Spain has a current population of 47 million people with a marked increase in recent years due to a significant growth in the immigrant population. The number of urologists is over 2,000, most of them members of the Spanish Association of Urology (AEU).
Education in urology is supervised by the National Commission of Urology composed of urologists and representatives of the Ministry of Education. This commission determines the number of residents accepted for the five-year programme. Access to residency training is through a nation-wide examination after the six-year medical school education.
Based on the score obtained the candidate resident chooses both the hospital and the specialty in which he/she will be trained in. A total of 7,131 new resident positions were offered in 2011 of which 1,918 were for Family Medicine and 98 for Urology. Of these, 20 were available in Madrid, 15 in Andalucia and 14 in Catalonia. All graduates receive the same certification that entitles them to practise urology with their skills and acquired knowledge as the only limitations. This means that in Spain we do not have office urologists since all perform surgery, but only with different complexity depending on skills, interests and the type of hospital where the urologist works.
The Spanish National Health System is markedly decentralised with a Regional Authority in each of the 17 autonomic regions (Fig 1). Local authorities set the goals of waiting lists, high-technology purchase, physician income, etc. Urologists are paid like other salaried medical professionals.
Additionally, on-call service, kidney harvesting and transplantation and special evening surgical programmes are compensated or paid as extra work. In general, most urologists working for the public sector earn around 70,000 to 90,000 euros per year before taxes. Overall, earnings are basically the same regardless of the type of hospital where the urologist is employed.
Due to the dense network of hospitals currently available in Spain, obtaining a position in the public sector, at the moment, is not difficult for most graduates after their residency training. Moreover, many urologists supplement their income by also working in the private sector. Unfortunately, mobility of professionals in Spain is markedly low due to the strong emotional links of people to their hometown which can influence one’s professional or academic career growth. One of the features of our health system is the rather small flow of patients between hospitals.
With the exception of some procedures such as radiation therapy, transplantation, paediatric urology and lithotripsy, all hospitals are supposed to take care of all the medical needs of the population within its area of influence, which is well defined. Fortunately, this is starting to change. In Madrid, for instance, with a population of more than six million, all health areas have been merged into one and citizens can choose both the hospital and the specialist that they prefer.
Success in kidney transplants
One of the greatest achievements of Spanish urology is its kidney transplantation programme, managed by the National Transplants Organization (ONT).
The success of the programme is built upon the role of the Hospital Transplant Coordinator who is in charge of detecting potential organ donors within the hospital, interacting with the specialists involved and the proper communication of each organ harvest to the regional and national offices for them to identify the best matching receptor. As shown in the accompanying figures, Spain has the largest world kidney donor rate and 2,225 kidney transplants were performed in 2010, of which 240 were from living-related donors.
Based on this experience the European Commission has chosen Spain to lead its ACCORD programme (Garcia Rada, A. BMJ 2011;343 doi:101136/bmj.d4413). Currently, there is an ongoing debate about the sustainability of our system. Health care is highly regarded and appreciated by the Spaniards.
It has been provided free of charge for all sorts of procedures and for everyone with only a 40% charge on the prescriptions for those employed. Nevertheless, it is most likely that major changes will be implemented in the coming years. The full version of the article and the illustrations are published in the October-November 2011 issue of EUT.