Abstract
Background: General practice training in Europe is still an unresolved issue. Italy has developed a formation course similar to specialty schools, awarding a certificate of attendance at the end of a 3-year period. Its training goals are defined mainly as work hours in medical facilities, including two semesters at two general practices.
Objectives: To evaluate if a registrar, during a semester in a general practice, has access to a case spectrum consistent enough to achieve the training goals, both ‘methodological’ (work organization targets) and ‘specific’ (targets of opportunity).
Methods: During a six-month period, every patient contact qualified for tutoring was recorded. For each visit, access mode and priority, patient name, age, patient reason for encounter (RFE), diagnosis, referrals, prescribed laboratory tests and treatment were recorded. Data was evaluated as in other Italian medical specialties; i.e. compared to target numbers.
Results: A total of 1 828 contacts and 2 437 RFE in 122 work days were recorded. There were 1 007 and 613 contacts with and without appointment respectively, 88 ‘family contacts,’ 44 scheduled check-ups, 11 phone contacts, and 65 nurse interventions. Of all contacts, 9.8% were indirect. In six months, we had at least one contact with 792 patients out of 1 500 (52.8%). Main RFE resulted from respiratory and musculoskeletal symptoms while most frequent diagnoses belonged to musculoskeletal, cardiovascular and respiratory fields.
Conclusions: A six months training period can be sufficient for representing a general practitioner's work organization and primary care epidemiology. However, deficiencies were observed.
Key message(s):
Six months in a General Practice provide sufficient patient contacts to become accustomed to ambulatory visits organization.
A specific training for home visits, phone contacts and integration with territorial structures would result in an overall improvement in formation quality.
Introduction
General practice training in Europe is still an unresolved issue. Title IV of the EU Directive 93/16/EEC defines minimum training of three years (Citation1). At present, each country may decide duration and contents of this post-graduation formation period, while the European Academy of Teachers in General Practice supports a unified training programme for Europe (Citation2,Citation3). Post-graduate formation ranges from three years in France and Italy, to five years in Denmark and Germany (Citation4).
Most European countries, including Germany, France, Spain and the UK, grant the title of ‘Specialist in General Medicine’ at the end of a course of study supported by universities. On the contrary, Italy developed a formation course similar to specialty training, organized by independent public structures on a regional basis and awarding a certificate of attendance at the end of a three-year period (Citation5).
The Italian general practice training goals are defined essentially as work hours in many different medical facilities, including two semesters at two different general practices. The aim for Italian young doctors to ‘learn how to approach diseases and overall problems managed by a primary care doctor’ by just attending a practice for a given time (Citation6).
In addition, during a semester in a general practice, a registrar should pursue ‘methodological’ and ‘specific’ goals. Methodological goals, such as learning how to apply theoretical course teachings, understanding the daily organization of work and approaching the optimal paths of care for common diseases, are mandatory. On the contrary, specific goals are targets of opportunity, created to allow customized formation path. Aim is to make the most of the pre-existing medical skills of both registrar and tutor and also to take advantage of the case spectrum, which may differ from practice to practice (Citation7). To learn to apply this teaching method, tutors attend specific courses. However, no effort was made so far to validate its efficacy and evaluate the outcomes for young Italian general practitioners (GPs). There are no publications in Italian or English language regarding this topic or the Italian vocational training overall.
Aim of this study was to evaluate whether a registrar has access to a case spectrum consistent enough to be representative of a GP's work and if this is sufficient to achieve the Italian general practice training goals, both methodological and specific.
Methods
Study population
Data from every patient contact with a single general practice qualified for tutoring activity were collected. Data was recorded by a doctor participating in the Italian formation course during medical training in a general practice covering a town in Lombardia, Italy with a population of 20 000 people. The practice was organized as an association of 3 doctors, supported by a secretary and a nurse. All 3 doctors were responsible for the care of a maximum allowed patient number of 1500, for a total practice population of 4500 people ().
Table I. Age and sex distribution of practice patient population compared with observed patient contacts.
Data collection
The data collection period was fixed at six months (122 working days from January to July 2010), corresponding to the first semester of the Italian vocational training. Only one semester was taken into account because it is required to spend the two general practice semesters in general practices with different organization of work, for instance a GP working alone versus a team of doctors including a secretary and a nurse. Therefore, the registrar has only one semester to become acquainted with specific work structures.
Methodological goals. Methodological goals include work organization targets such as planning appointments while granting free access visits to the acute patient, handling chronic diseases through scheduling of control visits, planning home visits, evaluating and handling the most common domiciliary emergencies, learning to use telephone contacts as a medical resource. Other methodological goals are using ‘time’ as a diagnostic and relational resource, thanks to the repeated patient–clinician contacts and the consequent trust relationship; understanding the role of family in the process of care; becoming aware of the social resources available in the regional health system; cooperating with other professional figures of the health system. To evaluate them, for each patient contact, information relevant to practice organization was recorded such as access mode (scheduled, urgent, telephone contact, indirect contact, i.e. relative asking for prescription renewal).
