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Introduction
International electives and exchange programs for medical students have been criticized, underlining that they may offer interesting experiences for the students with little in return for the host community1. These experiences also come with some acknowledged risks for both the students and host institution2, and can place a strain on host staff and patients, particularly when language and cultural differences are significant.
Are there potential benefits for both students and host community that could mitigate these concerns?
This article, co-authored by two international elective students and their host supervisors and based on the students’ observations, provides a brief comparison of primary care systems in the host country (Greece) and the students’ countries of origin (Ireland and Norway). This personal view is offered as an example of how international electives may contribute a helpful comparative perspective on a local healthcare system – in this case, primary care.
Background
The University of Crete (UoC) has been particularly active with the Erasmus Programme (EuRopean Community Action Scheme for the Mobility of University Students) since its very beginning, in the late 1980s. The UoC Medical School receives numerous students from more than 10 EU member countries. The incoming students are assigned various clinical practice tasks. Between academic years 2016 and 2019, the number of incoming students gradually increased. The top countries from which students arrived in 2018 were Germany (9 students), Poland (8 students) and Czech Republic (5 students), from a total of 40 arrivals.
The students’ average duration of stay is 4 months, which is equivalent to a complete academic semester (16 weeks). Students are offered clinical training in internal medicine, general surgery and subspecialties, paediatrics, obstetrics and gynaecology, ophthalmology, otorhinolaryngology, neurology, psychiatry and primary care. Based on the medical school’s records, primary care traineeship ranks as one of the top choices among the incoming Erasmus students, as it is a unique opportunity for them to come into direct contact with local communities either in a city or a rural setting. The UoC Clinic of Social and Family Medicine (driving academic primary care services) accepts foreign students regardless of language barriers, as well as formulates an individual training programs for each student, involving faculty staff members and physicians in primary care centres.
Two medical students who joined the UoC Medical School for a multidisciplinary Erasmus Programme placement in October 2019 are the first two authors of this article. They were fifth-year medical students. They both studied in English at the medical faculty of Nicolaus Copernicus University, in Bydgoszcz, Poland. AW was born in Germany by German parents and grew up in Ireland. She completed a bachelor’s degree in languages before she commenced medical school. She is now aged 32 years. EI is aged 25 years and is Norwegian. He had a year-long conscription in the Norwegian Army before starting his medical studies.
Both students spent a full academic year (October 2019 to August 2020) on Crete, where they had the same traineeships at the same time. They immersed themselves in the culture and received an in-depth perspective of the way of life, despite cultural and linguistic differences and challenges.
As part of their training, they completed a 4-week course in primary care. They spent time in both urban and rural primary care centres to experience and get an insight into how the Greek primary healthcare system is functioning and how it has developed. This article is based on their reflections. Both students have experience from their home countries. Could contrasting and comparing what they experienced in Greece with what they knew from their home countries help both them, and the academics who hosted them in Greece (authors 3–7), better understand the primary care system in Greece and how deep-rooted such a healthcare sub-system may be3-5?
Inspired by other students’ visiting experiences, reported in international journals6, it is useful to share similar observations from different settings. To that purpose, this article attempts to connect students’ narrations with supervisors’ reflections from a local primary care environment as a way to gain collective experience. It may also offer insights into how similar international educational initiatives can be further developed. The specific focus used is how the Greek primary care system is organised and the relative importance of primary health care in the existing healthcare system in Greece.
Student impressions and experiences
Experience from urban settings (students’ narration)
In the past 3 years, Greece has launched an initiative in which 200 primary healthcare units (called TOMY) were approved to be installed in cities across the country. In the city of Heraklion, Crete, there are currently four units and we got to spend some educational time in two of them. During our stay in these units, we observed well-equipped and professionally run facilities. The units are accessible to anyone living in the area, where each patient can get a personal primary care physician. This allows each and every patient to have their own medical doctor with whom they can seek medical counselling, whether trivial or urgent. After speaking to doctors working at these units and seeing the number of patients using the service, we got the impression that the units are getting more and more popular. We also had the chance to speak to some patients, who reported that the continuous care and the care on a personal level gave a higher patient satisfaction.
