Specialist training of Slovene family physicians

Abstract

Family medicine in Europe started to develop in the 1960s with the introduction of obligatory specialist training. Slovenia is a country with a long tradition of family medicine specialist training, but up until 2002 this was neither elaborated on nor conducted by peers in general practice/family medicine. When the country's socialist system started to transform due to political reforms, Slovenia began to modify its system in order to meet the criteria of the European Union. One of the changes was the introduction of a new healthcare system with an influential Medical Chamber responsible for postgraduate training in all specialities. A new model for vocational training in family medicine was established in 2002, following the recommendations of the European Union of General Practitioners (UEMO). According to the new programme, which lasts 4 years, trainees spend half of their training in a hospital setting and half in general practice, where they are supervised by a trainer in practice. This article describes the legal process of introducing new forms of specialist training in Slovenia, and its content.

Conclusion: A comparison with UEMO countries shows that the new model is comparable to other countries.

• Education
• general practice/family medicine
• Slovenia
• specialist training

Introduction

General practice in Europe is exercised by several types of physician, depending on the political situation, tradition, and undergraduate and postgraduate medical education of the country [1–3]. Practising physicians in general practice/family medicine (GP/FM) are either general practitioners (GPs) with completed undergraduate education or specialists in GP/FM, i.e. vocationally trained doctors. In some countries, both are entitled to practise, and there are even some states where specialists in internal medicine, paediatrics, etc. still practise general medicine [3].

Regulations concerning this matter in the European Union are the Doctors’ Directive 93/16 of the EEC Council, Directive 2001/19/ EC, Consensus Document on Specialist Training for General Practice of European Union of General Practitioners (UEMO), adopted in 1994 in Copenhagen [3], and the UEMO 2003 Declaration on Specialist Training, adopted in 2003 in Dubrovnik [4].

History of specialist training in Slovenia

The healthcare system in Slovenia has undergone important changes over the past 14 years. In 1992, a new system [5–9] was introduced, with a centralized national and voluntary health insurance, private practice, and the transfer of many administrative roles to the medical and pharmaceutical chambers. Two objectives—to open the healthcare system to private initiatives, and cost containment (national insurance and voluntary insurance fees) in a mixed public and private healthcare system—were pursued.

In the former Yugoslavia, the primary healthcare system was well developed, based on well-equipped health centres, found in every community throughout the country, offering basic medical and dental services. The funding of primary care was done mainly through a contract between the providers and the National Health Insurance Institute. The criteria on which the contract was based were predominantly capitation and fee-for-service. Hospital activities took place at the secondary and tertiary level within 12 speciality hospitals, all owned by the state. Institutes and clinics as tertiary-level organizations performed advanced-level treatment as well as educational and research activities. There was a gate-keeping system with several first-contact physicians: paediatricians, school medicine doctors, general practitioners, occupational medicine physicians and gynaecologists [5].

Specialist training in GP/FM in Yugoslavia started as early as 1961, first in Zagreb, Croatia, at the Andrija Štampar School of Public Health, and 1 year later in Ljubljana. Slovene vocational training was organized by the National Health Institute. Although it was not obligatory, many GPs attended and passed the training. Today, more than 60% of GPs are vocationally trained general practitioners, specializing in GP [10].

Development of the new programme of specialist training in Slovenia

Historical changes occurred in 1991 when political, organizational and legal changes took place not only in the political but also in the social arena in Slovenia, a newborn country. Some of the changes affected the healthcare system as well [5–9]. Starting from 1991–1992, these changes affected not only the delivery, but also the financing, control and reimbursement structure [6]. The goal of the reform was to reduce healthcare expenses without jeopardizing the health of the population. The central health insurance fund at the country level and under the direct control of the government was established in 1991. It is responsible for the realization of health policies defined by the government, and for the financing and control of healthcare services. In addition to compulsory health insurance, voluntary health insurance has been implemented [5].

The Department of Family Medicine at the Ljubljana Medical Faculty was established in 1994. It became obvious that the old specialist-training educational model, practically unchanged since 1962, was not efficient anymore, as it lasted 3 years and took place mostly in hospitals, with a 1-year course in public health. In 2000, the Department of Family Medicine introduced a new schedule of specialist training in GP/FM, which was accepted and started in 2001 [10].

