Contact EURACT

E-mail

Phone
(32) 16 33 74 64

FAX
(32) 16 33 74 80

Library Documents

MEMBERS OF THE NEW LEEUWENHORST GROUP
Dr. Claudio Cricelli (Italy)
Prof. Dr. Cor Spreeuwenberg (Netherlands)
Dr. Philippe Jaury (France)
Dr. Dag. H. Soevik (Norway)
Dr. Mercedes Mercader (Spain)
Dr. Carl Edvard Rudebeck (Sweden)
Dr. E.G. Buckley (Scotland)
Dr. Klaus Besel (West Germany)
Prof. Dr. Antun Budak (Yugoslavia)
Prof. Dr. Jan Heyrman (Belgium)
Dr. Gertraud Rothe (Austria)
Dr. lb Svendsen (Denmark)
Dr. Gunther Borgwardt (D.D.R.)
Dr. Marten Kvist (Finland)
Dr. Ludvik Olafsson (Iceland)
Dr. Michael Boland (Rep. of Ireland)
Dr. Giora Almagor, M.D. (Israel)
Dr. Chris Watkins (England)

Chairman:Prof. Dr. Cor Spreeuwenberg, Weegbree 2, NI-3434 ER Nieuwegein - The Netherlands Tel.: (31)3402164735
Secretary:Dr. Chris Watkins, 80 Kennington Road, GB London SE 11 - England Tel.: (44)117358881

INTRODUCTION

The New Leeuwenhorst Group is a European working party whose aim is to promote general practice as a discipline by learning and teaching. The Group is making this commentary as a first step in a process which will lead to further and more detailed recommendations for the education of general practitioners in Europe.

The New Group considers itself fortunate to be given the opportunity of building on the foundation laid by the original Leeuwenhorst Group. Their definition of the work of a general practitioner and their statements on education and general practice influenced the developments in learning and teaching in general practice which have taken place in Europe in the last decade.

Primary medical care is organized in different ways in the European countries represented in the Group. Consequently. there is considerable variation in the aims and methods of learning and teaching general practice. In spite of the differences some common elements are emerging and the Group felt that this was a good moment to review the present position of learning and teaching in general practice in Europe.

The survey is based on information from members gathered in London in October 1983 with some final amendments after the group meeting in Berlin, March 1984. The position of each member country is described and the key elements of the system of medical education in each country are tabulated.

This is a short commentary and we are aware that not every detail of the education of general practitioners is included. We trust that the commentary contains the most important information.

REVIEW OF EACH COUNTRY'S ACTIVITIES

Austria
General practice is not included in the undergraduate medical curriculum at the universities. Some lectures on the theme of general practice are given, but they are attended only by a few students. There are no professorial chairs or independent departments of General Practice.

In order to become a general practitioner in Austria, doctors must complete a three years vocational training period consisting entirely of hospital based experience. A few of the trainees spend four weeks in a teaching practice. There is no theoretical teaching of general practice for trainees.

It is considered a professional duty for all general practitioners to take part in continuing education, but there is no form of control of whether or not doctors fulfil this duty. Continuing education is usually in the form of lectures given to large groups of doctors from different specialties. There is a lack of small group meetings and of special courses for general practitioners.

Belgium
In two out of seven universities undergraduate teaching of general practice is given to all medical students. In Antwerp this teaching is compulsory. Professorial chairs in General Practice are established at four universities. Vocational training includes a theoretical part of at least 200 hours and a practical part of 2 years training after graduation. The theoretical part may take place before graduation. During the practical part emphasis is given to learning in small groups and every 2 weeks the trainees have to attend a half-day course arranged by a specially trained general practitioner.

Continuing education is voluntary, organized by universities, scientific societies, local groups of general practitioners and the pharmaceutical industry.

Denmark
Professorial chairs in general practice have been established at two of the three universities. At the third, the department of general practice is associated with epidemiology and social medicine. Undergraduate education in general practice is optional and placed late in the study. It consists of theoretical lectures and four weeks attachment to a general practice. In Arhus university, students in their first year take an obligatory course in medical sociology which is organized by a general practitioner in collaboration with the department of social medicine.

