General medicine in Spain
Dr. Fernando Perez Garzon
To understand the situation of general medicine in Spain, it is essential that we start in the year 1978, when Royal Decree 3303/78 was published, creating the speciality of Family and Community Medicine.This Royal Decree establishes a specialised training lasting three years, with an entrance examination similar to the other medical specialities (via MIR), a 1 7-month in-hospital residence training system, and 16 months at health care centres, making a total of 33 months of training.This Royal Decree (Article 8 and final transitional provision) furthermore regulates a number of transitional measures for access to the title of the new speciality by specialists who practised before this Royal Decree was published. We refer here to the system of acquired rights that applied to doctors who could accredit they had been working for five years, such that by following an advanced vocational training course they could obtain the title of 'Specialist in family and community medicine'.Problems started to emerge as a consequence of applying this system of acquired rights, that would not be implemented for another 11 years and was not effective until the publication of Royal Decree 264/89 in 1989. At the time there were some 8,500 doi lors who accessed the system through this method in Spain, and 2,100 of them still have to attend the advanced vocational training course. Ten years have gone by since then and the practical application of this measure of acquired rights has still not been completed.In addition, this Royal Decree 264/89 did not cover all those doctors who were practising at the time, but only those who fulfilled a number of strictly defined requisites, which has meant that there is a considerable number of specialists who have not had access to this possibility.The Community Directive 86/457/EC, on specific training in general medicine, called for an immediate solution to this situation, because it established mandatory post-graduate training to be able to practise within the social security system.From 1989 until 1995, various promotions of doctors obtained the speciality in family and community medicine under the official MIR system, that is to say, by an entrance examination to the restricted places called each year. These specialists amply comply with the requisites ruled in Directive 86/457/EC, and in this respect we are satisfied with the training in our country, but there is still the problem of those doctors who, in 1989, were not able to access the acquired rights system because, for a brief period of time, maybe days or weeks, they fell short of reaching the requisites for five years of practice.The mentioned Directive, 86/457/EC, that was repealed and compiled in Directive 93/16/EC, set out that, from 1 January 1995, all medical graduates were to follow a mandatory postgraduate training for two years at least, guaranteeing the acquired right of graduates before 1 January 1995 to practise general medicine, even without the title of specialist, within the framework of the social security.This complicated the situation for those doctors who were unable to benefit from the transitional measures established back in 1989.Royal Decree 931/95 was published on 9 June 1995, relating to access to training as specialists in family and community medicine for medical graduates after 1 January 1995, that establishes the obligation for the MIR training system in order to practise in the public health system in our country (which is practically the only employer), to obtain the speciality of family and community medicine.Last year, the Ministry of Health brought out a new Royal Decree 1 753/98, on 31 July, on 'exceptional access to the title of specialist doctor in Family and Community Medicine, and on the practice of Family Medicine in the national health system' directed to the pre-1995 general practitioner group, that demands that the following requisites be fulfilled:
• five years of professional experience as general practitioner in the public system (leaving out those doctors who practise general medicine in a different way);
• at least 300 hours of complementary training, that are assessed;
• an objective test to assess the candidate's professional competence, with final evaluation.
It seems this measure does not follow the principle of proportionality, because these are excessive requirements, especially considering these are general measures that do not take into account the situation of each doctor to whom they are directed.If we think about the fact that all these measures have been called for as a result of the publication of Directive 86/457/EC, the criteria adopted for their implementation as a domestic law should at least be 'proportional' to the end that is sought, to avoid any kind of discrimination.There is still much to be resolved, because from 1995 until the present time, an average of 600 doctors per year have not been able to enter any training system both for the speciality of family and community medicine and for other medical specialities, and consequently this has led to a new 'pool' of doctors who have no possibility of working in the national Spanish health system.
medical education (CME)