Comparative Review of Education Programs of Family Medicine (FM) in Bosnia and Herzegovina and Several Transition Countries.

Family Medicine as an independent medical discipline is relatively young in the countries of Southeast Europe. Still are used the old models of all forms of education in this module, although most countries accepted Bologna undergraduate teaching concept and already implement it with greater or lesser success. Measuring the effects of the qualities of these concepts and models is not done systematically nor in uniform manner, so it could not be compared by the unique variables measuring the quality of education curricula, and especially the quality of education level of the graduates at the first, second and third degree courses and other forms of education. This paper provides a comparative overview of the state of education in the area of family medicine in the region. It creates comparison according to the study duration for undergraduate and postgraduate studies, doctoral studies and specialized studies in specified areas. What stand out are the proposals to improve education in the field of family medicine in the region.

1. INTRODUCTION

Family medicine/Family practice is first step between health care workers and patients (the gate to the Primary Health Care System) - PHC, and with main role to health care protect all family members in the ambulance/surgery and at home (home care, palliative care, health promotion, health education, polyvalent patronage, etc ,of healthy and sick people) (1, 2).

Specialist in Family Medicine is a medical doctor who provides personal, primary, continuing and comprehensive health care to individuals and families in the local community regardless of their age, gender or disease. Specifically, it deals with the preservation and improvement of health, developing healthy lifestyles and prevention of communicable and non-communicable diseases. Family doctor treats patients who have chosen him/her by their own free, in the doctor’s office and the home of the patient, and follow them when they are treated in clinics and hospitals.

By conducting a program of specialized training achieves the objective that physicians on the basis of internationally recognized principles are involved in all aspects of primary health care (PHC). By specialist education the family medicine doctor is qualified to: Organize and taking part in equipping the family medicine offices and the rational use of equipment, personnel and financial resources; Managing the team of family medicine in the professional part and in the part of fulfilling the required documentation; Analysis and monitoring of statistical information and to propose the necessary preventive, as well as other measures for the disease prevention; Conduct necessary communication within and outside the health care system with a goal of implementing the integrated health care for the population. Also to conduct: Implementation of programs of measures for preventive and curative purposes during pregnancy and childbirth, labor, of the total children population, women, especially in the early detection of cancer and other diseases and in particular measures of family planning; Implementation of protection, detection and treatment of diseases in the elderly with timely prevention of chronic disease; Implementation of measures for early detection of malignant diseases; Timely implementation of necessary measures in prevention, education about and treatment of infectious diseases; Implementation of home treatment, care and rehabilitation; Conducting health education and training, as well as health promotion using individual and group methods; Implement necessary measures and procedures in the terminal stages of the diseases.

Other obligations of family doctor includes: Continuing education and updating their knowledge using professional literature, acquiring new skills and knowledge that are necessary for their daily work; Ethical relationships with patients, users of health care, towards associates and colleagues; Respect legislation that regulate primarily the work of family medicine in general and health care in general. Model and concepts of education of the Family medicine in South Eastern Europe and large are few different.

Main aims of teaching of Family medicine at faculties of medicine are (1, 2): a) to teach the students to understand principle of comprehensive primary health care - to preserve and promote health, early detect and diagnose diseases, carry out treatments and rehabilitation of individuals and families in their natural environment; b) to provide to the students the understanding of functioning and organization of Family medicine/practice; c) to acquire appropriate/adequate knowledge and skills for understanding and solving the most common symptoms, signs and complaints of every family members who belong to the one family medicine team at one community region; d) to acquire appropriate knowledge and skills for providing care to patients with most frequent acute and chronic diseases in every situations; e) to teach students about influence of social and economical factors for development of some unhealthy situations within family environment, at work place, in community etc. and how to react or prevent these situations (what measures to use); f) finaly, to teach students how decide, prepare, realized some research in their family practice and how to prepare and publish results of their investigations. On Table 1 are presented number of hours of Family medicine curricula at most universities in SEE countries downloaded from official web sites in September of the 2014 (3-45).

Table 1

Status of Education in FM within Southeastern Europe Legend: 0 - NO, 1 - YES, * - Data missing

2. EDUCATION OF PROFESSIONAL PERSONNEL IN FAMILY MEDICINE BY COUNTRIES IN THE REGION

2.1. Slovenia

Education of experts in the field of family medicine in Slovenia is carried out at two universities:

Faculty of Medicine, University of Ljubljana and;

Faculty of Medicine of the University of Maribor.