A new programme has just been established for doctors who wish to become general practitioners. It consists of four years internship in relevant hospital departments and ~,e year in a general practice, during which time the young doctors must attend a course of 150 hours. The Health Departments and the Danish College of General Practitioners are responsible for the vocational training programme.

Responsibility for continuing education was taken over by the general practitioner association several years ago. Each general practitioner has the right to attend 6 days of continuing education a year. The average actual attendance is only 2 days per general practitioner.

Federal Republic of Germany
Education in general practice is compulsory for all university medical students in the Federal Republic of Germany. There is an agreed curriculum in general practice. This curriculum is revised by all university departments of general practice at regular intervals. Students must pass an examination of their knowledge of general practice. There is one professorial chair and independent departments of general practice in all the German Universities.

There is noncompulsory vocational training for four years leading to the title of Doctor of General Medicine (Al lgemeinarzt). Up until now, postgraduate training of 18 months entitles any doctor to work as a practitioner (Kassenarzt). However, the Government has added another 6 months to this postgraduate training, of which is only part may be spent in General Practice.
There is an obligation for all general practitioners to undertake continuing education,. but the form and content are left to each individual to decide e.g.: reading medical articles, attending lectures or courses etc. There are as yet no forms of control.

Finland
Only one of the five universities (Helsinki) has a Department of General Practice. The teaching of General Practice usually takes place at Departments of Public Health. All medical students are supposed to have 1 A weeks of clinical training at a health centre.
General practice is one of 30 recognized medical specialties in Finland. To become specialists in general practice, doctors have six years of vocational training, these include two years of general training, one of which is spent at a health centre. Of the remaining four years, two are spent at relevant hospital departments and two at health centres. One of the two last years is used for subspecialization in one of the following branches of general practice: Public Health Administration, Ambulatory Care, Geriatrics, Paediatrics, Maternal Care, Occupational Health and Environmental Health. This last part of vocational training includes 60 hours of theoretical teaching and 20 hours of administrative theory and ends with a written examination.

A doctor working at a Health Centre can be obliged to participate in continuing education, but in reality participation is voluntary. General practitioners have little influence on the form and content of continuing education.

France
Undergraduate teaching of general practice is established in only five of 41 universities in France (Bobigny was the first to do this). Where it does take place learning relevant to general practice is in the form of a small group discussions on clinical issues.

Vocational training is given partly before and partly after graduation. It consists of theoretical teaching and from ~1 2 months traineeship in general practice.

Continuing education is optional, paid for partly by the Government through the Syndicates of Doctors, partly by Industry and partly by general practitioners. UNAFORMEC receives this money and redistributes it for local postgraduate education programmes.

German Democratic Republic
In all universities general practitioners give a short series of lectures preparing undergraduates for a 4 week exercise in outpatient care. The increasing number of general practitioners with an academic qualification enables those to give some lessons in "Komplexforlesung" about topics relevant to general practice. The total undergraduate medical curriculum lasts six years.

General practice is one of more than 30 clinical specialities and some subspecialties. Every physician is obliged to start vocational training in a teaching utility named by the territorial health officer. As a rule vocational training starts with six months service in the department of general practice of the teaching utility, followed by 18 months in hospital departments. A further 2 years are spent training in different aspects of general practice. Thus vocational training for general practice lasts four years.

Continuing education is one of the obligations of every physician, but there are no formal rules.

Courses are organized by Academies of Continuing Education and the Physicians Academy has a Chair in General Practice. There are also popular courses organized by the College of General Practitioners often in the form of small groups.

Iceland
Undergraduate teaching in general practice is in the form of two introductory lectures in the third year and a six weeks course in the sixth year. There is no independent department of general practice at the University of Iceland. Two assistant Professors and a number of general practitioners are responsible for the teaching. Attempts to expand the teaching of general practice in Iceland have met with strong opposition.

