In the Balkan context education in general practice varies greatly and it is in different stages of reorganisation and curriculum development. The postgraduate training in family medicine in Albania started in January 1997 with the goal of providing future family doctors with the proper knowledge, skills, attitudes, and professional values that will enable them to address the medical problems in the community. This paper describes the structure and content of the training programme and discusses some of its key elements.
- family medicine
- primary health care
- postgraduate training
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General practice throughout Europe is diverse in the organisation of its educational programmes. In the United Kingdom and Sweden vocational training in specialist disciplines is normally provided to physicians after they have completed undergraduate training and a period of hospital residency. Vocational training for general practitioners also fits this pattern in these countries.1 In the Balkan context education in general practice varies greatly and it is at a different stage of reorganisation and curriculum development. In Greece vocational training has recently been extended from three to four years.2
Primary health care in Albania was in the past characterised by the absence of specialist training.3 After graduation from medical school, physicians would practise for a year in a district hospital: six months in the department of internal medicine and six months in the department of surgery. After this basic training period and without any supervision or other educational support, they were required to work as general physicians in a primary care setting. Primary care physicians rarely went through a process of continuing education; consequently their clinical skills and their knowledge were never upgraded. These factors were mainly responsible for the low quality of services and as a result patients generally lacked confidence in their primary care physicians. After the democratic changes that occurred during the 1990s, the Albanian government identified primary health care and family medicine as the main vehicles for bringing about reform in the health sector.
In Albania, the responsibility for the provision of postgraduate medical education rests with the university. The preliminary work of introducing postgraduate training in family medicine started in 1994 with the appointment of four lecturers from other departments of the medical school of the University of Tirana, the only medical school in Albania, to the Department of Family Medicine under development. Two of the lecturers were from the Department of Internal Medicine, one from the Department of Obstetrics and Gynaecology, and one from the Department of Paediatrics. The idea was that these three specialties constitute the core components that should be provided to future family doctors.
The Department of Family Medicine was established in 1996 as an independent department with the support of the European Union PHARE project. The director was elected by the other members of the department. The postgraduate training in family medicine in Albania started in January 1997.
This paper reports the structure and content of the training programme and discusses some of its key elements.
STRUCTURE AND CONTENT OF THE TRAINING PROGRAMME
The aim of postgraduate training is to provide future family doctors with the proper knowledge, skills, attitudes, and professional values that will enable them to address the medical problems in the community. According to Albanian law, medical graduates applying for any specialist training, including family medicine, must fulfil certain criteria and are selected through a written examination. All the candidates must be under 40 years old, be fluent in at least one foreign language, and must have graduated from the medical school with a score of over seven out of 10. The duration of training in family medicine in Albania is two academic years, 44 weeks each. The trainees follow a rotation system as shown in table 1.
During the week the trainees are divided into groups and work in different departments according to the rotation schedule, under the supervision of the respective doctors. Two hours a day the groups meet together in “oriented” practice guided by a lecturer.
At the end of the week all the trainees attend two lectures concerning subjects relevant to family medicine and a workshop summarising the experience gained. In addition, a round table discussion is organised concerning different aspects of medicine and society with invited speakers from other institutions, governmental and non-governmental organisations, and foreign experts working in Albania. One day per week the trainees are on call at the emergency service of the university hospital.
At the end of the training period in each specialty the trainees are assessed for their practical and clinical skills. After completing their two years of vocational training, all the trainees have a final oral examination which focuses on problem solving ability and professional values in addition to theoretical issues.
For the last three years in which the postgraduate programme has been in operation, 48 physicians have completed the training in family medicine in Albania with more than 80% of them being female (table 2).
Presented here is a curriculum that might appear to be rather traditional to qualified medical educators, but which is of particular interest and importance when considering the country, situation, and role it reflects.4 In formulating the curriculum, the needs of the country as well as the available human and material resources have been taken into account, in addition to international experiences gained by the members of the department. Furthermore, some standard policies of the Faculty of Medicine concerning postgraduate medical training, such as the selection of the trainees, the structure of the programme, and the final examination had to be formulated.
In developing the programme, the members of the department were faced with three challenges. The first was to gain international experience concerning the structure and functioning of family medicine in countries in which postgraduate training in family medicine and primary health care is well established. For this purpose they received training abroad between 1994 and 1996 at the University of Utah, Salt Lake City, USA, the Royal Free Hospital, School of Medicine, University of London, UK and the Hospital of the Catholic University of Leuven, Brussels, Belgium.
The second challenge was to develop for the first time a national curriculum, to guide a state based training programme. The four lecturers, the dean and vice dean, and selected local and foreign advisors formed the steering committee of the project. A needs assessment study was not performed, but the existing studies from the Ministry of Health and the experience of the members of the steering committee were taken into consideration. The main goal was the identification of a core curriculum, containing a minimum of essential knowledge, skills, and attitudes for future family doctors. The argument about what is or should be the core curriculum has been an enduring one. A draft curriculum was prepared before the training of the lecturers abroad. After their return, the final curriculum was developed taking into account the experience gained and the advice of the specialists from host universities. Special attention was given to the role and education of general practitioners in relation to public health issues. The high incidence of infectious diseases led to the decision of having a separate period of training in this discipline.
Thirdly, all the parties involved in this process wanted to develop a comprehensive curriculum and not simply a syllabus of content. The curriculum was to include aims, objectives, teaching methods and resources, all within a framework that reflected Albanian society's needs and perspectives. It is within this context that the national curriculum was developed.
The training is mainly hospital based both because of the lack of qualified family doctors in primary care and because the trainees entering the programme have had previous experience in primary care. In order to minimise this limitation the programme is closely supervised by the Department of Family Medicine. In addition, lecturers from other departments were chosen by those with experience in primary care and it was arranged for trainees to work mainly in outpatient services.
The department is aware of the fact that the length of the educational programme is not sufficient and the short term training in some specialties is not yet fully effective, but reorganisation is under way. Our proposal is to extend the programme to three years, in accordance with the European Union's directives, starting with the academic year 2002–2003, but due to economic constraints this cannot be guaranteed. Half of the training period will be spent in primary health care under the supervision of qualified family doctors.
For updating skills and improving the quality of care, continuing medical education (CME) and continuing professional development are considered to be important. A CME programme, in collaboration with the Universities of Crete and Ioannina, Greece, and Linkoping, Sweden for the 48 doctors that have completed the postgraduate training is in progress. This programme will also contribute to the preparation of these individuals to be the first cohort of trainers for the primary care rotation of the future trainees.
It is hoped that recent national initiatives for tackling the problem of socioeconomic discrepancies in health care will encourage all the family doctors in Albania to fully embrace their role. Nevertheless, a more strategic approach in the development of training in family medicine is required in order to give family medicine the position it deserves.
Primary health care and family medicine have instrumental roles in the ongoing health system reform in Albania.
The dynamic developments in these fields necessitate comprehensive postgraduate training.
The particular conditions of the country impose an organic restructuring from the basic resources and assets at hand, including a systematic strengthening of the educational facilities.
International initiatives and advice in the process are most welcome, particularly when directed at empowerment of the available ground resources at the site.