Until now, Norwegian universities have relied on general practitioners to accept medical students based on an altruistic interest and goodwill, and have considered this arrangement adequate for both the students and the doctors. This era of unpaid efforts needs to end!
A growing number of treatment-related tasks are being performed outside the hospital setting: by general practitioners (GPs) and in primary care inpatient facilities, health centres and nursing homes (1). It is therefore important and appropriate that a larger portion of doctors' basic and specialist training takes place in these settings. To achieve this, GPs would need to dedicate more of their time to supervision, ensure that the supervision maintains a high standard and recognise it as an important part of their professional responsibilities. GPs are the main providers of supervision, and they are expected to supervise students, specialty registrars in general practice (ALIS) and other newly qualified doctors in practical training (LIS1).
The supervision of students will become more extensive in the future. The 2019 report by the Grimstad Committee recommended an increase in the number of Norwegian medical school places, from covering 47 % of the country's demand for doctors to covering 80 % (2). Currently, almost half of Norwegian medical students are still educated abroad. If student numbers are to increase in Norway, one of the biggest bottlenecks will be ensuring an adequate number of clinical placements, especially in the primary care service. The national curriculum regulations for Norwegian health and welfare education (RETHOS) (3) exacerbate the challenges. Norwegian universities currently offer around six weeks of clinical practice in general practice in addition to individual days in nursing homes, health centres and emergency departments. UiT The Arctic University of Norway is the only higher education institution already complying with the authorities' intention to provide at least ten weeks of clinical practice in the primary care service.
We believe that three aspects need to be addressed: supervisor training at a realistic level, coordination of the various supervisory tasks and better funding
More students and longer periods of clinical practice also mean increased competence requirements for student supervision. The recommended supervisor training amounts to a staggering 10 ECTS credits at the master's level, which corresponds to 250 hours of lessons or just over six weeks of coursework (4). Expecting self-employed GPs to prioritise this level of supervisor training is deluded. Even if the training is offered free of charge, the absence from their medical practice would result in significant financial loss. By comparison, all that is required for a GP to act as a supervisor of LIS1 doctors is a six-hour training session (5). Supervisors of specialty registrars in general practice (ALIS) must be specialists themselves, and it is recommended that they attend a two-day supervision course held by the administrators of the specialty registrars in general practice scheme (6).
We believe that three aspects need to be addressed: supervisor training at a realistic level, coordination of the various supervisory tasks and better funding. Efforts should be made to create synergies between the different types of supervisor training, as it is not practical to have three different competence requirements for three overlapping supervisory roles. In order to motivate GPs to take the necessary supervisor training, both the training itself and the role of supervisor must be attributed with significant merit in the doctor's own professional development and further education.
Furthermore, we are of the opinion that supervision should be included in the 'public duties' of a GP, on a par with work at child health centres and nursing homes. Currently, fewer than 300 of the approximately 2000 GP surgeries in Norway host students on clinical placements, and only around 400 of approximately 5000 GPs act as practice supervisors (7). Nevertheless, universities' attempts to secure more placements are often rejected. The reasons are complex: some don't have enough space, some don't have the time, and many are already busy supervising specialty registrars. Several have opted out of student supervision when their workload has become too heavy.
It is hoped that many doctors find it rewarding to have a student in their practice and that they enjoy the role of supervisor. However, supervision adds to the workload and detracts from other responsibilities. With 80 % of GPs in Norway being self-employed, it is evident that the remuneration for supervision does not cover the loss of income incurred by the reduced amount of time spent on patient care. Considerable additional funding is needed here, and in 2021, a working group comprising of the four universities recommended a tripling of the current level of funding (8).
Medical education carries financial implications and is a valuable investment, but we can no longer rely solely on unpaid efforts and goodwill.