The Royal Spanish Academy (RAE) dictionary defines “valorizacion”, in its third meaning, as “to increase the value of something”. Among the meanings of “value” two components are observed: the intrinsic, which defines the value of something in itself, its level of usefulness, and the extrinsic, which is that given by everyone else, its significance.
From Farmer et al.1 who observed that the counties in the USA with the lowest death rates adjusted for age were those with a higher density of family doctors, to the studies by Starfield et al.2 and others, on the impact of family doctors and Primary Care (PC) on health levels, the intrinsic value is demonstrated with evidence.
As for its importance, its recognition by the population on the health barometer is obvious.3 Its social function is recognised3,4; however, its academic and professional prestige is more in doubt.4 This, with the perception of working difficulties at primary level, is the basis of choosing Family and Community Medicine (MFyC) in Medical Internal Residency (MIR) training. Although the number of graduates choosing MFyC among the 1800 first places is in an intermediate position compared to the other 47 medical specialties, it is not proportional to the number of places offered by MFyC. A large number of graduates make it their initial choice, but also there is a significant volume of them that chooses it when the offer of places for other specialties is lower.
Bland and Stritter5 determined that the most powerful predictors for choosing Family Medicine are linked with its core presence in the curriculum. Several research studies4 are currently being conducted with the aim of finding out the opinion of medical students as regards Family Medicine. In the article “The reputation and professional identity of Family Medicine practice according to medical students: A Spanish case study6” the authors conclude that in order to improve the reputation of Family Medicine, and its consideration as an attractive professional option, not only does its development needs to be stimulated in the academic environment but also its practice conditions in the health system must be improved.
There are no doubts on the importance and pertinence of MFyC as a degree subject, given its soundness as an academic discipline. And we must be on the right track, when in the USA there are more than 100 Family Medicine departments and 95 in Europe.
Another item that appears to have an impact on the prestige of the profession is to do with the professional quality of life and influence capacity. The professional quality of life, according to several studies, is intermediate.7 Depersonalisation is high, as well as emotional tiredness, and furthermore, not many family doctors feel a high personal fulfilment. There is a relationship between the demands of the post and emotional exhaustion, and this, in turn, with professional quality of life. As regards the influence capacity, our health system, despite legislation, continues to be strongly centred on hospitals.
The MFyC and PC, given their intrinsic value, are currently faced with clear opportunities (chronicity, crisis, …) and have important strengths (legal framework, doctrinal development, consolidated network, …), but we must not ignore their weaknesses and threats. Emphasis must be oriented towards improving funding, with an increase GDP% (PIB) destined for PC, so that PC functions as the real centre of the Spanish National Health System and the teaching and training system. To do this, it must be “empowered”, to PC and MFyC as has been done in the United Kingdom (one of the few countries where their prestige is equal or greater than that of a hospital doctor). The number of PC doctors must be increased in relation to the total number of doctors in the NHS, at least by 50%, and thus redress the balance of specialist training posts, and to extend and encourage pro-coordination reforms between health levels and sectors.
As regards training in MFyC in the degree, the “Area of Knowledge” must be achieved as well as the inclusion of MFyC Senior Lecturers and Professors to teach MFyC as an specific subject but also as an integrated subject into human clinical training, into social medicine, into ethics, into communication…, and as a preferential subject in practicals. As for specialist training, family doctors must play a key role in core subjects. It must be followed by more in-depth specialist training in MFyC, achieving higher levels of solidness in the competence of our family doctors, and continuing and individualised professional development, with re-accreditation systems that will ensure that competence is maintained.
Research should clearly be promoted in PC. Its academic prestige is not just linked to sound training but also to its ability to generate knowledge. Its position in the system is privileged for health research, management and training, and also, to continue producing evidence in our country of its own effectiveness and efficiency as a central function of the health system.
Key points- •
The appraisal of Primary Care and Family and Community Medicine must be a clear and fundamental aim for Ministries of Health and Social Policy, Ministry of Education and Autonomous Communities.
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Primary Care must be “empowered”: to transfer power to Primary Care in the health system by means of sufficient funding, with decision, organisation and resolution capacity.
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Family and Community Medicine must have a fundamental role in degree training and as a core subject.
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Research must be stimulated as a means of making the intrinsic value of Primary Care and Family and Community Medicine visible and as a key tool for scientific and academic prestige.
