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The Annual Spring Meeting of the Royal College of General Practitioners was held in April this year in Cambridge. The three network organisations of the European Society were invited to make presentations. On behalf of EURACT Dr Igor Švab from Slovenia gave a European overview of undergraduate teaching of general practice, and Dr Ivar Østergaard from Denmark gave an overview of postgraduate training. Their presentations are summarised here – full texts are available on request. General Practice Teaching at the Undergraduate Level in Europe
Europe is a continent of differences. Because of them we have so many poets, writers, painters, sculptors and playwrights, each contributing to what we know as the European culture. In the European Union and the countries wishing to join it, there is a powerful movement towards integration. There has been some success in achieving a common European standard regarding vocational training of general practice, but the influence of the European legislation on basic medical education is not as strong. Nevertheless, general practice has changed from a low status discipline to one which is claiming an equal and sometimes leading position within the universities in Europe. An overview of key statements and recommendations been produced since 1970 provides the story of the development of an academic discipline called general practice/family medicine. 1970's: THE PIONEERS The 1970's were an era of technical medicine, which became highly specialised. The role of the physician was to fight the disease in order to cure the patient, and general practice was seriously challenged. The first department of general practice had been created in the UK in Edinburgh in 1963, and a second important event was the creation of a new university in Maastricht in 1974 introducing a problem-based programme. The third key event was the first meeting of the Leeuwenhorst group, a group of enthusiasts and thinkers, who decided to challenge the stereotype that general practice should not be taught at universities. They identified the key characteristics of the work of a general practitioner in their statement "The General Practitioner in Europe", produced in 1974, which became a key element in many curricula of general practice/family medicine throughout Europe. The 1970s were a time of very moderate changes in basic medical education. There were a few general practice departments in Europe, and some exposure to general practice was possible. 1980's: DISSATISFACTION AND DEVELOPMENT The 1980's are marked with a growing dissatisfaction with medicine as well as with medical teaching. This is the time when people found out that they needed someone to interprete the confusing and sometimes contradictory statements of different specialists. Although it was clear that changes in the universities were necessary, resistance within the universities was still sufficient to obstruct them. In 1981 The New Leeuwenhorst group was created, which in 1986 produced a statement on the importance of general practice in basic medical education. It not only claimed that general practice should be taught at the undergraduate level, but demanded that general practice should have a central position. The key recommendations were:-
The 1980s were a period of a rapid growth of departments of general
practice in Europe, mainly in its western part, but a lot of European countries
were still without departments of general practice. The only general practice
department in Central and Eastern Europe in existence was in Zagreb, while
in other countries, where primary care was based on the Russian model general
practice as we know it practically did not exist.
The number of teachers of general practice increased considerably and general practitioners were increasingly involved in education. In 1992 European Academy of Teachers in General Practice (EURACT) was launched, to promote the exchange of views through international cooperation. At the end of 1980's the communist block collapsed and left a group of new countries with the freedom to choose and change. Health care reforms were introduced throughout the countries of central and Eastern Europe and one of the key features was the new role of general practice within the health care system. General practice was rediscovered after decades. There was a need for the creation of university departments of family medicine. Some of the new countries have very boldly taken the path like Estonia and Hungary, while the development in some others is still slow. The universities in the West have grown and have continued to develop their curricula. The findings of the London Ontario conference in 1994 organised by WONCA and WHO included some devastating criticisms of medical education. It focused on the fact that medical education does not reflect the needs of the population it serves and general practice was identified as a key area which could solve a lot of problems in modern medical education. WHO Europe went on to produce its statement - "Framework for the administrative development of general practice/family medicine in Europe", which is surprisingly concrete. It also stated that the first requirement for education in general practice is an adequate basic medical training. General practice should already be an integrated part of undergraduate programmes and that all medical students should be exposed to general practice. Of the 10 specific targets for European general practice produced by the European Society mandatory undergraduate education in family medicine/general practice at all medical schools in Europe is the first. All this thinking was perhaps best expressed in the lecture given by prof. Jan Heyrman at the inauguration ceremony of the European Society of General Practice in Strassbourg in 1995. He said: "General Practice needs to be an accepted part of basic medical education in every medical faculty . Only at that moment, we will have achieved our mission. If we do not succeed in bringing the low prevalence, polyvalent, clinical and human application of medicine, called general practice, within the university walls, we will have failed to build general practice as a real medical discipline. If we do not achieve the goal, we will not grow towards an applied science, accepted by everyone to be a branch of medicine." These statements have moved from defining the importance and role of general practitioners to the methods to achieve them. The voice of general practice is getting stronger and more active. Students of medicine in Europe in the 1990's would normally expect general practice as a part their curriculum. The curriculum is usually well planned and. But this does not happen at every university and only in few occasions the department of general practice plays a central role in curriculum planning. GPs still have