Thirty years of family medicine specialty in Poland: a case study of its institutionalization, practice, and patient perception within primary healthcare

Background: Family medicine (FM) specialty in Poland was introduced in the early 1990s as part of broader health reforms aimed at restructuring primary healthcare (PHC) and improving access, continuity, and coordination of care. Despite three decades of development, FM continues to face systemic and professional challenges within the Polish healthcare system.

Objective: This study used a case study approach to explore the evolution of family medicine specialty in Poland, examining its institutional foundation, specialist training, its role in PHC delivery, and patient satisfaction with services.

Methods: An explanatory case study design was employed, drawing on policy documents, training curricula, peer-reviewed literature, and national statistics. Thematic analysis was guided by a framework for case study evaluation in healthcare systems.

Results: Family medicine specialty has gained full recognition as a clinical and academic specialty in Poland. However, only a minority of PHC physicians are formally trained in FM. While the postgraduate training program aligns with European standards, it lacks longitudinal assessment and consistent quality of supervision. Patients report generally high satisfaction with interpersonal aspects of care but rate family medicine lower than specialist services in areas such as communication, empathy, and emotional support. The specialty also faces recruitment difficulties, with many FM residency slots unfilled despite financial incentives.

Conclusion: Family medicine specialty in Poland has achieved significant structural milestones but remains underutilized and undervalued within the broader PHC system. Reforms should prioritize strengthening its educational pathways, improving working conditions, and addressing public perceptions. Enhancing communication skills and increasing the visibility of family physicians could improve both patient satisfaction and the attractiveness of the specialty.

INTRODUCTION

Family medicine (FM) is a distinct medical specialty that provides comprehensive and continuous healthcare to individuals and families addressing multiple levels of health system needs. According to the definition developed by the World Organization of Family Doctors (WONCA), family medicine is “an academic and scientific discipline, with its own educational content, research, evidence base and clinical activity, and a clinical specialty oriented to primary care (PHC)”. It responds to growing demands for first-contact care, chronic disease management, preventive services, and coordination of increasingly complex patient pathways [1].

From the perspective of occupational classification, the International Standard Classification of Occupations (ISCO-08) identifies generalist medical practitioners, including family doctors, under code  2211. These professionals “diagnose, treat and prevent illness, disease, injury and other physical and mental impairments in humans through the application of modern medicine” and typically work in settings that ensure continuity and comprehensiveness of care [2]. Family physicians serve as the first point of contact for patients within the healthcare system and are responsible for addressing undifferentiated problems at an early stage, ensuring continuity of care, coordinating referrals, and providing person-centered and community-oriented services. European Union directives such as Directive 2005/36/EC and its amendment Directive 2013/55/EU establish the requirements for medical specialization in FM [3],[4]. These include a minimum of three years of structured training (including both hospital and ambulatory care experience), and the acquisition of core competencies such as independent clinical decision-making, communication skills, interdisciplinary collaboration, and ethical medical practice. WONCA Europe outlines eleven key characteristics of the discipline, which are operationalized into six core competencies: primary care management, person-centered care, specific problem-solving skills, a comprehensive approach, community orientation, and a holistic view of the patient [1].

While FM is widely recognized as a clinical specialty in most European health systems, its academic foundation have developed more unevenly across Central and Eastern Europe (CEE). Academic FM refers not only to the inclusion of the discipline in teaching curricula but also to its institutionalization in university structures, the conduct of research, and the presence of dedicated scientific organizations [5],[6]. From a methodological standpoint, FM holds a unique position among medical disciplines. It integrates biomedical, behavioral, and social science approaches to understand and manage patient care in the context of families and communities. This includes population-level awareness, longterm care, preventive interventions, and a holistic perspective on illness [6]. Following the political transformations of the 1980s/1990s, many post-communist countries initiated reforms that sought to establish FM both as a practical model for PHC delivery and as a distinct academic discipline. In almost all CEE countries, departments of FM were created within medical faculties, and undergraduate and postgraduate curricula were updated accordingly [5].

