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Undergraduate medical education in general practice/family medicine throughout Europe – a descriptive study

  • Mette Brekke1Email author,
  • Francesco Carelli2, 3,
  • Natalia Zarbailov4,
  • Givi Javashvili5,
  • Stefan Wilm6,
  • Markku Timonen7 and
  • Howard Tandeter8
BMC Medical Education201313:157

DOI: 10.1186/1472-6920-13-157

Received: 26 April 2013

Accepted: 25 November 2013

Published: 1 December 2013

Abstract

Background

It is increasingly becoming evident that a strong primary health care system is more likely to provide better population health, more equity in health throughout the population, and better use of economic resources, compared to systems that are oriented towards specialty care. Developing and maintaining a strong and sustainable primary health care requires that a substantial part of graduating doctors go into primary care. This in turn requires that general practice/family medicine (GP/FM) strongly influences the curricula in medical schools. In the present paper we aim at describing the extent of GP/FM teaching in medical schools throughout Europe, checking for the presence of GP/FM curricula and clinical teaching in GP offices.

Methods

A brief questionnaire was e-mailed to GP/FM or other professors at European medical universities.

Results

259 out of 400 existing universities in 39 European countries responded to our questionnaire. Out of these, 35 (13.5%) reported to have no GP/FM curriculum. These 35 medical faculties were located in 12 different European countries. In addition, 15 of the medical schools where a GP/FM curriculum did exist, reported that this curriculum did not include any clinical component (n = 5), or that the clinical part of the course was very brief - less than one week, mostly only a few hours (n = 10). In total, 50 universities (19%) thus had no or a very brief GP/FM curriculum. These were mainly located in the Eastern or Southern European regions.

Conclusion

It is still possible to graduate from European medical universities without having been exposed to a GP/FM curriculum. The European Academy of Teachers in General Practice (EURACT) will launch efforts to change this situation.

Keywords

General practice/family medicine Medical education Undergraduate Clinical curriculum Europe

Background

General practice/family medicine (GP/FM) is the provision of first contact, person focused, ongoing care over time that meets the health-related needs of people, referring only patients with uncommon or serious conditions, and coordinating care when people receive services at other levels of the healthcare system [1]. Primary health care means GP/FM applied on a population level, and as a population strategy this requires the commitment of governments to develop and sustain such services. It is increasingly becoming evident that a strong primary health care system is more likely to provide better population health, more equity in health throughout the population, and better use of economic resources, compared to systems that are oriented towards specialty care [24]. The World Health Organization (WHO) identified primary health care as central to the achievement of the goal “Health for All” already in 1978 [5], and thirty years later encouraged all countries to orient their health care systems towards a strengthened primary care [3].

To develop and maintain a strong and sustainable primary health care requires that a substantial part of graduating doctors go into primary care [3]. This in turn requires that GP/FM strongly influences the curricula in medical schools, although institutional, legislative and market factors also play important roles [68]. Specialty selection by medical students determines the future composition of the physician workforce. Among multiple reasons influencing a career choice either towards or away from primary care, medical school curricula may affect students in their perceptions of the role of primary care physicians. Since students are greatly influenced by the cultures of the institutions in which they are trained, the negative attitude of a university towards FM/GP may negatively affect the number of students going into this specialty [6]. Selection of career specialties begins in earnest during the clinical rotations with exposure to the clinical and intellectual environments of various specialties. A recent study from Israel found that as many as 62% of last year medical students considered choosing one specific specialty, while the rest considered two or more [9].

Still, however, undergraduate medical education seems to be out of synchrony with accelerating development and training in GP/FM [8]. In a former paper, our group developed a “minimal core curriculum” for undergraduate GP/FM, meant as an aid for medical schools introducing the topic for the first time, usually starting with a very brief course [10]. Working in a GP/FM setting requires problem solving skills, that differ highly from the disease-centered linear thinking inside university hospitals and which dominates the curricula in medical schools. In primary care the focus is upon the whole person – body and mind – in his/her context, and over long periods of time. Complex and poorly understood health problems, as well as clusters of diseases have to be handled, and the doctor-patient relationship is an important working tool. No student should graduate from medical school without substantial understanding of these matters [8, 10]. In our opinion this requires – in addition to a theoretical GP/FM curriculum - a substantial component of “master-apprentice” learning in a primary care clinic.

