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History of the Leeuwenhorst group

Library Documents

Presented by Professor B. S. Polak at the 3^rd European Conference on Teaching in General Practice, Antwerp, September 1982.

I will try to tell you the history of our group. You understand, I presume, that I am telling a history being involved in what happened.

This has pro's and cons, but you have the luck that nine witnesses are amidst you and all of, them can correct me If they like so. The criterion of my choice of what I will tell you is the things I thought were relevant to you to know, to understand this conference the better. In 1970 in Brussels we had the first European Conference in the teaching of General Practice. This Conference was organised by our Belgian friends. Four years later the Dutch College organised the second conference in Noordwijkerhout in the Leeuwenhorst Center. Of the first conference the book is published, the second conference didn't result In such a publication but parts of it are published in Dutch and in English in Huisarts en Wetenschap, the journal of the Dutch College.

At Leeuwenhorst Horder and Bentzen took the initiative to form the European Working Party and the conference appointed 15 members to work in this group. The motives to this are motives that have at this moment the same validity as in 1974. First of all our wish was to exchange information, to exchange views and experiences, by people who, all over Europe, were confronted with a completely new task. Our second idea was to try to develop the thinking about general practice and teaching of general practice. The third reason was to encourage the participants to pursue their objectives in their own different countries and to support them in their very difficult struggle within their faculties. This all could only happen in a situation where in Europe, especially in Europe, a rebirth was going on of General Practice. This rebirth is in my opinion not sufficiently studied. That in future will be a task for sociologists. Part of the reaction of society and of a part of medical society upon the development of specialization and the consequences this specialization had upon the quality of health care. In a series of countries the appearance of general practice in the medical faculties, the fact that general practice took part in the teaching of medicine, the fact that general practitioners got the opportunity to do research, the development in different forms of a specific vocational training for general practice, the move a few years later of the European Community in the direction of an overall obligation of this training in the nineties, all the phenomena were a sign that general practice was on the way to be approved as specialty.

We formulated it in a statement we made in Klagenfurt in 1979, and later on in the same year in London, about a point I will talk about later on, in which we find this sentence: "the group believes that all countries should produce general practitioners in whom the people may have complete confidence" and then follows: "this can not be achieved unless the quality and duration of training are comparable with that of all other practicing clinicians" by what is meant the specialist. And in one of the papers produced by a member of the group we find the sentences: "what matters is that the training leads to a professional standard, considered to be of a quality equal to the standards of other doctors working in other specific clinical disciplines". The group was formed by fifteen people, , from eleven countries. Eleven people from European countries and four from socialist countries . From the eleven European people, eight of them came out of the European Community. This group came together from 1974 until now, twice a year in 10 of the 11 countries, who were host for them. The United Kingdom received us 4 times, Yugoslavia, the Federal Republic of Germany and Belgium each of them twice. The other times we met in one of the other countries. Notwithstanding enormous differences in the background of each of us, differences in social, economic, political and cultural structure of our countries, differences in the organisation of health and medical care, especially differences in the way people come into the health care system, if the general practitioner is always the first contact or not, not withstanding all these differences and the difficulties in the faculties composed of specialists for whom these general practitioners were foreign people, notwithstanding all this and notwithstanding the personal differences between fifteen people coming from all these countries, many of them having a burden of many tasks in practice, in medical organisations, in teaching and of other university tasks, people who were at their own place prima donna's, it was clear from the beginning that among these fifteen existed a consensus. The interest of general practice for the patients was so important that this interest was enough reason to defend this type of medical care in health care and in the universities. I can assure you that it was always and only a pleasure to attend the meetings. I had the luck to have attended all except one and always met a nice' companionship, a -tendency to,, work together, not to try to see the mistakes of. other people, but brainstorm and think to find new ideas and new developments in our profession.

We lost Pat Byrne, we lost Frau Hugel, for reasons we do not quite understand, but during those years there was nearly always a complete attendance. It has been only once necessary to cancel the meeting because of too few people could accept the invitation.

Only once a split happened. And that was a very frustrating experience. One of the members, who had a very important position in the organisation of health care in his country, needed for his work and in the line of development he saw support for an opinion about the duration of the vocational training. He motivated his point of view saying that it was a task of our group to take a stand, writing us: "The development of general medicine takes different directions in our countries but not for medical reasons. These differences are based entirely on the various social developments. All our results are only valuable if they can be practiced on the national level". We did not disagree, but at that moment the group did not have a point of view about what he asked. We tried to compromised, reluctantly, we compromised, we made a statement about the duration of the vocational training which we have published, we said in Klagenfurt: "The minimum duration of vocational training for general practitioners should be two years" and we added half a year later: "The group stresses the fact that the two years minimum period referred to in that statement is regarded as an interim measure". So we came a little bit back on the first statement. We understood that it was not the task of the group to make this kind of statements because our development did not go into that direction and because we felt that we had an academic task in developing teaching in general practice. We understood that it must be done and organised in every country but the international group had the task to think about it and come to conclusions the members of the group could use to work with in their own countries.

What happened that day in the group has been a reason for as to begin to evaluate the group process, but I must tell you that we have not been consistent in doing that. Sometimes we did, sometimes we forgot. We worked so long that at the moment, we had to lunch or otherwise interrupt our activities we did ' not think about it.

As you know the group produced three statements: in 1975 the first, the content of it being a job description and a description of the objectives for training. We produced this statement in three meetings and later on (1981) we revised the job description. You have got the text in your file. In 1977 we published a second statement which we produced in four sessions, about the contribution of general practice to the undergraduate training of all doctors.

