Editorial
Physician training in Spain in the 21st century
La formación de los médicos en España en el siglo xxi
J. Ena
Departamento de Medicina Interna, Hospital Marina Baixa, Villajoyosa, Alicante, Spain
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La formación de los futuros médicos en situación crítica" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1388 "Ancho" => 2566 "Tamanyo" => 232906 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Number of permanent professors by clinical knowledge area; the current total number (adjunct professors appear in blue, and staff professors appear in orange) and the number of retirements within the next 10 years are shown (both for staff and adjunct professors).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.P. Lara, A. Compañ, J.A. 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"apellidos" => "Álvarez-Sala" ] 7 => array:1 [ "colaborador" => "On behalf of the Conferencia Nacional de Decanos de Facultades de Medicina de España" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256518301541" "doi" => "10.1016/j.rce.2018.04.015" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256518301541?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887418301024?idApp=WRCEE" "url" => "/22548874/0000021900000002/v1_201902270625/S2254887418301024/v1_201902270625/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2254887419300219" "issn" => "22548874" "doi" => "10.1016/j.rceng.2018.11.012" "estado" => "S300" "fechaPublicacion" => "2019-03-01" "aid" => "1604" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Rev Clin Esp. 2019;219:79-80" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 7 "formatos" => array:2 [ "HTML" => 3 "PDF" => 4 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Internal Medicine and its future in health systems. 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"apellidos" => "Barreto" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256518303254" "doi" => "10.1016/j.rce.2018.11.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256518303254?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419300219?idApp=WRCEE" "url" => "/22548874/0000021900000002/v1_201902270625/S2254887419300219/v1_201902270625/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Physician training in Spain in the 21st century" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "81" "paginaFinal" => "83" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "J. Ena" "autores" => array:1 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "Ena" "email" => array:1 [ 0 => "ena_jav@gva.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Medicina Interna, Hospital Marina Baixa, Villajoyosa, Alicante, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La formación de los médicos en España en el siglo <span class="elsevierStyleSmallCaps">xxi</span>" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The 21st century's generation of physicians will have to face health problems in a population with significantly improved life expectancies. The vital statistics of 195 countries over the past 35 years show a reduction in mortality by communicable diseases caused by maternal and neonatal diseases, malnutrition and infections (HIV and malaria) and an increase in mortality from noncommunicable diseases, including cancer, ischemic heart disease, hepatic cirrhosis and dementia.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The demographic characteristics of the 20th century's population have enabled the classification of 4 generations: the Silent Generation, the Baby Boomers, Generation X and Millennials (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2,3</span></a> The Spanish philosopher and essayist José Ortega y Gasset (1883–1955) in one of his articles wrote, “The generation, a dynamic compromise between the masses and the individual, is the most important concept of history, and, so to speak, the hinge upon which history swings”.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Each generation has experienced historic periods and technological developments that have determined their demographic growth. Baby Boomers were the students who massively filled the medical schools in Spain between 1970 and 1980 and who currently hold managerial positions in academic institutions and hospital departments. This generation is close to their retirement, and, as a result, portend a marked deficit in the teaching and healthcare settings.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The Conference of Deans has issued warnings on the current and predicted deficits in permanent faculty (professor, associate professor and physician professor).<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> According to their estimates, in the next 10 years, 43% of the permanent faculty will retire, affecting 55% of the staff faculty of clinical areas, 34% of the adjunct faculty of clinical areas and 32% of the faculty of basic areas.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In addition to this retirement, there are other circumstances that have contributed to the deficit. Among those mentioned in the report by the Conference of Deans, there is the low number of favorable reports issued by the National Agency for the Assessment of Quality and Accreditation for teacher accreditation, low teacher replenishment rates and the prioritization of research accomplishments over teaching as the core of accreditation. The report issued by the Conference of Deans proposes corrective measures such as the bidding of posts according to actual needs, standardization of the replenishment rate and changing accreditation merits, considering teaching and research merits at the same level.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Academic medicine is also undergoing debate in other countries, perhaps not so much by the crisis in faculty but rather by the bureaucratic overload introduced in healthcare work. The time dedicated to patient contact has to be shared with recording the activities in the computer. Additionally, physicians are periodically obliged to take courses to satisfy administrative requirements and software updates. All these aspects contribute to professional burnout. In the Department of Internal Medicine of the Mayo Clinic in the United States, for example, 34% of surveyed physicians reported burnout criteria. This percentage increased among physicians who could devote less than 20% of their time to teaching or research tasks.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> Furthermore, 10% of those surveyed admitted their intention to withdraw from academic medicine within 3 years, to devote more time to research.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Those currently attending medical school who were born between 1981 and 2000 are part of the Millennial generation. The arrival of Millennials as students, teachers and clinicians will likely transition medical education and clinical practice. The use of the online educational resources has increased for students. Millennial students demand greater interaction in learning and will likely share their educational and learning experiences online. From the editorial standpoint, the use of hardcopy medical texts will tend to vanish.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Teachers and clinicians are undergoing a transformation in the practice of medicine, a transformation called high-value healthcare, which seeks to improve patient prognosis by considering the benefits of diagnostic and therapeutic interventions, their cost and the adverse effects they might cause.