EDITORIAL

Guaranteeing socially accountable and sustainable faculties of medicine requires maintaining adequate levels of quality and teaching staff

Garantizar facultades de medicina socialmente responsables y sostenibles requiere mantener la calidad y el profesorado necesario

Ricardo Rigual-Bonastre

Catedrático de la Facultad de Medicina de Valladolid. Presidente de la Conferencia Nacional de Decanos de las Facultades de Medicina (CNDFM). E-mail: rrigual@ibgm.uva.es

The sustainability of the Spanish National Health Service (NHS) and of universities are two issues that both politicians and the media debate on a daily basis. Faculties of medicine cannot elude this debate, since they participate from two different perspectives. On the one hand they generate knowledge and on the other they train future professionals. Yet, to be able to perform their roles successfully they also need adequate resources and facilities together with the sustainability of the NHS and the necessary human resources.

Most of us who are involved in medical education would endorse the title of this editorial, but it is obvious that it is not easy to achieve this goal and that the number of problems that may make it difficult to accomplish this has grown. The difficulty lies in the institutions involved (universities, ministries and the educational and healthcare councils concerned) reaching an agreement based on common sense, which is something that seems to be in rather short supply. I will, if I may, now go on to analyse the situation currently faced by faculties of medicine and put forward some solutions.

There are today 40 faculties of medicine, 31 of which are public and nine private. Some of them have many years' experience while others are more recent. Twelve of them have been set up in the last eight years and in eight cases there are students from the first year who have still not graduated. As could be expected, there are important differences as regards the problems they have with their teaching staff and how they are organised. On the one hand, the younger faculties have to ensure that they recruit the workforce they need and consolidate it, whereas the older ones have to renew their personnel. Other differences have to do with the distinct regulations that govern the teaching staff in public and in private universities. I will focus here on the problems that the public faculties have to cope with, although some of them are common to both cases. The profile considered is that of a faculty with a long track record in teaching and, generally speaking, conducts a wide range of research activities.

To become a member of the permanent university teaching staff (civil and non-civil service personnel) one has to be accredited by ANECA (National Agency for Quality Assessment and Accreditation) or by the authorised autonomic agencies and then pass the corresponding open competitions called at each university. Current regulations concerning this accreditation essentially grant more importance to teaching, research and management merits, without taking into account the particularities of a clinical lecturer. Indeed, healthcare merits are not given the importance they deserve, and less so if we consider that healthcare is a differential fact to which the future clinical lecturer will devote the major part of his or her working day. As repeatedly requested by the National Conference of Deans of Faculties of Medicine (CNDFM), the aim is not to lessen the value of those aspects that have already been acknowledged, but rather to recognise the true worth of healthcare tasks, which is an issue that we trust will be resolved by the new regulations on accreditation that are currently in the final stages of being drafted.

The teaching staff of a public faculty is organised along the same lines as that of the departments, which consist of the not-always-logical grouping of several different disciplines. Generally speaking, the departments of a faculty of medicine are made up of preclinical or clinical disciplines and play purely administrative roles, the true functional units being the disciplines themselves.

The teaching staff of a preclinical department consists mainly of researchers whose sole occupation is at the university. Their workforces are growing old as a result of the rule which only allows replacement of 10% of the positions that become available through retirements. New lecturers therefore need to be recruited to perform their teaching and research duties, which must be raised above the current 50%. The lack of medical lecturers in the preclinical departments is a great hindrance to the communication and vertical integration between basic and clinical subjects, something faculties of medicine have yet to get to grips with. It would be a good idea to achieve a balance between the medical and non-medical training of the lecturers teaching basic subjects. This would enhance the performance of both teaching and research tasks, and would foster a medical orientation in these subjects.

In the clinical departments, the number of secured lecturers (profesores vinculados) - those with a permanent teaching/healthcare position-civil servants (full professors and senior lecturers) - is very small and the standard labour (non-civil service) position of secured tenure-track 2 lecturer (profesor contratado doctor vinculado) is practically inexistent. Moreover, they are distributed in a heterogeneous fashion: a given discipline may be bloated in one faculty while there is a scarcity in others. Similarly, there are important differences among disciplines, with greater shortages in the surgical specialties or areas with less tradition in research. In many faculties there are areas with no secured lecturers at all. Adjunct lecturers (profesores asociados) of the health sciences - non-permanent lecturers - are a very important group in all faculties. Traditionally, these non-permanent members of teaching staff were responsible for the practical activities, although due to the shortage of secured lecturers they are becoming more and more involved in theoretical activities.

This outline of the teaching staff and their distribution in faculties of medicine leads us to ask: why aren't the doctors in university hospitals interested in becoming secured lecturers? Are clinical teaching staff organised in an appropriate manner? There are several different reasons that can account for this lack of interest. The main one is the scant appeal of a career in teaching: taking up a position as a secured lecturer requires an additional effort to be able to combine healthcare, teaching and research duties, without receiving any kind of acknowledgement from the university or from the healthcare institution. Such recognition, which affects both institutions, must be based on making it easier for the secured lecturer to carry out his or her healthcare, research and teaching duties in the same working day. Likewise, this effort must be considered a merit when it comes to promotion from one healthcare category to another and should also be reflected in his or her remuneration.

The above-mentioned lack of appeal and the difficulty involved in achieving accreditation that allows candidates to opt for a position as a secured lecturer have led to a significant decrease in the number of accredited lecturers in clinical areas. In addition to this reduction there is also the fact that these secured lecturers tend to be concentrated in departments and faculties with a greater tradition in research, therefore leaving the faculties that have a greater need for them in a more precarious situation. Spain does not have a strong culture of mobility and neither does the structure of the administration favour it. Furthermore, in each autonomous region the university and the health authorities need to reach an agreement before a secured position can be offered. This, together with the fact that the initial academic/healthcare equivalence for any category of secured lecturer is that of specialised graduate, provides all the ingredients needed to curb the mobility of associated or accredited lecturers.

After looking at the problems of lack of appeal and the difficulties involved in accreditation and mobility, all of which are inherent to the figure of secured lecturer, perhaps we should reconsider whether it is necessary to change the way teaching staff are organised and if it is worth maintaining the figure of secured lecturer. Something will probably have to be modified but it would seem that the secured lecturer, initially conceived as a compromise figure, continues to exist in public universities that coordinate with public hospitals, since by so doing both a teaching and a healthcare position are embodied in the same figure. Moreover, the concept of tenure-track 2 lecturer should be reassessed so that the working arrangements were better accepted by hospital doctors. Another possibility is to create an intermediate figure to somehow fill the gap between those of adjunct and secured civil servant, so as to allow a healthcare teaching career to be developed more gradually.

The NHS has excellent professionals who would have a very promising future, both in academic and healthcare terms, if the government had made a decided effort to attract practising physicians to university teaching. If both the university and healthcare authorities want to maintain high-quality faculties of medicine capable of responding to the citizens' demands, then they must understand the particularities of the teaching staff involved in healthcare-teaching-research and, consequently, ensure that faculties of medicine are staffed by sufficient numbers of high-quality employees.