Last year, an (Estonian Qualifications Agency) OSKA study focused on family medicine was published. The study came to a sobering conclusion: the current family doctor system cannot be sustained with the existing supply of qualified labor.

As part of the study, a projection was made showing that, in order to maintain the current number of family doctors, 50 new doctors would need to enter the healthcare system each year starting in 2028.

For comparison, according to the National Institute for Health Development, there were 4,772 doctors in Estonia in 2023, of whom 939 — or 19.7 percent — were family doctors. While the overall number of doctors in Estonia has increased in recent years, the number of family doctors has declined.

To reduce the shortfall, the Ministry of Social Affairs increased admissions to the family medicine residency program in 2022. Whereas previously 35 residents were accepted annually, in recent years the number has been raised to 40, making it the medical field with the highest intake. However, these slots are still not being filled.

Last year, 33 doctors entered the family medicine residency program, the year before, 36 and in 2022, it was 29.

"The current residency system simply cannot meet the demand. Is it even realistic to expect more than 50 family medicine residents at a time? I don't know," said Marta Velgan.

Another concern across the European Union is the aging population of family doctors. In 2023, the average age of family doctors in Estonia was 56 — six years older than the national average for doctors.

Notably, the number of family doctors over the age of 65 has nearly doubled over the past decade. "This means the situation could become quite difficult in the near future. We're talking about a large number of family doctors reaching retirement age soon," Velgan said.

Velgan noted that problems aren't limited to family medicine — other sectors of the healthcare system are also struggling. "But when primary care falters, the entire healthcare system begins to falter. Even if a patient can't go anywhere else, they still turn to their family doctor. I worry about the future too," she explained, emphasizing why the issue must be taken seriously.

Similar problems

Marta Velgan's doctoral dissertation consists of three studies. One focused on how students choose their medical specialty in three countries — Estonia, Belgium and Hungary. The second examined the career paths of newly qualified family doctors and the third looked at the emigration of family doctors.

All three studies revealed largely similar factors. "You can't really say that the factors influencing students' choice of specialty and those affecting doctor emigration are all that different," Velgan said.

The research found that an increasing number of people want a specialty that allows for a balance between work and personal life. "When that balance isn't achieved, people often start looking for better options. This trend is evident in how students choose their specialties and in the career goals of new family doctors. It's also a key reason why some family doctors decide to work in another country," Velgan explained.

At the same time, many view family medicine as one of the few specialties where achieving that balance is more feasible. "Continuity of care is also seen as a positive. Family doctors build long-term relationships with their patients, deal with a range of health concerns and can offer strong support in patients' health-related decisions. That relationship with people is what many consider the most important aspect of family medicine," Velgan noted.

More broadly, attention must be paid to the working conditions of family doctors and what kinds of work environments young, emerging doctors expect. Participants in the study emphasized the importance of feeling needed and valued. "It's also important to feel that things are moving in a positive direction. If there's a vision for how family doctors should work, there also needs to be evidence that progress is being made. People often become disillusioned with the system, which pushes them to seek other options," Velgan said.

A key issue she highlighted was the need to reduce bureaucracy — something that often affects both the process of establishing family medicine practices and adding patients to practice lists.

"Working conditions must improve so that less time is spent on paperwork and more time can be devoted to real people and their concerns," Velgan said.

She also investigated more specifically why some family doctors leave Estonia to work abroad.

"I don't think Estonia is in the worst shape, but we can't rest on our laurels. If conditions worsen, emigration could increase. Considering how small our country is and how much it costs to train doctors, we simply can't afford to lose a single one," Velgan stated. Therefore, the state must invest in ensuring that anyone even slightly interested in staying and working as a family doctor in Estonia is supported in doing so.

Although it's often assumed that salary is the main reason doctors leave the country, Velgan's dissertation found that this is not the case.

"Money is often seen as a bonus that people recognize only after they've already relocated, but it's rarely the main reason they go," she said.

Velgan believes that for those family doctors who have already moved abroad, returning should be made significantly easier if they ever wish to come back. In this regard, doctors cited a number of barriers, both within the healthcare system and more broadly within the country. Reducing these barriers could boost interest in the specialty, according to Velgan.

"Although one would expect that medical qualifications are recognized across all EU countries, this isn't always the case. For instance, if someone earns their degree in family medicine in Sweden and wants to return to Estonia, that already becomes a hurdle. Often, there's no clear information on where to turn or who to contact. When it comes to recognition of qualifications and support in starting work, there's no solid understanding of how the system should function," she explained.

According to Velgan, the shortage of family doctors is a complex issue without a single clear cause. "If we want to have enough doctors in any given field, we first need students to be genuinely interested in that field and choose it when they graduate from medical school," she said.

She also admitted that she had underestimated the influence of role models in students' choice of specialty. If a student had a role model who was a family doctor, that significantly increased the likelihood of choosing that field.

In international comparison, Belgian students stood out as choosing family medicine as their specialty much more frequently than their peers in Estonia or Hungary.

Velgan said the reasons for this can only be speculated on. "It's likely that family doctors in Belgium have better salaries and that there are significantly more family doctors per capita than in Estonia or Hungary," she said. In Hungary, the family doctor community is relatively small overall. In Belgium, family medicine as a discipline is also considerably older than it is in Estonia or Hungary, which may also affect its standing within the healthcare system.

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