EDITORIAL

"New core subjects" for specialised health care training. Are they necessary?

Una "nueva troncalidad" para la formación sanitaria especializada. ¿Es necesaria?

Arcadi Gual

Director de Educación Médica. E-mail: agual@ub.edu

When it was introduced back in the seventies, the system of specialised health care training currently used in Spain, based on residents (MIR, FIR, BIR, PIR), was a ground-breaking development that brought order to the area. At the same time, the specialists trained under this structure were acknowledged as being highly qualified and enjoyed a certain degree of prestige. The results of this specialist training system have been so good that nobody really dares to openly criticise it and I am certainly not going to be the first to do so. To the contrary, I will join those around the country who feel a kind of collective satisfaction for having such an excellent system of training for specialised professionals.

But time is unrelenting and what may have once been optimal later becomes far less so. And the system of specialised training has started to creak, not because it has got worse but because the world around it has evolved. The Spanish health care system now faces challenges that were undreamt of in the seventies. Then there was a surplus of physicians, but this is no longer the case. Then emigration predominated and now immigration prevails. Life expectancy was quite low and now we have one of the highest in Europe. In the past people could not voice their thoughts and now they are informed citizens who know and demand their rights.

So, in this new, distinct and fortunately better scenario, it should come as no surprise that something in specialist physicians' training needs changing too. The admission exam (or exams) that must be passed to be able to go onto specialised training is sure to be one of the issues that will have to be adapted to the new order of affairs (information and communication technologies, the needs of the Spanish National Health System, etc.), but that is not something we are going to deal with here. Another point, which we are not going to look at either, is that of assessment of both residents and also their tutors and the training system itself. And a third issue is the structure of the training plan - what have come to be known as core subjects.

In the current system, each specialty follows a specific training programme that it not linked with the programmes of other specialties. In other words, if you embark upon one specialty, there are no pathways running sideways or the chance to go back. The only solution open to you, if you want to change specialty, is to begin another one from scratch. If, over the years, the system of specialised training has been criticised from time to time, such remarks have invariably had to do with its rigidity, or perhaps it would sound better to say its lack of plasticity.

I used to hear residents complaining about the rigidity of the system years ago. If you choose a specialty and later you want to change, they said, you have to start all over again. Wouldn't it be possible to establish a common foundation? Today, they would speak of core competencies, but at that time the concept of competencies was not in use. But I have been hearing that same criticism about the lack of plasticity in the training system from heads of department, hospital administrators and management staff in general for the last 20 years. This system does little or nothing to help professionals retrain in another specialty!

I can assure you that there were resounding calls to replace the current system of 'one block of core subjects for each specialty' with another structure that included groups of competencies that were common to different specialties. This would make it possible to programme training periods that were common to several specialties.

From a purely technical point of view, the structure with periods that are common to different specialties is the one that best optimises the training period, the one that offers residents the best opportunities to plan their training and, if it were the case, the one that would allow them to change from one specialty to another most easily. Additionally, it would also be the one that allows the best management of human resources in the health care system if there were ever a shortage of professionals within a particular specialty. Above all, however, it is the one that can best help to cover the needs of the Spanish National Health System and, therefore, to provide citizens with the best possible health care.

I do not think I am mistaken if I say that a more plastic structure for the specialised training system can only be based on competencies and on an analysis of what competencies are common to different groups of professionals. Notice that I said 'groups of professionals', which do not necessarily have to coincide with medical specialties and even less so with areas belonging to this or that scientific society.

This editorial was not written to attack or to defend, or even to judge the proposals that are currently on the table to amend the model of specialised training. This journal has not played and will not play party, tribal or group politics, but it does believe it has an obligation to contribute to the debate from the technical point of view and to enrich it if possible. Would it be good to have a more plastic specialist training system? And if the answer is affirmative, we can then go on to ask other questions, such as: is it good for residents? Is it good for the Spanish National Health System? Is it good for citizens? And the answer continues to be yes to all of them. Therefore, we must work to endow the residents' training system with a higher degree of plasticity, while putting the interests of citizens before those of any agent or player involved in the actual process itself.

And who must work to achieve this? The answer is all the players, graduates and residents, the professionals that participate in the training, including tutors, local administrators, autonomic authorities and the Spanish Ministry of Health and Social Policy, the National Commission of Specialties in Health Sciences, scientific societies and professional associations. All of them must help to construct these blocks of 'new core subjects' without individual interests, historical privileges or deeply rooted customs interfering in the common good that takes the form of better care for citizens.

But not everything is going to be a bed of roses. We must not conceal the fact that a more plastic system of training will require more teachers and learners; a more plastic system of training will entail more complex logistics and more difficult management; and a more plastic system of training will make life more complicated for health care institutions. It will also force groups of professionals to constantly reflect on and reconsider what they are and where they are going. But we should not forget that there is only one referent - citizens - and that both institutions and their representatives are there to serve them.