In Poland, FM was formally introduced in the early 1990s, following the socio-political transition after the fall of communism. The origins of FM in Poland can be traced to a meeting on 23rd June 1992, when thirty-four physicians convened to establishThe College of Family Physicians in Poland (KLRwP, pol. Kolegium Lekarzy Rodzinnych w Polsce)  as a strategy-promoting institution for the integration of family doctors into the public health system [7],[8],[9]. Polish FM, modeled on PHC systems in the UK and the Netherlands, gradually replaced the former polyclinic model. Prior to this process, access to care was often inequitable, dominated by urban clinical centres and burdened by corrupt practices that disadvantaged provincial patients [9]. Throughout the 1990s, the KLRwP galvanized efforts to develop FM as a recognized medical specialty. By 1996, after a year-long evaluation, the KLRwP achieved full membership in the WONCA. In 1999, further advancement was achieved through the creation of the Polish Society of FM (PTMR, pol. Polskie Towarzystwo Medycyny Rodzinnej) [10]. The PTMR has since led development of training curricula, postgraduate education, peer-reviewed publications such as the Lekarz POZ (eng. PHC Doctor) journal [11], and fostering professional identity within the discipline. By its 25th anniversary in 2017, the specialty had gained increasing recognition from policymakers as both cost-effective and indispensable within the framework of primary healthcare. This also marked the structural transformation from a previously fragmented and urban-centric model to a more modern, accessible, and community-oriented system, centered around family physicians’ practices modelled after Western European systems [9]. In 2022, as the discipline celebrated its 30th anniversary, the report concluded that FM remained the most trusted and positively rated sector within Polish healthcare [8]. Over three decades, FM has matured into a recognized specialty and academic field, shaping PHC and influencing health policy at the national level.

The study aimed to describe FM specialty in Poland using a case study approach and identify its strengths and challenges in the national context.

METHODS

This study was conducted using an explanatory case study design, as described by Crowe et al. to investigate the development, implementation, and current functioning of FM within the PHC system in Poland [12]. The case study approach was chosen due to its suitability for exploring complex, real-world phenomena within their specific policy and institutional contexts. This study relied exclusively on secondary data sources (policy documents, training curricula, statistical reports, and peer-reviewed literature). As such, findings should be understood as interpretive and descriptive rather than empirically measured.

Case Selection and Boundaries

The unit of analysis was the national PHC system in Poland, with particular emphasis on the role and institutionalization of FM since its formal recognition as a medical specialty. The temporal scope covered the period from the introduction of FM in the early 1990s to the most recent policy developments as of 2024.

Data Sources

Data were collected from a variety of publicly available sources including: peer-reviewed literature on FM and PHC in Poland and Europe; national legislation and policy documents issued by the Ministry of Health and National Health Fund; postgraduate training program curricula and regulations; statistical reports from professional organizations and governmental databases; grey literature, including position papers and expert commentary from Polish medical associations. No primary data collection was conducted.

Data Analysis

The data were synthesized using quasi-qualitative narrative synthesis, guided by the framework proposed by Crowe et al. [12]. This approach emphasized the interpretive identification of contextual factors, system structure, and policy shaping the FM within Polish PHC. As the study relied exclusively on secondary sources, no formal coding procedure was applied. Key themes were iteratively developed and interpreted in relation to existing international models and recommendations for FM.

RESULTS

Family Medicine and Primary Healthcare in Poland

In Poland, FM plays a central role in the structure of PHC, which forms the foundation of the national health system. PHC services are delivered through a broad network of outpatient clinics and are primarily financed through capitation-based contracts with the National Health Fund (NFZ; pol. Narodowy Fundusz Zdrowia). Family physicians, alongside specialists in internal medicine and pediatrics, are authorized to provide comprehensive PHC services. Eligibility for full practice as a PHC provider includes holding a specialization in FM or being enrolled in FM training. In addition, internists and pediatricians may qualify if they complete a mandatory FM-specific training course. However, only physicians with recognized eligibility are permitted to collect patient declarations - a key mechanism for securing funding under the capitation model, leading to financial and organizational consequences for PHC practices. As of 2023, only approximately 9,000 out of 36,000 physicians working in PHC held a specialization in family medicine and actively practiced in public outpatient settings [13]. The majority of PHC providers continue to be internists and pediatricians. In this context, while FM is conceptually aligned with the goals of PHC, it is not yet fully established as the primary professional identity within the system [14].

