“ OVERCOMING TRAINING BARRIERS IN PRIMARY CARE – RURAL TRAINING ” EURIPA AND VASCO DA GAMA MOVEMENT JOINT WORSHOP Dr. Raquel Gómez Bravo ( Vasco da Gama Movement – Semfyc. Spain )

SPAIN

Spain has one of the oldest GP programmes in Europe... 1978 Medicine studies: 6 years 28 Medicine Faculties MIR (exam): 250 MCQ Choose Medical Speciality 6.388  1859 GP places 4 years for Family Medicine 1112 € + shifts = 1500-2500 €

1978

Medicine studies: 6 years

28 Medicine Faculties

MIR (exam): 250 MCQ

Choose Medical Speciality

6.388  1859 GP places

4 years for Family Medicine

1112 € + shifts = 1500-2500 €

1978  Health protection and care (Article 43 of the Spanish Constitution) Speciality of Family and Community Medicine : 3 years postgraduate training programme 1982  New Docent Units of Family Medicine 1983  Established Docent Units (structure, supports and functions). 1984  Basic health zones, Health center, Primary Care Team (teamwork) TIME LINE

1978  Health protection and care

(Article 43 of the Spanish Constitution)

Speciality of Family and Community Medicine : 3 years postgraduate training programme

1982  New Docent Units of Family Medicine

1983  Established Docent Units (structure, supports and functions).

1984  Basic health zones, Health center, Primary Care Team (teamwork)

1985  I GP Residency Training Programme 1986  General Health Care Act : TIME LINE “ Defines the Spanish NHS, created from the social security (SS) health services and which during the 20th century constantly widened its coverage and services, as the ensemble of “all structures and public services at the service of health”, and “the combination of state administration and autonomous communities health services”

1985  I GP Residency Training Programme

1986  General Health Care Act :

General principles of the National Health System Universal coverage with free access to health care for almost all inhabitants; Public financing, mainly through general taxation; Integration of different health service networks under the National Health System structure; Political devolution to the autonomous communities Region-based organization of health services into health areas and basic health zones TIME LINE

General principles of the National Health System

Universal coverage with free access to health care for almost all inhabitants;

Public financing, mainly through general taxation;

Integration of different health service networks under the National Health System structure;

Political devolution to the autonomous communities

Region-based organization of health services into health areas and basic health zones

1995  II GP Residency Training Programme It is compulsory in Spain to work as a GP in the public system (after the EU Directive from 1995). 2005  III GP Residency Training Programme (4 years). The fourth year fully takes place in a teaching surgery under the supervision of an accredited tutor. 2010  New training programme TIME LINE

1995  II GP Residency Training Programme

It is compulsory in Spain to work as a GP in the public system (after the EU Directive from 1995).

2005  III GP Residency Training Programme (4 years).

The fourth year fully takes place in a teaching surgery under the supervision of an accredited tutor.

2010  New training programme

17 Autonomous Communities 93 Docent Units 3000 Accredited tutors 734 Health docent centers 201 Docent Hospitals 1859 GP places 42% of the NHS’ doctors are GP 20.000 are “MIR”- GP GPs in Spain...

17 Autonomous Communities

93 Docent Units

3000 Accredited tutors

734 Health docent centers

201 Docent Hospitals

1859 GP places

42% of the NHS’ doctors are GP

20.000 are “MIR”- GP

GP Residency Training Programme (2005)

GP Residency Training Programme

GP Residency Training Programme It depends on the Docent Units…

GP Residency Training Programme 1) First year: INTERNAL MEDICINE and OTHERS SPECIALITIES : 5-8 months EMERGENCY (Shifts, 1 month) FAMILY MEDICINE : 3-6 months HOLIDAYS : 1 month

1) First year:

INTERNAL MEDICINE and OTHERS SPECIALITIES :

5-8 months

EMERGENCY (Shifts, 1 month)

FAMILY MEDICINE : 3-6 months

HOLIDAYS : 1 month

2 - 3) Second and third year: INTERNAL MEDICINE and OTHERS MEDICAL-SURGICAL SPECIALITIES : 8 months EMERGENCY (Shifts) PSYCHIATRY (2- 3 months) PAEDIATRICS, Children´s health... ( 2 months) RURAL TRAINING : 3 months (R2) Women´s health (family planning, breastfeeding, high-risk pregnancy…): 2-3 months

2 - 3) Second and third year:

INTERNAL MEDICINE and OTHERS MEDICAL-SURGICAL SPECIALITIES : 8 months

EMERGENCY (Shifts)

PSYCHIATRY (2- 3 months)

PAEDIATRICS, Children´s health... ( 2 months)

RURAL TRAINING : 3 months (R2)

Women´s health (family planning, breastfeeding, high-risk pregnancy…): 2-3 months

2 - 3) Second and third year: FAMILY MEDICINE or ELECTIVE ROTATIONS : ( 3 months) Rheumatology, Palliative Care, Dermatology, Geriatrics, Neumology, Surgery, Neurology, Digestive, Nefrology, Endocrinology, Radiology… HOLIDAYS : 2 months

2 - 3) Second and third year:

FAMILY MEDICINE or ELECTIVE ROTATIONS : ( 3 months)

Rheumatology, Palliative Care, Dermatology, Geriatrics, Neumology, Surgery, Neurology, Digestive, Nefrology, Endocrinology, Radiology…

HOLIDAYS : 2 months

4) Fourth year: Learning in FAMILY MEDICINE ( 11 months) HOLIDAYS : 1 month EMERGENCY (Shifts) Research project Common : - Self learning, - classes, - workshops, - teamwork…

