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Should we train doctors where they are needed?

Hilde Grimstad About the author

Many rural communities in Norway have difficulty recruiting doctors, especially general practitioners. Would it help if more of the training could take place in rural areas?

There is broad political consensus in Norway that the population should have access to good-quality health services irrespective of their place of residence (1). There is also a broad consensus on having strong primary healthcare services, including GPs, close to where people live. In countries with strong primary healthcare services people tend to have better health, the costs of providing health services are lower, and there are lower social health gradients in the population (2).

Some rural communities have for a long time faced difficulties in recruiting doctors to positions as contract GPs (3). Recently, it has also become more difficult to recruit contract GPs in general, and some have been concerned that the contract GP scheme is on the verge of collapse (4, 5). The specialist health service is also facing recruitment problems in some specialisations and regions (6).

This spring, the Committee of Health and Care Affairs in the Storting deliberated the recruitment problems for contract GPs, and submitted a proposal to the Storting: ‘The Storting requests the Government to submit a proposal for how adequate future recruitment of doctors to the primary healthcare services can be ensured in the years to come. The proposal must give an account, inter alia, of how to ensure that primary healthcare services can be included in medical studies in the future, as well as establishment of further training positions for specialty registrars in general practice’ (7).

The politicians thus seem to have faith in education as an instrument to ensure recruitment and doctor density. An article in this issue of the Journal of the Norwegian Medical Association deals with precisely this question (8): The establishment of medical studies at the University of Tromsø in 1973 was a political initiative to help increase doctor density in Northern Norway. The results from the study by Gaski and collaborators indicate that the University of Tromsø – The Arctic University of Norway has succeeded in training doctors who work as contract GPs in the rural communities, especially in Northern Norway and the University Hospital of North Norway. A large proportion of the doctors who have been trained at the University of Tromsø – The Arctic University of Norway have undertaken their practical training outside the university hospital and university town during their studies. In addition, students from Northern Norway have been prioritised for admission. In recent years, many of the students have had the opportunity to complete the final stage of their clinical training in Bodø. Plans are now in place for the establishment of similar solutions in Finnmark county.

The Norwegian University of Science and Technology has recently decided that each year, approximately fifteen students should undertake large parts of their clinical training in Nord-Trøndelag county starting from the autumn of 2018. These students will also undergo more of their training in the primary healthcare services. The objective is to encourage a larger proportion of these students to work as doctors outside the university hospital, and in the primary healthcare services. These measures are based on national and international data indicating that more doctors wish to work somewhere close to the place where they grew up and/or where they were trained, and in a discipline to which they were exposed during their training. Decentralised medical training has been implemented with good results in both North America (9) and Australia (10).

International studies also show that students from rural areas more often choose to work in such areas after having completed their training. We should therefore discuss whether more Norwegian medical students could be recruited from rural areas.

All four medical faculties in Norway have established teaching and practical training in general practice and primary healthcare services, and have for years wished to strengthen the opportunities for students to undertake practical studies in the primary healthcare services. In contrast to the specialist healthcare service, however, this option is neither funded nor statutory, and has therefore represented a challenge for the universities. Stronger statutory obligations have been introduced, but no specific funding plan is yet available. One way to ensure funding of practical studies in the primary healthcare services could be to let the funds follow the students.

Norway trains 11.2 doctors per 100 000 inhabitants (11). This level is low when compared to other countries with which such a comparison is reasonable. At the same time, Norway has one of the highest doctor densities in the world (12). Approximately one-half of all Norwegian medical students complete their studies abroad (13). A large proportion of them are trained in countries that give low priority to primary healthcare services and general practice, and that have little academic competence in general practice and no specialisation training in general practice. We need to train more doctors in Norway with a view to the needs of Norwegian health services. We can do this by using larger sectors of the health services for training purposes. Doctors should be trained to meet the patients where the patients are.

1

St.meld. nr. 11 (2015–16). Nasjonal helse- og sykehusplan (2016–19). https://www.regjeringen.no/no/dokumenter/ meld.-st.-11-20152016/id2462047/sec1 (7.8.2017).

2

Starfield B. Benefits of primary care in health care reforms. Sommer memorial lecture (Portland, OR, 2010). http:// ocw.jhsph.edu/courses/starfieldcourse/PDFs/Benefits%20of%20PC%20FINALSlidesNotes.pdf(1.8.2017).

3

Abelsen B, Gaski M, Brandstorp H. Fastlegeordningen i kommuner med under 20 innbyggere. Nasjonalt senter for distriktsmedisin, 2016. http://arkiv.nsdm.no/filarkiv/File/rapporter/Rapport_Fastlegeordningen_NSDM_2016.pdf (7.8.2017).

4

Stensland P. Fastlegeordninga bryt saman. https://www.aftenposten.no/meninger/kronikk/i/5XO4K/ Fastlegeordninga-bryt-saman-Gi-oss-2000-ferske-legar-til-fastlegeordninga-No–Per-Stensland (1.8.2017).

5

Sundby H, Johnsen TM. Du kan miste fastlegen din. Adresseavisen. http://www.adressa.no/meninger/ kronikker/2017/07/11/Du-kan-miste-fastlegen-din-15001362.ece(1.8.2017).

6

Gjersvik P, de la Rosa Carrillo D, Grimstad Ø. Hudleger vil helst bo i Oslo. Tidsskr Nor Legeforen 2017; 137: 519 - 20. [PubMed][CrossRef]

7

Innst. 450S (2016-2017) Innstilling til Stortinget fra helse- og omsorgskomiteen. Dok. 8:92S (2016-2017). https:// www.stortinget.no/globalassets/pdf/innstillinger/stortinget/2016-2017/inns-201617-450s.pdf (7.8.2017).

8

Gaski M, Halvorsen PA, Aaraas I et al. Utdanner Universitetet i Tromsø – Norges arktiske universitet leger til å arbeide i distrikter? Tidsskr Nor Legeforen 2017; 137: 1026 - 31.

9

Barrett FA, Lipsky MS, Lutfiyya MN. The impact of rural training experiences on medical students: a critical review. Acad Med 2011; 86: 259 - 63. [PubMed][CrossRef]

10

Greenhill JA, Walker J, Playford D. Outcomes of Australian rural clinical schools: a decade of success building the rural medical workforce through the education and training continuum. Rural Remote Health 2015; 15: 2991  [PubMed].. [PubMed]

11

OECD data. 2017. Medical graduates (indicators). https://data.oecd.org/healthres/medical-graduates.htm (7.8.2017).

12

OECD data. 2017. Doctors (indicators). https://data.oecd.org/healthres/doctors.htm (7.8.2017).

13

Den norske legeforening. Medlemmer av Nmf og totalt antall medisinstudenter i Norge og utlandet. http:// legeforeningen.no/Emner/Andre-emner/Legestatistikk/Medisinstudenter/I-Norge-og-utlandet-/ (1.8.2017). 10.4045/tidsskr.17.0621[CrossRef]

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