|
by1
Manea M2,Comişel G3, Dumitrescu M4, Săndulescu C5, Chirilă E6
Abstract
Introduction. After 1990, important changes took place in primary health care in Romania. The first step was the privatization of the practices and the introduction of a new health insurance system. The second step was „training the trainers” activity in which 68 family doctors were trained in international programs like MATRA (Holland) and NICARE (Great Britain) in practice research, management and teaching methods. The two steps developed simultaneously. The trainers took over the whole training activity of family doctors in the country: an intense and immense amount of work.
Objectives:to find out if it is any impact of this activity on the trainers.
Design: crossectional study on the academic family doctors .
Method: to study , based on questionnaires, the life style of those doctors, the problems they face and the way they cope with. The questionnaire was made by the authors and revised in a pilot study.
Results: the changes in the life of the focus group come up to our expectations and make sense to review the organization of family doctors in a proper way.
Discussions: about the experience concerning quality, quantity and motivation of the work delivered by the family doctors; the overload aspect, a warning for the women doctors own health.
Keywords
Family medicine, trainer, leader, life-style
INTRODUCE
The last 12 years have meant a real qualitative leap for Romanian general practice.
The first step was represented by family medicine being accepted as a specialty; this was done by the introduction of 3 years residency.
The second step was the training of family doctors in research, practice management and teaching methods. All these increased the intensity and quality family medicine activity.
As a result, the last 5 years the family doctors have been invited to participate to the undergraduate and postgraduate educational process, CME activities, national and international projects, research studies and publications.
In spite of the reluctance of the Romanian medical society to accept it, the family doctor succeeded to show it is a necessary and high quality institution.
STUDY MOTIVATION
We are talking now about a lot of activities in which the family doctor takes part beside his/her basic mission of offering continuous medical care to the population.
The question we want to give an answer to, through this study is if the extra activities performed by the family doctor have influenced or not both the qualities of the medical services he/she offered and his/her personal or family life.
We could obtain “the portrait” of a segment of Romanian family physicians, namely physicians with intense research, management and teaching activities, trained in two international programs, MATRA and NICARE.
MATERIAL AND METHOD
The target group consists in the group of family doctors who graduated the above programs (either research, management or teaching section) and became founders of National Center for Studies in Family Medicine.
They are all active persons, involved in different activities at national level beside being a family doctor.
As working instrument we have used the questionnaire.
The 68 members of the group received questionnaire forms both directly and by e-mail; the rate of response was 86,76 % (59 physicians).
The questionnaire was made up by representatives of each section: researchers in family medicine, managers and teachers in family medicine; the dissemination of questionnaires and the permanent feed-back from the interviewees was done by MATRA project coordinator; all these persons are co-authors of the study.
The questionnaire was created after the model of Jean Karl Soler’s (Malta) questionnaire for burn-out study; therefore, we think the internal consistency and reproductively of the study is checked up.
The questionnaire was pre-tested, then applied to the studied lot together with intent letter and necessary precautions for keeping confidentiality.
The questionnaire has three groups:
-
group A refers to personal data, anamnesis of medical route; identification of activities and time given to these activities; change of life style during the last 5 years.
-
group B refers to the physician perception towards his/her own activity, personal life, personal satisfaction and family relations.
-
group C offers 7 possible responses and possibility to note any other suggestion related to the following question:” if you should change anything in your present activity, what would you change “?
RESULTS
Interpretation of results for Group A:
When interpreting the questionnaire, we obtained the following characteristics of the studied lot: average age is 42 years old, feminine sex represents 71% of the studied population. Marital status – 80% married persons. Their children’s average age is 1,5 years old, 12% of doctors having children under 3 years old. The average period of time since university graduation is of 16,6 years.
It can be observed the following percentage concerning postgraduate training: 78% of doctors graduated probation period, 44% graduated residency, 72% passed an examination for the actual place of work.
Concerning the higher postgraduate degrees: 66,6% of doctors has a first degree in their specialization,
22% are following a PHD, 72% followed CME and 100% are trainers in family medicine.
Analysing the type of activities developed by the questioned doctors, we obtained the following results:81,2% are working in urban practices,13,3% in rural practices and 5,5% in both.
Other mentioned activities are: 3,3% are teaching in undergraduate system, 26,6% are working in other medical institutions as well(except their medical practice) and 78% carry out other activities beside the medical ones.
Analysing the average time given to different types of activities : for family doctor activity – 7,78 hours/day; medical education- 4,5 hours/day; activities in other medical institutions- 4,25 hours/day; other activities than medical- 2,6hours/day;other medical activities –1,3 hours/day; individual study –5,1hours/week; rest- 6,38 hours/day; spare time- 1,25hours/day; special mention: 4,44% have no spare time during one week.
The last 5 years the situations concerning the time given to different types of activities mentioned above, have changed or not, as it follows: for 7% of doctors the activity in their practice hasn’t changed; for 43% the time increased and 50% think they diminished the time spent in their practice.
The activity in educational system is the same for 50% of doctors and diminished for 50%. Other activities in medical institutions increased for 80% of doctors and 47% give more time to other activities than medical, 47% less and for 6% the situation is unchanged.
