Dr. Ozen Asut*
The significance of primary health care regarding community health in Turkey, had been established long before the Alma-Ata Primary Health Care Conference. The legislation on the socialization of health services was adopted in 1961 and the implementation of the socialized health services was started in 1963. The health centers established according to the socialization of health services are still in practice 40 years after the initiation of the first primary health care unit in the country.
A number of national and international expert opinions point to the specific need of a well-trained physician oriented to primary health care (PHC), namely the general medical practitioner (GP) (1). Primary health care premises are the workplace of GP’s where integrated health services, including promotive, preventive and rehabilitative aspects, are provided comprehensively and continuously to all members of the society in equity. PHC is the point of fist contact of the health system and should be accessible to all people without discrimination regarding age, gender, disease or any other characteristics. The function of the GP is to guarantee the quality of the services of the primary health care organisation (2, 3). Professor Dr. Nusret Fisek, the founder of the socialized health system in Turkey had pointed out to the necessity of a specialization oriented towards general practice and PHC (4).
The objective of this presentation is to describe the structure, organization, educational activities and the future perspectives of the Turkish Medical Association’s (TMA) Institute of General Practice, established for the purpose of specific vocational training in general practice for the final aim of increasing the quality of care in PHC.
International Progress and Documents on General Practice
The last 2-3 decades of the 20th century experienced magnificent changes in medicine and specialization has increased both in number and in depth, resulting more than ever in the need of a multi-function physician to evaluate the individual patient and the community in a comprehensive manner. Specific vocational training in general practice has become a focus of special interest in Europe during the last two decades. The Europian Community has developed certain criteria for the training required of GP’s to provide PHC of high quality in order to promote community health. A great majority of the European countries have developed GP training programs in compliance with the EU principles and criteria. With the EC Directive EC 86/457, specific vocational training in general practice is recognized by all EC countries since 1990 (5).
Consequently, all new general practitioners appointed to work in the social security system of EC countries from 1995 on must have received a minimum of two years vocational training (93/16/EEC). European Union of General Practitioners (UEMO), representing 400 thousand GP’s throughout Europe has insisted on a minimum period of three years for GP vocational training, considering the contents and the quality of the profession (6).
The European Union (EU) has recently become more involved in health and health manpower affairs. EU Doctors’ Directive 93/16/EEC has guaranteed high quality training for both specialists and GP’s. The efforts of UEMO at the European Parliament has ended up by an amendment of Directive 93/16, increasing the duration of vocational training of GP’s to three years, starting January 2006 (7, 8) .
The features of general practice training programs differ broadly even in the EU countries.
The general practitioners of Europe agree on the necessity of a common European core content for vocational training in general practice. A number of activities have been performed by relevant organizations in efforts to develop documents setting up minimum standards for GP specific vocational training. These documents include (9):
1.UEMO Policy Statement (Adopted 1991, expanded 1991 and 1995)
2.UEMO Criteria for General Practitioner Trainers (Adopted 1992)
3.UEMO Consensus Document on Specific Training for General Practice (Adopted 1994, in cooperation with the European Comission, World Organisation of Family Physicians (WONCA), International Society of General Practice (SIMG) and WHO European Regional Office)
UEMO has also developed particular documents on specific issues of the general practice
discipline such as equal opportunities, cancer training, palliative care, shared care, continuing medical education, therapeutic prescription and telematics.
General Practice Vocational Training in European Countries
The specific vocational training in general practice presents differing features in countries of Europe. As a common characteristic, the adopted minimum period of two years is generally implemented throughout the countries. In a similar way, the criterion of assuming control of all the training process by GP trainers is accepted and implemented in most of the countries.
The prerequisite for GP trainers is proper selection and trainers’training education.
On the other hand, other aspects of the vocational training programs are far from being standardized (10). The necessity of a core curriculum for all European countries is emphasized by the experts on the discipline. The question on whether GP is a specialist or not is currently answered by the diverse characteristics and jobs of the GP and the relevant education-training program, which obviously demands a different kind of specialty training (11).