problems in achieving the academic status. EURACT in 1997 made enquiries and managed to get the information about 297 medical faculties, in all the 26 countries represented. There is undergraduate teaching of family medicine in all countries, but only 191 faculties. The proportion of the medical faculties with undergraduate general practice teaching varies from 3,8 % to 100%. General practice is taught at every medical school in 18 countries. The extent and methods of education are very different. In some countries general practice is an obligatory subject, in others is not. The duration may be from a few days to several weeks, it may take place during the entire curriculum) or just in one part, usually in the end. Final examinations have been introduced in 14 countries (just above half of them). The world which enables people access to a lot of information is getting increasingtly confusing and although information is readily available, common sense is not. In the age of informatics people will still need a general practitioner, a person able to adequately assess the information that is readily available, and able to communicate with them in a humane way. General practice has survived because it has managed to keep its focus on the people. Students will still need role models and they will still need to be taught practical skills. They will still need to know how it feels when you are ill and what resources you can use when you are alone with the patient. They will still need to know how to talk to a patient who is ill and suffering. These are the key elements of general practice, produced by the old Leeuwenhorst group thirty years ago and they are still valid. The future is brighter than we might seem: general practice will be taught in all the years of the curriculum in Europe which will become the European standard of teaching medicine at the undergraduate level. Postgraduate education for general practice/family medicine in Europe
Vocational Training/Specific Training for general practice/family medicine is happening all over Europe. The training activities have been imposed on some countries and have been met with enthusiasm in other countries - but are consequences of rules for training of general practitioners laid down by the European Commission as conditions for general practitioners wanting to practise in any of the European countries. The current situation of general practice education is best characterised by words such as: multiform, multifactorial, multilateral, multiplied, multistaged, etc. Despite all the diversity in organisation of health care, structure of health systems, tradition, workload, tasks, money and so on, general practice education is changing and advancing in quality and quantity along the same lines in the majority of European nations. European Directive 93/16/EEC is still in force The European directive still in force is EU directive 93/16/EEC of April 5th 1993. This states that the education for general practice to be at least 2 years of clinical training in hospital and general practice, at least ½ year in general practice (clinics), and a theoretical course of "an appropriate number of hours". Professional bodies, especially UEMO, have made efforts to enhance general practice training, putting forward proposals based on the UEMO Consensus Document Copenhagen 1994 stating a training period of minimum 3 years, training in general practice of 1½ years, a theoretical course of 100 hours per year, and general practitioners in charge of all educational elements thus ensuring general practice orientation throughout the entire education. The proposals from the UEMO consensus conference were approved by the ACMT (Advisory Committee on Medical Training) for the Commission; the Commission also approved the recommendations - but only on a consultative status and is not intending to produce any legislation in order to facilitate implementation of the recommendations. A standstill prevails and the profession is frustrated at the moment. But what is the situation in European reality 1999? Postgraduate general practice education in Europe as of March 1999 is enjoying development, based on information obtained from EURACT Council members by a questionnaire. All 29 EURACT Council members representing 29 European nations responded. None of the 29 nations has a training period less than two years; in fact two thirds reported a total training period of 3 years or more. The training period spent in general practice is 6 months or less in 1/3 of nations (2 nations have no defined training in general practice at all), in another 1/3 of nations is about 12 months, and in the remainder range from 18 to 48 months. Thus the composition of the training period is still dominated by hospital based training in most nations, and in 50% of nations general practice trainees spend 24 months or more inside hospitals. Prior to entering the training programme trainees complete an internship of 12-18 months; but internship continues to be a confusing matter: in some nations it is part of the pregraduate and in others the postgraduate the programme, and 3 nations include internship in the specific training period. An educational programme is present in 18 and is obligatory in 16 of 29 nations. A theoretical course is included in the training in all nations but one. Training in research is included in 16 nations, and in quality development in 19 nations of 29, the remaining nations are considering incorporating these items in training programmes. In as many as 23 of the 29 nations an examination is performed on completion of training. In 28 nations general practice is a recognised specialty. Changes in specific training are being discussed in 24, planned in 21 and implemented in 19 nations of 29. The changes are concerned with more training time in general practice and quality development of all elements of the training process Total training time is 36 months or more in 2/3 of countries and training time in general practice 18 months or more in 1/3 of them. Hospital training time is still occupying at least 50% of total training time. Half the countries provide a theoretical course of more than 100 hours per (training) year, stimulating academic development of general practice. Conclusion: In broad terms European general practice is moving along the right lines, enhancing training time, and at the same time promoting the relevance and quality of training by getting control over more and more of the training period. Profession profile development is clearly observable in most individual countries, but reluctance prevails in the higher political administrative levels; wondering why is beyond the scope of this report of status presens - but the word resources (meaning issues round money, time and service) might be worthwhile to explore. |
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