EDITORIAL

Family Medicine East of Eden

Igor Švab*

*Professor and Chairman, Department of Family Medicine, University of Ljubljana, Slovenia and former President of WONCA-Europe.

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When the scientific values of family medicine are discussed, the questions of its universality often arise. Although family medicine took a lot of time to define its core values and characteristics, these are now firmly established.^1,2 But when one travels across the continent and meets colleagues from other countries, one is often struck by the differences in the ways family medicine is practised. In this respect, family medicine is different from other disciplines, where practices in one location can easily be transferred to another one. This is sometimes considered as a sign of scientific value of the discipline, although this is not true: the variability has nothing to do with science.

The variation in practices means that it is very difficult to suggest improvements unless one understands not only the discipline itself, but also the context in which it is practised. One needs to know not only about family medicine, but also about the context in which it is practised. This requires understanding of the culture, history, ethnology and legislation in a country. When we are struggling for uniformity and common standards in Europe, we are also asking ourselves: How much variation between the countries is desirable? The standards of the European Union try to merge standards of care by declaring the same levels of care to all European citizens. With greater mobility within Europe, it is now widely accepted that the European patient is entitled the same standards of care wherever he or she goes. If Europe is characterised by diversity, how much of it is beneficial and how much is not?

To be fair, in the area of family medicine and primary care, the standards are very relaxed and allow for a great variability among the countries, which are more or less free to decide on their policies. Primary care policies are left to the member states. The only real standard is the requirement for specialty training as a prerequisite for independent practice, and even this is subject do different interpretations, exceptions and sometimes manipulations.

Central and Eastern Europe is an interesting region in this respect. The area is big and diverse and has gone through big political and social changes in the past decades. Unfortunately, there is a relative lack of good information about the developments in this region in primary care.³ In a recent survey, done by an international partnership and sponsored by Wonca Europe⁴ it was seen that formally, family medicine is accepted as a specialty in all the countries of Central and Eastern Europe, regardless if they belong to the European union or not. The problem is that the levels of its implementation of values of family medicine vary across the countries. In most countries, family medicine is just one of many medical specialities in primary health care, and other specialities (e.g. paediatrics, sometimes, internal medicine and gynaecology) have an important role. Full introduction of family medicine, where family medicine would be the medical speciality in primary care, covering the whole range of problems and age groups, was so far successful only in Estonia. But the most worrying result of this review is that the initial enthusiasm of implementing family medicine has decreased in countries that have joined the European Union. These countries (e.g. Poland, Czech Republic, Lithuania, Latvia, etc.) have been very active in the implementation of family medicine and its principles in the 1990’s. A lot of this development was done through international grants (e.g. the World Bank) and these projects resulted in the developments of academic family medicine, speciality training and departments of family medicine. The development of academic family medicine resulted in an increased recognition of this discipline.⁵ The survey shows that it seems that there is no real initiative that would support this movement further and the transition process has stopped.⁴ This is as if the politicians would be complacent and would move to other problems on their agendas. Is there a role of the European Union to take a more active role in setting standards for primary care? The current laissez-faire approach by Brussels is going to result in interesting diversity, but not necessarily in greater quality of care, I am afraid.

On the other side, the countries outside the EU have (practically all of them) declared officially that they are aiming at joining the European Union. This position requires that they address the issue of family medicine as well, because this discipline can still often be practised without additional formal training. Due to this fact, the development of the discipline in this region is still very much alive. Recently, I had the chance of working in Montenegro and Macedonia. Both countries have demonstrated a commitment to improvement of family medicine.

The government of Montenegro has recently adopted a policy to re-train all their primary care physicians. A programme of specialisation of family medicine, lasting four years, has been adopted and the first group of re-trained doctors that are going to finish their re-training this autumn is going to be a pool of mentors for the new trainees.

The government of Macedonia has decided to re-train all their primary care doctors to specialists in family medicine by 2020. The process of implementation was very long and has been successful after many years of discussions. Since the programme has been accepted and the first new specialists have passed their exam in 2011 it seems that the process is well under way.

All these projects need support not only from within the government, but also from outside and experts that understand the specificities of the countries are essential. Slovenia is making its own small contribution by organising an international course of family medicine teachers every year.6 I am especially proud that we always can count on Portuguese family doctors, who are both course directors and participants to this activity.

 

REFERENCES

1. Allen J, Gay B, Crebolder H, Heyrman J, Švab I, Ram P. The European definition of general practice/family medicine. London: WONCA; 2002.         [ Links ]

2. Heyrman J. The Educational agenda of general practice/family medicine. Leuven: EURACT; 2004.         [ Links ]

3. Švab I. The blind spot issue. Eur j Gen Pract 2011 Sep; 17 (3): 143-5.         [ Links ]

4. Oleszczyk M, Švab I, Seifert B, Krzton-Krolewiecka A, Windak A. Family medicine in post-communist Europe needs a boost. Exploring the position of family medicine in healthcare systems of Central and Eastern Europe and Russia. BMC Fam Pract 2012 Mar 12; 13 (1): 15.         [ Links ]

5. Švab I. Academic family medicine - the jewel in the crown or the useless aristocrate? Rev Port Clin Geral 2007 Jan-Fev; 23 (1): 6-8.         [ Links ]

6. Bulc M, Švab I, Radić S, Correia de Sousa J, Yaphe Y. Faculty development for teachers of family medicine in Europe: reflections on 16 years’ experience with the international Bled course. Eur J Gen Pract 2009; 15 (2): 69-73.