In our eyes this was a very important question because this is the way in which all future doctors, many of whom will be specialists in their career, will learn something about general practice. In my opinion it is also necessary that the general practitioner in the universities and the organisations of general practitioners try to influence the content of the undergraduate training because until now it is formed by specialized medicine and not formed by us.

The consequences of this type of undergraduate training is that most of the specialists don't get to know enough about the meaning of general practice to influence them enough in their future career. After this publication we discussed different topics in several sessions, topics which are the subjects of this conference.

Then we went to work to the statement about continuous education. It has been published in 1980.

One of the most important topics was the problem of the specificity of our work. What is the difference between us and other doctors. What is specific about what we are doing? We treat patients in their own surroundings, with very small equipment and perhaps I may say only with our own hands and brains. I think that you must try to find,-and we have tried arid you should do it,-certain characteristics which make general practice specific. We must realize that specificity is principally found in our place and function in the system of medical-and health care. The general practitioner applies medicine in a specific situation but what he is applying is not specific. The appliance in the given situation forms his specificity. I can add one more thing, the contraforce to the negative aspects of specialization, the contraforce the general practitioner can exercise against these negative aspects, are for the healthcare a very, very important factor. I think we should add this point to our formula of the specificity of general practice.

A further topic was the specific vocational training for general practitioners. One of the members wrote a draft implementation of postgraduate training for general practitioners. There has also been discussion about the question what should be done in a country where general practice does not succeed in getting an officially accepted vocational training. One ideas which has been developed in Belgium, is a facultative training in the undergraduate system, another idea has been to offer doctors after their graduation supervision by experienced general practitioners, when the come into this career. There has also been discussion about element of our job description. Papers have been written about the aspect 'personal' in the job description, about the problem of continuity, about home visits. Not all the discussions about these topics have led to new publications or statements. When we tried to get an impression of the influence we had exercised we saw that the World Health Organisation has sent first documents to the health care officials of 35 governments, that the European Organisation of Organisations of general practitioners, the U.E.M.O. adopted our contribution and John Border, who has been our secretary in the first period, was our representative in discussions inside U.E.M.O. about vocational training. The European Commission, that is the council of ministers accepted in 1977 a resolution number 33 where you can find the text of our first statement and where you find expressions that show its influence. There is a paragraph about the place of general practice in health care systems where is stated that in order to achieve the optimal level of .health in the population, a primary health care of high quality must be developed. The point of entry to medical care is normally the general practitioner or the primary health care team with a general practitioner as a member. The continuity of the care is one of the mayor aspects and is the responsibility of general practitioner of the health center as mentioned. The general practitioner is the coordinator of health care.

You should realize that these quotes come from official documents of the Council of ministers of the European Community. It ends with the sentence: "It is essential that the profession, the University, and the Government recognized general practice as a subject in its own value". In my opinion this has been a very substantial influence of our first statement and can add that the Royal College of General Practice adopted our publication as a document.

It is interesting that in the journal of the Royal College we find in 1980 a paper with the title: "Why not tear up the European aims"? A group of doctors experienced in training for general practice is saying: "Tear up these aims", we don't accept them. their reason for saying this is that they find that we did not give a range of priorities, that we meant them all. They said: "They are not all of them like important, there are differences and you should understand that we can not do everything so we tear it up and will try ourselves to find other and better ones with a list of priorities. Now this doesn't give us a frustrated feeling, we are happy that other people discuss our publication. If they get better ideas they have to publish them an we can discuss the matter.

Our second publication did not have the same influence as the first one. It was entitled: "The contribution of general practitioner to undergraduate medical teaching".

In Holland the consulting body of the Dutch university Institutes for general practice, a body that functions since 1967, and which is of great help to all of us wrote a very critical note about undergraduate medical training in Holland. The medical University Community reacted nearly as if it had not been published, there was nearly no reaction. It is now three or four years later and we are trying to organize a national conference to give new publicity to our ideas. I think that the same seems to happen with our second statement. It criticizes undergraduate medical training not as directly as we did in Holland, but it criticizes by the way it expresses the role that general practice could have in graduate training. There is no reaction because the medical faculties composed of specialists have not reached the level where they can handle a critical reaction on their activities.

Our third publication was about continuing medical education. I think it is to early to judge the influence this publication can have. But there is one happy factor, it can get influence given the wave of growing importance of continuing education everywhere in Europe.

This is what I like to tell you about our group and about what we did. I think continuation of this work is necessary. A lot has been done. We have produced some results, but a lot more has to be done. There is a group of countries with very nice intentions but no action in this field. There is a group of countries with intentions, plans and some beginning, but no more. But not only for these two groups but also for the countries where something has been done also for a country like Holland where we have eight institutes, with somewhat more chairs of general practice at eight medical faculties and where we have an indirectly obligatory specific vocational training for general practice, even in countries like Holland and United Kingdom and the Federal Republic of Germany and Belgium it will be necessary to develop our ideas further and to defend our stand against the trends of specialization in medicine and in the medical faculties. Specialization is necessary, it is the way in which medicine developed to a high level, but is not in this way that medicine must be delivered to the people. It is no more than a help in certain situations and only general medicine is the way where we can counter the negative developments which grow out of specialization.

The critic of medical and health care you can find in the publication of Illich and other people who only see the negative aspects. To achieve all this, the people who in their different countries, on different levels, work in the field of general practice meet each other Inside these countries but also internationally. The motives for it have been given by me already, they are the same: to exchange information, experiences, ideas, to develop and test ideas, to support each other in our very difficult struggle. A good health care needs general practice and I hope that this conference may be for the participants a stimulus to work together for the development of general practice in the sense I spoke about and to try to come to a new group like our working party to support the development of general practice we all wish to achieve. I thank you Mr. Chairman.

See also: Inventarisation of Leeuwenhorst Group Publications