficulties, since knowledge or training is not enough to create an integral and full-fledged personality. The aforementioned ability of internal work is required, as well as the ability to draw messages from culture that will help to comprehend the difficult events. In the development of such competence, one can rely on literature, cinema and other types of art, as well as on deontological authorities, i.e. doctors who occupy an important place in medicine culture.