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Individual differences |
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- Main article: General practioners
General practioner (GP) training around the world differs.
General Practice in Australia has undergone many changes in training requirements over the past decade. The basic medical degree in Australia is the MBBS (Bachelors of Medicine and Surgery), which has traditionally been attained after completion of a six-year course. Over the last few years, four-year postgraduate courses have become more common. After graduating, a one or two-year internship (dependent on state) is required for registration before specialist training begins. For general practice training, the doctor applies to enter the three-year "Australian General Practice Training Program", a combination of coursework and apprenticeship type training leading to the awarding of the FRACGP (Fellowship of the Royal Australian College of General Practitioners), if successful. This qualification or its equivalent is needed to access the Medicare health system for remuneration as a general practitioner. Medicare is Australia's Universal Health Care system, and without access to it, a practitioner cannot effectively work in Australia. Most GPs work under a fee-for-service arrangement although increasingly a portion of income is derived from Government payments for participation in chronic disease management. There is a shortage of GPs in rural areas and increasingly outer metropolitan areas of large cities, which has led to the utilisation of overseas trained doctors (OTDs). GP incomes can match those of other internal medicine specialists, but not proceduralists. Many GPs feel that they are second-rate doctors because of lower incomes, less public respect than their specialist colleagues, lack of research opportunities, and lack of access to public hospitals. Historically GPs were the default group for those who had failed often brutal specialist training programs or for those without family connections to secure training positions for lucrative specialties, this is less so with the advent of general practice as a specialty in its own right, including a proper training scheme and certification process.
General practice in Brazil is called clínica geral or clínica médica. Any physician is legally allowed to practice without any training after graduation in the medical school, but recent efforts by the government, the Brazilian Medical Association and the specialized Sociedade Brasileira de Clínica Médica are trying to demand also a specialist title for its practice, just like for others such as cardiology, endocrinology, etc. The majority of Brazilian GPs are located in the public health sector and is constituted mostly by young, recently graduated physicians. The reason is that GP is not terribly profitable and about 40% of Brazilian doctors prefer to do specialized practice, instead. To do this, they are required to do medical residence of variable duration and submit to a board of medical examiners in order to get the title of specialist. Each medical society is in charge of organizing the examinations (which usually are carried out once a year) and granting the titles to those physicians who passed the requirements. The title is recognized by the Federal Council of Medicine (the Federal professional regulatory body), the Ministry of Education and the Ministry of Health.
Family medicine, on the other hand, has evolved only recently in Brazil as a separate specialization of general practice. It is a concept which was adapted from several community health models in Europe, such as in Italy, but particularly the one which was created successfully in Cuba, and which was felt to be the most adequate to Brazilian reality. Around 10 years ago, the government recognized that primary health care in Brazil was poorly organized and fraught with many problems, including a lack of attractiveness to young physicians, so a different approach, the Family Health Program (Programa de Saúde da Família or PSF) was tried, initially with some failures, but later with increasing strength and coverage. By spending a great deal of money in order to move the program forward, the Ministry of Health expanded and reinforced the public health care system, called Unified Health System (Sistema Único de Saúde or SUS) by decentralizing its management to the states and municipalities, by demanding in the Federal Constitution that a minimum percentage of the municipal budget should be spent in free health care to the population, and by setting up a new, multidisciplinary, family health-based system, the PSF. It is essentially based on teams composed by one to four physicians (usually a GP, a gynecologist/obstetrician and a pediatrician), one to two dentists, several nurses and a number of so called Community Health Agents (Agentes Comunitários de Saúde or ACS), who are trained lay persons who visit and have close contact with the families covered in a specific geographical location by the PSF team, in order to carry out preventative, educational and epidemiological work. Specific intensive training programs and recruiting efforts were set up in the country in order to form the PSF teams, which currently involve about 3,000 municipalities, with more than 45,000 teams already in operation; so that it can be considered one of the largest family health programs in the world.
Family physicians per se are still a rare specialty in Brazil, as the profession is generally shunning it (although economical incentive is no longer a valid reason, since physicians who work in the PSF units are generally well paid in comparison to primary health care physicians in the public sector). A few years ago a Brazilian Society of Family and Community Medicine was founded and has lobbied to have its own specialty title and board of examiners, but it has so far remained relatively small.
