The main topic of this review is invasive procedures used in Russian healthcare without sufficient indications. Recommendations are generally avoided here. Analogous conditions in adults have been discussed previously: the overuse of gastrectomy for peptic ulcers, of thoracic surgery for tuberculosis, bronchial asthma and other respiratory diseases, overtreatment of radiation-related lesions, spleno-renal anastomosis in diabetes, excessive and compulsory treatments of alcoholics, and cauterisation of cervical ectopy regardless of the presence of epithelial dysplasia [1]. Considering the breast cancer incidence, millions of women in the former Soviet Union underwent Halsted and lately of Patey mastectomy with removal of pectoral muscles without indications, often sans informed consent. This topic is interconnected with certain features of Russian healthcare, namely paternalism, authoritative management style, occasional disregard for the principles of informed consent, professional autonomy and scientific polemics. In conditions of paternalism, misinformation of patients, persuasion and compulsory treatments are regarded to be permissible. Of note, the principle of informed consent or assent is applicable also to adolescents and children. Considering shortcomings of medical practice, research and education, a simple increase in funding is unlikely to be a solution. Measures for improvement of the healthcare in the Russia Federation (RF) must include participation of authorised foreign advisors. Unfortunately, current international tensions are not contributing to this development.

Respiratory Conditions

The first method to be commented is the thoracic surgery with the denervation of lungs as a treatment of bronchial asthma [2-4] referred to as “the most accepted procedure” in the Guidelines by the Health Ministry [8]. Among others, the “skeletonization” of pulmonary roots with transection of nerves, auto-transplantation of lungs (complete removal with immediate re-implantation) [4,5] or cross-section of trachea with subsequent suturing [6] were applied. The theoretical ground was the assumption that denervation “precludes abnormal nervous impulsation” [2]. Such argumentation was usual at that time, when the so-called ideas of nervism, based on the concept of trophic function of the nervous system by Ivan Pavlov, were propagated. Exaggerated histological descriptions of “dystrophy” or degeneration in the autonomic nervous system, claimed to be irreversible, were presented as a theoretic basis of the denervation [2,7]. Stepan Babichev, the main protagonist of the asthma surgery, was a military surgeon, later the chancellor of Moscow Medical Stomatological Institute (currently named University) and assistant of the Health Minister. The surgical treatment of asthma was recommended by the Health Ministry [8] whereas thoracotomy with lung denervation was designated as “the most accepted surgical treatment.” The skeletonization was patented and advocated for steroid-dependent and infectious-allergic asthma varieties [8,9]. Repeated bronchoscopies were applied post-surgery because of the bronchial drainage impairment [4]. The pulmonary denervation and lung resections were recommended also for asthma cases when drug and inhalation therapy had been efficient. It was suggested that non-invasive treatment prior to the operation must be limited in time [8]. One research group found indications for surgery in 41.7% of 986 asthma patients; 457 operations were performed, whereas the following complications were recorded: in 27 patients - inflammation not otherwise specified; 12 - dysphagia, vocal fold palsy or Horner syndrome; 11 - pneumonia, empyema, pneumothorax, 2 cases of paraplegia and hemiparesis; 58 complications not otherwise specified; 6 patients died within a month after the surgery [10]. By 2002, the method was still in use [3]. Denervation was sometimes performed simultaneously with lung resection, lobectomy or bilobectomy [11]. In this connection, a quote from the recommendations of the Health Ministry [8] deserves attention: “The widespread idea that indication for surgery in asthma is the ineffectiveness of conservative therapy is incorrect. The presence of foci of chronic inflammation in the lungs and bronchi, even with a good effect from conservative treatment, is an indication for surgery. Delaying the operation serves to involve other parts of the bronchial tree in the inflammatory process, enhances the degree of allergy, degenerative changes in the innervation apparatus and endocrine organs” [8]. Such instructions could lead to resection of largely preserved pulmonary tissues, which was noticed by pathologists.

As mentioned above, the denervation surgery was sometimes combined with removal of pulmonary segments or lobes regarded to be pathologically altered [8]. Pulmonary resections in asthma were used also without denervation, even in the cases when inhalation or drug therapy was efficient. Among indications for the surgical treatment were focal lesions: chronic pneumonia, bronchiectasis and “bronchitis deformans” [12]. Sokolov [13] stated that ≤10% of their asthma patients underwent resections. The surgeries were performed also in patients with bilateral inflammatory or fibrotic lesions, both in exacerbations and in remissions, supposed to be indicated for a radical treatment of asthma. This concept was advocated by Fedor Uglov [12,14], who claimed a “resection of infected foci” to be the aim of asthma management. The therapy was based on the belief that “in 98% of cases, the cause of asthma is focal chronic pneumonia” [12]. The purpose of the operation was the “removal of focal infection.” Localized chronic pneumonia with bronchial lesions was by itself regarded to be indication for lung resection. Asthma patients were transferred from internistic departments for the surgical and bronchoscopic treatment. “After a course of therapeutic bronchoscopies”, Uglov [12,14] performed resections of the parts of lungs regarded by them to be pathologically changed.

Resections were applied to children with recurrent bronchitis and/or pneumonia; while particular efficiency of pneumonectomy was stressed, also in case of bilateral involvement [15]. The recommendation for progressive chronic pneumonia was “lobectomy for segmentary lesions and pneumonectomy in all other patients” [16]. Reportedly, “dysontogenetic” lung diseases in children were a more frequent indication for radical surgery than acquired conditions; whereas lobe- and pneumonectomies were predominantly applied [17]. Irina Esipova [18] found malformations in 66% and “bronchial diverticulosis” in 64% of resected specimens from children operated for relapsing pneumonia or “bronchitis deformans”. The same authors reported that, contrary to preceding publications, the changes in their material were not diffuse but local, thus justifying resections. Contemporary international literature was referenced scarcely in suchlike papers. Prof. Esipova [18], a well-known expert often cited in RF, claimed that misdiagnosis of malformations as chronic bronchitis led to undue postponements of surgery. In accordance with this concept, pathologists described in surgical specimens inflammatory infiltration, fibrosis, dystrophy and malformations without specifying their extent and severity, whereas descriptions were not the same as in the international literature e.g. (Ohm B, Jungraithmayr 2023), histological images being poor quality; images are in the book by Jargin [1].