These healthcare units were established to provide for a holistic primary care approach to urban inhabitants for free and the opportunity to supply continuous and personal care. They were also established as a counter-measurement to try to minimise the patient load of the emergency departments in hospitals. In a study conducted on an emergency department in a Cretan hospital, published in 2004, it is shown that 30% of patients visiting the emergency departments were patients with non-urgent problems7. It also reported that a further 10.5% had miscellaneous reasons for seeking health care at the hospital and were most likely inappropriately visiting the department7. This ongoing problem could easily be solved by patients seeking medical assistance from a local primary care centre, instead of overloading the capacity of the emergency departments. On many occasions, the reason for self-presenting to an emergency department is due to patients’ self-perception of their own health. Another important reason is due to the fact that not every citizen is accustomed to living in a community where a personal medical doctor is readily available. Accordingly, the purpose of these local units is to provide a faster, more personal and efficient line of care for inhabitants of the city, as evidence suggests that primary care can guaranty outcomes, quality and lower care cost8,9.
For historical reasons, the local population has misconceptions about visiting primary care centres. Primary care was facilitated mainly by private, specialised doctors, usually with the patient covering visiting costs. Urban primary care centres, with universal free health care for the city’s population, were lacking until 2017, with some sporadic exceptions. As an attempt to get more people to use urban primary care centres, in 2018 initiatives were launched in the media to raise public awareness5. Unfortunately, despite these efforts, people still tend to visit emergency departments rather than primary care physicians, a fact that is evident in the constant overcrowding of Greek emergency departments10. Another problematic aspect of urban primary care centres is that many doctors still have reservations to commit and work in these units, mostly due to the absence of a professional long-term contract, which will regulate all aspects of their employment.
Drawing comparisons to urban primary care centres that we have seen in both Ireland and Norway, the medical standards in the ones we saw in Heraklion are similar. There are of course differences in layout, building type and medical equipment.
Experience from rural settings (students’ narration)
A great part of the island of Crete is made up of mountainous areas and quite secluded villages. For people living in these communities, getting to a hospital or an urban primary health centre is not always a possibility. Therefore, rural healthcare centres were seen as a care-access solution in the late 1980s, due to the transport and technology limitations at the time4.
We were fortunate to do some of our traineeships in the rural health centre in the mountain-village of Agia Varvara (fondly referred to as ‘Santa Barbara’ in English). The village is about a 40-minute drive from Heraklion. On this occasion, we had the opportunity to see how a rural healthcare centre is run, and why and how it is an integral part of a rural community. The centre itself is equipped with an X-ray machine, a microbiology lab, a small emergency room and ambulance services. There were also a paediatrician, a dentist, laboratory assistants and nurses working alongside GPs.
During our time in Agia Varvara, we saw patients of all ages and walks of life, their health conditions varying greatly. We saw patients with everything from sports injuries to deep lacerations. We had patients with arrhythmias, exacerbations of asthma and chronic obstructive pulmonary disease, poisoning and various types of infections. If very sick patients came into the small emergency room, we were able to quickly transport them to Heraklion University Hospital, if needed. We also had some opportunities to join the paramedics on some callouts. The ambulance service means that people who are living in the most rural of communities, who do not have access to a vehicle, do not have to live in fear that they might not get the correct medical care as fast as possible. On one callout, we picked up an elderly lady who had slipped and fractured her femur. When we arrived to pick her up, the whole village was there to make sure that she got the best care and helped us where possible. Within 45 minutes we arrived at Heraklion University Hospital, where she was able to get the best possible treatment for her injury.
This particular rural primary healthcare centre appeared to be very important in the dynamics of the village in which it is located. It gave a sense of safety for the nearby population. The level of care and medical expertise portrayed by the staff seemed to be in accordance with what we have experienced in other countries. That being said, because so many patients with non-urgent cases choose to go to the hospital emergency department, GPs in these centres do not always get to experience rare disease cases or unusual symptoms. In a long-term period, this can of course lead to a disadvantage when translating knowledge into skills5.
The two of us are accustomed to difficulties with primary care in rural areas. Norway possibly would be the best example of how tricky it can be to instil the same healthcare access to all its population, because it is a massive country. Even as one of the richest countries in the world, Norway has difficulties, especially in the vast and rural north, to ensure the same healthcare access as it does for to the population of the south. This is especially for emergency healthcare access, as the distances are huge, and transport to hospitals can take several hours.
