Family medicine as a point of tension: what hinders the development of a critically important link
On May 19, the world and Ukrainian medical community celebrates the professional holiday of family doctors. In Ukrainian dispensaries, they work at the limit of endurance — without support, with bureaucratic burdens and, increasingly, without a sense of meaning. Formally, primary health care is the basis of the system: it is the family doctor who should become the first and main medical contact person for the patient. But in reality, he is an overworked specialist who manages more than a thousand patients, an administrator, a social worker and a dispatcher. The situation is even worse in villages, where there is only one available medical worker for several settlements. The lack of young personnel, the devaluation of the profession, the superficial reform that changed the funding model, but did not change salaries — all this makes the system of family medicine extremely vulnerable.
Why family doctors do not need bouquets, but support
Every year on May 19, the world celebrates the professional holiday of family doctors. This recognition of the role of those who provide continuity of care sees a person not as a set of diagnoses, but as a whole system with family, life, habits and fears. In Ukraine, where everyone has the right to choose their doctor, this holiday takes on a special meaning. In theory, it is the family doctor who should monitor the health of the whole family, know not only about diseases, but also about risks, heredity, habits and living conditions. According to international standards, this medical unit is based on the principles of long-term supervision, interdisciplinarity, prevention and coordination of care. A family doctor does not just prescribe tests, but evaluates the dynamics of health across generations. Its purpose is not to combat the consequences, but to predict and prevent them.
In reality, a Ukrainian family doctor daily balances between profession and bureaucracy, between responsibilities and resources, between patient expectations and system limitations. Family medicine in Ukraine is supported by the enthusiasm of those who continue to work, despite constant overloads and an imperfect system. State today, 2,541 primary care providers have a contract with the National Health Service, which includes more than 23,000 family doctors, pediatricians, and therapists. They receive patients in more than 7,000 locations across the country.
The average workload per doctor is 1,249 patients. This seems acceptable until you remember that for many it is just a number on paper. While every fifth doctor exceeds the optimal limit, working with overload, which has long become the norm. And although the total number of doctors does not decrease, and some of those who leave still return, the system does not receive oxygen, but survives in a mode of saving people and resources.
Level satisfaction of Ukrainians (79%) with the work of family doctors is gradually increasing. This is confirmed by the results of the independent study “Health Index”. At the same time, another reality is becoming increasingly apparent in the medical environment. More and more doctors themselves are openly talking about frustration and exhaustion.
The position of primary care is not just difficult, it has long crossed the line of anxiety. According to various sources, more than 70% of family doctors experience professional burnout. The main reasons have long been known. It is about an excessive number of patients, a lack of support, unclearly defined responsibilities, as well as constant pressure from both the system, and patients, and colleagues from other medical levels.
One of the most painful points is the lack of clear demarcation of functions. Primary care physicians are often forced to perform tasks that should belong to the duties of narrowly specialized specialists. For example, for hospitalization or receiving benefits, a family medicine doctor must not only collect anamnesis, but also fill out all the documents that should be drawn up by specialists. Although officially it is not his area of responsibility, in practice it is the family doctor that all the participants in the process turn to.
A similar situation is observed with the new EKOPFO system, which should simplify the registration of disability. According to the regulations, the medical opinion must be filled out by a specialized doctor. However, many specialists refuse to do this, citing excessive workload and lack of time. As a result, patients return to the family doctor with the demand to “do everything”, and he again finds himself in a situation where he has to perform work that formally does not belong to him.
Doctors talk about a systemic problem. On paper, the primary care reform looks logical and correct, but in practice it turned out to be skewed. On the one hand, family doctors are assigned many tasks, on the other hand, they have not received real powers or support. It turns out that the person who was supposed to be the key aid coordinator has become a temporary solution to all the problems that no one else wants to deal with.
Family medicine in Ukraine, which was meant to be the basis of a modern and accessible health care system, in practice turned out to be its most vulnerable link. This is especially clearly felt in villages and small towns, where first contact doctors were not simply left without systemic support — they found themselves in isolation, without resources, without protection and without prospects. The main response of the state to this is silence, and the main strategy is to shift the responsibility onto the shoulders of one doctor.
