EURACT - European Academy of Teachers in General Practice

Annex 1
Review of national educational activities
after EURACT Council meeting
in Vilnius, 2003

EURACT Council meeting
September 10-13, 2003
Leicester, United Kingdom

Many official national GP organisations support a new proposal on the organisation of general practice in Sweden (PROTOS). It implies a more structured establishment with a list system, a defined assignment, a well organised CME , salary both by capitation and result. A system like this was recently successfully carried through in Norway and that structure is very much a model.

A lot of the general information on what is going on in Sweden is published on the website of SFAM (Swedish Association of General Practice) www.sfam.se (an English version is available)

The impact of general practice in the undergraduate curriculum is increasing mainly in the early stages of the training. In Umeå, a university town in the northern part of the country a new theme "professional development" has been developed. All through the years in the undergraduate teaching a thread of "communication", "doctor's role", "clinical skill", "personal supervision"," humanities" is running and the different activities are organised by the division of general practice. The same structure will be organised in other universities.
In Göteborg the Erasmus/Socrates student exchange programme is getting more compre-hensive. We have had students from Germany, Holland and the UK that has made clerkships in Sweden (learnt Swedish in advance!) and this academic year new students will appear.

The European exchange programme for trainees (Hippokrates) has been introduced for Swedish trainees and an English version is created which I enclose below (from the website www.sfam.se). The presentation of the Swedish health care is also included and some of the host practices are presented - if you have any plans of sending/exchanging trainees to/with Sweden!

Hippokrates is a European Exchange Programme for Medical Doctors specializing in General Practice/Family Medicine supported by WONCA region Europe-the European Society of General Practice/Family Medicine through EURACT-The European Academy of Teachers in General Practice. The aim of the programme is to encourage exchange and mobility among young Medical doctors in the course of their professional formation as General Practitioners providing a broader perspective to the concepts of Family Medicine at both professional and personal levels.
The participants of the programme will acquire insight of the context of General Practice in the Primary Health Care of the European Countries gaining knowledge that will inspire to take an active part in the development of European Family Medicine as well scientifically as structurally. Furthermore the programme will enhance collaboration among the National Societies of General Practice/Family Medicine and recruit young professionals to these important tasks.

At the individual level the acquisitions are numerous: an international experience in a vocational setting, improving knowledge and skills, inspirational introduction to methods of professional development for lifelong learning, improving language skills, creating new friendships.

Hippokrates is launched at the 6th European Conference on General Practice & Family doctors in Vienna, Austria July 2-6, 2000. In the pilot phase of the programme there are 5 participating countries: Czech Republic, Denmark, Netherlands, Spain, United Kingdom.

In each country the programme is based in the National College of General Practitioners and there is a Country Coordinator in charge of the programme.

In the participating countries a number of General Practitioners and their Practices have been selected to be Host Practices. These practices are the cornerstones of the programme inviting visiting Medical doctors specializing in General Practice/Family Medicine from the other participating countries.

The duration of an Exchange Study Visit is two weeks. During this time the visitor will obtain a brief, broad introduction to the aspects and the role of General Practice/Family Medicine in the respective country by taking part in all activities of the Host Practice. The visitor will also meet, follow and exchange views with the local trainees specializing in General Practice/Family Medicine and will be encouraged to gain insight in local resources and quality improvement activities as well as local health care planning and health insurance.

In this catalogue the Country Coordinators and the Host Practices are presented not only with informational data but also with a short presentation of the specific Host Practice.

In the pilot phase of the programme there is no central funding. Grants supporting innovative initiatives will have to be found locally. As the programme develops and proves its justification and success it should be elaborated and made suitable for EU-funding through the EU mobility programmes Socrates/Erasmus or Leonardo da Vinci.

By all means intentions are to keep costs at a minimum through the pioneer spirit of the participants.

The programme is designed with a very flat structure relying on the activity and creativity of the participants. Thus through the principles of ownership enhancing the likelihood of success and sustainability.

The Country Coordinator makes the programme known among the Medical doctors specializing in General Practice/Family Medicine and distributes this catalogue.

A Trainee wanting to exchange takes direct contact to the practice of choice in the country of choice and makes preliminary arrangements for a study visit.

It relies then on the Trainee supported by the local Country Coordinator to find and apply for appropriate funding and to carry the exchange study visit through.

After the successful completion of an exchange visit an evaluation form will have to be completed. These forms will make up the basis for an annual report to the WONCA/EURACT-council on the progress of the programme.