In the last decades many European countries have undergone dramatic changes, including democratization, economic liberalization and a redefinition of the role of the state. Health care and social services systems have been reformed, and new challenges have had to be faced [4, 11]. In the present paper, we aim at assessing and describing the extent of GP/FM teaching in medical schools throughout Europe. Is there a GP/FM curriculum? And to which degree are the students able to participate in clinical work in a GP’s office? Is it still possible to graduate as a doctor from a European university having learned nothing at all about GP/FM? We have not been able to find previous surveys on this matter.

Methods

The authors of this paper are national representatives in the Council of European Academy of Teachers in General Practice and Family Medicine (EURACT) [12], and are members of EURACT’s Basic Medical Education (BME) Committee. Following a brain-storm within the BME Committee items for a questionnaire were identified. To achieve the best possible response rate the questionnaire was made as brief and simple as possible (Table 1) and was accompanied by the following text: “The European Academy of Teachers in General Practice/Family Medicine (EURACT) is running a mapping of the presence of undergraduate FM/GP rotations/clerkships in all European Medical Schools. You are kindly requested to answer the attached short questionnaire about your own medical school”. The questionnaire was sent by e-mail to GP/FM professors at each medical school in the countries of interest (where there were no GP/FM professors, the dean or another relevant professor was contacted). The authors divided the countries between them, and in several countries the national EURACT representative – not members of the BME-committee – aided in distributing the questionnaires and collecting the answers. Generally we accepted the data as they arrived from the respondents. The data collection took place in 2011 and until the end of 2012.
Table 1

Questionnaire presented by The European Academy of Teachers in General Practice/Family Medicine (EURACT)

Question

Answer

Name of medical school

 

City

 

How many years is your medical program?

 

Does the school have a GP/FM curriculum?

 

If so, does it have a clinical component (student sits in with GP)?

 

What is the duration of this rotation in weeks?

 

During which year is the rotation presented?

 

Do you have such rotations in more than one year?

 

As the study did not collect data on human subjects, no approval from an ethics committee was needed.

Results

We were able to obtain information from 259 European medical schools in 39 countries (Tables 2, 3, 4 and 5). According to the “Avicenna Database” run by the University of Copenhagen in collaboration with World Federation for Medical Education (WFME), there are about 400 medical universities in these 39 European countries (http://avicenna.ku.dk/database/medicine). Response rate was thus 64%.
Table 2

Western Europe – state of GP/FM curriculum in medical schools

Country (n = 5)

GP curriculum

Clinical component

Medical school (n = 53)

Yes/no

Weeks n

Which year

Austria

   

  Medical University Graz

Yes

5

6th

  Medical University Innsbruck

Yes

4

6th

  Medical University Vienna

Yes

3

5th + 6th

  Medical University Salzburg

Yes

4

5th

Belgium

   

  K.U. Leuven

Yes

10

2nd + 6th

  Univ Gent

Yes

10

2nd,3rd, 6th

  VUB Brussels

Yes

12

2nd,5th, 6th

  UA Antwerp

Yes

8

3rd, 5th, 6th

  UCL Brussels

Yes

2

3rd

  ULB Brussels

Yes

5

3rd + 6th

  ULG Liege

Yes

5

2nd + 6th

Netherlands

   

  Maastricht

Yes

10

5th

Germany

   

  Univ. Aachen

Yes

1

5th

  Berlin

Yes

1

5th

  Bochum

Yes

2

4th

  Bonn

Yes

1

5th

  Dresden

Yes

1

5th

  Düsseldorf

Yes

2

5th

  Erlangen

Yes

1

5th

  Essen

Yes

2

4th

  Frankfurt

Yes

2

5th

  Freiburg

Yes

2.5

5th

  Giessen

Yes

2

4th

  Göttingen

Yes

2

5th

  Greifswald

Yes

1

4th

  Halle

Yes

2

5th

  Hamburg

Yes

1

4th

  Hannover

Yes

2

5th

  Heidelberg

Yes

2

1st or 2nd + 4th

  Homburg

Yes

1

No information

  Jena

Yes

2

4th

  Kiel

Yes

2

4th

  Köln

Yes

2

4th or 5th

  Leipzig

Yes

2

4th

  Lübeck

Yes

1

No information

  Magdeburg

Yes

2-3

4th + 5th

  Mainz

Yes

1

5th

  Mannheim

Yes

No information

 

  Marburg

Yes

2

5th

  München (LMU)

Yes

1

4th

  München (TU)

Yes

2

4th + 5th

  Münster

Yes

2

4th

  Regensburg

Yes

?