The average time given to individual study the last 5 years is low to 77% of the participants, the time for rest has diminished as well for 75% and the spare time lowered for 92% (part of participants mentioned “the spare time disappeared “).
Interpretation of results for Group B:
These are results of the perception of the interviewees concerning their daily activity.
The satisfaction has three degrees, between 0 and 5: 0 means “not at all”; 1 means “not enough” or little,2 means “partly”, 3 means “enough”, 4 means “a lot”, 5 means – “very much”. The results are presented in the graph 1.
Referring to other activities than family doctor, 88% of participants consider them tiring enough and 17% very tiring.
When asked about their wish to involve in more activities, other than the present ones, 44% answered negatively, 44% partly and enough and just 6% wish very much to continue the involvement in other activities than family doctor.
At the question “ do you consider that the extra activities diminish your efficiency as family doctor”, responses were: 50% considers the extra activities don’t influence their activity as family doctor and 44% considers they diminish their efficiency enough; no respondent considers the diminishing is a lot or very much.
The interpretation of the following 8 questions is expressed just for the feminine sample of the studied lot, meaning the 42 women –doctors (71% out of all participants).
Responses referring to spare time perception (“do you consider you have enough time for yourself”) shows the following: 28% consider there is no time left for themselves, 66% consider there is a few time left, no person responds to degrees 3,4,5 meaning enough, a lot or very much.
At the question “do you spend enough time with your family”, 76% of the women-doctor consider they don’t spend enough time.
The questionnaire tried to observe also if the working style of the segment of family doctors damaged the relation/dialogue with spouse and/or children; the perception of the women doctor was that for 66% that happened rather frequently and very frequently.
The answers referring to the perception of health status and friends/ other close persons relations, cover all the possibilities, from 0 to 5; we must stress the percentage is concentrated on the central zone, namely 60% consider the present activity damaged their health partly and enough and 61% consider their relations with family and friends was damaged.
At the question “ does your daily activity damage your emotional life”, 11% consider it doesn’t,50% partly and 16% very much.
The satisfaction perception pointed through the question “are you in general, pleased by your actual life”, shows “ the “beheading” of extremes (no response for 0 – not at all and for 5- very much)., 11% appreciates the satisfaction is not enough,11% a lot,28% partly and 50% are pleased enough.
The last question in Group B try to appreciate the degree of difficulty of the present work by introducing the variable time; at the question” do you consider you will be able to continue your activity at the same pace for the following 5 years” the rate of response is: 14% consider they won’t, 37% partly, 14% - enough,14% -a lot and 21% very much.
The question “ what about the next 10 years”, the percentages change as follows: 44% not at all,14% the possibility is small,21% -it’s possible,7% enough,7% a lot, 7% very much possible.
Interpretation of results for group C:
The questionnaire offers alternatives to be answered to the question “if something should be changed in your present activity, what would you propose to do”.
The answer is optional, they can mark one/none/ as many as possible from the mentioned alternatives, by numbering each option; 1 means the most important; each participant had the possibility to add to the list of possibilities. The results show:
- all the participants filled in the group C of the questionnaire :
-
no option for giving up the activity of family doctor
-
76% consider of very few importance for improving their activity, to diminish the consultation time in the practice.
-
to the proposal of association with other colleagues in order to take over on short term, their tasks, options were: 46% consider it to be an important and very important alternative and 56% consider it to be a less efficient alternative.
-
In general, increasing the income of family doctors is considered the best solutions for 15% and increasing the income for the doctors with extra professional training is considered to be the best solution for 38%.
-
32% consider the creation of a remunerated specialization inside family medicine (researcher, teacher, manager) is important but 23% consider it of less importance.
-
Referring to the activities developed by these doctors at the level on CNSMF or National Society of Family Medicine,84% consider it is important to promote team working in order to diminish the workload of one person; this implies to enlarge the number of people involved in activities ;
-
other aspects stressed by the participants and considered important for change are: diminishing the bureaucracy in family doctors practices, higher respect of the population for the family doctor, better publicity of the patients rights which will save the doctor of excess of consultations.
DISCUSSIONS
The sample under analysis is relatively homogenous, with an age average of 42, +/- 5; the women/ men ratio is 3/1, reflective of the gender structure of the whole family physicians lot in Romania.
The average interval since graduation (16,6 years) allowed the subjects to have undertaken several postgraduate stages, and all are currently involved in research, management or family medicine teaching.
It is worth noticing that 22% of the subjects are set to reach the ultimate peak of medical training, as they are currently researching towards their PhD. However, the percentage of family physicians who are actives in undergraduate teaching is low (3,3%), which highlights reservations toward accepting family doctors among university staff.
Over 80% of the subjects practice in the urban area; given the financial and informational difficulties encountered by rural family physicians, it is hardly surprising that this is the ratio urban/rural.
Almost 27% of the subjects are also active in other medical premises than the family wards; an explanation for this lies both in the low wages as a family physician and in the numerous restrictions imposed by the legislation in effect. The involvement of doctors in other activities is triggered by financial need.