Teaching at undergraduate study at both universities last six years (12 semesters), while the Department of Family Medicine exist in both faculties in Ljubljana since 1994 and in Maribor since 2000.

Specialization in family medicine was founded in 1961, and the Association of FM doctors of Slovenia in 1966. The specialization in the field of family medicine lasts for four years, like in most European countries.

At the Medical Faculty in Ljubljana works 236 university professors, 91 assistant, 99 researchers, 29 young researchers and 397 professional and administrative staff.

In organizational terms, the Faculty is divided into the Department of undergraduate studies in medicine, Department of undergraduate study of Dental Medicine and the Department for professional medical activities.

2.2. Croatia

Education of experts in the field of family medicine in Croatia is carried out at four universities:

Faculty of Medicine, University of Zagreb;

Faculty of Medicine University of Split;

Faculty of Medicine, University of Rijeka;

Faculty of Medicine University of Osijek.

Undergraduate Studies

Teaching at the undergraduate studies in all four universities last six years (12 semesters), whereby the Department of Family Medicine exists at the Medical Faculty in Zagreb.

Education at the undergraduate medical course includes five groups of subjects: general education courses, nature courses, preclinical, clinical and public health courses.

Upon completion of graduate study of medicine graduate receive the professional title “Doctor of Medicine” (dr. Med.)

After completing undergraduate studies one-year internship is required, after which graduate takes state exam. After successfully passing the state exam graduate can be employed as a general practitioner in private and public clinics or continue to specialize in a more narrow medical field.

Department of Family Medicine was established on March 28, 1980 with aim to introduce students to the basic tasks of a family physician who provides personal, primary and continuing medical care to individuals, families and the community, regardless of age, gender and disease. The task of the teaching is that students learn about and adopt the pattern of a family physician that makes an initial diagnosis of any problem that encounters in his/hers medical practice. Students should learn how in the assessment of health and illness cover and provide concise review of the physical, psychological and social factors. Students should acquire the particular knowledge and skills needed in providing continuous care to patients with chronic, reversible or incurable diseases. The specific objective of teaching is to help students to integrate previously acquired knowledge and skills and the knowledge and skills to effectively apply in solving the problems of patients who came to a clinic, perform patient’s examination at home, and active, in cooperation with the consultants involved in the care of patients refer it to secondary and tertiary levels of health care.

Postgraduate study in Family Medicine is a compulsory part of specialization in Family Medicine (Ordinance on specialist training of medical doctors in family medicine, Official Gazette no. 129/11). As part of the theory program specialization is performed at the medical faculty.

Croatia should allow specialization of family medicine to large number of doctors working in family medicine in order to meet European criteria according to which all doctors who work in family medicine (EU directives 33/93) must be trained specialists. In 2011, according to the Croatian Institute of Public Health in family medicine worked 2287 physicians of which there were only 1095 (47.8%) family medicine specialists. In relation to the insufficient number of specialists in family medicine, and the age structure of family medicine specialists who work in the health care system, there is a about 150 doctors at specialist training a year. With this intention, is accepted a special project “Specialist training of family physicians”, financed by the State budget of the Republic of Croatia which is planned until 2015. In accordance with the human resources development plan, after 2015 graduate studies as part of specialization will attend about 100 doctors annually.

In addition to undergraduate and postgraduate courses, Medical Faculty in Zagreb organizes also teaching in continuing medical education for doctors of medicine.

2.3. Bosnia and Herzegovina

Education of experts in the field of family medicine in Bosnia and Herzegovina is possible at the:

Faculty of Medicine, University of Sarajevo;

Faculty of Medicine, University of Banja Luka;

Faculty of Medicine, University of Tuzla;

Faculty of Medicine, University of Mostar ;

Faculty of Medicine, University of Foca.

Teaching at undergraduate studies last six years (12 semesters with 225 teaching hours), while the Department of Family Medicine exist at the medical faculties in Sarajevo, Tuzla, Banja Luka, Foca and Mostar established in postwar time in B&H.

Family medicine in Bosnia and Herzegovina has a long tradition. In the period from 1976 to 1991, was conducted a teaching of family medicine in support of primary health care in Sarajevo, Banja Luka and Mostar, where the medical students carried out practical training in Experimental Regional Health Centers funded by the Alliance of Managing Interest Communities of health care, which have their own clinics in local communities and strictly defined rules and concepts of work of doctors and polyvalent home visit nurses. All patients were followed trough medical documentation and records in the created database.