 

  Rostock

Yes

1

5th

  Tübingen

Yes

2

5th

  Ulm

Yes

2

4th + 5th

  Witten/Herdecke

Yes

8-10

1st to 5th

  Würzburg

Yes

5

5th

Switzerland

   

  Univ of Basel

Yes

4

4th

  Univ of Bern

Yes

6

1st, 2nd, 3rd, 4th, 6th

  Univ of Geneva

Yes

3

2nd, 4th, 5th

  Univ of Lausanne

Yes

5

3rd, 4th, 5th, 6th

  Univ of Zürich

Yes

2

3rd, 4th, 5th

Table 3

Eastern Europe - state of GP/FM curriculum in medical schools

Country (n = 10)

GP curriculum

Clinical component

Medical school (n = 50)

Yes/No

Weeks

Which year

Belarus

   

  Minsk State Medical University1

No

  

  Vitebsk State Medical University1

No

  

  Gomel State Medical University1

No

  

  GrodNo State Medical University1

No

  

Bulgaria

   

  Medical University Plovdiv1

No

  

  Medical University Sofia

Yes

2

6th

  Medical University Varna1

No

  

  Medical University Pleven1

No

  

  Medical faculty Stara Zagora1

No

  

Check Republic

   

  Charles Univ in Prague, first fac of med

Yes

3

4th, 6th

  Charles Univ in Prague, second fac of med

Yes

1

6th

  Charles Univ in Prague, third fac of med

Yes

1

6th

  Charles Univ, fac of med Hradec Kralove2

Yes

3 h

6th

  Fac of med in Pilsen, Masaryk University

Yes

1

5th + 6th

  Fac of med , Palacky Univ Olomouc

Yes

1

6th

  Univ Ostrava, fac med1

No

  

Georgia

   

  Akaki Tsereteli State Univ, Caucasus

Yes

1

6th

  International Univ Tbilisi1

No

  

  David Agmashenelebi Univ of Georgia

Yes

2

5th

  David Tvildiani Med Univ

Yes

2

6th

  Iv. Javakhishvili Tbilisi State Univ

Yes

2

5th

  Petre Shotadze Tbilisi Med Acad

Yes

2

6th

  Shota Rustaveli State Univ1

No

  

  Tbilisi Med EduUniv Hippocrates

Yes

1.5

6th

  Tbilisi State Med Univ

Yes

2

1st, 2nd

Hungary

   

  Semmelweis Univ Budapest

Yes

1

6th

  Univ of Szeged

Yes

1

6th

  Univ of Pecs

Yes

1.5

6th

Moldova

   

  Univ Nicolae Testemitanu Chisinau

Yes

3

5th

Poland

   

  Med Univ of Bialystok2

Yes

2 h

6th

  Wroclaw Med Univ2

Yes

5 h

6th

  Med Univ of Gdansk

Yes

2.5

6th

  Med Univ of Silesia, School of Med in Katowice

Yes

6

6th

  Med Univ of Lodz

Yes

4

5th

  Med Univ of Lublin

Yes

2.5

6th

  Poznan Univ of Med Sciences2

Yes

<1

6th

  Pomorski Univ of Med Stettin

Yes

2.5

6th

  Med Univ of Warsaw

Yes

2.5

6th

  Ludwig Rydygier CollMed Bydgoszcz

Yes

2

6th

Romania

   

  Gr. T. Popa, Univ of Med, Lasi

Yes

6

6th

  Fac de Med Victor Papilian, Sibiu1

No

  

  Univ Transilvaia, Brasov2

Yes

No

 

  Univ Med Pharm, Victor Babes, Timisoara2

Yes

No

 

  Univ Med Pharm Iuliu Hatieganu, Cluj-Napoca

Yes

2.5

6th

Russia

   

  KrasNoyarsk2

Yes

30 h

6th

  State Med Univ Vladivostok

Yes

1.5

6th

  Amurskaya State Med Acad Blagoveshensk

Yes

1

6th

  State Med Univ Kursk2

Yes

6 h

6th

  State Med Univ Petrozavodsk2

Yes

6 h

6th

  Pavlov’s St.Petersburg State Med Univ

Yes

4

5th, 6th

  State North-West Med Univ St. Petersburg

Yes

2

6th

Slovakia

   

  Pavol Josef Safarik Univ Kosice

Yes

1

4th

  Jessenius Fac Med Martin

Yes

2

5th

  Comenius Univ Bratislava

No

  

1No GP/FM curriculum (n = 13).

