Overall, 118 participants participated in the study, 75 from FBH, 46 from RS and 1 from Brčko District. Officials from the Federation Ministry of Health were not available. (See Table 3 for details on key informants and focus groups.)
Three major themes and 9 sub-themes were identified from the interviews. (Table 4).
Theme 1 - Family Medicine Education Development:
Subtheme 1a): Establishing Departments of Family Medicine
There was overwhelming support for the strategy of partnering with Universities and establishing DFMs at an early stage. This was key to the successful implementation of program objectives. The DFMs are seen as cornerstones for the development of the discipline and are looked to for teaching of all medical students, the organizers and implementers of the PAT, trainers and examiners of Family Medicine residents and providers of continuing medical education (CME). Current department members were proud of their discipline and are committed to practicing and teaching its principles. They expressed that, undergoing FM specialization changed their perspective of themselves and their work, giving them a newfound sense of professional identity. There was consistent agreement that the knowledge base and clinical skills of family physicians in general have greatly improved.
Almost all DFM members were among the first generations of FM specialists trained under the Queen’s Program and see themselves as pioneers. However, this does place most of them in the same age bracket, causing some concern for succession planning in most Departments.
” The biggest change was in our heads. We had a changed perspective of ourselves and our work, a sense of professionalism.” DFM member.
All Directors of the dom zdravljas with teaching centers express pride in being the locus of training and have been supportive of consolidating and expanding teaching space as required.
The Medical School Deans express pride in the leadership of their DFMs and of the role played by DFMs in their medical curriculum and stated that, often, the DFM receives the award for best subject from graduating students. The Deans also acknowledge the key role played by the Queen’s Program in establishing the DFMs, developing and implementing the curriculum and changing how students were taught.
“I am grateful for the curriculum Queen’s created here and for the active creation of the Department of Family Medicine here. We have not had to change the curriculum at all since you established it!” Dean of Medical School.
There are still challenges in achieving equal status to other academic Departments in B-H. Although the other specialties are increasingly recognizing the skills and expanded scope of family physicians, DFM members at most schools still feel that their academic status is less than other specialties.
"We need to fight for our positions" DFM member
Subtheme 1b): Undergraduate medical curriculum change
Integrating a core subject of Family Medicine into the final year of all medical school curricula was introduced by the Queen’s Program in the late 1990’s and was an early achievement for the DFMs. All 6 medical schools (a new school was opened in Zenica in 2016) continue to provide core teaching during the final year, based on the principles and methods introduced by Queen’s, adapted to meet European standards. Lectures are supplemented with supervised clinical work in a mentor’s practice. This “hands-on” exposure to patient-centered care, with responsibility for real patients with real problems was novel at the time of its introduction. Discussions with students indicate that other disciplines still do not provide a similar type of practical experience. Students are unanimously enthusiastic about the FM teaching they receive and, in all sites, described it as the best in their medical training. There was a broad consensus amongst Deans, family medicine faculty and students that mandatory earlier exposure to the principles of Family Medicine would be beneficial.
“This was the best part of the whole curriculum! We gained a direct insight into how to work with patients and how the doctor-patient relationship is unique. Maybe make the first contact earlier in our teaching so we don’t discover it right at the end.” Senior medical student.
Theme 2 - Family Medicine as a Discipline:
Subtheme 2a): Family Medicine Specialization
The FMSP continues to thrive in both entities with 107 residents (FBH 55, RS 52) currently in training.
The academic structure to the programs continues to mature with relevant weekly academic seminars, resident scholarly projects and close FM mentor-learner supervisory relationships. The non-FM components of the specialization plan (e.g. in hospital speciality rotations) are not as well evaluated for their relevance and teaching, by both graduates and current residents. The concept of an academic year for all specialization trainees as an important human resource planning tool was dropped right after the Queen’s Program ended. Residents can begin training whenever approval is granted by the Ministry and the nationally standardized certification examination process has also been dropped, examination being conducted at the local/Cantonal level.
The waiting period to get an approved FM specialization position can be as long as 7 years, this serving as a deterrent to graduating medical students and demoralizing to practicing doctors. The PAT has served as a stopgap for some Cantons [administrative region in Federation], successful completion reducing the length of specialization by one year. However, it has also had a negative effect on approval of specialization positions by Directors of some dom zdravljas, since a doctor who completed the one-year PAT versus a longer absence to complete the specialization program, can contract with the Health Insurance Fund to provide FM services.
