EDITORIAL

More students, more faculties. Will any light come from this turmoil?

Más alumnos, más facultades. ¿El desorden traerá algo de luz?

José M. Peinado Herreros

Former dean of the Faculty of Medicine. University of Granada. E-mail: jpeinado@ugr.es

The academic year that is now ending has been one of the most intense experienced by Spanish Faculties of Medicine in recent years. The degree course has unwillingly been the subject of a debate that has involved an array of political interests, legislative changes, stagnation of the universities, welfare problems and a long list of other issues dominated by disorder and, to a great extent, the improvisation that is so characteristic of our country¹. In just 4 years the national health system has gone from unemployment and a surplus of doctors to a demand for professionals that is impossible to meet in a rational manner. Let's see how we reached this situation.

The introduction of specialised training by means of the MIR (Medical Resident Intern), together with an excessive number of graduates, led to an unprecedented change in the structure of the profession in our country in the late 70s. Only a few graduates were admitted to specialised training. The others, who were seen as a kind of second level, mainly sought jobs in primary care, in rural areas and on the vacancies lists at the unemployment office². Furthermore, in 1995 the European Directive regarding the free movement of professionals was applied, which made it impossible to practise the profession without a specialist qualification. And thus, given the insufficient offer of places to do the MIR, the 6 = 0 movement came into being and was to continue until the dawn of the new century³.

In early 2002, the responsibility for public health care services was transferred from the central government to the last 10 Autonomous Communities. The portfolios of services were completed in all of these regions and construction of new health centres and hospitals was stepped up. Our country was undergoing a period of great economic development. The population was ageing, but at the same time it had grown due to the arrival of over five million immigrants. Private health care services were growing at a spectacular rate. In a short space of time, two other decisions were taken that, according to our politicians, "would not reduce the quality of our health services": physicians over the age of 65 were pensioned off in half the country, and the Family Resident (MIR-F) now had to be completed in 4 years⁴. Nevertheless, despite underemployment and the precarious situation with regard to work contracts, there were still no warning signals going off⁵.

Generally speaking, the first difficulties to fill vacancies due to sick leave and holidays only began to be noticed four years ago. Although the number of doctors in Spain is one of the highest in the OECD, in relation to its population, we began to hear talk of a shortage of professionals. This situation, which was skilfully handled by the media, was gradually leading to the idea that our country needed more physicians. The alarms finally went off when the 2006-07 call for applications to the MIR left 87 places without candidates, of which 54 were for family medicine, although 5946 places were on offer and there were 9579 candidates⁶.

In this context, what has been the role played by the Faculties of Medicine? For almost 15 years the number of newly-admitted students at the 28 Faculties of Medicine in Spain had levelled out at around 4400⁷. If we look at the European standards, our country complied perfectly with the magic figure of 1 student for every 10 000 inhabitants. In fact, maintaining the number of students has made it possible to introduce substantial improvements in the quality of education over these years⁸. The coveted goal of ensuring specialised training for all graduates was gradually being accomplished.

It was in spring 2006 when the National Committee on Human Resources in the National Health System first addressed the University Coordination Council calling for an increase in the number of places for new admissions. In answer to this request, the Deans allowed an increase of 5% in all the Spanish faculties, although in reality the average increase was 9%, with a rise of 50% in the Faculty of Medicine of Las Palmas down to 5% in those that had not requested the increase. In this way the CND (National Conference of Deans) tried to show itself willing to collaborate with the administration and to satisfy social demands, although they were not based on any proven scientific foundation. They insisted on defending the idea that any increment should be based, on the one hand, on a needs study accompanied by a register of professionals and, on the other, on improved resources for the centres so as to be able to maintain the quality of education. Surprisingly, today neither of these two premises has been satisfied beyond the negotiations and facilities that some Chancellors have carried out within their own faculties.

The only study conducted by the Administration was the one carried out by the excellent economist from the Canary Islands Beatriz González López-Valcárcel, who points out that, taking into account forthcoming retirements, as of the year 2016 the system will need 7085 new physicians. This led to the well-known proposal from the Ministry of Education (now Science and Innovation) to increase the number of places on offer by 40% over the next 5 years. Nevertheless, in the same study the author also warned of the difficulties that exist when it comes to planning in a market that is excessively segmented and has a high degree of mobility. The profession warned that the number of physicians in our country was higher than the OECD average, that they were badly distributed, geographically speaking, and that there were shortages in particular specialities. The question was raised as to why over 40% of professionals registered in official associations did not work in the health system. And why some of the places accredited for specialised training were not on offer. All to no avail. No steps were taken in the short term to solve today's demand, although the Deans pointed out that the effects of the decisions concerning admission would only been noted in 12 years" time. If the current problem is true, then is providing physicians for the year 2020 the right step to be taken? What will our health care system be like then? The subject of quality in university education was not addressed either. The Chancellors agreed to offer more places, generally without demanding anything in return. The die was cast; our administrators, who were used to living a life of luxury, did not want to change the worn out human resources policy.