In Canada, there are no newly qualifying general practitioners: all medical students go on to a specialty, family medicine being the most popular. Following four years in medical school, a resident will spend 2-3 years in an accredited family medicine program. At the end of this, residents are eligible to be examined for Certification in the College of Family Physicians of Canada *. Many hospitals and health regions now require this certification. To maintain their certificate, doctors must document ongoing learning and upgrade activities to accumulate "MainPro" credits. Some doctors add an extra year of training in emergency medicine and can thus be additionally certified as CCFP(EM). Extra training in anesthesia, surgery and obstetrics may also be recognized but this is not standardized across the country.
There is very little private family medicine practice in Canada. Most FPs are remunerated via their Provincial government health plans, via a variety of payment mechanisms, including fee-for-service, salaried positions, and alternate payment plans. There is increasing interest in the latter as a means to promote best practices within a managed economic environment. As standard office practice has become less financially viable in recent years, many FPs now pursue areas of special interest. In rural areas, the majority of FPs still provide a broad, well-rounded scope of practice. Manpower inequities in rural areas are now being addressed with some innovative training and inducement mechanisms. An imbalance between physician manpower and a growing patient load has resulted in orphan patients who find it difficult to access primary care, but this is not unique to Canada.
In France, the médecin généraliste (commonly called docteur) is responsible for the long term care in a population. This implies prevention, education, care of the diseases and traumas that do not require a specialist, and orientation towards a specialist when necessary. They also follow the severe diseases day-to-day (between the acute crises that require the intervention of a specialist).
They have a role in the survey of epidemics, a legal role (constatation of traumas that can bring compensation, certificates for the practice of a sport, death certificate, certificate for hospitalisation without consent in case of mental incapacity), and a role in the emergency care (they can be called by the samu, the French EMS). They often go to a patient's home when the patient cannot come to the consulting room (especially in case of children or old people), and have to contribute to a night and week-end duty (although this was contested in a strike in 2002).
The studies consist of six years in the university (common to all medical specialties), and two years and a half as a junior practitioner (interne) :
- the first year (PCEM1, premier cycle d'études médicales, première année, often abbreviated to P1 by students) is common with the dentists (and, in some universities, with students of other paramedical professions like midwifery); the rank at the final competitive examination determines in which branch the student can go on;
- the following two years, called propédeutique, are dedicated to the fundamental sciences: anatomy, human physiology, biochemistry, bacteriology, statistics...
- the three following years are called externat and are dedicated to the study of clinical medicine; they end with a classifying examination, the rank determines in which specialty (general medicine is one of them) the student can make his internat;
- the internat is two years and a half of initial professional experience under the responsibility of a senior; the interne can prescribe, he can make replace physicians, and usually works in a hospital.
This ends with a doctorate, a research work which usually consist of a statistical study of cases to propose a care strategy of a specific affection (in an epidemiological, diagnostic, or therapeutic point of view).
India has the highest number of medical schools in the world, with approximately 204. In India to become a GP or a Family Physician, one has to enroll in a Medical Council Of India (MCI) recognised medical college and complete the Bachelors of Medicine and Surgery (M.B.,B.S) course, which is of four and a half years duration to be awarded the degree of M.B.,B.S and provisionally registered with the Medical Council of India. After one further year of compulsory rotatory internship, the Medical Council of India (or any of the State Medical Councils) confer permenent registration which licences the holder to practise as a General practitioner.
Higher Medical Education in IndiaEdit
A M.B.,B.S Doctor can appear for pre-post-graduate examinations (Pre-PG) at national, state or institute levels and gain entry to a MD (Doctor of Medicine), MS (Master of Surgery) or a Diploma course in a number of specialisations including Internal Medicine (or General Medicine).
One can also opt to join the National Board of Examinations (NBE)'s fellowship for Family Medicine at any of the NBE designated and recognised Health care center or hospital and appear for qualifying exams for fellowship to the National Board on successful completion of which, one is awarded the 'Diplomate of National Board' degree and title.
