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Revista Portuguesa de Medicina Geral e Familiar

versão impressa ISSN 2182-5173

Rev Port Med Geral Fam vol.29 no.1 Lisboa jan. 2013

 

EDITORIAL

From the President: The Value of Vasco

Professor Richard Roberts*

*President World Organization of Family Doctors


 

A recent trip to speak at a meeting in Aveiro, Portugal took me 1000 years. The actual travel time was about 24 hours. The meeting lasted three days. Yet, the journey gave me a chance to reflect back on the life of Vasco da Gama 500 years ago. It also inspired me to look 500 years into the future.

The ostensible purpose of my visit was to attend the 30º Encontro Nacional de MGF (30th National Meeting of General and Family Doctors) of the Associação Portuguesa de Medicina Geral e Familiar (APMGF). Portugal has a population of about 10 million people and 40,000 doctors. APMGF has 4000 members out of the 5700 Portuguese family doctors. Women comprise an estimated 80% of family medicine physicians and trainees. Post-graduate training involves 4 years. There are 400 new trainees each year; about one quarter of medical school graduates.

A primary care team in Portugal consists of a physician, nurse, and administrative assistant. Reforms were adopted in 2005 that provide options for the organization and payment of primary care. The traditional model (Unidade de Cuidados de Saúde Personalizados or «USCP») has a general doctor who works with a team constituted by the health services. There are three models under the reform program (Unidade de Saúde Familiar or «USF»): models A, B, and C. All USF practices can select their own team members, starting with Model A. In Model B, there are financial rewards if certain performance targets are achieved. Model C though not yet implemented, envisions private groups of doctors contracting with government, similar to a cooperative. Family doctors earn from 1800 (traditional) to 4000 (in Model B) Euros per month, compared to the Portuguese national average salary of 800 Euros.

Difficult days

The past few years have not been easy for Portugal. The fiscal crisis has prompted austerity measures. Unemployment is at about 15%. Health spending by government has been cut 9%. As civil servants, family doctors have experienced pay cuts up to 30%. I expected to find angry and discouraged Portuguese family physicians. I was wrong.

While there was concern and frustration, the mood was one of confidence and solidarity. Family doctors described their financial stresses as a reflection of the economic pain shared by all Portuguese. They felt a greater sense of responsibility for the health of their patients and the success of the health system during these trying times. They demonstrated something that is desperately needed, but not always found: leadership.

Watching primary care work

I visited the Aveiro Health Center, the main primary care facility in Aveiro. It was surprising to find all three models located in the same facility. There were two USCP (traditional) practices and two USF practices (one Model A and one Model B), each occupying a wing of the building. Each practice consisted of 6-8 doctors, responsible for about 15,000 patients, assigned to a practice team. The health center was open every day from 08:00 to 20:00. Those needing services outside of usual hours were referred to the hospital.

The facility was clean and well equipped. Each of the four wings had its own color, which was reinforced by the color of the trim on the uniforms worn by staff. The amenities were slightly nicer in the Model B wing, followed by Model A, and then the traditional wings. Even under the same health system, working in the same building, it appeared that practices that were more autonomous and performance-focused received more funds because they presumably delivered better outcomes and higher patient satisfaction. Some concern was expressed about inequities resulting from these models, especially when they were all located under one roof.

In the USF Flor de Sal wing (Model A), Dra Veronica Colaço was my host. During a typical work day, in seven hours of consultations, she sees 20-30 patients. She showed me the electronic health record, which facilitates the exchange of information between health centers and hospitals. She kindly allowed me to observe her with patients, which included a newborn baby brought in by her parents to establish care. I was pleased to see that Dra Colaço provided care to all age groups for a wide range of problems, including minor surgery. I also spoke about training in Portugal with Dra Joana Cristina Dias, the director for residency training at the Aveiro Health Center. At the time of my visit, the Center had eight trainees (“internos”) in Family Medicine, two in general residency training, and two nursing students.

I came away impressed with the Portuguese primary care system. Family doctors seemed well trained and highly motivated. They appeared to be eager, and more likely to provide a wider range of services to entire families, while having reasonable time for consultation (about 15 minutes). Other systems often limit family doctors to certain age groups (e.g., adults only) or limit their consultation time to 3-5 minutes per patient. These limits reduce the positive impact that family doctors can have on the health of their patients and communities.

Back to Vasco

Another of my pleasant duties in Aveiro was to speak to the Portuguese arm of the Vasco da Gama Movement (VdGM), named after the celebrated explorer of the Age of Discovery. Founded in 2005, VdGM (http://www.vdgm.eu) was the first multi-national group in the world formed by and for young family doctors in the European region. VdGM promotes education and training, Hippokrates exchanges, exchanges beyond Europe (especially Canada and Latin America), research, and the image of family doctors and Family Medicine. Like its namesake who discovered a route around Africa from Europe to India, VdGM aims to discover new directions for Family Medicine.

The VdGM meeting in Aveiro brought together 30 young family doctors, 13 of whom had participated recently in an exchange program. “Hippokrates” is a two-week exchange that allows participants to observe the care of patients in primary care. “Mini-Hippokrates” is connected to meetings such as the Encontro and offers a one week sampling of another health system. Sites are reviewed, approved, and monitored to assure quality learning experiences. Exchange participants at the Encontro came from Czech Republic, France, Luxembourg, Portugal, Russia, and Spain. It was inspiring to hear the young doctors describe their experiences and the perspectives they gained from spending time in another health care system. Their enthusiasm for Family Medicine and their commitment to improve the health of those they serve gave me hope for our next generation of family doctor leaders.

More on Vasco

Intrigued by the name selected by VdGM, I did more research on Vasco da Gama. Historians consider his voyage to India to be a seminal moment in human history. His unprecedented 10,000 km sailing across open seas was thought to be impossible. It is regarded as a key step toward globalization by establishing trade routes to India that enriched Portuguese commerce. The two ships that made it back from his initial expedition were laden with enough spices to yield a 60-fold return on the funds invested. Like most heroic stories however, there is more to the story. He failed to secure trading partners because of his use of ruthless tactics, such as firing cannons on civilians and cutting off the hands of competing merchants. He so alienated potential trading partners that they refused to deal with him.

The lessons of Vasco

Vasco da Gama’s cautionary tale can teach us some things about Family Medicine. Da Gama’s heroic act was in finding inspiration and using knowledge learned from others to take risks and accomplish a bold vision. Family doctors have a similarly bold vision: a healthier and more equitable world where every family has a family doctor. Having a family doctor improves the effectiveness, efficiency, and equity of health care services. We will achieve this vision only by remembering the wisdom of those who preceded us, by responding to changing circumstances as they arise, and by taking necessary risks. As we grow in numbers and influence, we are mindful that our power is earned through service to others. It is not a birthright or entitlement. Our challenge is to overcome obstacles (without cannons or amputations!) while staying true to the vision.

The young VdGM family doctors in Aveiro reminded me of the leadership principles and the vision that guide us. Their intellect, innovation, enthusiasm, and commitment will lead to better health care and a better world. I hope that our descendants will look back 500 years from now and conclude that we helped them become the kind of family doctors that we need, and that they can be.

 

Acknowledgements

Many thanks to Dra Verónica Colaço for her assistance with the manuscript and the Portuguese translation. This article is an edited version of a column that appears in English in the WONCA news at http://www.globalfamilydoctor.com/News/FromthePresidentTheValueofVasco.aspx and in Portuguese at http://www.globalfamilydoctor.com/News/PresidentedeWONCAElvalordeVasco.aspx

It is reprinted here with the permission of WONCA and the author.

See more in http://www.globalfamilydoctor.com

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