Many residents stated that FM was not their first choice but, after waiting perhaps seven years for any specialization position they accepted it. Despite this, FM residents, their educators and FM Specialists all spoke of the value of their training, its focus on clinical and communication skills and its patient/family-centeredness as compared to the other sectors of the system. Providing continuity of care to the whole family is important to their professional identity and patients see them as being "their doctor" and as their trusted source for medical care. This was shared by all FM specialists interviewed.
“Our patients know what we know, and they say: ‘Please don’t send me to someone else. Can’t you treat me’. This is a big change from the days when they just wanted me to refer them to someone else for tests.” FM Specialist
Subtheme 2b): Academic Development – research and publication
Within the DFMs there has been strong commitment by members to obtain academic credentials and experience, all obtaining master’s degrees and many with PhDs, necessary for academic promotion. (Table 5)
All DFMs are led by Family Medicine Specialists with PhDs and all department members are FM Specialists. This means that all FM teaching of medical students, residents and PAT trainees is done by competent FMS physicians.
FM Specialists in BH actively participate in national and international conferences, publishing articles in Conference Proceedings and journals. This activity is not restricted to DFM members and is well supported by the FM Associations. Four DFMs have published textbooks in Family Medicine for their students and residents to use.18-21
All of the Deans spoke highly of the academic place that Family Medicine holds in their medical faculties but also in the health care system.
“Family Medicine is in a special position within our health care system because there are special people involved with it and it is growing.” Dean of Medical School
Subtheme 2c): Family Medicine Associations
There are well established Family Medicine Associations (FMAs) at the entity level with seven branches in the Federation, including Brčko District. Each has a President with a supporting executive, with affordable membership fees. Essentially all General Practitioners from the previous system, graduates from the PAT and FM Specialists can be members. The Associations serve as an umbrella organization for family medicine in their region and one of their prime purposes is to provide CME.
Branches have developed collaborative relationships with the medical schools, the Deans expressing respect for their work in organizing CME, annual Days in Family Medicine and regional and international conferences. These events are highly regarded by members with Inter-entity activities well attended. Brčko District has its own branch and plans activities with both the Federation and RS.
The Associations have engaged in practical measures to improve clinical care, assisting Ministries with development of Clinical Practice Guidelines. Compared to some other Specialist Associations, the FMAs are seen as cooperative and collaborative in their approach to achieving progress.
They have worked with the Physicians’ Union in wage negotiations and in discussions about public-private practice. They act as advocates in the policy and health insurance arenas as well as for individual members who require financial support to attend important European medical meetings, or after personal or professional troubles. The Associations have also played a key role in educating the public about the new discipline of Family Medicine, providing speakers for media panels or community health education events.
“The Association has a vital role to work with the Ministry and the public. We are discussing important changes to the specialization curriculum to focus on enhanced skills which will improve quality of care and make Family Medicine more attractive to students.” FM Association executive member.
Theme 3 – Health Care System Issues:
An important program objective was to have the new certified FMS practitioners recognized as equals in the system and by the public, with incomes from the state competitive with other specialists. While there have been improvements in this perceived equality, there continue to be disparities in income and working conditions between family doctors and other specialists, primarily because of lack of private practice opportunities in Primary Care. Access to medical care is free to all citizens as are medications on an approved “essential” list for the elderly and disabled. Medication lists are decided at the Cantonal level depending on each Canton’s budgetary situation, the wealthier Cantons providing an expanded list of medications and diagnostic tests. Transferability of these benefits among Cantons is not always accepted. Because of its more centralized structure this is not a problem in Republika Srpska.
“The status of FM specialists is lower according to many other doctors and the public. They just don’t understand what the specialists do. The public needs to be educated about the importance of the primary care system.” Senior medical student.
Subtheme 3a): Continuity of Care
Access to a family physician (FP) is excellent with most patients seen on the same day if necessary.Appointment systems that were introduced by the program remain in place and mostly effective. The access to specialists is generally good and surgical wait times are reported as reasonable (e.g. 6 months for cataract surgery). There is also an organized system of home visits by both FPS and practice nurses. Our interviews suggested that there was now more continuity in the system; patients were less likely to ‘get lost’ and physician and patient satisfaction were much greater.