Some proposed criteria of malformations were formulated and illustrated unconvincingly: large bronchi with uneven, serrated (jagged) contours, bushy aggregations of small bronchi and bronchioles, variously differentiated mesenchyma with lymphoid infiltration, rhythmic muscular fascicles, and local agenesis of alveoli represented by connective tissue [19]. Reading descriptions by Esipova [18], it seems to an ex-Soviet pathologist that some resected lobes were not significantly abnormal: macroscopically whitish foci and coal pigment, singular cysts 2-3 mm; microscopically atypical bronchial branching, hypoplasia of bronchial walls, abnormal epithelial cilia etc. Descriptions of this kind were often used for largely normal specimens; clinical significance of the findings being unclear. However, such reports from pathology departments were suitable to justify resections. Undoubtedly, in some cases the surgery was indicated; but there has been an overtreatment tendency. It was rightly noted that many authors made no distinction between congenital malformations and developmental variants [20]. In a more recent publication an opinion was expressed that some histological phenomena described as malformations are common in postnatal lungs normally or after resolved pneumonia [21]. It was also noticed that diagnostics of lung malformations is difficult; the percentage of wrong diagnoses amounting to 65-75%. The patients were operated nonetheless based on the assumption that inflammatory complications are inevitable [15].

Concluding their articles, some pathologists generalized that the “disease that affects children in the first year of life, against the background of morpho-functional immaturity of the lungs, intense metabolic processes and imperfection of local nonspecific and immunological defense, is accompanied by a breakdown of typical protective reactions, impaired regeneration and postnatal development of the lungs, excessive expression and rapid depletion of compensatory and adaptive processes. The latter underlies the alterative-exudative changes, the impossibility to delimit inflammation, determines the progressive course of bronchiectasis and requires surgical treatment at the age of 2-6 years” [23], emphasis added.

Tuberculosis

After the successful development of medical treatment of tuberculosis (Tb), the use of surgery has decreased in many countries. The spread of drug-resistant strains of M. tuberculosis has reduced success rates of treatments with drug therapy alone and increased the number of patients who require surgery. Priority of RF in this field was claimed. The surgery has been performed not only in specialized centres but also in peripheral hospitals. This development was associated with the name of Mikhail Perelman, who criticized the Directly Observed Treatment, Short Course (DOTS) Program by the World Health Organization and endorsed the surgical treatment.

In the period 1973-1987, 285,000 patients with pulmonary Tb had been operated in the former SU, in 1987 - 26,000, while 85% of the surgeries were lung resections. In 1986-1988, ~17,500 operations for lung Tb were performed annually in RF only in specialized institutions. The incidence of Tb in 1986 and 1988 was, respectively, 43.8 and 40.8 per 100,000. More than 29% of newly diagnosed Tb cases were operated at that time. By 2003, the quantity of surgeries decreased down to 10,479 (~9% of newly diagnosed cases), regarded to be insufficient. In the foreign literature, corresponding figures are usually below 5%. The incidence of Tb in RF increased from 34.0 in 1991 to 90.4 per 100,000 in the year 2000. Similarly to other diseases, this drastic increase could have been partly explained by an underestimation during the Soviet period. In the year 2006, 12,286 operations were performed in RF for pulmonary Tb, including 9300 (75.7%) resections and 399 (3.2%) pneumonectomies. According to another report, the forms of Tb most frequently treated by resections and pneumonectomies were cavitary Tb (52.2%) and tuberculoma (43.9%). For example, a series of 578 operations in 502 patients, including those with fibro-cavernous Tb (196 cases) and tuberculomas (161 cases), was reported, whereas the most frequent procedures were resection (280 cases) and pneumonectomy (80 cases). The authors concluded that “indications for surgical management of pulmonary Tb should be generally expanded” [20]. Tuberculoma was the form of Tb most often operated by Giller: 81 from 179 cases in one series. The video-assisted thoracoscopic surgery (VATS) is used increasingly these days.

Resections were recommended also for patients with inactive post-tuberculous fibrosis including oligosymptomatic cases (Kiseleva 1976). On the other hand, operations were performed in florid disseminated disease. In some provinces of the Urals, Siberia and Volga regions, 25-40% of patients with destructive Tb were operated on (Priimak 1989). At the time of initial diagnosis, surgery is considered to be indicated in 15-20% of patients these days (Borodulina, Kalechenkov and Elkin 2016). According to another paper, indications for surgery were found in 20-30% of patients at the time of diagnosis and/or in those with active Tb (Perelman 2002). In Yekaterinburg and surrounding province (years 2006-2008), indications for surgery were found in 1784 from 4402 (40.5%) patients with pulmonary Tb, while 1079 (24.5%) were operated on. Among reasons of the supposedly low surgery rate were the patients’ non-compliance and unavailability. According to the recent handbook, ~6.4% of Tb patients are operated in RF; but “in some provinces, which cooperated with the Perelman’s Institute… the percentage has been much higher”. It was stated in the seminal article that a half of lung surgeries in RF had been performed for Tb.

The recommendation to remove tuberculomas stems from Lev Bogush (Editorial 1975). Non-progressive tuberculoma (generally or >2 cm) has been regarded as indication for surgery in adults and children. Tuberculomas >1 cm were often resected. Another indication in children and adolescents is the “absence of the positive dynamics” after 6 months of medical therapy or earlier in case of drug resistance. The drug resistance per se and “irreversible lesions” were declared to be indications for surgery. Note that tuberculoma is a stable lesion; and positive dynamics should not be generally expected. Now as before, tuberculoma is among the forms of the disease that are most frequently operated on. It was the most frequent indication for lung surgery in pulmonary Tb at the leading institution - the I.M. Sechenov Medical University: 44.2% in general and 40.7% in children. At some phthisiological hospitals this percentage amounted to 50-80%. The surgical treatment of tuberculoma was recommended also for cases with extensive lesions in remaining pulmonary tissues (Health Ministry 1983). Bilateral resections were performed in various forms of Tb including tuberculomas on both sides. A research from I.M. Sechenov University reported 771 lung operations, including 168 pneumonectomies, 181 lobectomies, 180 other resections, performed in 700 Tb patients, up to 4 operations per patient. Postoperative complications were recorded in 100 (12.9%) and lethal outcomes in 12 (1.5%) of the cases. Another example from the same Institution: among 60 operated Tb patients, the complication rate was 37%, mortality - 5%; 18.3% of the patients were released from the hospital with persisting complications.

Out of 1,311 Tb cases operated at the Phthisiopulmonology Institute in St. Petersburg, 241 had recurrences and 203 underwent repeated interventions. Postoperative recurrences were regarded as indications for repeated surgeries up to a concluding pneumonectomy and resections of the remaining sole lung. For example, repeated resections on both sides ending with a pneumonectomy, along with 52 bronchoscopies, were performed in one case. Bilateral lobectomies or pneumonectomy plus contralateral “sparing” resection were regarded to be indicated for patients with a Tb lesion on one side and non-specific inflammatory or fibrotic lesions in the contralateral lung. Bilateral resections and bilobectomies were performed in different specific lesions including tuberculomas. According to a recent monograph, among 420 patients operated for tuberculoma, bilateral operations were performed in 130 (31%). Resections were regarded to be applicable also in cases with severe respiratory insufficiency.