Just before Christmas 2007-08, what had been political pressure on the existing Faculties of Medicine to increase the number of students, became firm decisions to set up new Faculties. The decision could not be more catastrophic in a country that willingly accepts that laws "can be twisted" to change what was "illegal" into something "legal". Without satisfying the corresponding requirements, the Universidad Católica S. Vicente Mártir de Valencia began to teach the first year of the Degree in Medicine course in 2007⁹. The Catalan regional government, however, was the first to propose the creation of three new faculties" Gerona and Pompeu Fabra, which are public, and the Internacional de Cataluña, which is private "with a total of 220 new students. All the efforts of the Deans, medical students, the OMC (Spanish Organisation of Medical Associations), the FACME (Federation of Spanish Scientific-Medical Associations) or the Medical Trade Union itself had no effect on instilling some order into decision-making. A little after Christmas, following confirmation from the Deans in Madrid that it was physically impossible to admit twice as many new students, with a proposal for 880 new students, the regional government of the Autonomous Community of Madrid decided to promote the creation of four new faculties " Juan Carlos I, which is public, and three private state-assisted public hospitals: Alfonso X El Sabio, Francisco de Vitoria and Europea de Madrid. Now that the first step had been taken, there were many Autonomous Communities that shortly afterwards were to consider the idea of setting up new Faculties, for example, Jaén, Almería, Baleares, Católica de Murcia, Castellón, Ciudad Real, Toledo, and so forth.

This new fever, whose consequences remained to be seen, coincided with the opening of the period set aside by ANECA for the submission of proposals for degrees and courses that meet the requirements of the European Higher Education Area and seek authorisation to start in 2009. By the middle of February the following universities submitted proposals for verification¹⁰: Girona, Internacional de Cataluña, Pompeu-Fabra (qualification shared with the Universidad Autónoma de Barcelona), Juan Carlos I, Europea de Madrid, Alfonso X el Sabio, Francisco de Vitoria, Católica de Valencia and Católica de Murcia, in addition to the one already submitted by Navarra. Only the first five have been approved. Strange as it may seem, our system of verification only takes into account the documentary evidence provided by those putting forward the proposals. Nobody has verified the real situation¹¹, since neither external assessment nor previous accreditation is considered. Once the degree programmes have been approved, they can be assessed after 6 years of activity [sic]. Has anyone an idea of what may happen? Can anyone believe that, in our country, after 6 years and with 1000 students registered in the courses, a degree course can be closed down because it doesn"t fulfil the initial promises?

In my opinion the appearance of new Faculties in our country is already a process that cannot be stopped. The fact that this time some of them have not passed the bureaucratic test of the "Verifica program" does not mean that they are not going to do so in the next call for applications. It's just a matter of time. Those that have rushed to fill in the forms will now have more time and will do it better. Those that have not done so will do it well. Our country will have between 42-45 centres, more than any other country in the world except Cuba, in terms of the number of Faculties of Medicine per inhabitant. Faced with such turmoil, which has been condemned by the National Conference of Deans, the Government and the General Conference on University Policy¹² have decided to postpone the decision and appoint a committee to study the number of newly-admitted students in the academic year 2008-09. There may be a large number of Faculties of Medicine, but it seems likely that the number of students for each Autonomous Community will be set. Let's hope that this is the decision that is finally adopted!¹³ If this were the case, from now on, each autonomous community would consider the cost effectiveness of setting up new degree courses. I believe that the only way to prevent the surplus of doctors that occurred in the 80s and 90s from taking place again in our country (with all the accompanying frustration and lack of trust) is to regulate, on a national scale, the number of newly-admitted students and carry out annual reviews of the number of places available for MIR, particularly in the specialities with greater deficits.

On the other hand, the proliferation of private Faculties of Medicine will give rise to clearly unfair and unjustified situations of obvious (economic) inequality as regards access to the studies. The use of public hospitals or health centres for private training adds a little more social inequality to the situation and should not be authorised¹⁴. This is even more startling if we take into account the fact that specialised training is essentially a public system. Moreover, are politicians aware that the students in the new centres, especially the private ones, will come from all over the country and the EU? There would be no objections to this if the training were wholly private. This issue should also be considered in the future changes that may come about in the systems of admission to the degree courses and to MIR training.

