Hear
In recent months we have repeatedly read and heard the expression “abuse of a dominant position.” referring to the controversies and consequences generated by the deregulation of different areas, among others, health. It is worth rescuing the concept of “dominant position” as a reflection of an asymmetry of power when establishing, for example, contractual working conditions. Doctors, regardless of the health subsystem (public, social security – social works – or prepaid medicine), invariably face a “dominant position” that places them in often unacceptable working conditions.
Parallel, There is a factor of transcendent importance on the subject, which consists of the culpable and contradictory relationship of doctors with money. I am referring to the cultural “atavism” that dates back to the beginning of medical times, whose translation – still in force – is the priestly figure of the doctor. This symbolism of the professional practice of medicine as an “apostolate” has been extremely useful for those who have some “dominant position” before doctors in their various work settings. Doctors, dazzled by the idea of an imaginary liberal profession (long degraded), have fallen into this psychological trap. This has conspired against their right to develop the profession in conditions consistent with the demanding preparation and superlative responsibility of their work. Any medical activity that had a hint of “union” concern was for decades seen, by the doctors themselves, as “shameful”, located at the antipodes of the expected professional image. This scenario configured a “perfect storm”: doctors interacting with those who exercise “dominant positions” and at the same time facing their own contradictions and behavioral inhibitions. Society (the doctors’ employers, intermediaries and patients) has always required doctors to conform to the figure of the good Samaritan, so present in the collective unconscious.
In a recent editorial in La Nación (“The hidden costs of private health”), “the challenges to finance the health of the population.” It is described, in that category: “The advancement of medical technologies, drugs, devices, procedures for diagnosis, rehabilitation and defensive practices due to legal threat.” That list is absolutely faithful to reality. The highlight is that the professional fees category is mentioned, quite rightly, as the adjustment variable in the face of each crisis.
Why should society be concerned that doctors are subject to a process of impoverishment? The consequences of The degradation of doctors’ working conditions is already more than evident and even measurable. For educational purposes, I call them “the triple C medical crisis”: quantity crisis, quality crisis, and reliability crisis. The quantity crisis is evident in a fact that was unthinkable until a few years ago. The medical residency competitions do not cover available vacancies in critical medical specialties such as pediatrics, neonatology, clinical medicine, family medicine, intensive care, pathological anatomy, nephrology and child and adolescent psychiatry. The main reason, even evaluated in surveys, is the low profitability and the overwhelming demands involved in the exercise of these specialties. The Argentine Society of Pediatrics and other scientific medical societies have been warning about the clearly foreseeable consequences of this situation.
The quantity crisis has, in recent years, a new seasoning: foreign doctors who specialize in our residencies (one in three doctors who applied in 2023) no longer stay to practice in our country, because in their countries of origin the remuneration is clearly better. To this we must add the growing emigration of Argentine medical specialists in their search for better working conditions. Many guards no longer have certain specialists available 24 hours a day. Let’s see what the quality crisis means. A growing percentage of doctors enrolled in our medical schools are choosing not to join a medical residency (the best training system to train in a specialty). For the 4,930 vacancies that were offered in 2023 in the single entrance exam to medical residencies, there were 4,295 applicants. It is estimated that 30% of medical school graduates ultimately do not join residencies. The relationship between the number of applicants who finally took the exam and the space offered in the single exam in critical specialties is as follows: pediatrics and articulated specialties, 491/841; medical clinic, 433/683; general medicine and/or family medicine, 180/479; intensive therapy, 123/280. Clinical specialties in which the only service is consultation are the least chosen due to the meager income. (Source: Federal Observatory of Human Talent in Health. Ministry of Health of the Nation).
What is the reason that leads our young colleagues to make this worrying decision of not training? in a residence? Once again, the fundamental reason is low remuneration, added to hostile working conditions. The quality crisis is also seen in doctors who have already graduated from residences, who, faced with a progressive deterioration in their remuneration (salaries and fees), are forced to join the exhausting maelstrom of moonlighting. In this context, they have no time (or energy) left for the continuing medical education that our profession requires to keep us updated. Another consequence is the overload of work in hospital services in critical specialties, by reducing the number of professionals in them. This entire panorama clearly conspires against the quality of the service.
Regarding the reliability crisis, it is something very delicate, since it erodes ethical aspects of our profession. Intellectual honesty when addressing this issue forces us to admit that some professionals, faced with this very adverse work situation, resort to clearly reprehensible “compensatory” strategies and/or practices, such as over-providing and covert commercial alliances, among others.
In short, the reasons why society and its leaders should care are very clear. this topic. What has happened in recent decades, with all administrations, is that doctors do not appear on any political agenda because evidently we do not move “the ammeter” of political interest. Nor can we doctors expect too much from society, long burdened by other concerns, but also permeated by that cultural image of the good Samaritan who, unlike other professionals, is required to fulfill his “apostolate” without other considerations.
Who should lead the change that requires avoiding society this triple crisis of quantity, quality and reliability of medicine? The answer is the scientific medical societies, which urgently must become actively involved in these issues related to professional practice. Some of them are already doing it (but still on a discursive level). A large number of these societies were founded 100 years ago, when the scenario of professional medical practice was very different and access to scientific information did not have the fluidity that current technology allows. That is why its statutes were only focused on scientific and academic issues. The time has come for upgrade to, in addition to the scientific, deal with the new work challenges that the practice of medicine entails.
The impoverishment of doctors is creating an extremely serious problem in health care in all subsystems. Governments are not interested in this issue, society is distressed for other reasons and doctors have not yet found an effective way to channel this concern. All Argentines should ask ourselves: who will take care of our health in the near future?
Consulting professor of the Ophthalmology department of the Faculty of Medicine of the University of Buenos Aires (UBA). Clinic Hospital. Doctor of Medicine (UBA)