According to another report, tuberculoma was the most common indication, and lobectomy - the most frequent operation in elderly Tb patients, whereas potential contagiosity was among arguments in favor of the surgical treatment (Sokolov 1978). Statements of this kind can be found also in recent papers e.g.: “Surgery in patients with tuberculomas is recommended to reduce their infectiousness”. According to Giller and co-workers, a reduction of Tb incidence and mortality can be achieved only through a “radical sanitation” of contagious patients including those without destructive pulmonary lesions (Giller M. tuberculosis circulation in the society” has been declared one of the goals of the surgical treatment. Of note, tuberculoma is usually not contagious. Early compulsory hospitalization has been recommended.

Endoscopy

Bronchoscopy (Bs) has been used in bronchial asthma in spite of the existing opinion that it brings not much benefit. In the international literature, no particular role of Bs in the diagnosis and treatment of asthma has been specified, while the risk of complications may be enhanced. Among indications for Bs in asthma are persistent wheeze unresponsive to bronchodilators and other therapy. The common indication for Bs in asthma is a search for alternative causes of the symptoms while there are also other diagnostic tests. Lavage of bronchi can be indicated in severe asthma in certain circumstances. Recommendations are generally avoided here. The newest Russian-language textbooks are largely based on the international literature that is available today on the Internet. However, earlier manuals contained recommendations partly at variance with internationally accepted ones. In asthmatics, the purpose of Bs was claimed to be the search for signs of dependence of the pathological process on infection and characterization of inflammatory lesions (Isaeva 1994, Klimanskaia 1972, Palamarchuk 2019). The same authors noticed that Bs in asthma provokes bronchospasm. Abundant secretion or mucopurulent sputum in children was presented as an indication for Bs “for evaluation of the endobronchial inflammation” (Klimanskaia 1999). It was stated in the monograph by Klimanskaia (1972) that in children Bs is recommended “almost in all subacute and chronic respiratory diseases”. Asthma, tuberculosis (also if suspected), bronchitis, protracted pulmonary and bronchial conditions were presented as blanket indications for Bs in adults and children. In severe diffuse catarrhal-purulent endobronchitis in children, Bs was performed once every 4-5 days (Goikhenberg 1974).

Extension of indications for Bs compared to the more conservative earlier recommendations is associated with the names of Lev Ioffe and Fedor Uglov [12-15] wrote in an instructive edition that “Bs must be performed in all pulmonary diseases.” Uglov [12], reported on 2477 therapeutic and 5000 diagnostic Bs performed in his institution in patents aged 1.5-78 years predominantly with inflammatory diseases such as bronchitis, pneumonia and asthma, aimed at the “assessment of inflammatory changes in the bronchial tree.” The conclusion was that Bs is important for the detailed diagnosis of practically all pulmonary diseases and can be recommended also at an early stage. “After a prolonged course of therapeutic Bs”, Uglov applied resections of pulmonary segments or lobes regarded to be irreversibly changed (bronchitis deformans, bronchiectasis etc.) as a treatment method of asthma [12]. At the same time, difficulties with the local anesthesia were pointed out, which necessitated general anesthesia in 20-25% of the patients. In particular, technical difficulties of Bs were noticed in asthmatic patients. Considerable discomfort might have been associated with those “technical difficulties” without benefit for the patients. Many thousands of Bs in children and adults with asthma, bronchitis and pneumonia were reported in the same Collected Volume also from peripheral institutions and outpatient facilities. Repeated Bs in children under local anesthesia led to psychological derangements as well as to damage of teeth, larynx and bronchi. Health care authorities sometimes favored less individualized approaches applicable to large categories of patients.

Bs was applied and recommended in children and adults with bronchial asthma both during remissions and exacerbations, in mild and severe cases, as well as in “pre-asthma” i.e. bronchitis with “elements” of bronchospasm and allergy. Bs was discussed as a method of early diagnosis of all forms of bronchial asthma; it was used repeatedly “for a dynamic observation” (Skopina 1980). Some experts applied up to 15 Bs (1-2 weekly) in pediatric asthma. At the same time, Bs in asthma was noticed to be associated with enhanced complication rate. Nonetheless, the same experts performed 388 Bs in 216 asthma patients resulting in no changes of diagnoses.

Efficiency of therapeutic Bs in moderate bronchitis was pointed out by Uglov (1971), who applied 5-6 bronchoscopies per treatment course. In particular, the “atrophic type” of chronic bronchitis was regarded as an indication for Bs (Chernekhovskaia 2008). Laser therapy was applied in children and adults via bronchoscope in asthma, bronchitis and chronic pneumonia, also in atrophic bronchitis or “primary atrophic bronchopathy” including that supposedly caused by ionizing radiation, while histological specimens were thick and difficult to evaluate (Nepomnyashchikh 2000). Some images are reproduced in the book by Jargin (2024). Similarly to other forms of electromagnetic radiation, laser at lower power densities causes warming and at higher densities damages tissues. From the viewpoint of general pathology, atrophy may advance due to additional damage. Not only flexible but also rigid bronchoscopes have been used e.g. in chronic bronchitis or asthma also in children. For acute pneumonia in children, Bs was recommended to determine the type of inflammation in the bronchi (catarrhal, purulent); in chronic pneumonia it was held necessary for the same purpose and also to rule out Tb and congenital conditions. In pediatric chronic pneumonia, Bs was recommended by the Health Ministry (1976) for the diagnosis and therapy as “one of the main methods.”

Furthermore, broncho- and gastrodoudenoscopy were used as a second phase of screening in “chronic non-specific pulmonary diseases” (including asthma and chronic bronchitis) reportedly found in 4.08% of children residing in industrially contaminated areas of Moscow and the suburbs (Klimanskaia and Vozzhaeva 2001). Bs was used as a screening method in agricultural workers contacting with dust: both in healthy ones and in those with allergic rhinitis or chronic bronchitis; in bronchitis patients contacting with proteolytic enzymes; generally in bronchitis, acute and chronic pneumonia including children; in young patients supposed to have community-acquired pneumonia (Ismagilov 2009) e.g. 1478 procedures in 977 conscripts 19, 5±0,1 years old with supposed pneumonia. Finally, bronchoscopy was performed in patients with asbestos-related bronchitis and with suspected dust diseases.

