Specialist training of family physicians in non-UEMO countries: An Estonian experience

The article by Bulc et al. [1] concerning specialist training and principles in family medicine (FM) in Slovenia, and a comparison with other UEMO countries, gives valuable information on the regulation of family medicine training, and demonstrates great variability both in duration and training environment in different UEMO countries. In the current dynamic development of Europe, family medicine has taken great steps forward in several countries. The European understanding of general practice training expressed by UEMO and EURACT has been implemented in many European countries irrespective of their being a member of UEMO; yet great differences exist, even within countries. In Table I, information concerning countries not covered by the UEMO survey is presented, derived from the EURACT website in November 2006 [2]. However, the experience of implementing changes in family medicine education has not received enough attention, national experiences are rarely published, and there is no updated and methodologically correctly collected information covering the actual state of the art in all European countries.

Table I.  Duration of general practice/family medicine specialist training in countries not covered by the UEMO survey.

Country	Duration of general practice/family medicine specialist training, years	Duration of training in general practice/family medicine setting, years	Duration of training in hospital setting, years
Albania	2	0.2	1.6
Bosnia Herzegovina	3	2	1
Czech Republic	3	0.5	1.3
Estonia	3	1.5	1.5
France	3	0.5	2.5
Greece	4	0.9	3.1
Israel	4	2	2
Lithuania	3	0.5	2.5
Norway	5	4	1
Poland	4	2	2
Romania	3	1.3	1.7
Turkey	3	0	3

Having experience of 15 years of specialist training of family physicians (FP) but not being a member of the UEMO, Estonia has adopted the same principles of training and has shown similar trends in the development of FP training as those in other new European Union (EU) countries [3], [4]. The government of Estonia harmonized training in all medical specialities according to EU regulations in the year 1997. The key issues were acceptance of the special training needs for family physicians as a speciality in academic institutions, involvement of practising family doctors as trainers in training, conducting training during real work in family practice, joining of training and research, and having governmental financial support for the training.

In Estonia, as in Slovenia and other new EU countries, the training of FPs started at retraining courses for doctors working in primary healthcare (mainly internists and paediatricians). The main characteristics of the courses were the following: as trainees had different backgrounds and experience, the programme was individually tailored; training methods were based on the principles of adult learning and teaching; training was organized in-service over 3 years; training ended with a complex final exam and a certificate of the speciality of family physician. In Estonia, such training took place from 1991 up to 2004, and during this period 937 family physicians completed the training. This figure meets Estonia's need for FPs (calculated number of patients: 2000 per FP). Since 2004, all physicians working in family medicine are trained family physicians. In parallel, full-time vocational training (residency training) in family medicine was introduced in 1993, and since then 91 family physicians have completed the training. Today, and in the future, residency training will be the only possibility to apply for the FP speciality. Since the year 2000, 15 residents in family medicine have begun training every year. Residency training conforms to the principles of the EU Doctors Directive 93/16 and to other EU consensus documents in the training and core competences of family physicians: at least 50% of training is completed in a family medicine setting and 50% in other specialist clinical settings; training starts at the same point as residency training in other specialities, and residents participate in all activities that are obligatory for training settings. During training, trainees enter into a contract of employment with the training site, and their main activities are connected with work with patients. Not more than 20% of the training period is devoted to the theoretical part of training. Residency training starts, as in all other specialities, after completing a 6-year undergraduate course, which includes 0.7 years of practical work in hospitals and general practice (s.c. internship). The duration of vocational training in family medicine is 3 years. During the course of training, formative assessment (observation of trainees’ performance by trainers using the analysis of videotaped consultations for evaluation of communication skills, feedback, log-books, reports, research project, etc.) is carried out, and at the end of training a summative assessment (final exam: written test, oral problem-solving skills, practical skills demonstration) is provided. Completion of residency training grants an FP certificate. The Estonian government supports residency training financially, and the number of residents is planned by the government according to the need for doctors in the country. The training programme, the selection and supervision of training sites, the training of onsite trainers (practising family doctors) as well as the theoretical part of training and the final exam are the responsibility of the Department of Family Medicine at the University of Tartu in cooperation with the Society of Family Physicians of Estonia.

The family physician certificate ensures Estonian FPs free movement in Europe and allows Estonian physicians to work or plan to work in different EU countries [5].