Postgraduate Training in Family Medicine in Poland

The postgraduate training program in FM in Poland is a structured, competency-based residency designed to prepare physicians for independent practice within the primary healthcare system [15]. It is regulated by the Ministry of Health and aligned with national legislation on specialist training (Regulation of the Minister of Health of 4^th May 2023 on the specialization of physicians and dentists, Journal of Laws 2023, item 975). The standard duration of the program is four years (48 months), combining clinical rotations, supervised practice, theoretical instruction, and mandatory certification courses. The program begins with a onemonth introductory module covering the fundamentals of FM, the structure of the Polish healthcare system, and legal regulations relevant to medical practice. Following this, residents complete a series of  clinical rotations across key specialties that reflect the scope of family practice. These include internal medicine (6 months), pediatrics (4 months), obstetrics and gynecology (2 months), psychiatry (2 months), dermatology (1 month), otolaryngology and ophthalmology (1 month, combined), emergency medicine (3 months), and a 2-month combined rotation in geriatrics, rehabilitation, and palliative care. A central component of the training consists of at least  18 months of supervised practice in accredited FM clinic. During this period, residents gain experience in delivering continuous, patient-centered care across all age groups and conditions. The training emphasizes prevention, early diagnosis, management of chronic diseases, health promotion, and coordination of care within the health system. The program includes a minimum of 320 hours of theoretical instruction, covering topics such as communication skills, clinical reasoning, public health, ethics, and evidence-based practice. Trainees are also required to complete certified life support courses, including Basic Life Support (BLS) and Advanced Life Support (ALS). The program ends with a national specialization examination (PES, pol. Państwowy Egzamin Specjalizacyjny), which assesses medical knowledge, clinical judgment, and readiness for autonomous practice as a family physician. Although the Polish specialization program does not explicitly refer to international frameworks such as those developed by WONCA Europe, it aligns closely with the European Union’s Directive 2005/36/ EC (as amended by Directive 2013/55/EU), which outlines formal requirements for postgraduate training in general medical practice. In practical terms, the Polish curriculum covers the domains specified in WONCA’s six core competencies. However, when compared to postgraduate FM training systems in other European countries, certain areas for improvement in the Polish program become apparent [16]. Notably, while the training is formally competency-based, it lacks a structured system of longitudinal assessment that monitors the resident’s progress throughout the entire program. Unlike in countries such as the United Kingdom and the Netherlands, where trainees undergo continuous evaluation through workplace-based assessments, structured feedback, and the use of electronic portfolios, the Polish system relies primarily on a PES [15]. There is also limited use of validated tools to assess clinical skills, communication, and professional behavior. Furthermore, participation in trainer development programs is not mandatory, which may contribute to variability in the quality of supervision and feedback during training [16].

Challenges Facing Family Medicine in the Polish Primary Healthcare System

Despite more than three decades of family medicine serving as a cornerstone of primary healthcare in Poland, the discipline continues to face workforce, PR, and policy-related challenges [14]. One of the most pressing concerns is the chronic shortage and unequal distribution of primary care physicians. While Poland’s public spending on primary healthcare is among the highest in the Organization for Economic Cooperation and Development (OECD) (17% compared to the OECD25 average of 13%), the country still lags in physician density, with only 3.4 doctors per 1,000 population. Of particular concern is the extremely low proportion of general practitioners - only 8% of all doctors in Poland, as compared to the OECD33 average of 23% [17].

The attractiveness of FM as a specialty varies significantly across countries, shaped by systemic, educational, and personal factors. International studies emphasize that personal lifestyle considerations, such as work-life balance, fewer night and weekend shifts, and the ability to spend more time with family are among the most influential reasons for choosing FM [14],[18],[19],[20],[21]. Concerns that deter young doctors from choosing FM include a lack of prestige, high administrative burden, patient demands for unnecessary reports or prescriptions, and insufficient opportunities for subspecialization. Moreover, the presence of positive role models and the integration of FM into the undergraduate curriculum are reported to be decisive in shaping attitudes toward the discipline [18],[19],[20]. In Poland, similar dynamics are observed. A multicenter cross-sectional study involving over 2,000 medical students from five universities found that interest in FM increases during the course of medical education - from 17% in the first year to 30% in the sixth, indicating the positive impact of clinical exposure [20]. The most influential factor for choosing FM was the opportunity for professional development, followed by intellectual challenge and a favorable work-life balance. However, students who rejected FM cited limited opportunities to work in hospital settings, perceived bureaucratic burdens, and a lack of flexibility in switching specialties. These findings suggest that to enhance the appeal of FM in Poland, reforms should focus on increasing its presence in undergraduate curricula, improving the visibility and perceived status of FM, and offering structural incentives during postgraduate training.

Although admissions to medical programs have reached record highs - over 10,000 students in the 2024/2025 academic year, many FM residency positions remain unfilled. A key reason might be the persistently low prestige of FM among students, often reinforced by negative perceptions during training. Extra financial incentives were introduced in 2023, including higher base salaries for priority specialties such as FM. These measures represent a step forward, yet they have not led to significant improvements in recruitment. Given the long pathway from medical school to independent practice, such measures alone are unlikely to yield prompt results. Crucially, efforts to enhance the attractiveness of FM are hindered by a lack of systematic data on medical career preferences and the real-world impact of incentive programs [14].