All doctors undergo 16 months of clinical training after graduation. Four months of this postgraduate training are spent in general practice. An optional vocational training for general practice exists and has a duration of four and a half years, one of which is spent as a trainee in a general practice.

All doctors are required by law to keep their knowledge up to date, but continuing education is voluntary. Courses are organized by the Medical Association and by the College of General Practitioners.

Israel
Undergraduate medical education is orientated towards General Practice (Family Medicine) in the Beer Sheva medical school only. The three other medical schools are based on a traditional curriculum.

Vocational training is not obligatory, but has become very popular in the last few years. Training programmes and day-release courses have been implemented in all parts of the country. Doctors who complete vocational training are regarded as specialists in Family Medicine.

Continuing medical education is optional and supported jointly by universities and employers.

Italy
No undergraduate education in general practice exists in Italy and medical students have neither an introduction to nor knowledge of general practice.

The Italian College of General Practitioners is striving to introduce compulsory vocational training for general practice.
This is being done in concert with the other Italian associations of general practitioners. The aim is to implement the
E.E.C. directive on vocational training. A new contract between the Government and General Practitioners in 1985
may lead to compulsory vocational training.

Continuing education is compulsory in Italy since 1981. Though Health Authorities contributed very little to it, continuing education has greatly expanded over the past three years. Almost all initiative stems from the College of General Practitioners which is now proposing to all Italian general practitioners that they should undertake a 3 year programme. A special school has been created in order to prepare general practitioners as tutors in continuing -education and vocational education.

Continuing education is often in the traditional form of lectures, and is organized by local clinical societies, the pharmaceutical industry, hospitals, etc. The teachers are nearly always hospital specialists. In the West Cork Pilot Study, this traditional education is supplemented by small group teaching initiated by general practitioners themselves.

Spain
Undergraduate medical education is not oriented towards general practice. There is an excessive number of students compared with available resources and with the need for physicians. There is no holistic approach to medicine. Education is based on a mechanistic disease model.

There is no vocational training for general practice in Spain. Continuing education depends on personal and local initiative. There is no coordination or structured provision of courses for general practitioners.

Sweden
There are great variations in undergraduate teaching of general practice among the six medical schools. The extent and influence of general practice, community medicine and behavioural science are increasing in the undergraduate curriculum.

Vocational training has been compulsory since 1982. The importance of supervision by personal trainers is stressed. The lack of experienced teachers in general practice is being overcome by providing courses for general practitioners to become trainers.

Continuing education is not yet well organized and the goals, philosophy and financing of continuing education are still being discussed.

Switzerland
General practice is represented in pre-clinical as well as clinical teaching in the medical schools. Teaching takes the form of lectures and visits to teaching practices. An optional general practice attachment of up to 3 months is available in the sixth year. None of the teaching is compulsory except at Bern where there is a programme of visits to teaching practices in the first clinical year, plus a two day lecture programme in the third clinical year.

Vocational training is not compulsory, unless it is wished to gain the title of FMH for general practitioners, which is equivalent to other specialists titles in medicine. To gain the title FMH a doctor must complete vocational training of 5 years (4 in hospital and one in general practice is the possible pattern but this is not compulsory). The Swiss General Practitioner Organization is responsible for the vocational training, in association with the Swiss Medical Association. There are no examinations.

Continuing medical education is not compulsory, but a professional duty. General practitioners have some influence on the form and content of continuing medical education. There are no examinations. General Practitioner associations stake some responsibility for promoting continuing medical education, Courses for general practitioners are arranged by a wide variety of organizations, including Universities, Hospitals, and the Pharmaceutical Industry.

The Netherlands
General practice teaching is represented at pre-clinical as well as at clinical levels in medical studies, predominantly in the form of lectures, but also contributing to mini-symposia on topics such as the care of the elderly. In the sixth year, students can spend some weeks in a general practice. General practice is an obligatory component of undergraduate medical education.

