Post on 04-Jan-2016
GP JOURNEY THROUGH DECADESAn experience from the Czech Republic
Bohumil SeifertDepartment of General Practice
1st Faculty of MedicineCharles University in Prague
Zagreb, 13.12. 2014
The itineraire Personal introduction
A journey through decades: - a little bit of politics, history- health care / primary care function- general practice achievements and
perspectives
Czech Republic
Karlstein
Prague
Vltava riverMoravia
Charles University
The first University East of Paris and North of the Alps….
Founded in April, 7, 1348
Medicine + Law + Free Art + Theology
Fotka praxe
GP Department has been established 1996
Full academic function since 2003
Major development in 2009
Department of General Practice
First Faculty of Medicine
Charles University in Prague
Career path
General practitioner since 1985
Private practice since 1997
Academic career since 2003
Ph.D. completed in 2007, habilitation 2009
Head of the Department of GP Charles University since 2009
Scientific secretary of Czech Society of GP
GENERAL PRACTICE: 3 GPs and 2 nurses- population 3 000- teaching practice
A little bit of politics/history I.
Interval between world wars: The golden time of family medicine in the former Czechoslovakia
Austro-Hungarian empire until 1918 Czech Republic since 1993
A little bit of politics/history II.
1950´s An installation of the Soviet model with polyclinics and dense specialist network in countries of Central and Eastern Europe limited function and development of general practice.
GP has been recognised since 1978 (Alma-Ata conference) as a basic medical branch.
80´: starting a professional career
General Practice: 2nd choice discipline in 80´
Any other discipline was wide enough to satisfy my needs of complex approach to human person…...
Being too general v. too specialized The world also demands „the Great Synthesizers,“ people who specialize in interacting between disciplines and ideas. Communicating complex ideas that incorporate multiple bodies of knowledge is the skill that graduates and students need to have today.
General practitioners: „Great synthesizers“ in medicine.
Thomas L. Friedman, American journalist
and winner of Pulitzer prize
Choice of the discipline: Prerequisities for GP
Human prerequisites (patience, empathy) Communication/teaching skills Managerial skills Diligence Thoroughness
„If you are fascinated by ilnesses become hospital doctor, if youare fascinated by people, general practice can be your choice.“„If you get sick when entering the full waiting room, than avoid GP.“
A little bit of politics/history II.
The CEE countries have experienced dramatical changes,including the changes in the health care and in primary care
1989Velvet revolution
Windak A et al, EJGP 1998 Svab et al, Croat Med J, 1999 Seifert B et al., Family Practice, 2008Oleszyk M et al., BMC Family Practice. 2012
90´: difficult journey back to Europe Poor background of the GP discipline : - no theory behind - low recognition among other medical professions - low competence - bad image, low attractivity, „second choice discipline“ - no international contacts and experience- language barriers- high age averageBUT: - enthusiastic people - huge support from Europe
Support from European colleaguesRole of WONCA
In 90´s: new perspectives and possibilities• to travel and to meet colleagues• to participate at courses, conferences • to join WONCA networks, to learn and to adopt• to join research and quality projects
WONCA Region Europe, Prague 1997: the first meeting in CEE region
Personalities
Prof. Paul Wallace, Emeritus Professor of PHCInst. of Epidemiology & HealthFaculty of Population Health Sciences London, UK
Helge Bonlekke, GP in Thisted, Denmark, serving as a GP pensioner in Greenland
Prof. Richard Grol, a psychologist. Universities of Nijmegen and Maastricht
Prof. Roger Jones, Wolfson Professor of GPat The Guy's, King's, and St Thomas' School of Medicine, King's College, London. Since 2010 an editor in chief of Brittish Journal of GP
„Regional fellows“
Igor Svab, SLO J. Kersnik, D. Petric, M. Bulc
Adam Windak, PL Vaclav Benes, CZ
Mladenka Vrcic Keglevic, CR
PRIMARY CARE (96% privat contractors) GPs 5100(>15) average list 1 600 pts/1GP
PC PEDIATRICIANS 2200(<19) average list 900 pts/1PCP
PRIMARY CARE -Ambulatory gyneacologists-Home care agencies on referral-24 hours emergency services -Directly accessible specialists
