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

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.


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 [2][3][4]. 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 [6][7][8]. 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 diseasecentered linear thinking inside university hospitals and which dominates the curricula in medical schools. In primary care the focus is upon the whole personbody and mindin 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 doctorpatient 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 requiresin addition to a theoretical GP/ FM curriculum -a substantial component of "masterapprentice" 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 representativenot members of the BME-committeeaided 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.
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%.
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 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? 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. 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    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    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 [1][2][3][4]. 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 [6][7][8].
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 [6][7][8]. 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.