Vocational training is the task of the University departments of General Practice. The first half year is spent in a general practice with one day-release per week at the university; the second half year may be in General Practice or at some hospital department, but with release days at university. Because of medical unemployment, some young doctors have to wait up to four years to receive their vocational training.

Continuing education is not obligatory. It is organized by: (1) Universities (expensive, abstract); (2) Foundation of Continuing Education in General Practice (cheaper than universities); (3) Local groups of General Practitioners; and (4) Pharmaceutical Industry (low cost, simple). Members of the Dutch College of General Practitioners have agreed to complete at least one week of postgraduate education a year.

United Kingdom
There is a great variation from one region to another in the learning and teaching of general practice in medical schools. Of 30 medical schools, 15 have a professioral Chair of General Practice and 18 have independent departments of General Practice. All except one of these universities are principally concerned with undergraduate education.
Undergraduate teaching is mainly based on an attachment on a one-to-one basis with a general practitioner for periods of up to four weeks. Some form of general practice teaching for undergraduates is undertaken by all British Medical Schools. Some medical schools have an examination in General Practice.
Vocational training for general practice developed rapidly during the 1970's. Since August 1982, it has been compulsory for anyone who wants to become a general practitioner to complete a three year programme. Regional Committees are responsible for vocational training, through Regional Advisors who are themselves general practitioners with special educational skills and knowledge. During the trainee year and in some instance during all three years of postgraduate training, day-release courses are arranged where the emphasis is put on learning in small groups.

Continuing education is not compulsory. The Government strongly supports continuing medical education for general practitioners by providing all expenses for approved courses. The administration of these funds lies in the hands of the Universities and many courses have been in the traditional format of lectures by specialists. Increasingly general practitioners are arranging courses themselves. This has led to a change in the style and content of courses with a greater emphasis on performance review by small groups of doctors.

Yugoslavia
In Yugoslavia primary health care is organized in different ways in the different republics and is based partly on a family doctor system, and partly on a system of polyclinics. This means that the educational needs of doctors working in primary care vary from one university to another. In general, there is a tendency for the family doctor system to increase and strengthen.

Medical education takes place in 11 Universities and there are great variations between each of the 6 republics and 2 autonomous areas. The appendix shows how teaching and learning in general practice (or general medicine, which is the term used), is organized in Zagreb, Croatia. In other republics, as for example Slovenia, Macedonia, etc., there is no undergraduate education in general practice at all. Any young doctor can work in health centres as a general practitioner immediately after qualifying from university and passing his state examination.

There are two types of general practitioner in Yugoslavia, those with basic medical education and those who have completed vocational training. One-third of all general practitioners have completed vocational training.

CONCLUSIONS

Arrangements for teaching and learning in general practice differ to a great extent among the European countries described in this commentary. However, there do appear to be educational needs which are relevant and important for all countries: -

In general there is: -
- a need to strengthen the identity of General Practice as an academic discipline by clarifying its contribution in teaching and research.
- a need for more general practitioners who are competent and able to undertake teaching.

For undergraduate education: -
There is a need for independent and well resourced academic departments of general practice. Some medical educators require to be convinced of the broad nature of medicine and medical education so that they become willing to accept the contribution of general practitioners to undergraduate courses. General practice should pmvide a substantial contribution to undergraduate medical education.

For vocational training: -
There is a need to establish vocational training for general practice throughout Europe. The aim of vocational training is to enable a young doctor on completion to be able to work independently in a general practice. It is envisaged that this will require a maximum of three years of which at least twelve months should be spent in general practice.

General practitioners should have a major contribution to the organization and evaluation of vocational training.

For continuing medical education: -
There is a need for a coherent structure and support for continuing medical education for general practitioners.

It is essential that funds for the organization of continuing medical education should be made available by health authorities. Although the contribution of the pharmaceutical industry is recognized, continuing medical education should not be dependent on such support. General practitioners themselves should be responsible for providing and organizing continuing education. There is a dilemma as to whether continuing medical education should be compulsory or voluntary. The content, method and effect of continuing medical education should be evaluated to attempt to ascertain whether it meets the needs of general practitioners and their patients.