NCDs, Medical education and Health Care Strategies
NCDs and Family Medicine Services: Implications for Training and Continuing Medical Education
Von Renato L. Galeazzi
Family doctors are an essential input for the provision of good quality of services to patients with Non-Communicable Diseases (NCDs). This implies that health professionals do have appropriate profiles and skills and that emphasis is given to the way they are trained as well as how their professional standards are maintained through continuing medical education and learning systems.
General Medicine or Family Medicine (FM) has difficulties to be accepted as respected specialty in many highly developed countries such as Switzerland. This is counterbalanced by the fact, that the university medical education is broad ranging and that the education system typically produces educated, “undifferentiated physicians”, ready for post-university specialty training.
Unfortunately the situation in many countries of the former Soviet Union and Eastern Europe differs substantially: there is no tradition of General Medicine, not at the university nor in the post-university training nor at the primary health care level. Medical education is on the contrary often characterized by a high degree of specialization often not able to respond to the majority of common disease found at family medicine level (e.g. diabetes, hypertensions).
Characteristics of care for NCDs
Essential aspects to be considered when caring for patients with chronic NCDs are the following points:
o Patients need to be accompanied through the course of the disease
o by someone, who does not change at every visit
o by someone, who knows their other problems
o and knows their environment.
- Comprehensive Care
o by someone, who can understand their other problems
o who can judge their other problems
o who can treat their other problems
- Professional Care
o by someone, who is on top of current knowledge
o who behaves according professional ethics
o who has skills in personal relationship
These points correlate very well with the definition of General Medicine postulating a Comprehensive, Continuous care at a point of first Contact by someone capable of Cooperating with other health care providers.
This has crucial impacts for the medical educational system in all three phases, at the university level, during the post-university specialty training and over the whole life (continuing medical education and learning).
What needs to change?
University training, therefore, should abandon specialty training through separated faculties. This however remains the general situation in post-soviet countries. A general, knowledge and clinical skills based education, with long and guided practical training should form non-specialized, undifferentiated graduates after six years or so of under-graduate training. After this, doctors are ready for specialty training, be it as Generalists or as narrower specialists. During the university training it is important, that students get a clear understanding of general medicine as a respected specialty and not just as an alibi-exercise.
Post-university specialty training for General Practitioners, too, has to aim at a practical education not in high technology settings such as big university hospitals but at the primary health care level. Practicing GPs have to be integrated into this specialty training and a curriculum has to be followed which includes the diagnostic and treating aspects in patients with chronic NCD. Narrow specialists have to be embedded into this system in order to foster the cooperation between the GPs and the specialists.
Continuing Education and Learning
Continuing Education and Learning (Life Long Learning, or Continuing Professional Development), as the third phase in medical education, has to build up on the knowledge and skills learned in earlier phases.
But contrary to the under-graduate and specialty training, CME&L should not be based on institutional programs and hospital teaching but on the problems encountered in daily work of the practitioners. Decentralized, local Peer Review Groups (or Quality Circles) are in many settings of Eastern Europe and the former Soviet Union the best starting point for a system of CME&L. This approach allows to level out shortcomings in the educational system and to establish discussions among peers on day to day problems thereby specialists are not excluded but depending on the circumstance be associated as occasional teachers and instructors, either local or form bigger institutions or universities. As patients with chronic NCD are repetitively serviced in the HC system, their problems will continuously be in the focus of such a system.
For identifying new developments in diagnostics and treatment, however a central organizing agency may be needed. The same is true for overseeing the courses given and taken, where a system of accreditation of educational events and credits for the trainees is mandatory.
It can be concluded that medical education in all its phases has to be regarded as a field deserving special attention wherever the issue of chronic NCDs is emphasized in health care strategies.
*Renato L. Galeazzi is board certified in Internal Medicine and Infectious diseases, is Professor of Medicine at the University of Berne and worked as Clinician and medical educator. He is consulting on Medical Education for different institutions, especially for Swiss TPH, in Central Asia and in States of the former Soviet Union. In this function he provides since 2006 regularly advice and guidance to medical education reform and continuous education and learning approaches in Tajikistan.