2No or < 1 week clinical component (n = 9).

Table 4

Northern Europe – state of GP/FM curriculum in medical schools

Country (n = 9)

GP curriculum

Clinical component

Medical school (n = 45)

Yes/no

Weeks n

Which year?

Denmark

   

  Aarhus Univ

Yes

3

6th

  Univ of south Denmark Odense

Yes

6

6th

  Aalborg Univ

Yes

2

4th or 5th

  Copenhagen Univ

Yes

No information

 

Estonia

   

  Univ of Tartu

Yes

6

1st, 6th

Finland

   

  Univ of Helsinki

Yes

4.5

1st, 2nd, 4th,5th

  Univ of Kuopio

Yes

9

1st, 2nd, 3rd, 5th, 6th

  Univ of Oulu

Yes

4

1st, 2nd, 5th, 6th

  Univ of Tampere

Yes

5

3rd, 4th, 5th, 6th

  Univ of Turku

Yes

4.5

1st, 3rd, 5th

Iceland

   

  Med School of Iceland Reykjavik

Yes

4

2nd, 6th

Ireland

   

  Univ of Limerick

Yes

?

1st, 4th

  Royal College of Surgeons Med School

Yes

3

1st, 4th

  Queens Univ Belfast

Yes

4

4th

  Trinity College, Dublin

Yes

4

4th

  NUI Galway

Yes

6

1st,2nd, 4th

  Univ College Cork

Yes

7

3rd, 5th

Latvia

   

  Riga Stradins Univ

Yes

4

6th

  Univ of Latvia

Yes

4

6th

Norway

   

  Univ of Bergen

Yes

4

6th

  Univ of Oslo

Yes

7

1st, 2nd, 5th

  Univ of Tromsø

Yes

8

1st, 5th

  Norw Univ of Science and Technol, Trondheim

Yes

7

1st, 2nd, 6th

Sweden

   

  Sahlgrenska Acedemy Gothenburg

Yes

6

1st, 2nd, 3rd, 5th

  Linköping Univ

Yes

12

years 1-6

  Örebro univ

Yes

12

years 1-6

  Umeå Univ

Yes

6

3rd, 4th, 6th

  Karolinska Inst Stockholm

Yes

13

years 1-6

United Kingdom

   

  Keele Univ

Yes

23

3rd, 4th, 5th

  NewcastleMed School

Yes

8

years 1-5

  Barts and The London

Yes

5+

years 1-5

  Edinburgh

Yes

7

4th, 5th

  Brighton and Sussex Med School

Yes

4++

1st, 2nd, 4th, 5th

  Cambridge

Yes

12+

4th, 5th, 6th

  Lancaster Med School

Yes

15

years 2-5

  Leicester

Yes

7

4th

  Nottingham

Yes

4+

5th

  King’s College, London

Yes

10

years 1-5

  Dundee Med School

Yes

12

4th, 5th

  Bristol

Yes

7-8

years 1-5

  Univ of East Anglia

Yes

19

years 1-5

  St. George’s Univ of London

Yes

9

3rd, 5th

  Birmingham

Yes

9

years 1-5

  Glasgow

Yes

20

3rd, 4th, 5th

  Warwick Med School

Yes

8

2nd, 3rd

Table 5

Southern Europe – state of GP/FM curriculum in medical schools

Country (n = 15)

GP curriculum

Clinical component

Medical school (n = 107)

Yes/No

Weeks n

Which year?

Albania

   

  Univ of Tirana1

No

  

Bosnia-Herzegovina

   

  Med fak Banja Luka

Yes

3

5th

  Med fak Tuzla

Yes

No information

 

Croatia

   

  Rijeka

Yes

2

6th

  Zagreb

Yes

2

6th

  Osijek

Yes

2

6th

  Split

Yes

2

6th

Cyprus

   

  Univ of Nicosia1 (only first two years of med school)

No

  

Greece

   

  Athens1

No

4

6th

  Aristotle Univ of Thessaloniki

Yes

 

1st

  Patras1

No

4

6th

  Heraklion, Crete

Yes

2

 

  Ioannina

Yes

  