On average, the allocated time for professional activities amounts to 10 hours / day; the family medicine activity takes up most of the time (7 hours/day), followed, in decreasing order, by the teaching activity, activities in other medical institutions and other professional undertakings.
50% of the subjects estimate that, due to involvement in other activities, the time allocated to primary health care decreased over the last 5 years; the teaching activities remained unmodified for ½ of them and decreased for the other half , while 80% increased their share of time allocated to other medical activities.
Over ¾ of the subjects commented on the decrease in time allocated to individual study activities. The explanation is both the occurrence of other activities, of medical or different nature, and the fact that most of the doctors in questions have already been awarded all the medical distinctions for their career.
Rest time is mostly evaluated at 6 hours and leisure time at 1,25 hours / day. 75% of the subjects feel that rest time has decreased over the last 5 years and 92% feel that leisure time has decreased drastically; none of the subjects experienced an increase in rest or leisure time. All these aspects, new to health care in Romania, are indicatives of the increased importance of the role of family medicine within general health care.
However, a less beneficial factor is the involvement of the same individuals, who get overworked, in the efforts to develop and get recognition for family doctors. 44% of the subjects do not wish to keep up the same work rhythm over the next 10 years and 35% would only accept a marginal involvement in new activities. As a solution to this, the doctors have indicated attraction of fresh potential, new family doctors, in conducting the specific professional activities.
The doctors’ perception on their daily workload suggests that they also need to perform other activities than the family medicine ones; in doing that, 36% are motivated by pleasure, 26% by professional interest (self achievement and free practice) and 20% by financial reasons (a family doctors wages per workload are insufficient for a decent living standard).
The general perception is that all extra activities are tiresome; 44% are reluctant to get involved in any other activity. All efforts to ensure a satisfactory living standard and an optimal level of medical training are perceived as beneficial for family medicine; 50% of the subjects feel that their extra activities do not impinge on their efficiency as family doctors.
The perception of the female doctor on private life indicates a deterioration of the latter. 66% feel they have too little spare time; 76% feel that they don’t spend enough time with their family ; those 12% that feel they have enough time to spend with the family are exclusively male doctors.
66% of the female doctors think that their working style has endangered their family relations repeatedly. However, health seems to be less prejudiced, with only 6% feeling that their health is very much damaged. The motivation for health deterioration is the very intensive working style. The response to the question “ are you generally happy with your life” is not particularly encouraging; 50% are relatively happy, while no respondent has identified with “extremely happy/unhappy”.
In section C, the questionnaire offers scenarios for possible changes for the better in the current situation, leaving the list open for suggestions. The analysis of results shows that, although overworked, the respondents do not feel that the solution would be giving up on family medicine, and most of the subjects (76%) do not think it would be helpful to decrease the family medicine time share. The most popular options are to associate with other fellow family doctors for a better team share of tasks (which does not happen in Romania); to promote team work so that the work burden on one individual is decreased (this refers mainly to extra activities, such as research or teaching); to create a paid specialized area within family medicine (research, teaching, management); to increase wages for doctors with superior training so that they do not need to perform other activities for financial reasons.
Overall, the need to increase the family doctors’ income is (ranking 3, 4 and 5 as priorities), in order to ensure decent living standards.
CONCLUSIONS
-
Although only recently acknowledged in Romania as area of specialization, primary health care has evolved rapidly and several dedicated professionals have emerged from the field. They are overworked though, by means of a multitude of activities, such as research, teaching and management.
-
Most of the professional staff are women, which reflects the gender ratio of the whole family doctors lot in Romania. I order to cope with all medical or extra activities meant to both increase professional standards and to ensure living standards, the female doctor sacrifices spare time and acknowledges a deterioration of family or friendly relations, a decrease in the rest time and even health damage.
-
Overall, a contradictory tendency is displayed, between professional excellence and self achievement and the financial difficulties as well as biological limits, especially where the female doctor is concerned. Nevertheless, no family physician has indicated giving up practice as a solution to all this.
-
Family doctors currently perceive a need for restructuring within this medical segment. It is necessary to draw a financial and organizational distinction between doctors with various degrees of postgraduate training. Moreover, some initial necessary steps have been identified: team work, practice groups and payment of extra activities.
-
Family Medicine in Romania has not yet earned its rightful place. The wide public, as well as the legislation, are not yet in agreement over what is the role of primary health care. The respect toward this area of specialization should arise from within, as well as from outside, as this is currently of utmost importance.
1Correspondence: Dr Manea Mădălina, MD, Lecturer on Family Medicine, UMF Craiova, Petru Rare_ street, no 4, Craiova, Romania, code 1100, fax+04.051.12 27 40 e-mail: madmanea@xnet.ro
2GP specialist first degree, researcher on family medicine, Department of Family Medicine, College of Medicine, University of Medicine and Pharmacology (UMF), Craiova, Romania
3GP specialist first degree, researcher on family medicine, Craiova
4GP specialist first degree, MATRA teacher, Craiova
5GP specialist first degree, MATRA management section, Craiova
6MATRA-program coordinator, Bucharest, Romania
|