Since 1993, every graduate student has to attend a 2-year internship (performed almost exclusively in hospitals) and pass an exam in order to get a licence to start practising. Until January 2007, they can start practising as general practitioners or start their specialist training in any speciality they apply for.

We train about 75 trainees per year. For historical reasons, there are currently four types [10] of trainees in GP/FM in Slovenia: a) young doctors who pass their 2-year internship and final exam; b) general practitioners already practising (some have no specialist training and completed part of their training during residency); c) physicians with no internship (from the old Yugoslav educational system, with a 1-year residency and “state professional” exam), working in general practice for many years, but who have never been vocationally trained; d) physicians who have not yet practised GP/FM (employed in institutes, pharmaceutical companies, etc., only statistically regarded as GPs).

Results

This complicated situation urged Slovene teachers in GP/FM to prepare a completely new educational schedule and rules. Each trainee has a general trainer who has to be an experienced GP, having worked for at least 5 years as a specialist in GP/FM, acting as a general supervisor and coordinator of the trainee's educational schedule and training. This year, we have 169 trainers in the country, which is 19% of all practising general practitioners. The schedule and method of specialist training is then tailored to each trainee individually [8], [9].

Specialist training in GP/FM lasts 48 months: half of this time is assigned to clinical subjects and half is practical work at the trainer's practice (64 training posts at health centres and 48 training posts at private independent contractors with the national Health Insurance Institute of Slovenia in 2006) and modules. There are currently 10 basic and 15 optional modules. The basic modules are mandatory, and optional modules are chosen according to the type of trainee. They are organized and taught by teachers in general practice/family medicine and also by invited professionals [10]. An overview of the programme is shown Table I. Table II shows the content of the modules.

Table I.  Content and duration of clinical part of Slovene-specific training in family medicine.

Education and training	Duration (mo)	Training institutions (H = hospital)
Internal medicine	6	H
Infectious diseases	2	H
Surgery	3	H
Paediatrics	3	H
Gynaecology/obstetrics	2	H
Psychiatry	2	H
Neurology	1	H
Dermatology	1	H
Orthopaedics	1	H
Ophthalmology	1	H
ENT	1	H
Oncology	1	H
Total	24	H

ENT: ears, nose and throat.

Table II.  Content of modules.

	Title of module	Content/comment
1	Family in health and in illness	Family cycle and function
2	Organization of practice work	Theoretical and practical issues, legal obligations, teamwork
3	Communication with patients	Communication skills training by role paying and video
4	Quality assurance	How to conduct audits, and assessment and control of GP performance
5	Diagnostic procedures	Possibilities and limitations of diagnostic procedures in family medicine
6	Prescribing	Rational pharmacotherapy in practice
7	Preventive activities	Strategies of prevention of chronic diseases, limitations to prevention
8	Chronic patient	Active management of chronic patients; long-term partnership, compliance
9	Addictions	Lifestyle change
10	Physical medicine and rehabilitation	Rehabilitation as a part of GP's everyday tasks; role of physiotherapists, people with disabilities
11	Healthcare of children and youngsters	Preventive and curative activities, role of GPs and paediatricians
12	Healthcare of workers	Safe working places; role of GPs and occupational medicine specialists
13	Healthcare of the elderly	Special aspects of care, nursing homes, home visits
14	Terminal patient	Breaking bad news, communicating with patient and family, role of specialist palliative care
15	Pre-hospital emergency level	Emergencies in everyday work, out-of-hours work, practical skills training
16	Home visits	Out-of-practice work, decision making, equipment
17	Home for the elderly	GPs tasks in nursing home
18	Ethical problems	A selection of common ethical problems in general practice
19	Cooperation with specialists	Communication with specialists, referrals
20	Evidence-based medicine	Critical reading, sources of evidence
21	Burn out	Limitations of medical profession
22	Communication with patients II	Difficult cases in communication
23	Research in GP/FM	Preparing a paper, thesis
24	Public health	GP as public worker, basics of public health approaches in primary healthcare, community-oriented primary care
25	Medical error	Dealing with errors, complaint procedure

The training is audited by peers (nominated teachers in GP/FM) in co-operation with the Society of Slovene Family Physicians, and supervised by the Medical Chamber of Slovenia. Trainees and residents have to pass the assessment at the end of each clinical cycle and a final examination. Final assessment takes place at the Department of Family Medicine. The demands are the same for all trainees: trainee's report, examining committee member's visit to the trainee's practice, and a final examination assessing the trainee's knowledge (MCQ written test) and clinical skills (OSCE stations). Those trainees who pass both have a final oral examination [10].