As mentioned above, bronchial biopsy specimens have been used for research, some histological specimens being poor quality. Morphological descriptions were often stereotype, morphometric and other quantitative indices changing uniformly. E.g. inflammatory indices (serum immunoglobulins, T- and B-lymphocytes, and markers of phagocytosis) were influenced in the same direction both by medical and surgical asthma treatment (Savchenko 1982). Manipulation of statistics was proven in some cases; more details and references are in the book by Jargin (2020). Some histological descriptions were doubtful e.g. “atrophic processes” in bronchi of asthmatic children increasing with time: atrophy or “subatrophy” reportedly found in 79.5% of asthmatic children older than 12 years. Biopsies were taken for research from large bronchi of patients with known lung cancer; the quality of histological and ultrastructural images was low, which implies additional discomfort with no consequences for the therapy. Another example: lavage fluid collected by Bs from patients with lung cancer and from those with tuberculosis (including focal forms, tuberculoma etc.) was examined by infrared spectroscopy, apparently, with no repercussions for theory and practice.

In the pediatric clinic of the Sechenov Medical Academy (a leading institution where textbooks have been written, endoscopic methods have been broadly used for diagnostic, therapeutic and scientific purposes since the 1960s. Bs was used in children with pneumonia, bronchitis and asthma, while complications were noticed. Besides, gastrodoudenoscopy with biopsy used for research was applied in children with rheumatoid arthritis, dermatomyositis, scleroderma, systemic lupus erythematosus, respiratory and hepatobiliary diseases. Gastroscopy was used for the screening of children born to mothers with bronchial asthma.

Bs has been applied in all forms of tuberculosis (Tb) in many institutions and research cohorts, also when Tb was suspected in adults and children, in (sparce) bacillus excretors (Saveleva 2024); among others, in a framework of diagnostic algorithm for suspected Tb with the sputum negative for M. tuberculosis (Palamarchuk 2019). Primary Tb was regarded as an indication for Bs in children (Isaeva 1994), although it is reportedly no more sensitive for the culture than gastric aspiration. Bs was used as a screening method for Tb in patients with general malaise, having both negative and “hyperergic” (high degree of hypersensitivity) tuberculin tests, or as a second step of screening for Tb in children. Endoscopic monitoring was applied in pulmonary Tb with non-specific bronchial lesions. In the recent handbook of pediatric pulmonology, “suspected Tb” is listed among indications for Bs (Blokhin 2021). Therapeutic Bs and bronchoscopic monitoring has been applied also in supposed Tb with non-specific bronchial lesions. In destructive Tb, therapeutic Bs (1-2 weekly during 2-4 months) was recommended by the Health Ministry (1982). An example: 22,469 Bs were performed in 5195 patients from 1994 through 2013 (1123 Bs yearly on average), including 1766 (34%) patients older than 65 years, at a phthisiological hospital in Moscow (705-1225 beds at different times; 368 surgeries performed in 2013). Of note, viruses can be transmitted at endoscopy (Saludes 2013). Not surprisingly, the incidence of hepatitis B was found to be five times higher in Tb patients than in the general population of RF (Kulakova 2004). The enhanced frequency of viral hepatitis or of its markers in Tb patients including children was reported. Indications for Bs are beyond the scope of this review. Outside the former SU, Bs has not been routinely performed in all Tb patients; details and references are in (Jargin 2021).

Some bronchoscopic methods used for diagnostics and therapy have been patented; several examples follow. Therapy monitoring of chronic catarrhal bronchitis by means of repeated examinations of bronchial washings obtained by Bs every other day during the whole period of treatment; bronchitis diagnostics in children and adults; laser therapy via bronchoscope of “atrophic bronchitis deformans”. The treatment of pulmonary tuberculosis by endobronchial instillations of surfactant every other day during 3-8 weeks was discussed by Jargin (2013). As mentioned in other above, the principle of informed consent was not sufficiently known and observed, being mentioned only in some recent Bs studies. Paternalistic and authoritative attitude to patients often prevailed. Admittedly, as far as it can be perceived from the literature, endoscopy is less frequently used for research today and informed consent is often mentioned. In the study by Fedorov (2005), Bs was performed in children 5-15 years old with moderate to severe asthma, while informed consent was obtained from parents. Note that the principle of informed consent (or assent) is applicable also to adolescents and children. When a child is able to give assent to decisions about participation in a research, investigators must obtain it in addition to the consent by parents or legally authorized representatives. Adolescents are in a sense between children, who are to be treated according to their best interests represented by parents or caregivers, and independent adults, who are to be treated according to their wishes.

The mentioning of informed consent started in papers from RF not long ago; for example, in a bronchoscopic study of pediatric asthma, where consent of parents was sufficient. The principle of informed consent or assent is applicable also to adolescents and children. It is recommended in the recent monograph titled “Pulmonary tuberculoma” to explain to the patients in popular form that surgery is necessary instead of objective depiction of pros and cons. The training of medical personnel under the imperative of readiness for war has been another motive. Some surgical and other invasive methods with questionable indications were advocated by first generation military surgeons. The Soviet period brought about an expansion of admission numbers to universities and medical educational institutions, sometimes with little regard for the quality of the academic preparation. At the same time, medical faculties were separated from universities; and medical science was partly detached from the mainstream scientific thought (Burger 2004). Furthermore, among factors contributing to the use of invasive procedures with questionable indications has been the partial isolation from international scientific community, insufficient consideration of the principles of professional autonomy and scientific polemics, as well as paternalistic attitude to patients. Ethical and legal basis of medical practice and research has not been sufficiently known and observed in RF. The term “deontology” is often used for medical ethics in this country. Textbooks and monographs on deontology explained the matter somewhat vaguely, with truisms and generalities but not much practical guidance. Insufficient coordination of medical studies and partial isolation from the international community can result in parallelism in research, unnecessary experimentation, and application of invasive procedures without sufficient indications (Jargin 2020). All said, the role of surgery in Tb remains controversial. The message of this review is that patients should not undergo invasive orocedures to comply with doctrines. Evidence-based clinical indications must be determined individually, the patients being objectively informed on potential benefits and risks. 

