News from the Nordic Colleges of General Practitioners

The future of general practice in Sweden is totally dependent on the recruitment of future specialists. In a study of medical students’ preferences for future specialty only 17% stated that they wanted to become general practitioners (GPs). This proportion tends to increase during the last part of their internship work in our field but it is still not enough to meet the future need for GPs. Political and administrative decisions are required in order to improve the situation but while waiting for these decisions the Swedish Association of General Practice (SFAM) intends to make the path to specialist qualification in general practice more attractive. Several projects are in progress and these are now starting to bear fruit. In the following a few of these will be presented.

Hidden specialty during undergraduate training

In a recent study of medical students’ first choice of future specialty 17% stated they intended to become GPs [1]. In order to be able to meet future needs and to provide a good working environment and a reasonable workload, the proportion ought to be in the region of 30%, according to recently published figures from the General Practitioners’ Organization (Distriktsläkarföreningen) [2]. One way of increasing the proportion of students who would consider our specialty as their future career is to increase the contact with general practice during undergraduate training, and various institutions of medical education have in recent years stressed this [3], [4]. This is important not just in order to increase the students’ interest in our specialty but also in order to increase knowledge of the specific issues and clinical problems that exist in primary care.

Increased interest during internship

At the latest yearly national internship congress there was considerably more interest in general practice as second choice – but the participants wanted to try something else first. What is attractive is the image of the “real” doctor with the responsibility for deep and long-lasting care of the patient, and in addition the greater possibility of combining work and family life. One problem is that general practice is the final part of the internship and many have at that point already applied for, and got, their first temporary job.

One way of making it more appealing for non-licensed residents to remain in the field of general practice is to both start and end their internship in primary care, and to make it possible for each of them to keep in touch with her/his general practice and the tutor there in the interim. This is for instance being tried in Malmö but it still requires exemption from the rules of the National Board of Health and Welfare.

Increased influence on the GP trainee

Undergraduate training has traditionally had its focus on knowledge; the road to specialist competence is more like the travelling apprenticeship of the past, a competence development. This requires reflection-in-action, on your own but also together with an experienced colleague, tutor, or mentor. It is very important early on to establish the habit of continually assessing your abilities, identifying your learning needs, constructing your own learning plan, going through with it, and then reflecting and assessing again. This process adds to the responsibilities of the GP trainees but it also entails an increased influence on their own education. At the same time the foundation is laid for continuing professional development [5].

Whilst the GP trainee's influence increases, the role of the director of specialty training is changing. From previously having been entirely responsible for how the GP trainees’ service was modelled, the director's role now is more that of a coach and evaluator of competence. The director of specialty training must also, jointly with the head of the clinical unit, be responsible for the assessment of when the GP trainee is ready to apply for specialist authorization.

In order to discover any possible process error in good time, and to achieve competence assessment that is uniform to the highest degree possible throughout Sweden, a workplace-based assessment by an external examiner halfway through the GP trainee period (mitt-i-ST) [6] is recommended.

The model in which the GP trainee is in charge of the training programme is being tried in practice. With a large proportion of the country's GP trainees, Stockholm leads the way to give them this increased influence. The GP trainees have been divided into district-based groups and have been allocated time and financial means to initiate lectures and student meetings for themselves. They also have the authority to administer the periods of service in other specialties. Several GP trainees have said that it has become harder to plan their training programme but it seems from the opinions that have reached SFAM's GP trainee advisory committee that the more responsibility and influence that is given to the trainees the more enthusiastically they talk about the system's advantages.

Cooperation strengthens

An expressed concern is that the new system could possibly let down the more reticent and quieter trainees. The best way to diminish this risk is to create possibilities for the GP trainees to cooperate. A good example of this is SFAM's GP Trainees’ Days: for the last five years the GP trainees have met at a conference of their own during three cold February days. This has now become an annual event with subsequently increased attendance – lately with approx. 35% of all Swedish GP trainees present. With a rich medley of lectures, workshops, exhibitions and – not to be forgotten – social events, the GP Trainees’ Days contribute to creating an active professional group – something that has previously been difficult in a thinly populated and widely spread country.

Similarly, and with inspiration from colleagues in the rest of Europe and the newly launched Vasco da Gama movement [7], a national network for GP trainees has been established. Its purpose is to facilitate discussions on all kinds of educational issues and connected to this is a mail network, which, after a slow start, now is well under way.

From knowledge to competence

During the last couple of years SFAM, together with representatives from four other specialities (internal medicine, general surgery, psychiatry, and clinical chemistry), has participated in the National Board of Health and Welfare's efforts to create a new model for description of aims (målbeskrivningar) in specialty training [8]. The model, which is mandatory for all specialties, requires that a certain limited number of learning outcomes must be stated within four different competence areas: in addition to clinical competence are communicative competence, leadership competence, and competence within quality development and medical research. For each learning outcome, learning methods and assessment criteria must be stated. The only time stated is a minimum of five years of clinical practice under supervision after licence (legitimering).

Based on this framework the prolonged work of revising the description of aims for Swedish general practice specialty training has basically been finalized [9]. It is now entirely competence and outcome based, and there are no fixed periods of service in other specialties. General practice is best learnt by practising it and we have therefore stated that at least half the residency should be spent in general practice. Our description of aims also includes the tools for continuing professional development, requirements for supervisor/tutorship even during the periods of service in other specialties, and the possibility of external assessment [10].

Educational portfolio on the Internet

Representatives from SFAM have also taken an active part in another project aiming to facilitate continuing professional development, namely the drafting of a digital educational portfolio, partly based on the Danish model. The Swedish Medical Association and the Swedish Society of Medicine plan to launch the portfolio at the end of this year.