It must be understood, however, that if the requirements legally set out in our laws and regulations have been complied with, then the new qualifications must be accepted without hesitation. Yet, I foresee important problems in their implementation which go beyond drawing up a programme of studies or the construction of appropriate physical infrastructures. High quality medical training requires not only the presence of teaching staff with the right skills and abilities but also with formal qualifications and accreditation. This will be no easy matter, especially in areas in which the high degree of involvement in health care makes research more difficult. On this matter all we have to do is consult the National Committee on Research Activity (CNAI) databases. Is it possible to authorise the implementation of degree courses without teaching staff?

Nonetheless, I can see a faint glimmer of hope in this turbulent scenario. Setting up new Faculties, without the existing traditional conditioning factors, could allow new, more innovative teaching methods to be adopted that are more likely to be able to tie in with European convergence. Working in small groups supervised by a tutor with integrated teaching and early exposure to the reality of health care, as proposed in the Bologna Reform, is not compatible with oversized groups. Furthermore, the changes that need to be introduced into the MIR examination and the long-awaited introduction of mandatory core materials, together with suitable planning of the number of places to be offered in the MIR, the creation of a register of specialists, and policies designed to retrieve "inactive" professionals can effectively adjust the demand to fit the supply in decent working conditions.

Due to a lack of planning and short-sighted political interests, our country is closer to missing a wonderful opportunity to enhance medical training and the actual national health system than it is to incorporating the new university dynamics that are to be found in Europe and the United States. Widespread national agreement between all the institutions involved is needed. But, in view of the above, although I acknowledge a certain degree of pessimism, I believe that the next few months are going to be really exciting. The way our system of medical training works over the next 25 years is going to depend on what happens now.

1. "It is difficult to implement a sensible health care policy without having a reliable register of data about specialists." Mr. Marcos Peña. Director-General. Spanish Ministry of Health and Consumer Affairs. 1992.
"Proper planning of human resources in the National Health System is a fundamental element to ensure high quality health care. The working group that is addressing this issue has made considerable progress, perhaps the most important example of which is the need to implement a register of health care professionals. This register will provide the Health care authorities with a key instrument for allocating resources, and this will be complemented with the study of specialists" needs that is being drawn up." Ms. Elena Salgado. Spanish Minister of Health. 13^th September 2006.

2. They often acted as specialists, although they were not qualified to do so, which later gave rise to another paradoxical situation that had to be resolved: the MESTOS (Specialised Physicians without Official Qualifications).

3. In the year 2000, while Romay Beccaria was Minister of Health, student demonstrations and protests took place all over Spain calling for a larger number of places on the MIR.

4. The Regulatory Framework was applied in Andalusia, Aragon, Asturias, Cantabria, Catalonia, La Rioja and Valencia. In 2008, about 1500 physicians will be unable to join the job market. Some authorities now consider the possibility of their being able to take up a job "sui generis" following the third year, without finishing the residency. [sic ?].

5. Only the CESM Foundation analysed the number of physicians in Spain in 1999.

6. In this call for applications, 2007-08, the number of places left without candidates has been even higher, 253, of which 189 were for family medicine and 1 for Preventive medicine. The rest, as in the previous year, were for schools. The number of places on offer was 6388 for 10 564 candidates. In my opinion, all this reflects two points: On the one hand, there is a large amount of recirculation among residents in the system. On the other hand, many of the candidates choose not to do the exam again the following year.

7. See the White Book on the Degree in Medicine. The creation of the Facultad de S. Pablo CEU did not represent any kind of increase because it shared its students with the Universidad Complutense.

8. In any case, it must borne in mind that our system of access to specialised training "the MIR exam" has facilitated the predominance of conceptual education at university, rather than training in skills, which was assumed to be part of specialised training.

9. It was only under pressure from the CND that the degree course was reconverted into an Advanced Diploma ("título propio" in Spanish), but with the hope that its students will not waste a year when the qualification is confirmed some time in the future; to date this has not happened.

10. The Verifica program developed by ANECA (National Agency for Quality Assessment and Accreditation) evaluates the proposals for new study programmes by assessing their resources, objectives, systems of access, quality assurance systems, implementation schedule, and so forth.

11. The Oxford dictionary defines "verify" as: "make sure or demonstrate that (something) is true, accurate, or justified."

12. Regulated in the Royal Decree 546/2007, dated 27 April, this conference is made up of representatives from the Autonomous Communities and five members appointed by the Ministry.

13. Today, 17^th June, the decisions taken by this committee remain unknown.

14. It is surprising to note that some Autonomous Communities have decided to revoke the agreements between public hospitals and public universities and draw them up anew with private universities.