Family medicine as a teaching subject in a particular form of education began to be realized at the Faculty of Medicine, University of Sarajevo in 1996, by introducing the Canadian family medicine model Queens University of Ontario in Canada. The same model has been applied in other university centers in Bosnia and Herzegovina. But their concepts in the same period have been experimentally in realized some other countries: Switzerland, Italy, Spain, Netherlands, etc. Over time, the individual Department of Family Medicine began to combine certain concepts trying to create some kind of Bosnia and Herzegovina model. Plan and program for undergraduate course in Family Medicine at the Medical Faculty of the University of Sarajevo can be found on the website of the Department www.unsaporodmed.org.

Legal basis of specialization in the field of Family medicine is regulated by the Ordinance on family medicine (“Official Gazette of BiH” No. 07/99, 50/00 and 22/02), in the framework of the Department of Family Medicine, Medical Faculty University of Sarajevo, Tuzla, Banja Luka, Foca and University of Mostar. Duration of specialization program in B&H changed from 36 to 48 months last year (Family Practice - 19 months and other medical disciplines: Internal medicine - 9; Pediatrics - 4; Emergency medicine - 3; Gynaecology - 2; Psychiatry - 2; Surgery - 2; Public Health - 2; Quality of Health Care and Accreditation - 2 and other education programs by choice - 3 months). Our Program is simmilar with program propsed by EURACT.

Teaching in family medicine during undergraduate studies is conducted during the 11th and 12th semester in the total amount of 210 hours. Specialization internship for family medicine doctor in the in the Republic of Srpska lasts 36 months, from which the theoretical part takes 1296 hours and 5256 hours of practical work, making a total of 6552 hours.

2.4. Serbia

Education experts in the field of family medicine in Serbia are possible at the:

Faculty of Medicine, University of Belgrade;

Faculty of Medicine, University of Novi Sad;

Faculty of Medicine, University of Nis;

Faculty of Medicine, University of Kragujevac.

Teaching at undergraduate studies last six years (12 semesters), without title family medicine, but is used the term General Medicine Department.

Specialization least for 36 months, consisting of the clinical part in duration of 12 months and the outpatient part in duration of 24 months.

Clinical part consists of the following areas:

Outpatient part of specialization lasts 24 months and takes place through lectures, tutorials, seminars and workshops and has been made in consultation with coordinator for teaching in the field of general medicine.

Within this part of specialization are required the following seminars in public health for a period of 12 weeks: Social Medicine–4 weeks; Statistics with informatics–4 weeks; Hygiene–2 weeks; Epidemiology–2 weeks

2.5. Montenegro

Education of experts in the field of family medicine in Montenegro is performed at the Medical Faculty of the University of Montenegro.

Medical Faculty organizes undergraduate studies for the professional title of doctor of medicine for a period of six years or 12 semesters.

The syllabus is designed according to the model of the curricula from faculties in the region, which have a long tradition and embraced the principles of the Bologna Declaration, so that basic studies include preclinical and clinical content, which allows students to systematically acquire the necessary fundamental theoretical knowledge and practical and efficient training, on the other side. Medical Faculty organized and carried out postgraduate studies.

Specialization at the Medical Faculty, University of Montenegro in the field of family medicine is regulated by the Ordinance on specialization “Official Gazette of the Republic of Montenegro”, dated 4 December 2006, but has not yet started implementation of specialized studies.

2.6. FYR of Macedonia

Education of experts in the field of family medicine in Macedonia is performed at the Medical Faculty of the University of St. Cyril and Methodius, University in Skopje and the Faculty of Medicine of the University Goce Delchev in Stip.

Medical Faculty organizes undergraduate studies for the professional title of doctor of medicine for a period of six years, or 12 semesters.

The syllabus is designed according to the principles of the Bologna Declaration, so that basic studies include preclinical and clinical content, which allows students to systematically acquire the necessary fundamental theoretical knowledge, and quality practical training.

Teaching in family medicine at the University of Skopje takes place during the fifth and sixth years of study within the course called “family medicine”–30 hours, and “Clinical practice in family medicine”–40 hours.