Other than Alopathic Doctors, graduates of homeopathy, ayurveda, and unani courses from recognised medical colleges and institutions and duly registered with the respective state or national boards of these medical systems can also practice as family practitioners.
General practice in The Netherlands is considered fairly advanced. The huisarts (literally: "home doctor") administers all first-line care, and makes required referrals. Many have a specialist interest, e.g. in palliative care.
Training consists of three years of specialisation after completion of internships.
In Spain the médico de familia/médico general commonly called médico de cabecera, works in multidisciplinary teams (pediatrics, nurses, social workers and others) on primary care centers. They are in most cases salary-based healthcare workers.
After the graduation in medicine (with a duration of 6 years), the medical doctors pass a national written exam called MIR (Internal Resident Doctor). The speciality devoted to primary care is "Family and Community Medicine Specialist".
To obtain it, the postgraduate doctors must complete a 4-years training period working in primary care centers (2 years) and hospitals (2 years) as residents.
Some of the specialist in family practice in Spain are forced to work in other countries (mainly UK, Portugal and France) due to lack of stable work offers in the public health system.
|Old System||New System (Modernising Medical Careers)|
|Stage 1:||Pre-registration House Officer (PRHO)||Foundation trainee (F1 and F2)|
|Stage 2:||Senior House Officer (SHO)||Specialist Trainee (combining Basic and Higher)|
|Stage 3:||Specialist Registrar or GP Registrar||Senior medical practitioner (e.g. Consultant or GP)|
|Stage 4:||Consultant or General Practitioner|
In the United Kingdom, doctors wishing to become GPs take at least 4 years training after medical school, which is usually an undergraduate course of five to six years (or a graduate course of four to six years) leading to the degrees of Bachelor of Medicine and Bachelor of Surgery (MB ChB).
Up until 2005, those wishing to become a GP had to do a minimum of the following postgraduate training:
- one year as a pre-registration house officer (PRHO) (formerly called a houseman), in which the trainee would usually spend 6 months on a general surgical ward and 6 months on a general medical ward in a hospital;
- two years as a senior house officer (SHO) - often on a General Practice Vocational Training Scheme (GP-VTS) in which the trainee would normally complete four 6-month jobs in hospital specialties such as obstetrics & gynaecology, paediatrics, geriatric medicine, accident & emergency or psychiatry;
- one year as a general practice registrar.
This process has changed under the programme Modernising Medical Careers. Doctors graduating from 2005 onwards will have to do a minimum of 5 years postgraduate training:
- two years of Foundation Training, in which the trainee will do a rotation around either six 4-month jobs or eight 3-month jobs - these include at least 3-months in general medicine and 3-months in general surgery, but will also include jobs in other areas;
- two years as on a General Practice Vocational Training Scheme (GP-VTS) in which the trainee would normally complete four 6-month jobs in hospital specialties such as obstetrics & gynaecology, paediatrics, geriatric medicine, accident & emergency or psychiatry;
- one year as a general practice registrar.
At the end of the one year registrar post, the doctor must pass an examination in order to be allowed to practice independently as a GP. This summative assessment consists of a video of two hours of consultations with patients, an audit cycle completed during their registrar year, a multiple choice questionnaire (MCQ), and a standardised assessment of competencies by their trainer.
Membership of the Royal College of General Practitioners is optional and can be awarded by examination, or by systematic assessment of an existing practitioner. After passing the exam or assessment, they are awarded the specialist qualification of MRCGP – Member of the Royal College of General Practitioners. General practitioners are not required to hold the MRCGP, but it is considered desirable. In addition, many hold qualifications such as the DCH (Diploma in Child Health of the Royal College of Paediatrics and Child Health) and/or the DRCOG (Diploma of the Royal College of Obstetricians and Gynaecologists) and/or the DGH (Diploma in Geriatric Medicine of the Royal College of Physicians. Some General Practitioners also hold the MRCP (Member of the Royal College of Physicians) or other specialist qualifications, particularly if they had a career in another specialty before coming into General Practice.
There are many arrangements under which general practitioners can work in the UK. While the main career aim is becoming a principal or partner in a GP surgery, many become salaried or non-principal GPs, work in hospitals in GP-led acute care units, or perform locum work. Whichever of these roles they fill the vast majority of GPs receive most of their income from the National Health Service (NHS). Principals and partners in GP surgeries are self-employed, but they have contractual arrangements with the NHS which give them considerable predictability of income.
