Lega secretary Matteo Salvini has returned to propose the abolition of limited enrollment in medical courses with the aim of solving the shortage of doctors and doctors in Italian hospitals. It is a measure that has cyclically received a lot of attention in recent years, particularly during the period of the coronavirus emergency, when health care has often been lacking. Salvini explained that the abolition of the limited number does not cost the state anything, rewards merit and counteracts the shortage of doctors. “It’s simple common sense: I believe in young Italians,” he wrote on his social media profiles.
In reality the question is not so simple, because the mechanisms of access to the medical profession concern different sectors and responsibilities such as the university and health facilities, and above all because there is a significant delay between decisions and their effects: current problems, in fact, are the result of a rough planning work by many of the governments that have followed one another in the last two decades. Salvini, as has happened to other politicians in the past, seems to overlook the fact that the decisions taken today will only take effect in a few years: the abolition of the limited number, many experts and several unions agree, does not help solve the current shortage. of doctors.
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Today a person who wants to become a doctor must overcome two major barriers to entry, in training and in the profession. The first is the entrance test to the Faculty of Medicine and Surgery, which has a limited number of places, which means that a limited number of places are available. The next entrance test, for example, will guarantee access to the faculties of health professions to 14,740 people compared to the approximately 60 thousand people who apply for a position every year.
The second barrier is the specialization required for hiring in hospitals. In short, medical specialists to become medical specialists must win a national competition from the Ministry of Education and obtain a scholarship to practice a specialization in hospital. Once specialized, they can participate in competitions to be hired for an indefinite period by the national health service (SSN).
The path to becoming a family doctor is slightly different: if a person graduated after 1994, he or she can participate in an exam that allows access to the specific training course in general medicine, organized and financed with scholarships from the Regions and not from the university. At the end of this course, doctors can enter the regional rankings and make an agreement with the national health service as a family doctor.
The limited number of admissions to universities and the number of scholarships made available each year therefore determine the number of doctors and doctors who will work in hospitals and on the territory as family doctors in the future.
To be optimal, planning should take into account various indicators: how many professionals are close to retirement, how many and what services are needed by hospitals, how many doctors drop out of their studies, and how many decide to leave public facilities to go private. According to an estimate by ANAAO Assomed, one of the main unions of hospital doctors, by 2024 there will be at least 40,000 doctors missing due to wrong programming.
This problem is the result of rough forecasts, cuts and insufficient corrections. There have been periods, such as in the early 1970s, in which far more doctors were trained than needed, and other phases in which scholarships and in general economic resources for health have been excessively reduced. , as in the ten years between 2010 and 2020.
When the amount of scholarships for specializations is not sufficient to guarantee a place for newly graduated people, an imbalance is created that the unions call a “training funnel”. In recent years, many graduate doctors have not been able to access specialization courses because few scholarships have been made available. To remedy the training funnel, with the latest Budget Law it was decided to finance 12 thousand scholarships every year.
The calculations made by ANAAO Assomed help to understand what the situation will be in the coming years. In the academic year 2021/2022 enrollments in universities have been increased to 14 thousand: these students will finish their studies between 2031 and 2032 and only at that point will they be able to work. The analysis of the trend in recent years shows that about 13 thousand people will graduate, net of dropouts. Two thousand of them will follow the training course to become family doctors, while 11 thousand will become specialists. So there is no shortage and there will be no shortage of doctors, i.e. graduates in medicine and surgery, given that between 2021 and 2030 about 117 thousand will be trained. “Those who want to abolish the barrier to medicine in full swing of the vote have not understood anything about the problems of training doctors and the national health service,” said Pierino Di Silverio, national secretary of ANAO Assomed. “How can a university support 60,000 students every year? With big screens in the square? And then how are specializations guaranteed? ».
The risk, according to the union, is that even the increase in scholarships decided with the latest budget law will not solve the problems. Indeed, it could create a new one: the work funnel. The 12 thousand scholarships a year, in fact, do not seem to take into account the needs of the territory, nor the hospitals or the number of professionals who will retire.
The need to replace retirees in the national health service has been estimated at 3,000 doctors per year after 2030 and 2,000 by 2034. Even considering that some of the trainees will be hired by private structures, at least 6,000 new doctors ready to work will have difficulty in find a place. «This is yet another result of an absence of planning and confrontation with the parties. Money does not always solve problems, especially if it is not used to the best », Di Silverio said.
The programs of the major parties presenting themselves in the upcoming elections address these problems differently. According to the PD, the limit of the training funnel has been definitively exceeded thanks to scholarships funded in recent years. “Now, strengthened by this result that allows us to look to the future of public health with greater confidence, an extraordinary effort is needed to overcome the current condition of fatigue and dissatisfaction of the health professions put to the test by the Covid emergency”, reads in the program.
Verdi and the Italian Left propose to hire 40,000 health workers over the next three years “to bring the staff back to pre-crisis levels, at the same time reducing spending on precarious work, external collaborations and outsourcing of services”.
Action, which together with Italia Viva forms the so-called third pole, argues that the shortage of doctors can be resolved with “a more rapid career rise in the health field and an adequate remuneration for the workload and above all for the responsibilities, so as to limit at the same time the phenomenon of emigration of health professionals to foreign countries ”, a solution also proposed by the 5 Star Movement. Regarding the training of doctors, Action explains that it is “essential to adopt a specific training and work contract that goes beyond the mechanism of scholarships”.
In the program of Fratelli d’Italia and Forza Italia there are no indications, while according to the Lega the shortage of doctors is caused by the lack of turnover of retired doctors “mainly due to the limited number imposed by the university and to enrollments in the Faculty of Medicine and the number of scholarships for access to specializations, essential for being hired and included in the national health service “. The League maintains that enrollments must be free, without an entrance test.
Despite Salvini’s words, the League’s proposal still provides some barriers: «at the end of the first semester, a national test will be scheduled on questions relating only to the subjects studied (such as physics, biology, histology and anatomy). Only those who have passed all the exams foreseen in the study plan relating to the first common semester will be able to take the annual test. Students who pass the test will be able to complete their enrollment in the course of study. Those who, on the other hand, will not be able to pass all the exams of the first semester or pass the admission test will have to abandon the course of study. However, the validation of all the exams taken for other degree courses will be recognized ”.
The model that inspired the League’s proposal is the French one, which was reformed in 2020 because it had some limitations. One of the most significant problems of this model is the strong selection, imposed by the impossibility of training tens of thousands of doctors, which every year causes a certain disillusionment among students forced to change their studies. In Italy the tension linked to the admission process lasts for the time of the entrance test, in France at least six months. “Removing the limited number would risk opening the doors to less talented and motivated students and reducing the quality of teaching”, he wrote in the Sole 24 Ore Giovanni Fattore, professor of health economics at Bocconi University. “The strong selection at the entrance to medical degree courses guarantees students with high potential and the possibility for degree courses to teach in classes with few students, combining frontal training with tutoring and practical activities”.