  Alexandroupoli1

No

  

  Larissa1

No

  

Italy

   

  Univ of L’Aquila

Yes

1

1st, 6th

  Fac La Sapienza

Yes

4

6th

  Fac di Med et Psicol Roma2

Yes

30 h

5th

  Campus Biomedico Roma

Yes

1

5th

  Univ of Udine

Yes

2

6th

  Univ of Trieste1

No

  

  Central Milan

Yes

1

5th

  S.Paolo Milan

Yes

1

5th

  Vialba Milan

Yes

1

5th

  S.Donato Milan

Yes

1

5th

  Univ of GeNoa

Yes

2

6th

  Univ of Bari et Foggia

Yes

2

6th

Macedonia

   

  Univ SS Cyril & Methodius Skopje

Yes

1

6th

  State Univ Tetovo2

Yes

15 h

6th

  Univ Goce Delcev Stip2

Yes

15 h

6th

Malta

   

  Univ of Malta

Yes

4

4th

Montenegro

   

  Podgorica

Yes

1

4th, 5th

Portugal

   

  Univ da Coimbra

Yes

10

6th

  Univ da Lisboa

Yes

10

1sr, 2nd, 6th

  Univ da Porto

Yes

4

6th

  Univ da Beira Interior

Yes

4

1sr, 2nd, 4th, 5th, 6th

  Univ da Minho

Yes

16

5th, 6th

  Univ da Algarve

Yes

16

1st, 2nd, 3rd

Serbia

   

  Med Fak Nis

Yes

1

5th

  Med Fak Belgrade

Yes

3

6th

  Med Fak Kragujevac1

No

  

  Med Fak Novi Sad1

No

  

  Relocated Med Fak from Pristina1

No

  

Slovenia

   

  Ljubljana

Yes

7

6th

Spain

   

  Cadiz

Yes

4

 

  Cordoba2

Yes

No

 

  Granada2

Yes

No

6th

  Sevilla

Yes

3

 

  Zaragoza

Yes

4

6th

  Asturias2

Yes

No

 

  La Laguna

Yes

6

5th, 6th

  Las Palmas

Yes

8

6th

  Cantabria

Yes

?

 

  Salamanca

Yes

3

6th

  Valladolid

Yes

4

3rd, 6th

  Albacete

Yes

6

6th

  UAB-Univ AutoNoma Barcelona

Yes

11

1st

  Univ Barcelona

Yes

4

5th

  Girona

Yes

2

3rd, 4th, 5th 6th

  Lleida

Yes

6

6th

  Rovira I Virgili

Yes

2

6th

  Extremadura

Yes

8

 

  Santiago

Yes

4

3rd

  Univ AutoNoma de Madrid

Yes

4

6th

  Complutense de Madrid

Yes

4

5th or 6th

  Europ Univ Madrid

Yes

No information

 

  Alfonso

Yes

2

 

  Murcia

Yes

4

6th

  Navarra

Yes

4

6th

  Valencia

Yes

1

3rd

  Catholic Univ Valencia

Yes

4

3rd, 4th

  Miguel Hernandez, San Juan

Yes

6

 

  Pais Vasco

Yes

2

6th

Turkey

   

  Acibadem Istanbul

Yes

13

1st, 2nd, 3rd, 6th

  Cukorova Adana

Yes

3

6th

  Kocatepe Afyon1

No

  

  Ondokuzmayis Samsun

Yes

4

6th

  Osmangazi Eskisehir1

No

  

  Selcuk Meram Konya1

No

  

  Sutcu Imam Kahramanmaras

Yes

4

6th

  Trakya Edirne

Yes

2

4th

  Uludag Bursa

Yes

1

6th

  Tayfur Ata SokmenHatay

Yes

4

6th

  Bozok Yozgat1

No

  

  Gulhane Askeri Tip Akademisi

No

  

Ankara1

   

  Ankara Univ

Yes

1

5th

  INonu Malatya

Yes

4

6th

  Marmara

Yes

8

3rd,5th, 6th

  Pamukkale Denizli1

No

  

  Mersin1

No

  

  Dokuz Eylül Izmir1

No

  

  Onsekiz Mart Canakkale

Yes

8 (elective)

5th, 6th

  Yeditepe Istanbul

Yes

6

6th

  Adnan Menderes Aydin

Yes

5

5th, 6th

  Akdeniz Antalya

Yes

5

3rd, 6th

  Baskent Ankara

Yes

2

4th

  Izzet Baysal Abant1

No

  