Comparison of Slovene model with Europe

The European Union's roles and responsibilities for healthcare are defined in Article 129 of the 1991 Maastricht Treaty. A recent revision to Article 129 has raised considerable expectations that politicians will take the opportunity to create a legal and institutional basis for integrated health policies, stating that priority should be placed on major diseases, failing to consider the broader determinants of health. Governments like the diction, but it marginalizes issues such as welfare policy, inequalities in health and access to health services. Education is still dominated by disease-oriented ideology, which serves as a basis for the priority-setting process [9].

Since the recognition of diplomas in EU countries is still not clearly defined, the UEMO Quality Assurance Working Group decided to review specialist training in member countries. They launched a survey on structure, duration, auditing and financing of GP/FM specialist training, starting in 2002–2003. The data collected show that the total duration of specialist training in GP/FM in Europe differs a lot. The minimum duration of training is 3 years (Austria, Croatia, the Netherlands, Spain, the UK and Slovakia). In Belgium training lasts for 42 months, Slovenia and Ireland 4 years, and in Denmark, Germany, Hungary, Iceland, Portugal, Sweden and Switzerland it takes 5 years. The longest specialist training is in Finland (6 years) (Table III).

Table III.  Duration and structure of specialist training in family medicine in UEMO countries (2003).

	Duration (mo)
Country	Clinical part	GP/FM part	Total
Slovenia	24	24	48
Austria	30	6	36
Belgium	6–12	24–30	42
Croatia	23	13	36
Denmark	36	24	60
Finland	30	42	72
Germany	18–44	18–36	60
Hungary	20	40	60
Iceland	36	24	60
Ireland	24–36	12–24	48
Italy	24	12	36
Luxembourg	no data	no data	no data
Netherlands	12	24	36
Portugal	12	22	36
Spain	25	11	36
Sweden	30	30	60
Switzerland	48	12	60
Slovakia	32	4	36
UK	24	12	36

In all UEMO countries, specialist training consists of a clinical and a GP/FM part. The structure of the clinical part is similar in all participating countries. Trainees have to attend courses in internal medicine, surgery, infectious diseases, paediatrics, neurology, psychiatry, orthopaedics, ophthalmology, ear, nose and throat (ENT), dermatology, gynaecology, and emergency medicine [10] in Croatia, Germany and Iceland, and in Slovenia. Some UEMO countries (Austria, Belgium, Denmark, Finland, Hungary, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden, Switzerland, Slovakia and the UK) train their trainees in internal medicine, surgery, infectious diseases, paediatrics, neurology and psychiatry, while dermatology is not a part of the curriculum in Denmark, Finland, Ireland, Italy, Portugal, Sweden, Switzerland and the UK. Trainees also have to pass ear-nose-and-throat medicine courses in Denmark, Ireland, the Netherlands, Sweden, Switzerland and Slovakia. Orthopaedic training is obligatory in Spain and Switzerland, ophthalmology in Hungary, Spain and Switzerland, and emergency medicine in Hungary, Ireland, the Netherlands, Slovakia and the UK. Infectious diseases are taught in Finland, the Netherlands, Spain, Switzerland and Slovakia. We did not receive data from Belgium and Luxembourg.

The duration of the clinical part of the training in some countries represents the major part of the entire training, in some half of it, and in others the minor part (Table III).

Slovenia introduced modules to the general practice/family medicine part of its vocational training. Modules deal with subjects typical for family medicine: the family, practice management, communication with patients and other specialists, quality assurance, evidence-based medicine and research in GP, management of chronic diseases, prevention, children and youngsters, the elderly, terminal care, home visits, ethical problems, and medical error (Table III). Very similar subjects are also dealt with in Croatia, Denmark, Iceland, Ireland, the Netherlands, Spain and Sweden; in other countries, not all, but some, of these subjects are included (Austria, Finland, Hungary, Italy).