Invasive procedures including endoscopy and biopsy used for research without sufficient clinical indications fall under the jurisdiction of the Declaration of Helsinki. In any case, such research presupposes integrity and informed consent. The consent for participation in studies implies that the subjects fully understand their role and risks, being able to withdraw any time without disadvantage. Children need additional protection. In the author’s opinion, biopsy and endoscopy for research, Bs in particular, should not exist as such; it must always be implemented according to clinical indications. Research can be performed on biopsy specimens collected for diagnostic purposes. However, enough tissue must remain for the diagnostics. Archived tissue in paraffin blocks may become necessary for repeated diagnostic examinations. In any case, the research involving humans should yield valuable results, not procurable by other methods. Furthermore, medical research involving human subjects must be conducted only by experts with adequate training. Finally, significance of the procedural quality assurance in endoscopy must be stressed. The procedures should not be performed under the time pressure. The training methods not involving patients e.g. using anatomic models and video technologies must be applied as much as possible. Objective selection of capable trainees is of great importance. Lack of experience and skills reduces diagnostic and therapeutic yield of endoscopy, enhancing risks at the same time.

Radiation-Related Thyroid Lesions

It is known that the incidence of thyroid cancer (TC) among people exposed to ionizing radiation at a young age from the Chernobyl accident (hereafter accident) increased considerably. The precipitous elevation of TC detection rate, started ~4 years after the accident, could be predicted neither from studies of atomic bomb survivors in Japan nor from experiences with radiotherapy. As discussed previously, some dose-effect relationships have been caused or influenced by bias and confounding factors, especially the dose-dependent selection: individuals knowing their higher doses or residing on more contaminated territories would be on average more motivated to undergo medical examinations, being given more attention by medics. TC was comparatively rarely detected among young people in the former SU prior to the accident: in Belarus (1981-1985) in people younger than 15 years the incidence rate was ~0.3 and in Ukraine 0.5 cases per million per year. In the northern provinces of Ukraine, overlapping with those contaminated after the accident, the incidence rate of TC was as low as 0.1 per million per year. According to another source, the incidence of TC among patients younger than 14 years increased from 0.3 (1981-1985) to 30.6 (1991-1994) cases in Belarus, and in the whole Ukraine from 0.4 to 4 per million per year.

The above-cited pre-accident figures are very low compared to other industrialized countries. A table with incidence rates for different countries is presented in the article. In a later publication an overview of worldwide statistics is given, whereas it is stated: “The incidence of TC in children below 14 years of age is 0.5-1.2/million and 4.4-11/million for adolescents between 15 and 19 years of age, with constantly growing number of cases in both Europe and America”. A comparison of these figures with those quoted above indicates that there were neglected TCs in the population of Belarus and Ukraine prior to the accident. The fact that a screening can elevate the TC detection rate many times has been known long since. Moreover, some people strived for recognition as victims of the accident to get better therapy for their diseases. TC cases from non-contaminated territories wrongly registered as Chernobyl victims must have been on average more advanced as there had been no mass screening outside the contaminated area. Accordingly, TCs found during the first decade after the accident were on average more advanced than those detected later.

Apparently, the considerations delineated above have been camouflaged. The time span 1986-1990 (when the screening already began and the TC frequency started to grow) was chosen by the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR 2008) for comparison with post-accident figures because “1986 and not earlier, data on TC incidence have been specifically collected by local oncologists”. Fridman (2014) claimed that the TC incidence in Belarus in the period from 1971 to 1985 did not significantly differ from that in other countries, referring to the paper by Williams (2008), where no such information was found. Balonov (2013) stated without references that the pre-accident TC incidence in children ≤10 years old in Belarus and Ukraine was 2-4 cases/million/year, that is, much higher than the statistics quoted above. Apparently, the mass screening after the accident found advanced neglected malignancies that were misinterpreted as aggressive cancers developing due to the radiation exposure after a short latency. This gave rise to the doctrine that radiogenic TCs tend to be rapidly growing and early metastasizing, which has contributed to excessive radicalism of the treatment.

In the earlier report with participation of Edward D. Williams (2008) it was stated that “The exposed and unexposed tumors from the same geographical area are essentially identical morphologically and in their degree of aggressiveness. Childhood papillary TC (PTC) from Japan were much more highly differentiated (p<0.001), showed more papillary differentiation (p<0.001) and were less invasive (p<0.01) than Chernobyl tumors”. Later on, in publications by the same authors without E.D. Williams, the accents have been modified: “Childhood Japanese PTC differed from Ukrainian PTC by more pronounced invasive properties… higher morphological aggressiveness of PTC in young Japanese patients”. In a more recent paper, Bogdanova (2021) acknowledged that Ukrainian “radiogenic” or “radiation-related” PTC “had a solid-trabecular growth pattern and displayed morphological features of aggressive biological behavior” without any satisfactory proof that (a considerable part of) tumors in the studied residents of Kiev, Chernigov and Zhitomir provinces were caused or influenced by radiation. What was indeed different about inhabitants of these regions were the screening with detection of neglected cases and some over-diagnosis, radiophobia with increased self-reporting, as well as registration of some unexposed people as Chernobyl victims. Differences in the histological grade of malignancies may reflect diagnostic quality, that is, averagely earlier or later tumor detection in a given country. Associations of various markers with the tumor progression can become a field for the future research and re-interpretation of data obtained in studies comparing malignancies from different countries. The prevalence of certain markers may reflect efficiency of healthcare services.

Here follow several quotes concerning Chernobyl-related TC (from Russian): “Practically all thyroid nodules, independently of their size, were regarded at that time in children as potentially malignant tumors, requiring an urgent surgery”. The recommended treatment was: “Radical thyroid surgery including total thyroidectomy (TT) combined with neck dissection followed by radioiodine ablation” and irradiation with 40 Gy. Certain experts generally advised TT with neck dissection for TC. Less radical surgery was regarded to be “only acceptable in exceptional cases of very small solitary intrathyroidal carcinomas without evidence of neck lymph node involvement on surgical revision” (Demidchik 2006).

In a later study, 69% of post-Chernobyl pediatric TC patients underwent TT; among them, radioiodine was administered to 69% of the cases. As per the same article, in patients diagnosed with TC after the Fukushima Daiichi accident, hemithyroidectomy was applied in 92% and TT in 8% of cases. In another study, “given the presence of radiation exposure in the patients’ histories”, TT was performed in 405 out of 465 (87.1%) papillary thyroid microcarcinomas with postoperative radioiodine therapy in 76.1%. The neck dissection was performed in ~50% of the cases. Of note, recurrences were recorded only in 1.3% of the cases (median follow-up 5.2 years). The authors acknowledged that microcarcinomas in their series were “rather indolent” and advised “more frequent organ-preserving surgeries vs. TT even for potentially radiogenic papillary thyroid microcarcinomas”. The long-term overall survival of post-Chernobyl TC patients was excellent: during the 1990-2014 period, 21 (1.9%) pediatric TC patients died, among them only 2 from progressive carcinoma, 3 from other tumors, 3 from non-oncologic diseases, 6 due to trauma; 7 TC patients committed suicide. These figures are indicative of the overdiagnosis of cancer and overuse of TT. The relatively high suicide rate could have been caused by adverse effects of TT including cosmetic ones: many TC patients were young females.

