 |
|
Recent Trans-European Initiatives in General Practice
Lee Randol Barker, MD, MSc
Arch Fam Med. 1999;8:379-381.
ABSTRACT
Recently, several initiatives have addressed the situation of general practice in Europe. These trans-European developments in medicine have paralleled the continuing emergence of geopolitical Europe. Most of these initiatives have emanated from 2 events in that occurred in 1995: the mandatory implementation of the European Union's directive governing the duration of postgraduate training in general practice and the founding of the European Society of General Practice/Family Practice.
INTRODUCTION
Oh, the leaky boundaries of man-made states!/
How many clouds float past them with impunity/
how much desert sand shifts from one land to another/
how many mountain pebbles tumble onto foreign soil in provocative hops!—Wis awa Szymborska, 1996 Nobel Prize for Literature
Effective March 1995, the Schengen Accord eliminated passport control between 6 member states of the European Union (EU). A Europe without (passport) frontiers was an important way in which the "European Concept" evolved in 1995. That year also brought several trans-European initiatives that are intended to advance the quality of general practice. When American generalists encounter European colleagues in the years ahead, they will probably notice the effect of these initiatives. The purpose of this article is to describe the recent changes affecting generalist education and practice throughout Europe.
GEOPOLITICAL BACKGROUND
The EU is the entity that constitutes a legally united Europe. Those countries that are not yet part of the EU are active in many trans-European initiatives and organizations, including those related to general practice.
In 1995, the EU grew to its current size, 15 nations and about 350 million inhabitants, with the accession to membership of Sweden, Austria, and Finland. The EU is the name for the still-developing union that began in 1951 as the 6-nation European Coal and Steel Community, which grew to 12 members and formed supranational governing bodies in 1986, and which enacted in the 1992 Maastricht Treaty a plan to introduce a single European currency in 1999. The principal governing bodies of the EU are the 626-member European Parliament; the Commission, whose 20 members are appointed by the Parliament (2 from France, Germany, Italy, Spain, and the United Kingdom; and 1 from each of the other 10 member states); the Council of the European Union, composed of the ministers from each state in domains such as foreign affairs, agriculture, labor, and health; and the Court of Justice, which comprises 15 judges. The Parliament and Council discuss and vote on EU legislation, which is initially proposed by the Commission. Legislation often leads to directives that govern activities in sectors such as medical education and practice.
Citizens of EU member nations experience their identity as Europeans in several ways. Every 5 years, they elect representatives to the European Parliament. They carry European passports. They cross the frontiers of the 6 Schengen Accord member states without encountering passport checks. They see the 15-star flag of the EU flying beside their nations' flags. In their work, they adopt standards legislated by the EU. Almost daily, they learn from the news media how the evolution of the EU will affect their lives. Less perceptibly, they pay taxes on goods and services to support the activities of the EU.
TRANS-EUROPEAN INITIATIVES IN GENERAL PRACTICE
Two published monographs describe the current situation of general practice for individual countries in Europe.1-2 Each of the policies and organizations described below transcends national traditions and institutions. The definition of primary care used throughout Europe is similar to that proposed in 1994 for all generalist disciplines in North America.3
POLICIES AND ORGANIZATIONS AFFECTING GENERAL PRACTICE IN EU COUNTRIES
Unrestricted exchange of goods and services is fundamental to the idea of the EU. In accord with this principle, a 1975 directive of the Commission granted to EU physicians the right to practice in any member nation. The task of establishing educational standards for EU physicians was assigned to an Advisory Committee on Medical Training (ACMT), a mix of practicing physicians, university faculty members, and health care policymakers from each country.4 The ACMT has guided the development of directives that define the training needed by physicians who want to practice within the government-funded health care systems of the EU.
The first EU directive addressed to general practice was enacted in 1986. It required that by 1995 all physicians entering general practice must have completed 2 years of postgraduate training, 6 months in a general practice setting. In 1986, only a few countries had postgraduate training for general practitioners (GPs) that met either of these requirements. By 1996, all EU countries had met both.5
The force behind the 1986 directive was the European Union of General Practitioners (UEMO), which was founded in 1967. In its most recent consensus document, published in 1995, UEMO advocates expanded standards for postgraduate training throughout the EU: a minimum of 3 years, at least 18 months in a general practice setting, administrative control by GPs, a common core curriculum, and promotion of research and quality assurance in settings that teach general practice.6 These recommendations closely match the missions of the organizations described in the next section.