THE ACTIVITIES OF THE TURKISH MEDICAL ASSOCIATION AND THE FOUNDATION OF THE INSTITUTE OF GENERAL PRACTICE (IGP)
The Turkish Medical Association (TMA) has endeavoured to point out to the community-based solutions of health problems prevailing in the country, starting as early as the beginning of 1970’s. The necessity of a well-trained general physician working at the frontline of the health system has been emphasized in almost exclusively all activities of TMA. The adoption by the Turkish Parliament of “the Law on Full-time Employment of Public Doctors” was a consequence of the intense efforts of the executives of the TMA in 1979. The public benefits of this legislative action was experienced all over the country.
TMA has also supported the socialized system for the last three decades, in spite of the negligence of the primary health care system by governments, who promoted secondary health services and continued to construct hospitals.
The governments of the 1980’s adopted the objective of increasing the number of physicians in the management of health care problems. A number of new medical faculties without adequate infrastructure were founded and the number of the medical students in the previous faculties were increased without any improvement of the facilities. These conditions resulted in a degradation of the quality of the medical manpower in the country. The governments continued these policies disregarding the opposing opinions of the relevant expert groups and organisations, including the TMA (12).
The increases in the number of doctors ended up with an enlargement of the GP population both in size and in proportion because of the limitations of specialisation chances. Only about 10% of the medical graduates were able to start post-graduate specialist training. Consequently, the proportion of GP’s rose up to 39% in 1980’s and to over 50% in 1990’s,
compared to the 36% of 1970’s (12,13). The ratio of GP/specialist was 58% in 1998. According to the data of 2000, 53% of the total 89 thousand doctors were GP’s, whereas 47% were specialists (14). The distribution in years of GP’s and specialist doctors is reflected in Table 1. The conspicuous increases in the number and proportion of GP’s started a debate on the discipline of general practice.
The Establishment of the IGP and Relevant TMA Activities
Realizing the meaning and importance of the general practice discipline and primary health care services, a group of GP’s started a discussion in the TMA late 1980’s and early 1990’s. The TMA General Practitioners’ Division (TMA GPD) was established in 1989 and branches of the Division were organised in medical chambers throughout the country. One of the subjects of interest in the GPD was GP vocational training, which ended up in the formation of a new working group to work on GP training.
The working group on the vocational training for general practice started activities to evaluate national and international experiences. Data were collected on country practices and representatives of GPD attended international meetings, including UEMO plenums.
In the light of all the experience and data collected, the GP’s organised in TMA declared that general practice is a specific medical discipline, after a workshop in Bolu attended by GP’s from all over the country.
Afterwards, dicussions on the need for the institutalization of general practice vocational training started among the GP’s of the GPD. This new concept was considered and evaluated broadly among the GP’s of the TMA. Finally, the establishment of the Institute of General Practice under the organisational responsibilty of TMA was approved by the Annual National Congress of TMA in 1996. After technical preparations of two years, TMA Institute of General Practice was founded in 1998 (12).
ACTIVITIES OF THE INSTITUTE OF GENERAL PRACTICE (1998-2004)
Definition and Objectives
The TMA IGP, established to organize the post-graduate education and training of GP’s working in PHC settings was defined in the IGP Regulations as follows (15):
“TMA IGP is an autonomous institution with representatives of other relevant organisations established under the organisational responsibility of TMA to organize the vocational training in general practice.”
Central Bodies of IGP:
The foundation of IGP was followed by the formation of an Executive Board (EB), some members of which were from the IGP Working Group, to work in the transitional
period of general practice training. An Executive Committee of five members, a president and a general secretary were elected from among the Executive Board. The compositon and functions of the EB were described in the IGP Regulations as follows (15):
“The IGP EB comprises 21 members, who are elected
*5 members from IGP General Assembly (GPD in the transitional period)
*5 members from the GP Trainers Board
*2 members from the IGP Scientific Advisory Board
*4 members from the TMA divisions (2 of whom come from the GPD)
*2 members from the General Practitioners’ Association
*1 member representing the medical faculties
*1 member representing the Ministry of Health
*1 member representing the Ministry of Labor .”
The EB elects a president, a general secretary and the Executive Committee.”
