Dr Iva Petricusic - Rural Health in Croatia

 Dr Iva Petricusic is a rural family doctor form Croatia. She is the vice chair of the young doctor committee of the Croatian Medical Chamber and a coordinating member of EUROPREV.   Episode summary: 01.15  Iva tells us about her professional background and how she became interested in rural health 03.15  What does she most enjoy about living and working in a rural area?  What is most challenging? 07.45  What are the characteristics of the place and community where she works? 13.00  How is primary care organized in Croatia?   17.15  How is family medicine training organized in Croatia? 20.45  What are some of the challenges facing rural communities in Croatia? 26.10  What has changed to improve recruitment and retention into family medicine? 33.00  What would be needed to improve recruitment and retention in Croatia and on the islands? 38.45  What are the challenges faced by doctors thinking about going into rural careers in the European context?   Key messages: She would recommend that everyone try living in a rural area to understand the context. Rural areas have a slower pace of living and as a doctor you have multiple roles in the community. As a doctor in the village you are involved with many parts of the patient's life. This can be challenging as you can feel like you are more responsible for them and their health.   She often finds herself in situations for which she was not prepared for during her medical training or residency.   There are three general practitioners and two pharmacies serving a population of about 5000 people.  They also provide care to several nursing homes. Outside of her village there are many places that have been without a doctor for years, they have not had proper medical care, sometimes doctors would be there for a few hours every day or every other day.  Young doctors are often placed in such communities and this is very demanding. Local community supported her in getting the supplies that she needed to work but was not available when she arrived.   It is difficult to find healthcare workers and attract them to the local region. Not many young doctors decide to stay. Many GPs are retiring.  There are 2173 doctors in family medicine in Croatia and the average age is 52 years, of which 858 of those are above the age of 60.  It is difficult to find replacements. Slavonia was affected by the war.  There are areas that have been abandoned and have difficulty maintaining even a nurse in their community.   Croatia has primary care divided into three levels: family medicine, primary pediatrics and primary gynaecology, and it includes dentistry.  Primary care is also divided into private and public sectors.  However private is not really private, it means that the national insurance company directly has agreements with the doctors working there.  In the public sector the national insurance provider has an agreement with the employer that doctors work with.  Everyone works for the public sector, but they are paid differently and from the same source. After finishing medical school and internship in Croatia you can work as a GP, in the emergency department or as a prehospital doctor (with the ambulance service).    It is suggested but not obligatory to have specialist training in family medicine.  Around 1000 of the current family doctors have completed specialty training.   The residency program lasts four years, 22 months are spent with a mentor in family medicine practice and 18 months in hospital rotations.   There are no rural training pathways in family medicine residency. In undergraduate training there is a requirement to spend 1 week in rural practice.   An aging population with multiple comorbidities and complex health needs is becoming more of a challenge.   Poor transport infrastructure makes it very difficult for patients to attend secondary care appointments or attend diagnostic tests.   Not all villages have an accessible pharmacy, sometimes this means having to organize the medication for a patient to be collected by a nurse, friend or family member who can travel 20km to the pharmacy. Certain tertiary care is only available in Zagreb, 300 km away.  This can prolong the time between when a need is identified and a patient receives care.  District nurses are important members of the team who can support patient care and share important information about what is happening with patients in the community. Most of the current residency programs in family medicine are funded by the European Union.  At present there are about 300 residents in training in Croatia.  This is still not enough to compensate for the colleagues that are expected to retire. More local municipalities are recruiting young doctors, such as Istra, they invested funds in this.  Local municipalities are looking at how to attract doctors, they offer places in kindergarten for children (childcare is difficult in urban areas), free accommodation, and other privileges.  Tourist areas are not attractive to doctors in Croatia due to the extra pressures during tourist season. The number of patients per doctor can grow to 5000 or 6000. Supporting specialist interests for GPs is seen as an attractive opportunity that could support rural practice in Croatia. Housing is a challenge in rural and island communities. Healthcare facilities need investment in equipment and facilities.   Croatia has created a Doctor Atlas which provides up to date information on the health workforce.  The data is updated daily.  Family medicine is something that you either like or don't like, it is different to other medical specialties.     Thank you for listening to the Rural Road to Health! Rural Health Compass