The common language is English however it is an asset if the visiting Trainee is capable of speaking the language of the hosting country.

For legal reasons the visiting Trainee must take no independent active part in the examination and treatment of patients of the Host Practice.

On the following pages you will find a brief introduction to the organisation of General Practice/Family Medicine as well as presentations of the Country Coordinators and of the Host Practices from each participating country.

Sweden has a population of about 9 million. The Swedish health care system is a public sector responsible for providing and financing health services for the entire population Responsibility for these services rests primarily with the 21 county councils.

Primary health care in Sweden is since the late 1960's organized in health centers which has facilitated teamwork. Most family doctors are salaried employees, and it is most common to work in a health center, side by side and as a team with nurses, midwives and physiotherapists, but there are also some private alternatives. There is no long Swedish tradition in doctors listing patients; the doctors working in a health center hold responsibility for the people in the most nearby area. The last ten years though there has been some dynamic in the Swedish system of primary care, and there is now more diversity in the way of organizing local primary health care in different parts of the country. A law that states that every citizen in Sweden has the right to choose a doctor who has qualified as a GP as their own family doctor, which has led to a more prominent position for Primary Health care in swedish society. In 2002 the government also put resources into the Family Medicin Institute, which has as its main purpose to enhance the position of Primary health care in Sweden on all boarders.

Medical school, basic undergraduate medical education, is 5 1?2 years, in which general practice occurs on the curriculum throughout the education. Internship is 18-21 months, of which 6 months in General Practice. Successful completion of this programme gets the doctor a license to practice (full registration). Specialist training is at a minimum 5 years, and is carried out in a salaried position with medical responsibility. There are nationally stipulated goals for what knowledge and skills the trainee shall acquire to become a specialist in family medicine, and an individual plan for training is designed for each trainee. The whole time in training the registrar has her personal supervisor, with whom the progress in skills and knowledge is continually evaluated and reflected upon.

Tasks in general practice

Primary care in Sweden provides all basic healthcare that does not demand medical and technical facilities of a hospital. That includes preventive and rehabilitative care, child- and maternity-health care services, healthcare in schools as well as medical care of the very oldest in the community. The referral rate from general practitioners to specialists is less than ten percent.

Country coordinator for Sweden

Eva Jaktlund
Gubbyn 3357
841 96 Erikslund
Sweden
eva.jaktlund@swipnet.se

Arlövs Vårdcentral, Svenshögsvägen 6, 232 38 Arlöv
Phone:+46 40536900 , fax:+46 40435211

Geography: Our clinic is situated in the small community of Burlöv, which is located between the larger towns of Malmö and Lund in the south of Sweden. A good location with a mixed population who generally visit their clinic before trying other health providers in the nearby towns with large hospitals and abundant private practices. Also nearby are airports (Sturup and Kastrup), the Oresund Bridge joining Sweden to Denmark and making travelling to the centre of exciting Copenhagen just thirty minutes by train or car.

Doctors: We are a fairly large clinic with nine GP's working in the clinic, some part-time some full-time. Most of the time there are 1-2 young doctors training in family medicine and 1 young doctor at preregistration level. At times we also have medical students in the clinic.

Staff: The staff consists of over twenty employees ranging from nurses, secretaries, occupational therapists, physiotherapists to lab technicians.

Clinic: We run a well equipped modern clinic with a full computerised filing system. We service an area containing approximately 15.000 inhabitants.

Preferred visiting periods: Avoid in general the months of June, July, August and December.

Accommodation: There is plenty of low-cost accommodation available in the nearby towns of Malmö and Lund.

Dr Mats Rydberg, Bäckagårds vårdcentral
Bäckagårdsvägen , 30271 Halmstad
0046-35-134306, 0046-35-134304

Welcome to Bäckagårds health center.

Bäckagårds health center is in the city of Halmstad on the west coast of Sweden. The city is situatuated in a beautiful landscape with miles of sandy beaches. Halmstad is a popular summer resort, known for it's good opportunities for bathing in the shallow water and in the sun, and in the summer there is far more than the usual 80 000 inhabitants living in the city and the near surroundings. The city is easy accessable by plane, car or train. The nearest larger airports are in Gothenburg and Copenhagen.

Our surgery, which is recently renovated, is in the outer part of the central city, close to the sea in a well-situated area, where the majority of the inhabitants live in self-owned houses. The health centre serves about 5500 people. We also serve two geriatric wards, and a special-housing for healthy elderly people. As for all primary care health centers we take care of the preventive child care in our area. The surgery is well equipped: ECG-registrator, defillibrator, spirometer, eye- and ear-microscope. There are also facilities and equipment for gyn exams, procto- and rectoscopy examanitions and for chirurgia minor.