Another central structure of the Institute is the Scientific Advisory Board.
The composition and functions of the Board were described in detail in the Regulations.
The Scientific Advisory Board comprises two representatives from each of the six basic
modules, one member from each of the 12 clinical modules, 5 members from the IGP General
Assembly, one representative of the Continuing Medical Education Journal of TMA, one member from the General Practitioners’ Association and the general secretary of IGP. The Board convenes every three months.
The third central body of the IGP is the GP Trainers Board. As described in the IGP Regulations,
“The GP Trainers Board comprises GP trainers elected from among the GP trainers in the various regions of the country. The Board convenes every three months...”
The regions have been determined by the IGP EB . At the present time, there are 10 regions througout the country, where GP traners have formed groups to train other GP’s in the region.
IGP General Assembly
The utmost body of the IGP is the IGP General Assembly, where the basic policies of IGP are determined. According to the definition in the Regulations:
“IGP General Assembly, comprising all GP trainers of the IGP, is the body which determines the fundamental policies of IGP. The Assembly elects five members for repesentation in the EB and five members for the Scientific Advisory Board.” (15)
IGP Regions and Local Bodies
The regional organisation of IGP is made up of two bodies as a projection of the central IGP organisation. The regional activities of IGP, formerly performed by the GP commissions organized in the local medical chambers are in the responsibility of these local IGP bodies since the beginning of 2003, namely the IGP Regional Committee and
GP Trainers Local Committee.
IGP Regional Committee is described in the Regulations as follows:
“The IGP Regional Committee comprises representatives of the following groups: Local medical chamber, GP committee of the medical chamber, local health administration, local medical faculty, General Practitioners’ Association local branch. The committe is responsible for organising the GP training activities in the region on behalf of the IGP.”
According to the Regulations,
“IGP GP Trainers Local Committee is formed by all the GP trainers in the region. During the transitional period, it is sufficient to have attended the training course of one of the six basic modules to become a member of the GP Trainers Local Committee, valid only on the condition of continuing the rest of the training program.
Methods of Training and GP Trainers
The IGP has adopted a group-based modular training program using interactive and participatory methods and mainly taking place at the PHC settings (12,16).
The trainers are selected experienced GP’s working at the health centers of the socialized public health system, preferably with training experience and willing to take part in the GP education program.
Contents of Vocational Training and Relevant Activities
The contents of the GP training program of the IGP were finalized after the discussions in the EB of IGP with consideration of the feedback from the field, reflecting the opinions of GP’s working in PHC centers. The final decision of the EB was that the program would consist of
six basic and 12 clinical modules. The modules are listed below:
Basic modules of IGP GP vocational training program:
1. The philosophy and basic features of general practice
2. Training skills
3. Communication skills
4. Epidemiology for PHC
5. Health administration
6. Utilization of computers at PHC
Clinical modules of IGP GP vocational training program:
1. Emergency medicine
2. Risk groups: Child care
3. Risk groups: Geriatrics
4. Risk groups: Health of the working people
5. Forensic medicine
6. Reproductive health
7. Chronic diseases
8. Minor surgery
9. Laboratory and radiology for PHC
Workshops for goals and learning objectives of the modules
The first activity of IGP with broad participation was the workshop on the goals and objectives of the basic educational program, organized on 5-8 November, 1998 in Ankara.
A total of 33 physicians consisting of GP’s, family physicians and public health specialists attended the meeting. The goals and learning objectives of the basic modules were determined at this workshop.
A similar workshop was organised for the clinical modules on 12 -13 June, 1999 in Ankara,
with the participation of 77 physicians, comprising both GP’s and clinical specialists. In this workshop, the goals and objectives of the 12 clinical modules were determined (17).
Training courses for GP trainers
The IGP EB and Scientific Advisory Committee jointly decided to start the education of GP trainers by training courses. Thus, the first trainer groups were determined to initiate the courses. The first course of the IGP was organised in İstanbul on 22-26 November 1999, which was a “Training Skills” course. Since then, 62 courses of basic modules have been organised in different regions of the country. The number of trainees who have started the IGP educational program is 260. Of these, 72 trainees have completed the six basic modules, as of May 2004 (Table 2). The GP trainers’ training program is to continue in the coming years to manage the education of the great number of GP’s in the country. The training program for GP trainers was published by the IGP in 2003 (16).
