EDITORIAL

Numerus clausus in medical schools. Criteria and responsibilities in the number of admissions and in their distribution

El numerus clausus de las facultades de medicina. Criterios y responsabilidades en el número de admitidos y en su distribución

Arcadi Gual, Felipe Rodríguez de Castro

Presidente de la Fundación Educación Médica (A. Gual).
Presidente de la Sociedad Española de Educación Médica (F. Rodríguez de Castro).

Correspondence

This issue of the FEM journal includes the full transcription of a statement recently issued by the Forum of the Spanish Medical Profession, entitled "Why have numerus clausus in medicine?" This document examines a number of issues that, while undeniably debatable, are grounded upon three irrefutable principles: maintaining or improving the quality of doctors' training (and therefore the quality of healthcare), maintaining or improving the cost-effectiveness of education, and maintaining or improving common sense.

It is true that many universities that do not have their own faculty of medicine have made efforts to be able to offer these studies and that they have done so on the assumption that, without wishing to discredit any other degree or qualification, offering a degree in medicine as one of their programmes increases their social visibility. Likewise they consider it boosts both research activity and the transfer of knowledge to society, as well as endowing them with an added capacity to establish multiple synergies with different institutions and organisations. But the opposite is also true, that is to say, many rectors have come to realise that a faculty of medicine is another important difficulty that further complicates the already complex task of university management. A medical school is always a problem that a rector's office has to deal with when they have to explain, over and over again, the characteristics distinguishing this degree from others: medicine is different. The teacher-student ratio, the number of lecturers needed, the nature of clinical placements, the technical, technological and human costs involved, the organisational complexity, the agreements with healthcare institutions, and the difficult and costly methods of evaluation are just some examples of the differences that exist between a degree in medicine and a degree in the humanities or in social sciences, for instance.

Maintaining and raising the quality of our doctors' training is a social responsibility that falls to not just universities but also to other actors and institutions. Without fear of being mistaken, we could state that none or practically none of our faculties of medicine were originally designed to hold the number of students they are training today. Perhaps if we said that the standard of teaching goes down when there are too many students, somebody might disagree with us, so we will be better off not saying it. Yet, it is obvious that more food and more cooks are needed to feed fifty people than to feed five. So, we suppose that nobody will try to refute our argument if we say that, given the same resources, a faculty would prepare doctors better if the number of students were lower.

Supposing it were possible to have all the means needed to educate students in a medical school in the best possible way and that these resources grew as the number of students rose, then we could consider the possibility of having, for example, a faculty of medicine with two thousand students per academic year and thus twelve thousand students wandering around its classrooms and care centres. Would such a situation allow good doctors to be trained there? Would it make good common sense to provide instruction under such conditions?

Having accepted the fact that allowing faculties of medicine to admit large numbers of students is a questionable alternative if we want to guarantee the quality of doctors' training, we must therefore consider the opposite possibility. If we were to set very restrictive criteria with regard to the maximum number of new admissions -let's say fifty students per faculty- it would be easy to ensure there were resources enough to provide high quality training; but on the other hand having so few students in each academic year might mean having to increase the number of faculties in order to cover the need for physicians. It seems obvious that increasing the number of medical schools entails a clear deviation in terms of cost-effectiveness and again we are forced to ask ourselves whether having more faculties with fewer students in each really makes good common sense.

The aim of these obviously rhetorical questions is to simply to underline the need to find a reasonable way to square two diametrically opposing issues. One of them is to match the number of doctors needed to the number of doctors to be trained. Once we have established the number of students that will be admitted to our faculties to study to be doctors every year, all we have to do is to evaluate the optimum number of students that can be taught in the medical schools available today. If this figure were lower than the number of doctors required by society, then it would mean that more faculties of medicine are needed. If the opposite were the case then we must assume that we have enough with the existing faculties and that, proportionally, we could even lower the number of students undergoing training. Isn't that just a question of common sense?

There are several different authorities involved in doctors' education, each of them on a different level. The need to strike a suitable balance among doctors' needs, the number of students and the number of medical schools is an issue that is continually being discussed by those responsible for these faculties, and more particularly by the Spanish National Conference of Deans of Faculties of Medicine, which repeatedly stresses the increasingly obvious mismatch between the number of students admitted to study medicine and their chances of finding a job after graduating. Unfortunately, the deans are not responsible for adjusting these three parameters and lack even the executive capacity to do so. They already do quite enough by making themselves heard both in their universities and in calle Alcalá and in the Paseo del Prado in the hope that, one day, the rectors and above all those responsible for universities and healthcare in their respective ministries decide to take joint action in this respect. Note that in order to solve this problem it is necessary, on the one hand, to take decisions and, on the other, to do so as a joint effort. We can still read quotes from over ten years ago requesting, calling for, a joint education-healthcare structure with the executive capacity to make decisions about the question of numbers in the training of doctors. Is it impossible for the directorate-generals of healthcare and universities to have a linked structure -not just something put on for show- that actually allows them to discuss how many medical undergraduates, how many doctors pursuing specialised training and how many faculties of medicine are required to ensure that the Spanish National Health System has all the professionals it needs to guarantee that citizens are provided with a high quality cost-effective healthcare system? Don't you think that would make good common sense?

Correspondence:
Fundación Educación Médica.
Departamento de Ciencias Fisiológicas
I. Facultad de Medicina.
Universitat de Barcelona.
Casanova, 143. E-08036 Barcelona.
E-mail: agual@fundacioneducacionmedica.cat