Specific goals. Specific goals are targets of opportunity, depending on the case spectrum of the single practice. The most important ones are: understanding the real incidence of illnesses on the general population, exploring the central role of the GP involving public health problems, and handling the patient with non-specific symptoms, which should allow the registrar to develop problem-solving capabilities.
Since ‘specific goals’ include primary care epidemiology, we searched PubMed for similar studies for comparison with the collected data in this study. Four studies were found (Citation8–11). The largest one was the Australian government BEACH study (Bettering the Evaluation and Care of Health). Moreover, it was the only one coded using the International Classification of Primary Care—Version 2 (ICPC2) that also allows analysis of patient reason for the encounter (RFE). (Citation12) Therefore, we decided to use the same method adopted in the Australian study. For each patient contact, in addition to ‘access mode,’ we recorded patient name, age, sex, patient RFE (up to four), diagnosis (if any, up to four, new/old problem to the practice), specialist referrals, laboratory tests prescribed, treatment (drug name without dosage), and notes, which included, i.e. performing an immunization, nurse intervention for medication, writing a sickness leave certificate. In the latter case, we recorded how many leave days were assigned.
Data analysis
At conclusion of the data collection period, we transcribed all data on an Excel spreadsheet. ‘Patient RFE,’ ‘diagnosis’ and ‘referrals’ fields were then coded using ICPC2. Using Excel filters and formulas we divided and counted contacts for access mode, day and age range. Data was also expressed as percentages of the total number of contacts. For each ICPC2 chapter, the ratio of new/old problems to the practice was assessed.
Methodological goals. To evaluate whether the registrar experience in a GP is sufficient to achieve these goals, ‘access mode’ collected data was evaluated following the same method used for all other medical specialties. In Italy, every specialty has a table for practical goals. According to this table, an important and frequently used ability is fully developed by exercising it 250 or more times. For instance, a neurology resident follows 250 clinical cases and a general surgeon performs 250 small interventions. In the same way, an important but infrequent ability has to be performed at least 100 times, while a difficult or infrequent one, 50 times or more (Citation13).
Specific goals. Patient RFEs and diagnosis were compared with each other and with international studies’ epidemiological data to evaluate if the registrar had access to a significant case spectrum. Other data (therapy, referrals) are subject to the judgment of the single physician and, therefore, less useful for this research. Unpublished data may be requested from the author by e-mail.
Results
We recorded a total of 1828 contacts and 2437 RFE (1.3 RFE/contact) in 122 working days from 7 January to 2 July 2010, for an average of 15 contacts/day (range: 2–29) and 20 RFE/day (4–41). In six months, at least one contact with 792 different patients out of the 1500 total patients referred to the tutoring GP (52.8%) and 8 new patients were visited at the practice. During this time, 392 patients came for a single visit, 176 came twice, 108 were visited three times, 53 were visited four times, 63 contacted the practice five or more times. Mean consultation duration was 16 min, with an average of 15 consultations in four hours daily. We report contact distribution for age and sex in . As expected, frequency of consultation increased with age.
Methodological goals
Work organization is demonstrated by assisting to a consistent number of visits. Collected data distribution for ‘Access mode’ is summarized in . Contacts by appointment and urgency are well above the 250 cases required by other specializations. Chronic diseases represent the most contacts; this makes up for the low number of scheduled disease-specific visits. Of ‘work organization’ targets, the ones that have not been reached are integration with other local health care professionals (such as physiotherapists, social workers, palliative care operators and psychologists) since contacts included only visits with the practice nurse; and ‘phone contacts.’ Apparently, the presence of a secretary did not allow the achievement of sufficient expertise regarding this resource.
Table II. Observed ‘access mode’ data compared with formation targets.
Other methodological goals include the ‘importance of family as a resource,’ which was thoroughly explored during 88 visits involving more family members, and 168 contacts that included at least one patient's RFE concerning a medical problem of a relative who was not present. These data, in addition to telephone contacts, account for 9.8% indirect contacts.
Administrative procedures were dealt with in 493 cases: this should allow the registrar to develop sufficient confidence and competence to interact with the local healthcare system. A trustworthy relationship, developed through repeated contacts, is experienced in 400 patients that have been visited two or more times in the six-month period.
Home visits goals have not been reached. Training hours were constrained to ambulatory hours. This and the need to attend frontal lessons in the remaining hours proved to be an obstacle in the routine following of a GP during home visits.