Three GP's are working here: dr Mats Aili, who is also a pediatrician , dr Ulf Peber and dr Mats Rydberg. The staff also holds three nurses, secretaries, assistant nurse, physiotherapist and occupational therapist. There are district nurses as well.

The best time to come here is april-june or august-september. Please contact us for more information:
mats.rydberg@lthalland.se

Jämjö vårdcentral, Hammarbyv 6, S-373 00 Jämjö
Tel 0046 455 735600

Welcome to Jämjö vårdcentral.

Our practice is located in the Souteast corner in Sweden where the migraiting birds leave Sweden in the autum and return early in the spring. Karlskrona the closest town is situated 25 kilometers to the west and has a long military history, now part of the worlds heritage. The area is rural and costal with a few inhabited islands.

The practice was established in the early 70`s. The population is about 7000. We are three Family doctors who have worked here at least ten years: Elisabet Jernby, Börje Carlsson och Ingemar Lilja (. Most of the time we also have a trainee. At the clinic there are also three nurses, two auxiliary nurses and two secretaries.

Our priorities are the old and sick with a high degree of accessibility and no waiting list.

We are all interested in palliative medicine and we have time put aside each week to visit our sick and dying patients in their homes.This is done with the close cooperation of our district nurses who also take care of our child health care.

You are welcome to visit us all year around and we can provide accommodations in our homes or according to your wish. Please contact us for more information!

Mölndals vårdcentral, Bergmansgatan 5, 431 30 Mölndal.
Tfn 0046-31-87 84 00

Welcome to Mölndals vårdcentral.

Mölndals Vårdcentral is situated on the beautiful Swedish west coast,in a small suburban city just outside Gothenburg. We are five doctors and six nurses working here, and two secretaries.

Jacob Wennberg, Inger Dagnell and Dimitri Edin Zylberstein have been fellow workers since the start of the practise in 1994. Kenth Wikhager and Katarina Järbur came along in 2002 when the practise expanded.

We serve close to 10.000 inhabitants in Mölndal and we are responsible for several nursing homes for elderly and handicapped in our neighbourhood. We have a special child welfare clinic in our practise too. Normal reception time is between 8.00 am to 5.00 pm but on Mondays, Wednesdays and Fridays we recieve patients in the evening up to 8.00 pm.

We have a psychologist working with us too, to better help our patients with psychiatric problems.

We are all very interested in teaching, and we like to supervise both medical students and doctors under education.We do look forward to introducing a colleague from another country to the Swedish family practise. We also look forward to learn and be inspired by other ways to do the work of a family doctor in another country, culture and system. Please contact us for more information

Our health center, Rens Hälsocentral, is situated in the small town of Bollnäs, in the midst of Sweden, in a beautiful landscape of forests, mountains and lakes. Here is wildlife experience right at your doorstep. Quality of life is top priority.

At our health center are five GP's and two doctors in training. There are also nurses, assistant nurses, occupational therapists, chiropodist and physiotherapists working in the clinic. We provide basic health care as well as child healthcare for a population of 9000 people. We use modern technology in our daily work, and in communicating with our patients; our website has all information about the health centre, and patients can contact us by e-mail. The patients can even book their own consulting time at their doctor on the web. The webaddress is www.renshc.nu.

The most relevant and updated presentation of Swedish CME is given by Dr Anders Lundqvist from Örnsköldsvik in northern Sweden. In an international correspondence on CME (to the BMJ) he gave the following answers to some appropriate questions.

Dear Rana Khodadoust!

I am a GP in a small community in the northern parts of Sweden, and at the same time chairman of the CME-council at the Swedish Association of General Practice. I will try to give you some answers to the questions you are asking. First you need a little background: (warning - long message follows!)