The primary link of medicine in Ukraine has long been functioning not according to the logic of reform, but according to the logic of survival. Formally, the patient has a declaration with the family doctor. In reality, a doctor treats more than two thousand patients, simultaneously receives, goes on calls, makes referrals, reports in the electronic system and tries to explain to at least someone that he is not a registrar and not a dispatcher. In many rural dispensaries, the doctor was left alone, without a nurse, without a driver, without elementary support. He is entrusted with functions that no model of Western family medicine could withstand.
The “all-in-one” format is not multifunctionality, but a banal replacement of the system by a person. The situation is especially critical in district centers and villages, where the distance between settlements reaches dozens of kilometers, roads are often unusable, and challenges increase many times during periods of seasonal morbidity. In many regions, the entire community has one car, often a personal one. Some of the doctors have reached retirement age, but cannot resign – there is no one to transfer their practice to.
A big problem is the lack of support for young doctors. Even when graduates of medical universities are ready to go to work, they do not have housing, proper working conditions, legal guarantees and personnel support. Receiving a salary of 15,000-17,000 hryvnias, young people cannot endure rural life. There, where the doctor is offered to work at the FAP, and the house is 15 km away, without a road, the doctor will not stay. Therefore, the primordial either ages or disappears. Young people do not go to work in the village, because the rate in the village without infrastructure, housing and support is not motivation, but a sentence.
A separate problem is the workload, which does not correlate with either the pay or the opportunities. A family doctor must conduct outpatient appointments, go on calls, work with chronic patients, issue sick leave, vaccinations, referrals, social certificates, electronic prescriptions, registration in eHealth, communication with the National Health Service. Every day – up to 40 patients at the reception, not counting phone calls. In conditions of a shortage of specialists, this leads to chronic burnout, and most importantly, low quality of work.
That is why patients have little faith in family doctors. Due to overload, rush and lack of time for communication, people perceive doctors as officials from medicine and not as partners in health. They don’t understand why the doctor can’t “prescribe” anything, why he doesn’t give a CT scan or prescribe “something serious” like he used to. Often, the family doctor is transformed into a “pass-through” between the patient and a narrow specialist, without authority and even space for real medical work.
Local self-government, which after decentralization received the authority to manage dispensaries, often does not understand the specifics of medical work. When the community controls the funding and has no professional advisor in the field of medicine, repairs overlap salaries and administrative decisions are not based on the needs of patients or doctors. In some communities, dispensaries do not have basic facilities such as a laboratory, a refrigerator for vaccines, an X-ray machine, and sometimes even water supply.
Diagnosis at the primary care level also remains weak. Legislation provides for a wide list of examinations that must be provided by state funds. But in practice, there is no clear scheme of implementation — neither implementation control, nor stable financing. The system of monitoring the quality of doctors’ work has not yet been fully launched.
As a result, we have a model that is officially declared reformed, but in reality is disoriented, fragmented and often paralyzed. However, despite everything, the reform remains a chance to build an effective model of medical care. But its success depends not only on declarations, but on the practical cooperation of all participants in the process – the state, medical professionals, local self-government and the patient community.
How family medicine appeared
Family medicine is not a new invention – for centuries most doctors have been generalists. In ancient Rome, wealthy families had a medical slave in their home, responsible for the health of the entire family. This model of general medical practice existed until medicine began to actively break down into specializations.
In the 19th century within the Russian Empire, after the abolition of serfdom, zemstvo doctors relied on medical care for the population. They serviced gigantic territories, often saw over a hundred patients a day, and worked in conditions that required not only knowledge but real endurance. They combined the functions of therapists, surgeons, obstetricians and even epidemiologists.
In the USA, family medicine was the main field of practice until the middle of the 20th century. However, with the development of science, most doctors began to specialize narrowly, which led to the crisis of general practice. Specialists became more prestigious, received higher salaries, and family doctors began to lose ground. This had serious consequences, because the integrity of medical support was lost, which forced the state to reconsider its approach. In the 1960s, the need to rebalance was officially recognized. This is how the specialty “family practice” appeared in the USA, and in 1969 – the American Committee on General Practice. The role of the family doctor was returned to the system level, emphasizing long-term support of patients and disease prevention.
The Soviet approach to primary care was based on the precinct model. General practitioners mostly referred patients to specialized specialists, rarely having the opportunity to manage patients comprehensively. However, they came directly to the sick in their districts, providing primary care and consultation, which was very convenient, especially for the elderly and people with disabilities.