“My patients now have excellent access, with good teamwork with my nurse. For patients with chronic conditions we can plan their visits in advance and the appointment system works well for them.” FM Specialist.
Subtheme 3b): Comprehensiveness of Care
Family medicine teams are now providing more comprehensive care to families. School medicine (care for school aged children) has been disbanded and now children over age 6 are seen by FPs. This was seen as a positive step by most because it allows for better continuity with the family but, by some, also seen as negative, because it increases the workload for an already overworked and understaffed sector.
However, FPs cannot practice to their skill level. Specialty- trained family doctors are skilled in diagnosis and management of both acute and chronic disease but continue to be hampered by outdated regulations. Ability to order some basic diagnostic tests (e.g. MRI, CT scan, thyroid testing, PSA or HbA1c) or to refer patients for endoscopy, prescribe insulin or screen women for cervical cancer is blocked by old rules that have not been re-examined and these tests and referrals must be ordered or done by other specialists.
“A cardiac ultrasound can take 5 visits, back and forth between the family doctor, general internist and cardiologist” FM Specialist.
Preventive health programs have become more common and this is seen as one of the strengths of primary care reform. There are now initiatives in cancer screening, smoking cessation, nutrition education and programs which focus on chronic diseases such as diabetes.
“We have seen a 4% decrease in services provided per year because of improved prevention and education by FM teams.” dom zdravlja Director.
Subtheme 3c): Practice Organization
Most FPs practice in dom zdravljas or neighbourhood-based ambulantas as salaried employees doing assigned shifts. They are paid by the number of patients rostered with no graded payment based on patient characteristics. Bonus incentives for meeting specific targets have been introduced in a few areas. Recently, there have been a few exploratory attempts to establish private clinics in some major cities but the regulation of these is yet to be worked out.
There is a shortage of available FM positions in most areas, making roster sizes untenable for practicing comprehensive care. FPs reported seeing 40-50 patients in a typical 7 1/2-hr shift, but often up to 80 when short-staffed, which happens frequently. Roster sizes vary between 1800 -5000, depending on Canton and city. Electronic record systems have been implemented but FPs report having to continue to complete a double entry on paper. This is very time consuming and inefficient which adds to practice burden.
“Our biggest problem is frustration with the system, and we are psychologically exhausted. We begin to lose our motivation and get suffocated.” FM Specialist and teacher.
The medication prescribing process has improved. While a few other specialties working in community settings can prescribe, FPs still prescribe the majority of medications, often those recommended by consultants and not necessarily compatible with a patient’s other conditions, leaving FPs in difficult positions. Patients who require ongoing prescriptions can now get 3 months of medication at a time (rather than 2 weeks as it used to be) and don’t need to attend in person. E- prescribing is now well established in both entities.
Subtheme 3d): Health Human Resources
While all education programs continue to be implemented, trainee numbers in the FBH are limited by Cantonal budgets. (Table 6) However, centralized human resource planning is not well implemented in the Federation, with decisions made at the cantonal and dom zdravlja level. Positions are limited in both entities for new family doctors as are specialty training positions. When a physician is ill or on leave, absences must be covered by existing colleagues, further adding to their patient loads.
A major concern expressed by many of those we interviewed is that many medical students are leaving the country for residency training elsewhere because of the limited opportunities both for specialty training and family practice, as well as for private practice options. The students we interviewed at some of the universities said that a majority of their class was considering leaving the country. Some also expressed a concern that, if they chose Family Medicine, they would not be able to control where they were assigned to practice, including being sent to rural areas with larger practice rosters.
“Seventy percent of our class is studying German. We have to find clinical work after graduation and even these jobs are hard to get. So many will leave because they can’t even get to that first step! Sitting and not working for a year is unthinkable.” Senior medical student.
An alternate view was expressed by a medical school Dean. “Students leaving the country is nothing new for Europe with its open borders. It is healthy to get broader perspectives and see other systems. The trick is to get them to come back home after. It’s not a problem for them to go away but it is if they don’t return.”