The MB ChB medical degree is generally considered equivalent to the North American MD medical degree. Doctors educated in the United States, Canada, Ireland, and Great Britain have more ability to move between the countries than other national systems.
Visits to GP surgeries are free in the United Kingdom, but most adults of working age who are not on benefits have to pay a standard charge for prescription only medicine.Recent reforms to the NHS have included changing the GP contract. General practitioners are now not required to work unsociable hours, and get paid to some extent according to their performance, e.g. numbers of patients treated, what treatments were administered, and the health of their catchment area. They are encouraged to prescribe medicines by their generic names. The IT system used for assessing their income based on these criteria is called QMAS. A GP can expect to earn about £70,000 a year without doing any overtime, although this figure is extremely variable. A recent report notes that a GP can potentially earn £300k per year. These potential earnings have been the subject of much criticism in the press for being excessive .
GP Practices have been criticised by their lack of accountability, in particular with complaints procedures, as recent report described "an NHS complaints system failing to detect issues of professional misconduct or criminal activity". Practices are independent contractors and thus are able to exercise discretion in how they conduct themselves, the Primary Care Trust is not able to handle complaints before the Practice has, and patients do run a risk of being removed from the practitioner's list.
In the United States, a general practitioner has completed the one-year internship required to obtain a medical license, after having received at least an undergraduate Baccalaureate degree and a four-year Doctor of Medicine or a Doctor of Osteopathic Medicine degree. A family medicine physician, however, has completed a 3-year family medicine residency in addition to the undergraduate and doctoral studies, and is eligible for the board certification now required by most hospitals and health plans.
Starting in the 1970s and 1980s, many board-certified family physicians in the United States began to consider the terms "General Practitioner" and "GP" as somewhat demeaning and derogatory, discounting their additional years of training.
A family physician is board-certified in family medicine. Training is focused on treating an individual throughout all of his or her life stages. Family physicians will see anyone with any problem, but are experts in common problems. Many family physicians deliver babies as well as taking care of all ages of patients. Family physicians complete undergraduate school, medical school and 3 more years of specialized medical residency training in family practice. Board-certified family physicians take a written examination every 6, 7, 9, or 10 years to remain board certified, depending on what track they choose regarding the maintenance of their certification. Three hundred hours of continuing medical education within the prior six years is also required to be eligible to sit for the exam.
Between 2003 and 2009 the board certification process is being changed in family medicine and all other American Specialty Boards to a continuous series of yearly competency tests on differing areas within the given specialty. The American Board of Family Medicine, as well as other specialty boards, are requiring additional participation in continuous learning and self-assessment to enhance clinical knowledge, expertise, and skills. The Board has created a program called the "Maintenance of Certification Program for Family Physicians" (MC-FP) which will require family physicians to continuously demonstrate proficiency in four areas of clinical practice: professionalism, self assessment/lifelong learning, cognitive expertise and performance in practice.
Certificates of Added Qualifications (CAQs) in adolescent medicine, geriatric medicine, or sports medicine are available for those board certified family physicians who meet additional training and testing requirements. Additionally fellowships are available for family physicians in adolescent medicine, geriatrics, sports medicine, rural medicine, faculty development, obstetrics, research, and preventative medicine.
The family medicine (FM) paradigm is bolstered by primary care physicians trained in internal medicine (IM); although these physicians are only trained in internal medicine, adult patients provide the majority of the patient base of many family medicine practices. In the United States, there is a rising contingent of phyisicians dually trained in internal medicine and pediatrics (peds) (which can be completed in 4 years, instead of the 3 years each for IM and pediatrics). A significant number of family medicine practices (especially in suburban and urban areas) do not provide obstetric services anymore (due to litigation issues and provider preference), and, as such, this blurs the line between the FM and IM/Peds difference. One suggested difference is that the IM/Peds-trained physicians are more geared towards subspecialty training or hospital-based practice. Even so, there are many groups with FM-trained and IM/Peds-trained physicians working in seamless harmony.