The Ukrainian path to modern family medicine began in 1987 with an attempt to change the district model in Lviv. There, therapists and pediatricians were gradually transferred to a new service format. The first temporary instructions appeared, and since 1990, an internship for the training of general practitioners. In 1992, the first family outpatient clinic was opened in the city of Drohobych, and already in the mid-90s, the Ministry of Health officially recognized the specialty “family medicine”. In 2000, a government resolution was issued on the systematic introduction of family medicine in Ukraine. In 2018, the “Doctor for every family” campaign was launched, which gave every Ukrainian the opportunity to independently choose a family doctor and sign a declaration with him.
Today, when in many countries of the world the role of a family doctor is considered strategic, May 19 World Day symbolizes more than just professional recognition. It is an annual reminder that an effective health care system does not start with the hospital, but with trust in the doctor, who should know his patient by more than just a medical record number.
Family medicine abroad: an experience worth learning
Family medicine is a key link in modern healthcare systems around the world. In many countries of the world, it is the general practitioner who is the central figure in the daily medical care of the population. In contrast to Ukrainian realities, where the primary care often exists on the verge of exhaustion, foreign practice demonstrates an approach with a clear division of functions, financial stability, organizational support and trust of patients.
In the British model of health care, the family doctor (GP) is the mandatory starting point for every patient. You cannot get to a narrow specialist without his referral. The principle of “gatekeeper” (from the English “input control” – ed.) allows you to effectively manage the resources of the NHS system and minimize unnecessary costs. Physician remuneration consists of a rate, practice funding, as well as bonuses for achievements in the field of prevention, management of chronic diseases and compliance with quality standards.
In Germany, the patient independently chooses a doctor and concludes an agreement with him through a health insurance company. Such a doctor not only serves, but also coordinates all further medical care. The financial model is based on payment for each service provided by insurance funds, as well as additional rewards for preventive work and successful management of patients with chronic diseases. The doctor is interested in the fact that the patient remains healthy, because this saves money and brings bonuses.
The Canadian model focuses on family practices with broad mandates. Family doctors can work in individual clinics or be part of an interdisciplinary team. The payment depends on the province and the form of work organization. It can be a fixed rate, payment for the number of patients, or a fee system for individual services. Additional payments are provided for preventive measures, vaccination, early diagnosis. In remote areas, the state supports doctors not only financially, but also provides housing, equipment, and logistical assistance.
The French patient also has his family doctor with whom he contracts. The state partially reimburses the cost of admission (about 70%), the rest is paid by the patient or additional insurance. The system provides that the patient will receive a full reimbursement of specialist expenses only if his doctor is available. This creates a close bond between the patient and the doctor. Remuneration depends on the number of appointments, compliance with treatment standards, participation in preventive programs and filling out electronic documentation.
Norway, Sweden and Denmark offer one of the most effective and loyal to the doctor systems. Each citizen is automatically assigned to a specific doctor. Practices have a clearly defined number of patients, which allows maintaining a high quality of service. The basis of financing is a fixed rate, which is supplemented by payments for preventive work, the implementation of planned programs and the provision of individual medical services. Much of the administrative work is taken over by digital systems and medical assistants, allowing the physician to focus on patients rather than reporting.
As we can see, the foreign experience of family medicine is an excellent example of how the effectiveness of this link depends on several key factors: stable funding, professional autonomy, motivation for prevention, reduction of workload due to digitalization, and the presence of clear quality standards. At the heart of a successful model is not declarative care for the doctor, but real tools for his full-fledged and decently paid work. These practices are not an unattainable ideal, but an example of systemic respect for primary care actually working.
Family medicine is considered the most rational way of organizing primary care for a reason. People rarely live alone. Not only the body is sick, but also life, lifestyle, habits, genes. When one doctor knows the medical history of several generations of the same family, it is not just convenient. Such an approach increases the chances of timely diagnosis and real treatment, rather than cosmetic embellishment of symptoms.
In many countries of the world, the family doctor has long been the basis of the health care system. There it is not a “therapist plus a pediatrician in his spare time”, but a trained specialist who knows how to keep his finger on the pulse of an entire household. In Ukraine, this direction is still undergoing a difficult transformation. Loud reforms launched in recent years gave a start, but did not guarantee results. Family medicine in our country is more like a draft, which the state has not yet dared to completely rewrite.