  Karadeniz Techn Univ Trabzon1

No

  

Trabzon1

   

  Celal Bayar Manisa1

No

  

  Yildirim Beyazit Ankara

Yes

4

6th

  Capa Istanbul1

No

  

  Gazi Osman Pasa Tokat

Yes

4

5th

Israel

   

  Ben –Gurion Univ Beer-Sheva

Yes

6

6th

  Hebrew Univ Jerusalem

Yes

2

6th

  Tel-Aviv Univ (6 y med school)

Yes

4

6th

  Tel-Aviv Univ (4 y med school)

Yes

3

4th

  Technion Haifa

Yes

6

6th

1No GP/FM curriculum (n = 22).

2No or < 1 week clinical component (n = 6).

Out of the 259 respondent universities, 35 (13.5%) reported to have no GP/FM curriculum (Table 6). These 35 medical faculties were located in eleven different European countries. In addition, 15 of the medical schools where a GP/FM curriculum did exist, reported that this curriculum did not include any clinical component (n = 5), or that the clinical part of the course was very brief - less than one week, mostly only a few hours (n = 10, Table 6). In total, 50 universities (19%) thus had no or a very brief GP/FM curriculum.
Table 6

Medical universities without GP/FM curriculum, or with clinical GP/FM teaching lacking or shorter than one week

Country

Medical schools without GP/FM curriculum (n = 35)

Belarus

Minsk State Medical University

 

Vitebsk State Medical University

 

Gomel State Medical University

 

Grodno State Medical University

Bulgaria

Medical University Plovdiv

 

Medical University Varna

 

Medical University Pleven

 

Medical faculty Stara Zagora

Chech Republic

Univ. Ostrava, fac med

Georgia

International Univ Tbilisi

 

Shota Rustaveli State Univ

Romania

Fac de Med Victor Papilian, Sibiu

Slovakia

Comenius Univ Bratislava

Albania

University of Tirana

Cyprus

University of Nicosia (only first two years of med school)

Greece

Athens

 

Patras

 

Alexandroupoli

 

Larissa

Italy

University of Trieste

Serbia

Med Fak Kragujevac

 

Med Fak Novi Sad

 

Relocated Med Fak from Pristina

Turkey

Kocatepe Afyon

 

Osmangazi Eskisehir

 

Selcuk Meram Konya

 

Bozok Yozgat

 

Gulhane Askeri Tip Akademisi Ankara

 

Pamukkale Denizli

 

Mersin

 

Dokuz Eylül Izmir

 

Izzet Baysal Abant

 

Karadeniz Techn Univ Trabzon

 

Celal Bayar Manisa

 

Capa Istanbul

 

Medical schools with no or <1 week clinical teaching (n = 15)

Chech Republic

Charles Univ, fac of med Hradec Kralove

Poland

Med Univ of Bialystok

 

Wroclaw Med Univ

 

Poznan Univ of Med Sciences

Romania

Univ Transilvaia, Brasov

 

Univ Med Pharm, Victor Babes, Timisoara

Russia

Krasnoyarsk

 

State Med Univ Kursk

 

State Med Univ Petrozavodsk

Italy

Fac di Med et Psicol Roma

Macedonia

State Univ Tetovo

 

Univ Goce Delcev Stip

Spain

Cordoba

 

Granada

 

Asturias

Tables 2, 3, 4 and 5 show details of the GP/FM curriculum in the medical schools in the four European regions (according to the United Nations’ Geo scheme and also including Israel). Roughly, the comprehensiveness of the GP/FM curriculum varies between the regions, as all faculties without any such curriculum are located either in Eastern or in Southern Europe, as are also the majority of schools without or with a very short clinical GP/FM component. Only few medical schools in Eastern Europe have a rotation period longer than two weeks, while the majority of schools in Northern Europe have at least five weeks, and several up to 12–13 weeks.

There are substantial variations in length of the clinical component within countries and even inside the same city: for example the time spent in a GP’s office is two weeks in one Brussels medical school and 12 weeks in another.