Epidemiologists warned against false-positive diagnoses of malignancy in thyroid nodules. Experts argued that the worldwide increase in the TC incidence has been caused by the screening, improvements of medical surveillance and technological advancements in diagnostics. The author agrees with the following statement: “The extent to which opportunistic thyroid cancer screening is converting thousands of asymptomatic persons to cancer patients without any known benefit to them needs to be examined carefully”. Health-related and social (stigmatization as a cancer patient) adverse effects of surgical hyper-radicalism are known. Apparently, the risk of complications associated with thyroid surgery (nerve injuries, hypoparathyroidism and others) is proportional to the extent of thyroidectomy (Ramirez 2007). The rate of adverse effects was additionally elevated because of insufficient qualification of some surgeons engaged after the Chernobyl accident in conditions of a high workload. The extent of surgery for well-differentiated PTC is a matter of debate, which is beyond the scope of this review. In particular, performing subtotal thyroidectomy instead of TT may be a better choice in order to preserve parathyroid function. Elective neck dissection is usually performed in patients with clinically evident nodal disease although there is no general agreement on this matter. Ceteris paribus, TT should be avoided if thyroxine supplies are unreliable, e.g. in conflict-stricken regions.

The sources were misquoted to support the recommendation: “The most prevailing opinion calls for TT regardless of tumor size and histopathology”. In the cited publications the subtotal resection is discussed. Moreover, the sources were misquoted by Demidchik and Kontratovich (2003). Along the same lines, the radical thyroidectomy was applied in TC patients exposed to radiation in the Urals. The author agrees with the following conclusions: “After the Chernobyl and Fukushima nuclear accidents, thyroid cancer screening was implemented mainly for children, leading to case over-diagnosis”; “The existence of a natural reservoir of latent thyroid carcinomas, together with advancements in diagnostic practices leading to case overdiagnosis, explain, at least partially, the rise in TC incidence in many countries”; “Total thyroidectomy, as performed after the Chernobyl accident, implies that patients must live the rest of their lives with thyroid hormone supplementation. Additional treatment using radioactive iodine-131 therapy in some cases may result in potentially short- or long-term adverse effects”. Histological images from Russian textbooks, potentially conductive to false-positivity, were partly reproduced and discussed previously.

Dentistry

This section analyzes development of dentistry in RF since the 1970s with special reference to dental caries in children. In this connection, minimally invasive dentistry (MID) is discussed. The concept of MID applied for the caries treatment includes modified methods of tooth preparation based, as far as possible, on individual evaluation of the caries progression rate. The concept of MID is applicable also to periodontal conditions. The necessity and possibility to spare dental tissues have been undervalued. The motto of Soviet healthcare was the priority of prophylaxis, implemented by regular medical checkups (so-called dispensarizations) at schools and colleges. The approach to dispensarizations was rather formalistic. Among drawbacks were paternalistic attitude to patients, insufficient quality control and disregard for the principle of informed consent. Last time, it has been proposed to revitalize the program of dispensarizations. Patients at dental polyclinics, where free treatments are provided, are requested in advance to sign a form certifying their blanket consent to unnamed diagnostic and therapeutic procedures. At the same time, a tooth preparation can be started during examination without asking for consent.

An early start of the restoration cycle and suboptimal quality of filling materials caused progressive enlargement of cavities: the restorations failed, the cavities were further enlarged. This led to fractures and extractions often at a young age. Initial and questionable carious lesions found at dispensarizations or occasional visits were treated by dry cutting, sometimes with dull rotary instruments, which led to excessive removal of hard tissues. At schools, dental dispensarizations were recommended to be performed twice yearly. The consent for the treatment at dispensarizations was often not asked especially from children and adolescents or their parents. The dental preparations were in fact compulsory: “The doctor identifies children who evade the treatment and takes measures jointly with the school administration”. If an adolescent or even medical student asked “not to drill”, a trick sometimes followed: “I’ll just inspect”; a switched off handpiece introduced into the oral cavity, then followed dry cutting. Poor-quality filling materials did not hold long. Due to the early start and acceleration of the restoration cycle, so-called tooth death spiral, extensive dental prosthetics at an age around 30 years have been not infrequent. The checkups and treatments were performed under the time pressure. The explorer fixation in a pit or fissure (stickiness), enamel surface roughening and discoloration were regarded as diagnostic criteria of caries. Today, the probing of suspected lesions with the checking of stickiness is regarded to be obsolete, since it achieves no gain of sensitivity and can cause damage. Apparently, the overdiagnosis of dental caries has been continued until today: “The prevalence of dental caries in 3-year-old children was 67%, in six-year olds 87% and in 12-year olds 92%”. Even a 100% (55.73% in need of treatment) prevalence of caries was reported in a study of 1030 patient’s ≥35 years old. Corresponding figures in the international literature are generally lower. Dental dispensarizations have been largely abandoned in the 1990s; but the large-scale privatization of dentistry created new problems (discussed below).

Superficial caries was defined as a lesion limited to the enamel without involvement of the enamel-dentin junction. Mechanical preparation and restoration was recommended for superficial occlusal caries and superficial caries in general; this recommendation was sometimes stressed as obligatory. Individual anatomic features of pits and fissures as a possible cause of the explorer stickiness were not discussed in handbooks and monographs. Erosion as an entity to be distinguished from caries was briefly mentioned without specifying therapeutic consequences. Admittedly, erosion and its therapy has appeared in recent editions along with a general adjustment of the Russian literature to international prototypes that are available online these days. In some manuals, mechanical preparation was recommended also for areas of enamel discoloration with an intact surface: “Mechanical preparation of hard dental tissues and filling can be performed without waiting for the cavity formation”. Accordingly, many “lesions” treated by mechanical preparation were anatomic variations of the grooving, fissures and pits, pigmented fissures, erosions etc. First restorations were usually placed in childhood. Exploration with a probe was often performed with excessive force, which could be partly explained by the fact that “enamel softening” was presented by handbooks as a diagnostic criterion of early caries (Iakovleva 1992). It is known that demineralized but non-cavitated enamel lesions can be remineralized. Recent studies suggested that demineralized but structurally intact dentin can be remineralized. Nevertheless, the habitual use of the probe has been recommended also in a recent monograph. As for the endodontic therapy, it can be seen on radiograms that the quality of root canal treatment was often inadequate; and sometimes only traces of filling materials are visible in the roots. Not all dentists have sufficient skills to perform endodontic treatments. Procedural quality was additionally impaired by the limited availability of effective anesthesia. Pulpitis treatment and endodontic manipulations were usually performed without local anesthesia, after arsenic trioxide devitalization of the pulp until the mid-1990s and in places also later. Dental anxiety, real phobia in many cases, prevented patients from asking professional help after restoration failures and tooth fractures so that some of them waited for pulpitis or periodontitis, which finally ended with extractions.