4) Fourth year:

Learning in FAMILY MEDICINE ( 11 months)

HOLIDAYS : 1 month

EMERGENCY (Shifts)

Research project

SHIFT HOURS DISTRIBUTION DURING GP TRAINING IN DIFFERENT EMERGENCY DEPARTMENTS 100% 12,5% 12,5% 75% R4 100% 8% 12,5% 4,5% 12,5% 37,5% 25% R2 / R3 100% 75% 25% R1 TOTAL HOSPITAL EMERGENCY MED-SURGICAL TRAUMATOLOGY GYNAECOLOGY PAEDIATRICS HOSPITAL EMERGENCY PM / RURAL

EVALUATION Submit a Learning Portfolio (LEAP) Obligatory courses of continuous training Shifts (5-6 per month) Evaluation of each rotation by acredited tutors Congress, workshops, oral communications or posters, self learning… Research project in the last year Marks: 0-3 points Annual

Submit a Learning Portfolio (LEAP)

Obligatory courses of continuous training

Shifts (5-6 per month)

Evaluation of each rotation by acredited tutors

Congress, workshops, oral communications or

posters, self learning…

Research project in the last year

PRIORITY and RESPONSABILITY LEVELS

PRIMARY CARE RURAL TRAINING in SPAIN

- Compulsory rotation since 2005 2 months / shifts Diversity between different rural communities No docent rural centers in all of them or accredited tutors Elective rotation in another docent unit / country Environmental barriers: The rural/remote location of practice Isolation from colleagues, Transport: timetables, own car... Lack of resources and staff sometimes... BARRIERS IN RURAL GENERAL PRACTICE

- Compulsory rotation since 2005

2 months / shifts

Diversity between different rural communities

No docent rural centers in all of them or accredited tutors

Elective rotation in another docent unit / country

Environmental barriers:

The rural/remote location of practice

Isolation from colleagues,

Transport: timetables, own car...

Lack of resources and staff sometimes...

SOTO DEL REAL (MADRID)

3 MONTHS OF RURAL TRAINING RURAL SHIFTS (1-2 per month) SOTO DEL REAL (MADRID)

3 MONTHS OF RURAL TRAINING

RURAL SHIFTS (1-2 per month)

Very good: 155/400. Good: 161/400. Bad: 80/400. Very bad: 4/400. Rural Medicine during the postgraduate training period in our country (Spain) Rate of participation Rate of ID satisfation Valiente Hernández, S. et al. RESULTS RMPP implementation : 29/34 Average duration : 2 months (and shifts) Mean number of visits/day : 25 patients Mean distance to hospital : 50 km; (25-80) Infraestructure problems : Lack of official training responsibles for CTU, Need of a private mean of transport and extra expenses for ID.

RESULTS

RMPP implementation : 29/34

Average duration : 2 months (and shifts)

Mean number of visits/day : 25 patients

Mean distance to hospital : 50 km; (25-80)

Infraestructure problems :

Lack of official training

responsibles for CTU,

Need of a private mean of

transport and extra expenses for ID.

MANZANARES EL REAL (MADRID)

PATIENTS Patients' expectations and behaviour Necessary patient education about the evidence base of treatments, antibiotics, consultations, moves... Patients may prefer to see their regular GP Patients not wanting to see someone with less experience Not hurry More sincerelly grateful, presents... Differences whithin population: Residents (elderly people) Temporary residents

PATIENTS

Patients' expectations and behaviour

Necessary patient education about the evidence base of treatments, antibiotics, consultations, moves...

Patients may prefer to see their regular GP

Patients not wanting to see someone with less experience

Not hurry

More sincerelly grateful, presents...

Differences whithin population:

Residents (elderly people)

Temporary residents

LA CABRERA (MADRID)

The workload in rural general practice Isolation experienced in rural practice Limited time in attending Inadequate computer system and d ifficult internet access Difficulty in attending continuing medical education events Not available treatments or tests Lack or poor resources to encourage GP research, for continued medical education, difficulty in accesing practical workshop - Quality of Life / Funny experience GP TRAINEES / TRAINER

The workload in rural general practice

Isolation experienced in rural practice

Limited time in attending

Inadequate computer system

and d ifficult internet access

Difficulty in attending continuing medical education events

Not available treatments or tests

Lack or poor resources to encourage GP

research, for continued medical education,

difficulty in accesing practical workshop

- Quality of Life / Funny experience

CARDONA Montmaneu Cataluña

No preparation at Medical School Coordinating different organisations The continuity of care in the community Chronic disease management Dermatological conditions Minor surgery Preventive health Unsupervised decisions A great spectrum of illness Holistic approach to health, person and family Conflicts with the placement of GP trainees (between hospital and rural areas)

No preparation at Medical School

Coordinating different organisations

The continuity of care in the community

Chronic disease management

Dermatological conditions

Minor surgery

Preventive health

Unsupervised decisions

A great spectrum of illness

Holistic approach to health, person and family

Conflicts with the placement of GP trainees

(between hospital and rural areas)

At hospital, You have everything… Specialist, training and support, staff, adequate computer system and internet access, friends… Different sort of medicine No possibility of continuity of care in the community, chronic disease management, dermatological conditions, minor surgery... Consultation just for one person not the whole family But…

We consider being rural GP as a career possibility...

Thanks for your attention! It was a pleasure! Please don’t hesitate in contacting me! [email_address]