2.7. Kosovo

Education of experts in the field of family medicine in Kosovo is performed at the Medical Faculty of the University of Pristina and Kosovska Mitrovica. Medical Faculty organizes undergraduate studies for the professional title of doctor of medicine for a period of six years, or 12 semesters. The syllabus is designed according to the principles of the Bologna Declaration, so that basic studies include preclinical and clinical content, which allows students to systematically acquire the necessary fundamental theoretical knowledge, and quality practical training. Integrated studies of first and second degree for obtaining academic professional title Doctor of Medicine, last six years or 4705 hours of theoretical and practical courses, student work and practice in health care facilities in accordance with Directive 2005/36/EC of the European Parliament and of the Council of Europe from September 7, 2005 on the recognition of professional qualifications in the part related to medical doctors.

2.8. Albania

Education of professionals in the field of family medicine in Albania is performed at the Medical University of Tirana, founded on 23 January 2013 by merging the existing Faculty of Medicine and Faculty for nurses. University of Medicine in Tirana consists of five faculties, 17 academic departments and 26 academic programs. The programs are divided into three academic levels: Bachelor, Master and Doctoral. UMT has more than 8,000 students, and at it work 350 employees from the ranks of teachers and other school staff with the help of 60 people employed in administration.

Teaching is held according to the Bologna process with three levels; three years Bachelor, Master two years, and three years of doctorate. In addition, there is Specialization. The University offers programs of study in general medicine, pharmacy, dentistry, public health, health sciences, physiotherapy, radiology, geriatrics, etc.

2.9. The Republic of Bulgaria

Education of experts in the field of family medicine in Bulgaria is provided at the:

Medical Faculty, University Sofia;

Medical Faculty, University of Pleven;

Medical Faculty, University of Plovdiv;

Medical Faculty, University of Varna and;

Medical Faculty, University of Trakia.

Study of Medicine in Bulgaria is in accordance with the state program and lasts 6 years. The study is structured as follows: two years of preclinical studies, three years of clinical studies and the sixth year of clinical practice, or internships. The student may choose to study in English or in Bulgarian language with relatively low living and tuition costs, and diplomas recognized in Europe and beyond. Teaching in field of family medicine is performed on the third and fourth semester (second year students) with weekly number of hours 2 +2.

2.10. Republic of Romania

Education of experts in the field of family medicine in Romania is provided at the: Medical University of Cluj-Napoca; Medical University of Lasi; Medical University Timisoara; Medical University of Targu-Mures; University of Medicine Carol Davila Bucharest; Medical University of Oradea; Medical University Constanta; Medical University of Arad; Medical University of Craiova; Medical University of Sibiu; Medical University “Titu Maiorescu” Bucharest; Medical Faculty Transilvania University of Brasov.

Basic studies for obtaining the title of Doctor of Medicine last six years, or 12 semesters.

Data on specialty of family medicine is not available.

2.11. Czech Republic

Education of experts in the field of family medicine in the Czech Republic is carried out on the:

First Medical Faculty of Charles University in Prague;

Second Medical Faculty Charles University in Prague;

Third Medical Faculty of Charles University in Prague;

Medical Faculty in Plzen, Charles University in Prague;

Medical Faculty in Masaryk University in Brno;

Medical Faculty of Palack University in Olomouc

Teaching in family medicine, takes place within the course “Hygiene and Preventive Medicine” in the fifth year of the study with 30 hours, and the course “Social and medicine, public health, hygiene and preventive medicine” in the sixth year of studies with 30 hours.

2.12. Republic of Slovakia

Education experts in the field of family medicine in Slovakia are provided at the:

Medical Faculty–Slovak Medical University in Bratislava;

Medical Faculty, Pavol Jozef Safarik in Kosice;

University Komenskeho in Bratislava, Jessenius Lékařské Faculty in Martine;

University Komenskeho in Bratislava, Medical Faculty

Medical Faculty was established within the Slovak Medical University in Bratislava and it is the successor of the Slovak Graduate Academy which has developed and offered a model of continuing medical education organization cyclical seminars.

Medical Faculty, Pavol Josef Safarik in Kosice lasts 6 years (12 semesters), and teaching is in English. After graduation is obtained the medical degree from this college, accredited by the European Union.

The University was established in 1959 and is the second largest in Slovakia. Faculty has made a significant contribution to the development of education and research in Slovakia. Medical Faculty was established in 1948 and trains students who want to become doctors and surgeons in the field of medicine, preventive aspects of the same and providing full medical care.

Program at JLF UK in Martin University

Review of data on research programs in the Slovak Republic is given in the following tables.