Assessment of the trainee in Slovenia is performed at the end of each subject and at the end as a final examination, consisting of multiple-choice questions (MSQ test), objective structured clinical examination (OSCE), the trainee's report, visit to the trainee's practice with assessment of practice organization, medical records and trainee performance, and oral examination. In Europe, only Irish GPs have to undergo the same; the others have only one or more of these assessment methods, although nearly all (except Hungary (final), Iceland (none), Sweden (continuously) and the UK (continuously and final)) have assessment at the end of each subject and a final examination. The assessors are peers in GP/FM in Croatia, Germany, Iceland, Ireland, Switzerland and the UK. In Slovenia as well as in Austria, Denmark, Hungary, Italy and Spain, specialists are also present.

Discussion

Specialist training is a prerequisite for good practice and must take its starting point as soon as possible in general practice. It must be conducted on both a theoretical and practical level, and ought to be of direct use in the practitioner's daily work. Specific general practice training must be oriented towards general practice throughout the entire training period. General practitioners/family physicians are in principle the first point of contact for non-selected groups of patients. Health education, preventive activities, early detection, problem-oriented care, terminal care and palliation are the tasks GPs should be able to address and perform, as well as the coordination of specialist treatment and with existing services within the local healthcare system [9–11].

General practitioners should be familiar with all common diseases in the community and with all preventable conditions, with the therapeutic principles of pharmaceutical products, and their side effects and interactions, since they prescribe most of the medicaments in ambulatory care. They must also consider treatment possibilities in other medical fields in order to be able to support their patients. To achieve all this, a GP/FP should have special communication skills, since he/she has to be able to inform patients about their diseases and treatment options in a way adapted to the individual patient.

The 2004 UEMO Declaration on Specialist Training [4] has changed the length of training from 3 to 5 years, aiming to achieve the same length of training as other specialties have.

Slovene family physicians have achieved all these aims [3], [4], [14] regarding the documents of the European Union and the UEMO Copenhagen statement:

1. Specialist training for GP/FM starts at the same time as other specialist training does, and lasts for 4 years [1], [3].

2. Effective training is centred on general practice; the duration of education spent in general practice is one half of the total duration of training [3], [4].

3. Training outside general practice is organized into a curriculum, adapted in collaboration with other specialities, but supervised by general practice trainers [3].

4. Common European core content for specialist training in GP/FM is incorporated in the training [13].

5. Specialist training includes both formative assessment throughout the course and summarized assessment at the conclusion [1], [3], [12].

The modular type of education represents a novelty in postgraduate education in Slovenia, not only in family medicine, but also among nearly all specialities (except paediatrics), which still largely rely on lectures or practical work in clinics.

Comparison with European UEMO countries shows that very similar subjects are also dealt with in countries in which GP/FM has a long history and is well developed, e.g. in Croatia, Denmark, Iceland, Ireland, the Netherlands and Sweden, although not in the same modular form.

The new method demands much more time and energy from module leaders than previous methods. They have to prepare schedules, choose lecturers and working group leaders, prepare tasks for working groups, define the tasks and goals of the module, and prepare “homework” for trainees. Trainees have to perform all practical tasks in their (or their trainer's) practices, to get better insight of their own performance, skills and knowledge.

Slovene specialist training in GP/FM now lasts 4 years. This is the average duration of specialist training in GP/FM in Europe. At present, a 4-year course is the best solution for Slovene general practice since, due to a lack of about 50 general practitioners, the Slovene healthcare system can not afford longer absence of its trainees from general practice [10].

The introduction of a new schedule of specialist training in Slovenia has not only raised the educational level, but also the value and importance of the speciality itself. The Department of Family Medicine, being one of the first to implement modern teaching methods, now has the honour of lecturing in this subject to other departments and institutes at the Medical School of Ljubljana University.

We thank all the trainers and trainees who have provided us with useful comments, and the foreign experts and UEMO delegates who were so kind as to volunteer their data and expertise, and share their experience with us.