ORGANIZATIONS AFFECTING GENERAL PRACTICE IN MOST COUNTRIES
In October 1995, leaders in general practice from 29 nations of Europe, including most of the former Soviet-block countries, convened in Strasbourg, France, to inaugurate The European Society of General Practice/Family Practice (ESGP/FP). Plans for this umbrella organization had been developed over several years by a committee of generalist leaders from 8 countries. At the meeting, the European Chapter of the World Organization of Family Doctors merged with the new society, bylaws were approved, officers were elected, and the European Journal of General Practice became the official organ of the ESGP/FP.
The new society's purpose is to foster networking among European educators, scientists, and practitioners in the field of general practice. Activities of 3 organizations, described in the next 3 paragraphs, are now promoted by the ESGP/FP. The initial issue of the European Journal of General Practice contained a description of these organizations. Each reports its news in the quarterly issues of the journal.
The European General Practice Research Workshop (EGPRW) was started in 1974 by GPs to stimulate multinational research on general practice. The EGPRW is governed by an executive board and a full board consisting of representatives from most European countries. There are 2 meetings each year at which freestanding papers and papers on the meeting theme are discussed. Abstracts from presented papers are published in the Journal of Family Practice. A model trans-European project of EGPRW was a survey to determine the extent to which longitudinality characterizes physician-patient relationships.7 The most recent project of EGPRW is the plan to develop a masters degree program in primary care research.8
The European Academy of Teachers of General Practice was established in 1992. It consolidated the 20-year activities of a group of generalist educators (the Leuwenhorst Group) who had met periodically to promote general practice education throughout Europe. There are 31 member nations, each of which selects a representative to the governing council. Membership is open to anyone involved in teaching general practice in Europe. Recent initiatives of the European Academy of Teachers of General Practice have included organizing task forces on clinical guidelines, accreditation of physicians and practices, and clinical skills assessment; creating a computerized information package that describes residency training for each country and contains a glossary of definitions and concepts basic to general practice education; sharing recent advances in education in each nation (part of the agenda at each council meeting); and facilitating surveys on general practice education throughout Europe.9-11
The European Working Party on Quality in Family Practice (EQuiP) was founded in 1991 to foster teaching and projects in quality improvement in general practice. Currently, 20 European countries are active members. Since 1995, EQuiP has sponsored twice-yearly meetings open to practicing physicians, administrators, and others interested in quality improvement in the host countries for the meetings. In the Communication section of each issue of the European Journal of General Practice, EQuiP publishes profiles of quality improvement activities in general practice from member countries. Like the European Academy of Teachers of General Practice and EGPRW, EQuiP has functioned as a Europe-wide laboratory. Using key persons (2-16 per country) in 1994 to 1995, EQuiP compiled a description of quality improvement activities in 26 countries.12 A recent editorial outlined strategies for integrating frequently fragmented quality improvement activities in general practice.13
CHALLENGES
It is not yet possible to know the effect of the initiatives described above on the quality of physician learning and patient care in Europe. Like the political EU, trans-European general practice faces formidable challenges, several of which stand out. Oversupply of GPs in most of western Europe threatens practitioner morale and complicates efforts to promote higher standards and rational distribution of GPs. A different problem confronts the former Soviet-block countries where planners must help physicians and patients embrace general practice and depart from the polyclinic tradition of individual body-system care. Other conflicting traditions, such as those described in books14 and in trans-European surveys,15 are present and must be considered by those trying to promote more uniform standards for general practice. Finally, a concern that has dominated American health care—cost containment—is a priority also in Europe, and initiatives to curtail rising costs will probably shift increased responsibilities to primary care physicians.16
The importance of developing a European-level consensus on education and practice was recently recognized at the First Congress of the European Federation of Internal Medicine.17 It seems that this organization will address for hospital-based generalists (ie, most internists in Europe) issues similar to those identified for primary care generalists when the ESGP/FP was founded in 1995. Both of these initiatives in generalist medicine concretely indicate the implications of the strategy begun more than 40 years ago to unite the nations of Europe.