General / Family Practice
in the Czech Republic
The point of the first medical contact within the health care system
Private providers List system Mixed reimbursement:
capitation +fee for service+bonus system No gatekeeping function but people seek
for care first by GP
Outpatient contacts per person per year
Norway 3,8Czech Republic 15,0 (contacts with GPs 6,0)
Czech Republic: - a lot of non medical reasons for encounter with GPs - open access to specialists - dense network of specialists
Since 2009:- regulative fee per visit - Rx OTC - 3 sick days not paid GPs: 4,2 (2012)
Comparison of practices in six European countries
Figure 3 Percentage of responses from small medium & large practices within each country
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
England
Netherlands
Czech Republic
Poland
Greece
Spain
missing data
large (7+)
medium (4-6)
small (1-3)
Seifert B, et al, The management of common gastrointestinal disorders in general practice. Digestive and Liver Disease, 2008; doi:10.1016j.dld.2008.02.020
Dr. Harold Frederick Shipman, GP born 14. 1. 1946, UKSerial murder : 215 victimsJudged to lifelong prison 31. 1. 2000Committed suicide 13. 1. 2004
Quality balance
• There is no evidence that systems with strict external control show higher quality
• These systems demand a lot of administration and demotivate providers.
CONTROL AUTONOMY
GP Task Profile Acute conditions, small injuries Chronic conditions: diabetes, hypertension, ICD, COPD, asthma,
musculoskeletal problems Systematic prevention + screening + vaccination Home visits Assessment for social services, sport, employers Occupational medicine
POCT technology: CRP, INR, glyk.Hgb, ECG, ABI, Holter BP monitoring,…
Alternative methods (homeopathy) uncommon
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aging of GPs in the Czech Republic 1990-2007
70+ 70+ 70+ 70+ 70+ 70+
do 39 do 39 do 39 do 39 do 39 do 39
60-69 60-69 60-69 60-69 60-69 60-69
50-59 50-59 50-59 50-59 50-59 50-59
40-49 40-49 40-49
40-49 40-49 40-49
1990 1995 2000 2005 2006 2007 5 224 GP 5 166 GP
Lack of GPs: Policies and interventions
GP academic dpt. + GP Society + Government improvement of pregraduate curriculum: - best examples in training practices- information campaigne about GP career
effective postgraduate training: 36 months
governmental support of residency programme since 2008
over 200 newly qualified GPs every year
Academic general practice An academic GP - a new kind of human in the Czech Republic How to assert in a competitive academic environment? Unique teaching! - one to one teaching, proximity to patients/people,
proximity to physicians, meeting healthy people, meeting not only diseases but problems, practice management
We have a strong message for students.
academic attributes: research, publications, academic life
Quality development in general practice in the CR
Organizational improvement:- appointment systém, more time for a patient
IT development
POCT technology + equipment
Competence in chronic disease management
Research in General Practice
the ultimate attribute of all disciplines which relate to a scientific context
evidence of the role of primary care in making the health care systems effective necessary for survival in academic environment
Research in primary care is difficult...
Colorectal Cancer Screening GPs have played a crucial role in screening in the Czech Republic; - in recruiting people, - counselling for screening, - distributing and performing FOBT, - dealing with negative and positive results and referring for a colonoscopy.
Guidebook for European general practitioners.
University education
Good clinical practice
Postgraduate education
Research
Quality improvement
Continuous education
Teaching
GENERAL PRACTICE…. offers all atributes of medical speciality for continuous professional development
QUALITY
CONTINUOUS PROFESSIONAL DEVELOPMENT
2005 2013
Margaret Chan, WHO general director
Out of the ashes built up by highly specialized, dehumanized, and commercialized medical care, family medicine rises like a phoenix, and takes flight, spreading its comprehensive spectrum of light, with the promise of a rainbow. This is the ancient historical covenant between doctors and patients, and this is where the health and medical professions need to return. I encourage all of you to continue to cultivate the human side of medicine.
The journey continues….
Thank you