The traditional approach to the caries treatment (extension for prevention) has not been questioned until recently. The current consensus that carious dentin does not need to be completely removed has not been uniformly accepted. According to the National manual of therapeutic stomatology, “it is necessary to remove all damaged tissues.” With this approach, a removal of hard dental tissues is inevitable. The Manual of pediatric therapeutic stomatology recommends removing only demineralized tissues, mentioning the possibilities of de- and re-mineralization especially in children. On other pages of the same book, a “maximal removal of pathologically changed dental tissues” is advised. A complete removal of non-viable, carious and pigmented dentin has been usually recommended. Insensitivity of dentin during diagnostic preparation (“drill test”) is considered as a sign of its non-viability, “which is important for determining the extent of preparation”. In the international literature, a non-selective removal of dentin is not recommended. For deep lesions, complete caries excavation is considered to be overtreatment. Recent research supports less invasive strategies, highlighting that a complete removal of soft dentin may not be always necessary or desirable. Selective removal of soft dentine in deep lesions leaving it on the cavity surface adjacent to the pulp is often indicated.

Thanks to the Internet, the Russian-language literature is adjusting to the international prototypes, the above-mentioned topics being elucidated more and more comprehensively. Certain foreign books have been translated. Controversies of caries treatment in RF give rise to questions that should be answered on the basis of scientific evidence: which dental lesions, in children and in adults, must be treated by mechanic preparation and which ones can be left for observation or non-invasive therapy. The research should not be commercially influenced. The general deceleration of tooth decay because of the widespread use of fluorides, better oral hygiene and more conscious diets are arguments in favor of less extensive preparations.

Entering the tooth restorative cycle should be avoided as long as reasonably possible. An economical re-routing of dental practices is needed, so that they could survive using preventive and minimally invasive methods more extensively. Dental treatments at the polyclinics, providing free care to children, must be performed on the state-of-the-art level. Improvements in ethical standards of healthcare providers and managers of all levels are needed: “Dentistry for the patient” instead of the “dentistry for the dentist”.

A case study illustrating overdiagnosis of schizophrenia in the former Soviet Union has been reported previously. A 16-year-old schoolboy (hereafter patient) with mild communication abnormalities was brought to psychiatrist by his mother. Later the patient admitted that the real goal was exemption from conscription. The author observed the patient for many years and did not notice any mental abnormalities, apart from alcohol dependence that developed later on. Aside from shyness during adolescence, the only notable complaint was the statement that his “nerves were like ropes”. This was interpreted as cenesthopathy and sluggish schizophrenia was diagnosed. The concept of cenesthopathy was coined to describe unusual bodily sensations without objective findings; it is no longer in the mainstream of contemporary psychiatry. However, Russian literature has a body of publications on cenesthopathy culminated in the recognition of cenesthopathic form of schizophrenia. Besides, cenesthopathy has been regarded as a symptom of “hypochondriacal” and sluggish schizophrenia. The overdiagnosis of the latter entity in RF has been discussed previously. It is known that some forms of adolescence turmoil may lead clinicians to diagnose a serious condition to be confronted one day with a completely recovered patient; although severe disorders in adolescence usually do not disappear completely. The patient was prescribed a phenothiazine drug and trihexyphenidyl (known in RF as Cyclodol). There was no control of the drug intake. The patient brought Cyclodol pills to school and offered to other adolescents with the comment that it is a narcotic drug. Curious teenagers took it during lessons, which remained unnoticed by teachers. One boy suffered intoxication with a delirium-like condition after an intake of ~15 trihexyphenidyl pills together with alcohol. The patient was registered at the psycho-neurological dispensary, exempted from conscription, denied a driver’s licence and directed to a specialized educational institution, where he acquired a profession of floriculturist. After that he worked in city parks. Later on, following advice of his friends and some medics, the patient switched to car repair work, completed an evening technical education, married, and reduced his alcohol consumption. The patient suffered from stigma all his life: the registration with psycho-neurological dispensary was known by surrounding people, impaired his relationships and employment possibilities. Apparently, this contributed to his alcohol abuse.

Schizophrenia has been often overdiagnosed in the former Soviet Union, while the concept was broader than that used in the United States and other countries. Overextended diagnostic criteria of the sluggish schizophrenia affected many people having nothing to do with politics or dissent. Personality disorders, neuroses, reversible derangements in adolescence were misdiagnosed and treated as schizophrenia. It can be illustrated by the citations (verbatim from Russian): “A part of the patients with sluggish schizophrenia, after a juvenile crisis, achieved a complete social and professional adaptation, continued education and got married” or “a majority of patients with juvenile sluggish schizophrenia become compensated”. In the Soviet literature, schizophrenia has been considered a lifelong process: despite remissions and periods of health, the disease is regarded to be present, the diagnosis thus remaining appropriate (Holland and Shakhmatova-Pavlova 1977). Accordingly, patients were registered with the psycho-neurological dispensaries throughout their lives, which implies stigma for them and their families. The procedure of cancellation of the registration has been rare and usually unsuccessful. The registration can contribute to unemployment because some employers ask for a certificate from a psycho-neurological dispensary. Access to foreign professional literature has been limited, while in Russian textbooks differential diagnosis between personality disorders, neuroses and schizophrenia is explained vaguely, leaving space for individual judgment. For example, in the textbook by Lichko (1995), the differential diagnosis between the sluggish schizophrenia, neuroses and personality disorders is not discussed at all, while it is only stated that many months of observation can be required, thus justifying prolonged institutionalization. Psychopathologic phenomena typical for neuroses (hysterical, dissociative, obsessive-compulsive), unusual interests, eccentricity, were presented as diagnostic criteria for schizophrenia. Existence of subclinical, asymptomatic and non-manifestative forms of the disease was postulated.