Specific goals
Main patient reasons for consultation resulted from respiratory and musculoskeletal symptoms while most frequent diagnosis belonged to musculoskeletal, cardiovascular and respiratory fields (, overall frequency percentages are also reported).
Table III. Comparison between observed patient reason for encounter (symptoms before medical evaluation) and problems managed (after diagnosis being performed).
In the ‘developing diagnostic and problem-solving capabilities’ goal, 49.9% of ‘general and unspecified’ in patient RFEs has been reduced to 20.4% in problems managed after medical evaluation, as shown in . This is indicative of a performing diagnosis but is also depending on the tutors (and registrar's) specific proficiencies; therefore results cannot be standardized.
Most common new problems to the practice were diagnosed in fields involving respiratory (68.4%), dermatological (58.3%) and ocular (50.9%) specialties. Situations involving psychiatric (15.6%), oncologic (15.8%) and cardiovascular (18.2%) problems were less frequent.
The goal ‘integration with public health’ has not been achieved. The training period, forcedly located in the first six months of the year, did not allow, for instance, acquiring the organization skills for a vaccination campaign since these are usually administered in November.
At last, among specific goals there is an ‘interest in family medicine research and ability to perform clinical and epidemiological research.’ We think realizing this study allowed us also to reach this goal.
Discussion
In the six-month period of this study, a significant number of patient contacts were recorded. Patient reasons for consultation were well distributed in all fields of medicine, providing the registrar with a broad experience and achievement of most specific goals. Analysis of the collected data on work organization also shows that methodological goals have been mostly achieved.
While six months proved to be enough to achieve most goals, some aspects of the mandatory goals have not been fully accomplished. Since this study was performed in the first of the two GP semesters, the registrar had a second chance to refine these topics. For instance, a second general practice with different features can be chosen. In this case, a practice without non-medical personnel would allow a better acquaintance with phone contacts.
Strengths and limitations
Some weaknesses of this study must be underlined. Data was collected in a single general practice, which may not be representative for Italian family medicine. Furthermore, the vocational training is organized on a regional basis. While guidelines are defined on a national level, differences may exist in their implementation in specific geographic areas. However, several reassuring verifications have been carried out. Registrars from other regions, enquired about their experience, provided a description very similar to our own.
The strengths of this study include the large number of contacts collected, the ICPC-2 standardization of results, which allows comparison with epidemiological databases and future studies regarding this topic. There is a substantial coincidence between the observed epidemiology and literature data from Italy, Europe and other continents (Citation8–11). Furthermore, this is the first study on the Italian vocational training. Until now, no effort was made in trying to validate its efficacy in reaching the educational goals within the given time.
For this reason, we encountered some difficulties in comparing found results with the currently available studies. European studies are mainly focused on chronic diseases and use ICD-9 coding system, resulting in an unreliable comparison. A more accurate comparison is possible with the Australian BEACH study, although there are differences in local epidemiology that must be taken into account such as the high prevalence of melanoma that causes a consistent number of contacts for skin related problems.
Implications
Considering the limitations of this ‘n =1’ study, we propose to replicate this study on a larger scale, using a representative sample of Italian tutoring practices. Nevertheless, even this small study provides food for thought. We think to reach Italian and European standards it is necessary to reconsider the ‘goal’ system based on spending a preset amount of hours in a specific setting. First of all, separating training hours from ambulatory hours would improve flexibility. This would allow a real experience in domiciliary visits and should make it possible to follow the tutor in his interactions with local primary care professionals and organizations.
We also suggest extending the two general practice training periods to all months of the year, and to not keeping them both in the first semester, as it currently is. The incidence of certain diseases, i.e. influenza, changes dramatically depending on the season.
Finally, some goals are considered ‘target of opportunity,’ and inserted in the ‘specific goals’ list because they also depend on the registrar's ‘luck.’ However, we think they could be routinely reached by providing the right conditions. For instance, writing this study was possible mainly for the enthusiasm and motivation of both registrar and tutor. Furthermore, registrars do not have autonomous access to the necessary resources, ranging from a scientific library to the expertise of a workgroup that had already published on scientific journals. It is possible to overcome these limitations by improving central organization of the vocational course, for instance by merging the registrar's rotations in a single medical centre, at least to obtain access to both local and regional resources.
Conclusion
A six-month training period can be sufficient for an accurate representation of a GP's work, at least concerning ambulatory visits. It can provide an appropriate number of patient contacts to become accustomed to working organization and primary care epidemiology, allowing the registrar to achieve the most important goals of vocational training, both methodological and specific. However, deficiencies were observed as well.
Acknowledgement
This study was realized without any kind of financial support.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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