Discussion

One limitation of this study is that by labelling curricula as including or not including GP/FM, we assume the curricula to be mainly discipline based. We thus may have overlooked that a problem based or case based curriculum could include elements from GP/FM without having a proper GP/FM section. We also are aware of the fact that the mere existence of a GP/FM curriculum is not synonymous with high quality teaching. A further limitation is that we were not able to obtain data at all from some countries: Ukraine, Lithuania and France. These countries are “white spots on our map”, although we have got information from a key informant in France that all Universities have incorporated FM/GP in their BME curriculum and that all of them have a clinical component (2–6 weeks). This information is in line with the rest of Western European universities, as all of them have GP/FM training with a clinical component. Also, not all universities have responded from each country. For example, we got data only from seven universities in Russia, while the number of medical schools in this country is more than 60. Similarly, for Turkey we have data from 29 universities out of more than 50. Therefore, we cannot provide statistically valid information on the situation in Europe as such. On the other hand, the information that we do have from 259 European medical schools, in itself brings new insights, although curricula are in constant evolution and data captured at a certain point of time will not reflect such a dynamic situation.

In 2010 an independent international commission published a report on the need of transforming medical education in the future [13]. The commission states that professional education has not kept pace with the needs of patients and populations, and that fragmented and outdated curricula produce ill-equipped graduates. Reforms are therefore needed, and a list of ten proposed reforms is given. Point number eight states the need for medical schools to achieve: “Expansion from academic centers to academic systems, extending…….into primary care settings and communities…” [13]. It is thus positive that the majority of medical schools throughout the European regions do have a substantial GP/FM curriculum – 209 out of the 259 faculties assessed. Even so, there is ample room and need for improvements, as 35 schools have no GP/FM teaching whatsoever and clinical teaching is absent or very brief in several others.

Most former communist countries now let GP/FM play a key role in their health care system. A GP/FM curriculum is also increasingly being introduced into medical training at undergraduate and postgraduate level, and GP/FM is developed as an academic discipline [11, 14]. Our study revealed that this task can not yet be seen as completed. It is especially worrying if it is possible both to graduate without any GP/FM competence and subsequetly set up a practice in a country without a mandatory vocational training program.

European primary care is currently facing high expectactations, regarding its promises to improve population health, control costs, and attribute to less socioeconomic inequality of care [14]. But: Do strong primary care systems indeed perform better? And what determines how strong primary care is? [15]. These important questions have recently been addressed by means of a EU-funded project: the Primary Health Care Activity Monitor for Europe (PHAMEU) [16]. Based on information from 31 European countries the study was able to show that strong primary care indeed was associated with better population health outcomes, lower rates of potentially avoidable hospitalization, lower socioeconomic inequality in self-rated health, a reduced growth of health care spending, but also with higher levels of total health care costs [17]. In total, this should support the efforts of policy makers to prioritize primary care. Development of primary care workforce is part of such efforts [18], and developing a comprehensive GP/FM undergraduate curriculum comprising a clinical rotation is a necessity in this process [68].

In our study most clinical GP/FM rotations were placed in years four, five or six, but as the length of the clinical teaching period increased, it is common to spread it over several semesters. For example the 12–13 weeks of rotations at three Swedish universities involve the years one to six. This probably has a positive influence on recruitment to GP/FM, as students are exposed to role models throughout their entire education [68]. In our opinion GP/FM should be positioned as one of the main clinical topics in every European medical school, and teaching in a one-to-one situation in a GP’s office should be offered for at least four weeks, preferably longer.

Conclusion

Although the majority of the assessed universities reported to have a theoretical GP/FM curriculum as well as a clinical rotation, it is still possible to graduate from some European medical schools without having learned about clinical work in a primary care setting. The European Academy of Teachers in General Practice (EURACT) will lance efforts to change this situation. Special efforts should be made in Eastern and Southern Europe, where a FM/GP curriculum does not exist in several universities, and where the clinical GP/FM component is generally short.

Declarations

Authors’ Affiliations

(1)
Department of General Practice, Institute of Health and Society, University of Oslo
(2)
University of Milan
(3)
University Campus BioMedico in Rome
(4)
Department of Family Medicine, State Medical and Pharmaceutical University “Nicolae Testemitanu”
(5)
Department of Family Medicine, Tbilisi State Medical University
(6)
Medical Faculty, Institute of General Practice, Heinrich Heine University
(7)
Institute of Health Sciences, University of Oulu
(8)
Department of Family Medicine, Ben Gurion University

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  19. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/13/157/prepub

Copyright

© Brekke et al.; licensee BioMed Central Ltd. 2013

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