2.13. Hungary

Education experts in the field of family medicine in Hungary are done to:

Semmelweis University, Faculty of Medicine Budapest

University of Debrecen, Faculty of Medicine

University of Pécs, Faculty of Medicine

University of Szeged, Albert Szent-Györgyi Medical University

Semmelweis University, Budapest was founded in 1635 and today’s name dates from 1969, in honor of “Ignác Semmelweis” who discovered the cause of puerperal fever. Today, Semmelweis University includes faculties of medicine, dentistry, pharmacy, physical education and sport science and Faculty of Health Sciences. Currently at the Faculty of Medicine study 3,200 students, the Faculty of Dentistry 630, and at the Faculty of Pharmacy 649 students.

University of Debrecen–Medical studies last six years (ten semesters + 1 year internship). The first two years of the curriculum are focused on the theoretical aspects of medicine. Starting from the third year, students learn the theory underlying diseases, internal medicine and surgery basics. During the sixth year students give final exams in internal medicine, surgery, gynecology, neurology, psychiatry and pediatrics.

Internal Medicine–10 weeks;

Pediatrics–7 weeks;

Surgery–5 weeks;

Gynecology–5 weeks;

Neurology–4 weeks;

Psychiatry–4 weeks

The University of Szeged was founded in 1581 in Kolozsvár and is the first institution of higher education in Hungary. Empress Maria Theresa reorganized the institution of the Faculty of Medicine–Surgery in 1775, which was after World War I, moved to Szeged in 1921. Since 2000, the Medical Faculty became part of the University of Szeged, which has 12 faculties. In the academic year 2013/14 the Faculty of Medicine studied 1,036 students (English and German program), at the Dental Faculty 144 and at the Faculty of Pharmacy 63 students. University of Pécs–This is the oldest university in the country, established in 1367, by King Louis the Great. International program began in 1984 and students come from 39 countries around the world. In the academic year 2013/14 was enrolled 151 students in study of general medicine. After six years of the program candidates may receive a general practitioner, after which they can get specialization in various fields. Medical program lasts for six years, or 12 semesters. The first two years includes classes from pre-clinical subjects, from three years of theoretical training has been expanded with clinical practice, where students participate in the clinical departments and teaching hospitals. The last two semesters, students perform clinical rotations for a period of 37 weeks. At the end of the title receives a medical doctor.

3. DISCUSSION

Education in the field of family medicine in the region takes place in more or less similar manner except that there are differences in terms of organization, as well as the names of subjects in which instruction is given. In this regard, it would be desirable that faculties who have not already done so introduce the term “Family Medicine”, as well as to harmonize the curricula in undergraduate studies.

As there is a significant difference in terms of organization of faculties in the region, and some does not have established the Department of Family Medicine, it would be desirable to establish it as soon as possible. Duration of graduate program has been agreed in the region and it is six years everywhere, although there are minor differences that come to the fore in the last semester, doctoral studies are also agreed and last for 3 years, but there are significant differences in the duration of specializations that generally lasts for three, sometimes four years, which certainly need to be harmonized. Also embodiment of theoretical and practical work in the context of specialization is not complied with and the need to harmonize (Table 11). As for the number of students in medical schools, as well as the number of learners in family medicine are in front Romania, Bulgaria, Poland and Hungary. It is noticeable that the Web sites of some of the University from the countries in the foreground have promotional material such as pricing of studies, accommodation, etc., while the data on the curricula are difficult to find or not available.

Table 10

Program of the first degree–a master study program

4. CONCLUSION

Given the importance of family medicine and the existence of the Association of general-family medicine Southeastern Europe which Bosnia and Herzegovina belongs to, unfortunately through two entities member, and other organizations, it is necessary to continue the exchange of experiences in order to strengthen the role of family medicine in the region. It is necessary to reform the health care system in the counties member of the association, as well as to perform additional training the existing workforce in similar manner as Croatian example.

Table 1a

Example from curriculum of the Course in Family Medicine at the Medical Faculty Zagreb, Croatia

Table 2

Course Family Medicine Syllabus, Medical Faculty, University of Sarajevo

Table 3

Organization of the clinical part of training in family y medicine in the Republic of Serbia

Table 4

Organization of the outpatient part of specialization in family medicine in the Republic of Serbia

Table 5

The ratio of enrolled students and graduates at study medicine in Timisoara by years

Table 6

Structure of students enrolled in 2013 year

Table 7

Masters in English–and parallel master’s program was attended by a total of 386 students, of which 321 students of general medicine and 65 of dentistry.

Table 8

Program–an integrated first and second cycle

Table 9

Program in the first degree–bachelor program of study

Table 11

Comparison of Family Medicine Program Specialization available by EURACT