PERSONAL OBSERVATIONS
The information for this report was obtained during my 1995 sabbatical in Barcelona, Spain. My purposes were to offer workshops on teaching skills to Spanish GPs and to learn about the evolving European context in which they, as all European GPs, work. At meetings, including the inaugural meeting of ESGP/FP, and through correspondence with generalist educators, I learned that the development of general practice as an academic discipline in Europe has paralleled our own process during the past 10 to 20 years. An important difference is that the leadership for the European movement has come almost entirely from national colleges of practicing GPs and not from university faculties. A second difference is that access to health care does not preoccupy European GPs because health care is publicly funded for all citizens throughout Europe. The similarities that I noted—in the priorities identified for general practice and in the development of organizations that unite colleagues from a vast geographic expanse—were more apparent than our differences. The future that general practice faces on both sides of the Atlantic will make the continued sharing of our experiences worthwhile.
AUTHOR INFORMATION
Accepted for publication December 18, 1998.
This study was supported by the Institut d'Estudis de la Salut, Barcelona, Spain and a Senior Lecturer Award from the United States–Spanish Fulbright Program, Madrid, Spain.
Corresponding author: Lee Randol Barker, MD, MSc, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave, Baltimore, MD 21224.
From the Division of General Internal Medicine, the Johns Hopkins Bayview Medical Center, and the Johns Hopkins University School of Medicine, Baltimore, Md.
REFERENCES
| |
1. Boerma WGW, de Jong FAJM, Mulder PH. Health Care and General Practice Across Europe. Utrecht, the Netherlands: Netherlands Institute of Primary Care; 1993.
2. World Health Organization. General Practice Profiles for Europe. Copenhagen, Denmark: WHO Regional Office for Europe; 1995.
3. Committee on the Future of Primary Care, Institute of Medicine. Defining Primary Care: An Interim Report. Washington, DC: National Academy Press; 1994.
4. Meisch G. Overview of function of the ACMT. Postgrad Med J. 1993;69:S6-S9.
5. UEMO (European Union of General Practitioners) Paper 95/103. Advisory Committee on Medical Training. Draft Report and Recommendations on the Review of Specific Training in General Medical Practice. Dublin, Ireland: UEMO Office; October 1995.
6. Ostergaard I. General practitioners of Europe state: quality of education must be ensured to enhance quality of care. Eur J Gen Pract. 1995;1:13-14.
7. Pastor-Sanchez R, Lopez-Miras A, Perez-Fernandez M, Gervas J. Continuity/ longitudinality of care in general practice [abstract]. Fam Pract. 1995;12:505-506.
8. Dobbs F. European general practice research workshop: developing research skills throughout Europe. Eur J Gen Pract. 1997;3:162.
9. Santos I, Ramos V. General practice vocational trainers in Europe: an overview. Eur J Gen Pract. 1995;1:71.
10. Barker LR. Arrangements that allow general practice trainees to provide longitudinal care for patients. Eur J Gen Pract. 1997;3:69-72.
11. Barker LR. Continuing medical education for European general practitioners in doctor-patient relationship skills and psychosocial issues. J Cont Educ Health Prof. 1998;18:39-46.
12. Grol R, Baker R, Roberts R, Booth B. Systems for quality imrpovement in general practice: a survey of 26 countries. Eur J Gen Pract. 1997;3:65-68.
13. Grol R. Comprehensive systems for quality improvement: a challenge for general practice. Eur J Gen Pract. 1997;3:123-124.
14. Payer L. Medicine and Culture: Varieties of Treatment in the United States, England, West Germany, and France. New York, NY: Henry Holt & Co Inc; 1996.
15. Thomsen OO, Wulff HR, Martin A, Singer PA. What do gastroenterologists in Europe tell cancer patients? Lancet. 1993;341:473-476.
FULL TEXT
|
ISI
| PUBMED
16. Whitney CR. Rising health costs threaten Geneva benefits in Europe. New York Times. August 6, 1996;sect CXLV:1.
17. Davidson C, Muller HP. European perspectives on general medicine. Lancet. 1997; 350:1645.
|