First impressions (student narration)
As both of us come from countries where primary care is well established and well respected within the communities, it was interesting to see how this is developing in Greece. In Norway and Ireland, you must visit your GP to be eligible for referral to a hospital. This is something patients do not question, as it had been this way for a long time. There are of course emergency departments remaining in use for acute medical cases or accidents. On Crete, however, this is still a work in progress, as seen by the queues of people in the emergency department waiting rooms. The idea of developing primary health centres in Greece is to change this picture, and this seems to be slowly happening. A change is sorely needed, as primary care gives the patients better health outcomes with continuous health care. This is especially important in a country where chronic diseases are disproportionally prevalent compared to other countries within the EU5. The patients we saw and spoke to were very satisfied with the services provided by the centres. They liked the personal connection they get with their GPs. As the rural healthcare centres have existed for much longer, it seems that the patients who need more time to adapt are those in the cities, as they also have easier access to the hospitals.
Communication difficulties (student narration)
When looking after patients, we as medical personnel all want to provide the best service possible. As medical students, we feel a little out of our depth at times, and when you do not speak the language this feeling increases greatly. We had some phrases and words in Greek, but nowhere near enough to be able to hold a conversation. Thankfully, all the medical staff in the centres made a big effort to translate for us. Some of the patients spoke a little bit of English, German or Italian, so between all of us we managed to make ourselves understood.
Immersing yourself in another culture and another language gives you a much more authentic experience when working abroad. It is also a humbling experience, as you realise how important communication is between a doctor and a patient. It is quite an unsettling feeling when you need to comfort your patient but do not have the words to do so. We became very fluent in body language and gestures!
Needs and expectations (student narration)
Looking back on our 4-week placement in the primary healthcare system on Crete, we have been given a great insight into the way these centres work. Although the core principles of primary care are similar in our countries, there is still some work to be done before citizens truly value and recognise the need for and the benefits of these centres. This is especially so, as highlighted previously, in urban communities. This is exactly why cultural exchanges are so important, where we can compare, contrast, learn and ‘absorb’ from each other’s countries, meanings, traditions and knowledge.
Supervisor reflections (supervisor narration)
Implementing primary care in Greece dates back to the early 1980s, when a national healthcare system was inaugurated4. Since then, almost 200 primary healthcare facilities have emerged in rural areas across the country4. In 2017, a legislative reform act (Law No. 4486/2017) included a plan to install 200 new local primary care units in urban zones, based on a European project fully funded for the first 2 years5. These units are team-based and equipped with GPs, internal medicine doctors, paediatricians, nurses, assistant nurses, social workers, administrative staff, and in some cases midwives. As of January 2019, more than 100 of these units were fully operational, which is still only a partial coverage of the urban population in Greece5.
The need for a developed primary care system in Greece has been made remarkably clear by the queues of patients at the emergency departments in the hospitals7,10, even though many of those cases could be triaged and treated by a primary care provider. Because much of this demand is due to chronic disease exacerbations, Tsiachristas and colleagues convincingly discussed the urgency to handle chronic diseases in Greece by investing in prevention and providing effective integrated care, while keeping the rise of healthcare expenditure flattened11. Inaction was listed as a synonym for health system collapse11. The need to improve an already dented economy so that healthcare wishes can be moved in the right direction has also been mentioned previously. This means that non-emergency care patients should be seen by a primary care practitioner first. Experience at an international level has shown that primary health care is an integral part of the healthcare system, with cost-effective dimensions. Reassessing the function of primary care and its resources, as well as a core group of competent administrators, is needed3. In a recent report from Crete and before pandemics, it was highlighted that continual efforts to learn will provide a strong orientation towards public health with an emphasis on major public health threats and problems, to shape integrated health care in a country that recently came out from austerity12. This discussion becomes currently and globally relevant.
Greece has the highest per-capita rate of licensed physicians among the EU member states. However, in stark contrast, it has the lowest number of GPs, as recently summarized in a recent development paper of the Clinic of Social and Family Medicine5. This seems to be a vicious cycle because, prior to the primary health centres being developed, there was no initiative or even opportunity for a generalist to work as a GP in an urban area. Today, urban centres are available, and this gives an incentive for doctors to choose general practice as their career choice. However, as the standardised curriculum has only recently been developed5, all of these things will take some time before a solid foundation for primary care is advanced.
Implications for international medical education exchange
This article has shown that the experience of Erasmus students can interact constructively with local environments.
Strengthening primary health care in Greece is an urgent priority, especially in a period of pandemic. Discussion of new primary care reform is again on the table.
International medical student education programs can have a role in this reform. As described in this paper, Erasmus students’ reports, undertaken with a collaborative academic and clinical spirit, can stimulate helpful reflections on primary healthcare services in Greece, how they compare with systems in other countries, and perhaps offer opportunities for further constructive development.