Satisfaction of patients with primary healthcare services

In the Polish healthcare system, family physicians are a core component of PHC, working alongside internists and pediatricians to provide comprehensive first-contact care. However, the current organizational and reporting structures do not distinguish between these provider groups in service delivery or evaluation. As a result, most available data on patient satisfaction refer broadly to PHC services as a whole, without isolating experiences specific to FM. This structural limitation makes it difficult to assess the distinct contribution of family physicians to patient satisfaction. Therefore, this section focuses on general patient satisfaction within PHC, recognizing that the findings reflect the shared performance of all eligible providers, including those trained in family medicine.

According to the Quality and Costs of Primary Care in Europe (QUALICOPC) study, Polish patients generally report positive experiences with PHC services, especially in the domains of quality of care and patient-doctor communication [22]. The highest satisfaction was associated with interpersonal aspects of care - patients valued clear explanations, attentive listening, and the physician’s ability to show empathy. Notably, the met expectation index (MEI) for quality of care was the highest among evaluated domains, followed by equity, continuity, and accessibility. Despite accessibility being ranked as the most important attribute by patients, it also showed the greatest potential for improvement, highlighting systemic shortcomings in timely and convenient access to services. The study revealed a mismatch between patient preferences and experiences in areas such as involvement in decision-making and the opportunity to discuss psychosocial concerns during consultations. Overall, the findings emphasize the importance of continued investment in communication skills training and patient-centered approaches for PHC physicians. Polish patients’ satisfaction with family doctors seems to be primarily shaped by the quality of interpersonal interactions, rather than technical competencies or contextual factors alone [23]. Expressions of dissatisfaction were more often linked to contextual aspects of care, such as waiting times or access barriers, whereas positive feedback focused on physicians’ personal qualities and communication style. These patterns are substantiated by another analysis from the Polish arm of the QUALICOPC project, which explored both patient and physician perspectives on PHC services [24]. Consistent with later findings [22], the study confirmed that patients reported the highest satisfaction in domains related to interpersonal aspects of care, particularly quality and equity, while highlighting accessibility as an area needing improvement. Importantly, the study also identified that longer consultation times, rural practice settings, and greater physician experience were positively associated with patient satisfaction, reinforcing the significance of time investment and relational continuity in shaping patients’ experiences. Although patients rated core elements of care delivery positively, physicians expressed more critical views, especially regarding care coordination and comprehensiveness, suggesting a systemic disconnect between patient-reported satisfaction and provider-perceived performance.

Other studies have similarly emphasized the central role of interpersonal factors, such as empathy, active listening, and clear communication in shaping patient satisfaction across levels of care [25],[26]. While Polish patients generally report satisfactory experiences with PHC services, notable differences remain when compared to specialist ambulatory care [25]. As demonstrated in a recent large-scale web-based cross-sectional study, patients rated PHC consultations less favorably in domains related to emotional support, clarity of communication, and physician engagement. FM doctors were often perceived as providing less detailed explanations, showing limited concern for patients’ broader well-being, and offering fewer opportunities to discuss psychological or coping-related concerns [25]. Findings from local studies conducted in small Polish communities also reinforce the role of interpersonal factors in shaping patient satisfaction within PHC [26]. In a comparative analysis of patient experiences in public and private PHC centers in the Lubelskie Voivodeship, trust in the physician, the accuracy of diagnosis, and the quality of patient-staff interactions were strongly associated with continued use of services. Older patients, in particular, emphasized the importance of kindness, compassion, and attentiveness, not only from doctors but also from nurses, highlighting the relational nature of satisfactory care. The study further confirmed that negative perceptions were often linked to poor communication, lack of information about treatment progress, or feelings of being disregarded by medical personnel. Importantly, differences in patient satisfaction were not primarily attributed to the public or private nature of the healthcare provider, but rather to perceived accessibility, infrastructure quality, and interpersonal relationships. This aligns with previous research indicating that satisfaction is driven less by the technical or administrative structure of care and more by the patient’s personal experience during the consultation [22],[24].

CONCLUSION

FM has operated as a recognized specialty in the Polish healthcare system since the early 1990s, contributing to the transformation of PHC from a fragmented and hospital-centric model to a more accessible, community-oriented structure. Despite these achievements, the number of family physicians remains disproportionately low within the PHC system. The case study identified several strengths of the current FM model in Poland, including its formal institutionalization, alignment with European training standards, and the high level of patient trust associated with interpersonal aspects of care. However, persistent challenges include workforce shortages, the limited attractiveness of the specialty among medical graduates, inconsistencies in postgraduate training quality. To ensure the longterm sustainability and effectiveness of FM in Poland, targeted reforms are needed. These include improving the quality and visibility of FM training, integrating family medicine more fully into undergraduate education, promoting its professional identity, and addressing barriers to recruitment and retention. Importantly, efforts to strengthen family medicine should not only be policy-driven but also informed by the lived experiences of both providers and patients within the PHC system.