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> This practice of medicine incorporates the elements of “choosing wisely” and “less is more” strategies. The American College of Physicians is interested in including high-value healthcare in the academic curriculum. Structured assessments of physicians in training can help to determine the physicians’ diagnostic capabilities (using the medical history and physical examination without additional tests) and communication abilities (explaining why a diagnostic test or a treatment might be unnecessary). Master classes and bedside teaching should not be abandoned but will have to be supplemented by virtual sessions on communication strategies between physicians and increasingly informed patients.</p><p id="par0045" class="elsevierStylePara elsevierViewall">High-value healthcare should also incorporate moral reasoning, ethical sensitivity and empathy. A study conducted by Yuguero et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> with medical students from the University of Lerida, Spain, showed how ethical sensitivity and empathy decrease in the last years of the medical degree. The main determinants that affect the development of moral reasoning and empathy seem to be the clinical tutors’ values, attitudes and behavior.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> Clinical tutors have the responsibility to be role models, communicating concepts in preventing and healing diseases and instilling a passion for knowledge and the critical assessment of scientific literature.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> Future physicians will have to interact with patients who are increasingly informed through the Internet and who will want to take part in the decisions regarding diagnosis and treatment. The classical models of the patient-provider relationship and communication strategies will need to be revised to adapt to this demographic change.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In a survey conducted of internal medicine interns who were completing their specialization training, most reported that they did not know the specific learning objectives of each rotation, and approximately a third of them felt inadequately supervised.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> There might be deficient dissemination of the specialty's content and a lack of knowledge of high-value healthcare communicated in each rotation. Although most of the interns had published at least one article or given a presentation at a congress, we do not know the level of participation in generating the topic of research or the degree of knowledge they had in resolving the topic under investigation.</p><p id="par0055" class="elsevierStylePara elsevierViewall">There are many medical doctors who also perform teaching functions as specialist tutors or as physicians responsible for a rotation period. It is estimated that medical intern tutors consist of approximately 10,000 practitioners, with a high level of motivation, who perform essential work for the proper implementation of specialized training. Royal Decree 183/2008 established the competencies of tutors regarding the training of medical intern physicians, defining their profile, functions, necessary skills, responsibilities and characteristics for their appointment. The responsibility for the post of resident tutors and the time spent in administrative functions is significant and not always well understood. Moreover, only 30% of tutors reported having conducted a training course for resident physicians.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> Despite their workload, however medical interns continue to assess their training as excellent.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In summary, teachers are retiring at a rate faster than replacement, which could jeopardize the future of medical education in Spain.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> The traditional teaching model should be adapted to current technology. Physician teachers of undergraduate and graduate education should be role models who communicate the expertise and passion for patient care, as well as an interest in self-training. Interactions with increasingly informed patients demand greater understanding and appropriate communication strategies to achieve high-value healthcare.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ena J. La formación de los médicos en España en el siglo <span class="elsevierStyleSmallCaps">xxi</span>. Rev Clín Esp. 2019;219:81–83.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">The Silent Generation<br>1928–1946 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Baby Boomers<br>1946–1964 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Generation X<br>1965–1980 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Millennials<br>1981–2000 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69–86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51–68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30–50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><29 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Technology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cars \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Television \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Computers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tablets/smartphones \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Communication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Letters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Telephone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Email and SMS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Social networks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Goals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Owning a home \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Having a job \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Achieving a work-life balance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Having freedom and flexibility \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Leadership \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hierarchy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consensus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Participatory \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Selfless<br>Hard worker<br>Follows rules \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Personal growth<br>Efficient worker<br>Questions authority \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Breaking the routine<br>Self-sufficient<br>Wants structure and direction<br>Skeptic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">More women studying medicine than men<br>Multitasker<br>Tenacious<br>Goal-oriented \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Workforce 2020–2025, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1974107.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Generational characteristics in the 20th century.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "GBD 2015 Mortality and Causes of Death Collaborators" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(16)31012-1" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2016" "volumen" => "388" "paginaInicial" => "1459" "paginaFinal" => "1544" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27733281" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0080" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Baby boomers: can my eighties be like my fifties?" 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