The duration of the post-graduate educational program of GP’s in Turkey is determined as three years by TMA IGP. However, the duration of the program in the transitional period
evidently will be shorter and planned to be one year. The transitional period for GP training in Turkey is defined as follows by the IGP:
“The transitional period is the interval of voluntary GP training program,which will last until the recognition of general practice as a specific medical discipline by the national authority.” (15)
At the present time(May, 2004), the training programs for all the IGP modules are being developed and modified for the field training of GP’s working at PHC settings and specifically the health centers of the socialized system. The GP’s have been informed about the IGP program and the training of voluntary GP’s shall be started in summer 2004
at the different regions by the IGP GP trainers at the region.
The GP education and training program of IGP has been developed in compliance with the maximum content of the European and other country programs. The program has also utilized the national experiences of the previous GP training programs oriented towards PHC. Nevertheless, the IGP program is a unique model, covering a broad area of the knowledge and skills needed for the general practice discipline and practice. Another chacteristic of IGP is that all of the activities have been realised by national nongovernmental facilities and manpower, with almost no support from the government.
An important feature of te IGP experience is the democratic, voluntary and participitative nature of the activities in the whole progress. The TMA IGP is a unique experience started and developed creatively by GP’s actively working in the field, by the assistance and guidance of their professional organisation, the Turkish Medical Association.
IGP Basic Module Training Courses
Module Number of courses Duration (hours)
1. Price-Waterhouse Danışmanlık Şirketi Master Plan Etüdü, 1990.
2. Çiçeklioğlu, M. Sağlık Hizmet Araştırmalarında Farklı Bir Yaklaşım: Birinci Basamak Sağlık Hizmetlerinin Değerlendirilmesi. Toplum ve Hekim, 13: 328-333. (Eylül-Ekim 1998)
3. Belek, İ. Türkiye’de Aile Hekimliği Modeli: “Herkes İçin Sağlık” Perspektifli bir Değerlendirme. Toplum ve Hekim, 12 (78):8-17. (Mart-Nisan 1997)
4. TTB Haber Bülteni, Sayı 18, Nisan 1989.
5.Criteria for General Practitioner Trainers. Adopted by the UEMO Plenum Meeting in Paris, May 1992. In: European Union of General Practitioners Reference Book 2000-2001, 24-25.
6. UEMO Policy Statement (1990, Amended 1991,1995). In: UEMO Reference Book 2000-2001, Edited by T.E. Kennedy, 16-18.
7. Bergen, Jan. GP in Europe- the GP and the European Union. www.uemo.org 06.08.2002.
8. Fabian, C. The Future General Practitioner/Family Doctor in Europe- A Specialist. www.uemo.org (Visited May, 2004)
9.UEMO Reference Book 2000-2001, Edited by T.E. Kennedy.
10.UEMO Questionnaire on the Current Status of Specific Training in General Practice.
In:UEMO Reference Book 2000-2001, 148-151.
11.Jarmatz, Heinz. The Specialty/Generalist Dilemna in General Practice. In:UEMO Reference Book 2000-2001, 71-72.
12. Türkiye’de Genel Pratisyenlik Enstitüsü Kuruluş Çalışmaları. Ankara, Türk Tabipleri Birliği, Mayıs 1999.
14. Türkiye Sağlık İstatistikleri 2000, Ankara, Türk Tabipleri Birliği, 2000.
15. GPE Çalışma Yönergesi (2003). TTB Genel Pratisyenlik Enstitüsü Çalışma Raporu 2002-2004, Ankara, Türk Tabipleri Birliği, 2004, 75.
16. TTB Genel Pratisyenlik Enstitüsü Genel Pratisyenlik Meslek Eğitimi Temel Modüller Eğitim Programı. Ankara, Türk Tabipleri Birliği, 2003.
17. TTB Genel Pratisyenlik Enstitüsü Çalışma Raporu 1998-2000, Ankara, Türk Tabipleri Birliği,2000.