GPs in Sweden are nowadays subject to a period of five years of vocational training. They are for the most part salary-paid and work in health care centres. Single practices are rare. About 20 percent work in a more entrepreneur-like fashion on a contract negotiated with the health authorities. Primary health care in Sweden developed after the great expansion of hospitals in the fifties and sixties, and has had quite a hard time of establishing itself as a natural point of first contact in the health services. Only about 20% of the doctors (at the specialist level) are in fact GPs. The all too many hospitals in this country make it difficult for politicians to allocate the needed amount of resources to primary health care. Shifting the balance in favour of the GPs has proved to be a really difficult task, but in the last few years the Government has expressed a strong political will to make this shift come true. A national plan for primary health care was launched in 2001, and evaluation by the National Board of Health Care proceeds until 2008. A special institute called Fammi has a facilitating function in this process. There is still a lack of GPs in the countryside and the number of trainees really needs to grow to make a difference. Slowly its becoming more popular to be a trainee in General Practice, so we are now beginning to look forward to a brighter future as opposed to the dismal years of the nineties. There is still a lot of work to be done!

To the questions:

The attitude to CME from the employers varies greatly within the country. From a "laissez-faire" tradition where the pharmaceutical industry is the main provider, to an organized system with local bodies of professionals in a supporting, coordinating function where the employers ask for personal developmant plans.

Usually every health care center has a budget for professional development. A substantial part of that goes to the GPs. Money is really not the problem. Time is.

In my region we have a personal account of 25 000 kronor a year which covers travelling, hotel, course fees, litterature and so forth. My income is the same as if I was working in my practice. Those who work on a contract usually have to allocate extra resources to cover loss of income. CME-wise we are considered to be a progressive region.

Sadly the pharmaceutical industry still dominates the scene, but for those who feel reluctant about having the industry as the main provider there are good alternatives.

On the local level we have a system of small CME groups (50% of GPs participate), mentoring functions and Balint groups are options in some places. Regular monthly meetings (4 hrs) with CME-activities for all the GPs in a specified area is the standard in most regions.

On the regional level we have special Pharmaceutical committees responsible for making a list of recommended substances to be used in the health care services. They also arrange theme-oriented CME-activities to all prescribers about 2-4 times a year (8 hrs on the average). One or two doctors in the regions work as EBM-facilitators and visit practices or groups o colleagues at meetings. In some regions there are local professional bodies that arrange indepedent CME based on needs expressed by their GP-colleagues. The range of that varies from occasional activities to 8-10 days a year. Hopefully this is a growing phenomena.

On the national level we have Kursdoktorn (The Course Doctor) an organisation partly funded by the above mentioned Fammi and partly by the 1 million size Västra Götaland region (incl Gothenburg) which offer a catalogue of activities available to all GPs in the country. For this year about 35 activities are scheduled ranging from 1-5 days. We also have a fund in one of our unions responsible for about ten 3-5 days activities per year. SFAM the Swedish Association of General Practice arranges annually a 3 day congress for its members, which is becoming increasingly popular. We also arrange various activities for special interests-groups during the year.

SFAM has a policy on CME since 1993. We want CME for GPs to be self-directed, based on adult-learning theory and independent. Small CME groups, mentoring, Balint groups, and personal development plans are the cornerstones in the CME we wish to encourage. We also want to provide our members with commercially independent course activities of good quality on a national, regional as well as local level. Our CME-council is the driving force for that purpose and we meet 4 days a year. Recently we have formed (helped by fammi) a national network of CME-coordinators consisting of 60 GPs all over the country. We meet two days each year and communicate in the e-group format. The Nordic countries has started a small network for key persons.

Apart from reading BMJ do you mean? Your magazine is quite popular here but I dont think the average GP spends a lot of time reading English magazines or books. Very few I believe take part in any interactive CME-activities online.

Shouldn't be really. The amount of information available in Swedish is really enough for most GPs however.

No, not really, but I think maybe a few more GPs would be interested if that was the case. Online CME has yet to be discoveerd for most of us.

I'm not really sure what you mean by Gap assessment, but as far as revalidation goes this has yet to become an issue here. The health authorities are keeping a low profile in this matter. As I told you before SFAM wants to encourage personal development plans, but nationwide this has not been a success. In some places doctors were given bonuses to present PDPs, but once the bonuses stopped the production of PDPs ceased. A lot of the CME- activities taken by GPs are not deeply reflected on beforehand so to speak.

SFAM has a voluntary form of assessment procedure called ASK see abstract below.

If you want some more information feel free to ask again! It was interesting hearing from you!

Anders Lundqvist, GP, Vårdcentralen Viken, S-891 33 Örnsköldsvik, Sweden
Tel: +46(0)660 898 30, Fax: +46(0)660 898 03

In different national general practice meeting I have informed about EURACT. A direct link to EURACT is now on the web site of Swedish Association of General Practice/Family Medicine (see above). The Wonca definition has been referred to in various reports and publications. The Swedish members have been informed of the different activities that EURACT organises.