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FEM: Revista de la Fundación Educación Médica

versión On-line ISSN 2014-9840versión impresa ISSN 2014-9832

FEM (Ed. impresa) vol.20 no.4 Barcelona ago. 2017  Epub 16-Ago-2021 


Difíciles equilibrios en la formación médica especializada

The difficulties of balancing specialised medical training

The difficulties of balancing specialised medical training

Amando Martín-Zurro1 

1Vicepresidente de la Fundación Educación Médica

Specialised training is the key element in building competencies in doctors, a process that begins in their undergraduate studies and is subsequently honed throughout the continuing professional development phase. For many years, and in a great number of countries, undergoing and passing specialised training is an indispensable requirement (legally, technically and ethically) to be able to forge one’s own individual career in any of the branches of medicine. It is an accepted fact that during the degree training the future professional will acquire the basic competencies, many of which are of a cross-cutting nature, that enable the graduate to draw the maximum benefit, in terms of improving their theoretical-practical know-how, from the ensuing phases of the training continuum.

Specialised medical training has a set of common methodological foundations in the developed world, which are deeply rooted in the progressive acquisition of competencies and skills based both on study and on organised and supervised practice within institutions, services and programmes accredited for this purpose.

The training curricula in the different specialties are developed with the aim of allowing learners to acquire the theoretical and practical elements that go to make up a previously defined profile. Ideally, this is achieved through the combination of the requirements concerning knowledge, abilities, aptitudes and attitudes of each speciality and adapting them to the specific characteristics and needs of the health system.

Medical specialties are not homogeneous. An important number of them refer to alterations in one or more systems in the body, others focus on certain diagnostic or therapeutic technologies and resources, a third group involves the specific competencies required to attend to particular age groups in the population, and the fourth addresses health problems and their prevention from a population-based perspective. Family medicine, the conceptual basis of classic clinical care (what was formerly known as general medicine), has its own specialised skills profile in that it is focused on caring for the person within their familial and community context, regardless of their age and the kind of health issues they may present. In this grouping of specialties we can distinguish two large blocks: one vertical and the other horizontal. The first, essentially comprising those that address problems affecting the different systems in the body, has as its chief aim to ensure the most comprehensive command of the clinical and technological elements corresponding to each case. In this block, the rest of the skills components are often considered as being of secondary importance. The block of horizontal specialties is made up of the others mentioned earlier, which require broader skills bases and, from the technological and clinical point of view, include the care of groups of certain ages or with problems affecting several systems or, as is the case of family medicine, care of the person as a biological, psychological and social whole. Some of the paradigmatic specialties in this block include paediatrics, family medicine and public health.

Striking a complex and difficult balance in the specialised medical training system is further hampered by the confusion that often arises, especially in our setting, between specialty and area of work. This is the case, for example, of urgent care or that delivered in the workplace and in the fields of physical education or forensic medicine. Adapting to these areas of work may require the addition of a few extra skills, but does not justify the recognition of new medical specialties.

The list of legally recognised specialties varies widely from one country to another. The systems regulating the postgraduate training of each state share the methodological elements outlined earlier, but differ greatly in their orientation, organisation and the types and number of specialisation programmes, according to the medical training culture and the structure of each healthcare system. The task of reconciling differences that reflect historical characteristics and a variety of current and future needs on a European or worldwide scale appears to be anything but easy. And taking this homogenisation regarding the duration, specific contents and organisation of the different programmes in addition to the legal recognition of the different specialties as our non-negotiable watchword may be a wrong move. It is undoubtedly important that the training methods and skills profiles of the specialists trained in different countries guarantee a sufficient level of quality and safety in the practice of each specialty (and to do so they must establish appropriate mechanisms of equivalence and assurance of competencies), but it does not seem necessary or effectual to insist on the total unification of training programmes and systems at any price.

Another aspect of specialised medical training that is difficult to balance concerns the generation of a common training base for the entire system which has to ensure the acquisition of a series of key competencies that are necessary to pursue a career in any of the branches of medicine. In the case of Spain, the idea has been to cover this aspect with the process of introducing mandatory core materials into the training programmes, grouping related specialities and placing the acquisition of these key competencies in the first two years of learning. The difficulties that the implementation of the mandatory core curriculum has run up against are well known, some of which derive from errors that can be corrected while others stem from unavoidable sectoral and corporative proposals. One of the most significant in the first case is the actual grouping of the specialties as mandatory core materials: perhaps it would have been more logical, and acceptable to all, to design core training blocks taking into account the vertical or horizontal nature of specialties discussed at the beginning of this article, as well as the extent and type of interaction with patients, citizens and users, and to define common training periods and contents governed by one key word: flexibility. It must be accepted that, although the common key skills have to be acquired by all or nearly all professionals (some at the degree stage), their conceptual orientation, duration, intensity, learning methodology and placement in the curriculum can vary significantly for the different specialties.

Establishing a common training base for the medical specialties is a necessary step towards producing professionals whose profiles include a sufficient and balanced combination of versatility together with a specific command of the field of specialisation.

Specialised medical training is a primordial factor determining the quality of the healthcare delivered to citizens. Its progress and keeping the difficult balances within it require the collaboration and generosity of all the stakeholders involved. The undertaking is a big gamble for us, as professionals, but it is even more so for our patients.

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