In some textbooks, sluggish schizophrenia was presented as a synonym of a schizotypal personality disorder according to the International Classification of Diseases (ICD). Although the 10th Revision of ICD, endorsed by the 43rd World Health Assembly in 1990, was accepted, the Soviet-era classification has been further in use, while ICD was criticized (Polishchuk 2001). The term sluggish schizophrenia continues to be used, whereas the same Russian term vyalotekushchaya is now translated in English summaries of some articles not as sluggish but as “slow progressive”. After some debates in the 1990s (Kotsiubinsky 1992), the topic is hardly discussed anymore. It was pointed out by leading psychiatrists that the Soviet classification of mental disease is based on etiology and pathogenesis, supposed to be an advantage over foreign classifications based predominantly on syndromes (Zharikov 1999). Note that the etio-pathogenetic approach, in conditions of insufficient knowledge on etiology and pathogenesis and lack of diagnostic tools, contributes to overdiagnosis.

The sluggish variety was reportedly the most common form of the disease: up to 50% of all schizophrenia cases. The entity was additionally expanded by so-called schizophrenic reactions, a concept that allows diagnosing reactive conditions as “psychogenic exacerbations” of the disease that had been non-manifest prior to environmental stress (Ilina 2006). Another contribution to the overextension of the entity was the doctrine about the “Nosos and Pathos” by the leading Soviet psychiatrist Andrei Snezhnevskii (1971), Lichko (1995), where the dynamic process is defined as Nosos and hereditarily predisposing constitutional traits as the Pathos of schizophrenia. According to this doctrine, the Nosos can transform into the Pathos and vice versa. In this way, the disease is mixed up with constitution, permitting personality disorders and constitutional traits to be diagnosed as schizophrenia. Furthermore, childhood autism, which had been introduced into Russian classifications in the late 1980s but not uniformly accepted, was classified and treated as childhood schizophrenia. With regard to the treatment, antipsychotic drugs have been recommended by Russian handbooks for all forms of schizophrenia, including the sluggish and “increasing shizoidization” (Lichko 1995). The over-institutionalization of patients with mental disorders has been common practice. Accordingly, the Russian Federation (RF) had one of the highest levels of psychiatric beds per capita in Europe. Conditions in psychiatric hospitals, where the patients stay for a long time, were primitive: overcrowding, no privacy, insufficient hygiene.

It is known that invasive procedures can exert a placebo effect, which might have contributed to reported efficiency of some methods discussed here. However, by definition, placebo must be free of risks and adverse effects. Factors contributing to the persistence of suboptimal practices include a partial isolation from the international scientific community, shortages of medical education, unavailability of many internationally used handbooks. Admittedly, foreign literature is available via the Internet today, many guidelines being adjusted to international standards. It is taken for granted and nobody gives thanks. We can hardly imagine what immense work and immaculate integrity stands behind reliable medical research. On the contrary, some writers analyze complications of therapy in foreign countries without mentioning professional misconduct in RF; details and references are in the books by Jargin (2020, 2024).

Certain published instructions have remained without due commentaries, so that a comeback of suboptimal practices is not excluded. Suboptimal practices have been used as per instructions by healthcare authorities and leading experts’ publications. The lacking professional autonomy has contributed to the persistence of outdated methods in the healthcare. Some colleagues encountered impediments to their careers when they did not collaborate in dubious research and practice. Manipulation of statistics has been not unusual. In conditions of paternalism, misinformation of patients, persuasion and compulsory treatments are regarded to be permissible. Justifications of surgical hyper-radicalism could be heard in private conversations among medics, for example: “The hopelessly ill are dangerous” i.e. may commit reckless acts undesirable by the state. For example, glioblastoma patients were routinely operated on, while it was believed by some staff that the treatment was generally useless, just forcing many patients to spend the rest of their lives in bed. Finally, the obstacles to the import of drugs and medical equipment should be mentioned. Domestic products are promoted sometimes despite questionable quality and possible counterfeiting. Today, the economic upturn enables acquisition of modern equipment; and scientific research is encouraged by authorities. Under these circumstances, the purpose of this review was to remind that, performing surgical or other invasive procedures, the risk-to-benefit ratio must be kept as low as reasonably achievable.

Examples discussed here are only a tip of the iceberg. Essential point is that some former party and military functionaries, their children and dependents, occupying leading positions in academies and universities, have become involved in research and practice of poor quality. They also travel abroad misrepresenting Russian scientific community. The younger generation can learn from them that scientific misconduct brings scientific degrees, profit and success. It is largely understood that true medical science is made abroad; and here it is often about scientific degrees and career. In fact, scientific misconduct has become an ingrained habit in the former SU, at least in some fields of medical and biological science. One of the reasons thereof is that medical education and research require hard and meticulous work leaving almost no leisure time. Some of the functionaries’ children are not accustomed to it. Furthermore, cases are known when scientific co-workers abroad had scrupulously performed a technical part of a joint study, e.g. molecular-genetic or immunohistochemical tests, and later found themselves embroiled in research of questionable reliability, which includes among others the Chernobyl theme discussed here. In RF, there is a Higher Attestation Commission, generally known as VAK, the main purpose of which is maintenance of a high level of scientific research. VAK awards or approves of all academic degrees. Nevertheless, there are dissertations (theses) with detectable trimming of data, manipulations with statistics, misquoting etc., for example, the doctoral thesis of the chancellor (since 2010) of the Sechenov Moscow Medical University (previously named Sechenov Medical Academy) contains numerous inaccurate citations.

Some invasive methods with questionable indications were introduced or advocated by first generation military surgeons. The Soviet period brought about an expansion of admission numbers to universities and medical educational institutions, with insufficient regard for the basic knowledge of entering students. One of the motives to overuse invasive procedures was personnel training, among others, with the objective of readiness for war. Note that military and medical ethics are not the same. The comparatively short life expectancy in RF is a strategic advantage as it necessitates less healthcare investments and pensions. Malignancies are diagnosed here relatively late. As mentioned above, among factors contributing to the use of invasive procedures with questionable indications have been the partial isolation from international scientific community, insufficient consideration of the principles of professional autonomy, informed consent and scientific polemics, as well as paternalistic attitude to patients.

Ethical and legal basis of medical practice and research has not been sufficiently known and observed in RF. The term “deontology” is often used for medical ethics in this country. Textbooks and monographs on deontology explained the matter somewhat vaguely, with truisms and generalities but not much practical guidance. Today, the growing economy enables acquisition of modern equipment; and medical research is on the increase. Under these circumstances, the purpose of this review was to remind that, performing surgical or other invasive procedures, the risk-to-benefit ratio must be kept as low as possible. Insufficient coordination of medical studies and partial isolation from the international community can result in parallelism in research, unnecessary experimentation, and application of invasive procedures without sufficient indications. Considering shortcomings of medical practice, research and education, governmental directives and increase in funding are unlikely to be a solution. Measures for improvement of the healthcare in RF must include participation of authorised foreign advisors.

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