Working in SpainBMJ 1998; 316 doi: http://dx.doi.org/10.1136/bmj.316.7145.2 (Published 30 May 1998) Cite this as: BMJ 1998;316:S2-7145
Medical life on the Iberian peninsula has its own particular charms as Elaine Duncan has discovered. Steering your way through the bureaucracy is not easy…
Spain's a great place - it's hot nearly all the time, and people hardly do any work. Both are true, and both are a double edged sword for British doctors seeking employment. For example, you wish to appear calm as you approach your local medical college for the fourth time in your attempt to register. With the temperature at 30½ C you arrive, instead, hot and sweaty to be told that the person processing your application has left for the day (at 1.40 pm) and will not be back for six days because of public holidays, the weekend, and other unspecified absence; and it only gets more bizarre.
The health service
Surprisingly, Spain is one of the countries in Europe whose health service most closely resembles the British NHS in structure: universal coverage free at point of access with general practitioners acting as gatekeepers. This familiarity makes it initially appealing to British doctors when set against the mysteries of insurance based systems: general practitioners have geographically based lists and are paid through various permutations of fixed salary, capitation, and incentives, although, like hospital doctors (who receive a fixed salary), they are health service employees. General practitioners should also note that primary care for children is often provided by hospital trained paediatricians working as part of the primary healthcare team.
Entry to the system
So how can a shivering Brit, fed up with freezing fog and lane closures on the M6, make the switch from blood and bitter to sangre and sangria?
Entry to the system can occur at three levels: undergraduate, after qualifying, or as a trained specialist, but transferring part way through any of these stages is not practicable.
After six years at university, Spanish medical graduates sit a national competitive exam, the MIR, to obtain a training post in their chosen specialty (see 1). This exam is open to doctors from other countries of the European Union, but competition is tough as Spain overproduces doctors. Successful candidates enter a three or four year residency programme (sometimes longer), with general practitioner trainees spending their final year in a training practice. In principle, training completed in Spain should entitle you to a certificate of completion of specialist training (CCST) back in Britain,(1) but check details with your royal college before proceeding.
Having completed your training, either in Britain or via the MIR system, your next step is obtaining a post as a general practitioner or hospital specialist. These fall into three categories: plazas en propiedad, interinidades, and sustituciones. Your aim is to obtain a permanent post - una plaza en propiedad (literally, “a place of your property”) - which is every Spaniard's dream. Once installed, it is well nigh impossible to remove someone from such a post, and any administrator contemplating doing so will probably die (literally or politically) in the attempt.
Access to these permanent posts, like all public sector posts, from judges to cooks' helpers, is organised via another exam of a type known as oposiciones. For doctors, this usually consists of an MCQ plus an assessment of merit according to a strict points system known as a baremo. It is here that the foreigner is likely to come unstuck as the design of the baremo (always a hotly disputed political issue) will not have taken into account the existence of non-Spanish applicants and many items you consider ought to attract points (such as membership of one of the royal colleges) will not count.
Unlike the MIR, oposiciones are no longer national but regional, with those regions that do not run their own health service coming under the oposiciones in the large area covered by the Insalud. Like the MIR, allocation of posts after the exam and assessment of merit is based, quaintly, on the number of marks you obtain overall.
Thus, the person with the best marks is given first choice of all the permanent posts on offer, the person with second best marks gets second choice, and so on down the line.
Many people therefore end up with permanent posts in places that are not of their choosing, far from family and friends, depending on what was left when their turn came. The only solution for these people is to await a round of transfers - traslados - and apply to be moved nearer home. Again, the choice of posts in the traslados depends on your position on a points scale, but this time there is no exam, and years of service - antigÑedad - are a key factor. Furthermore, oposiciones are held irregularly; in my region there has not been an oposicion for doctors for over eight years, with the result that no doctors have been permanently appointed in this time.
This brings us to the second category of job, interinidades. Between oposiciones, posts obviously become vacant, but these are not made available for another doctor to occupy permanently: rather, they are filled by a long term locum - un interino - and “saved up” for the next round of oposiciones or traslados. The same interino has the right to stay in the post until such time as either of these events occurs, which places him a cut above doctors working in the final category, sustituciones.
Sustituciones are locum posts in the British sense, covering sickness absence, holidays, and maternity leave. Accepting such posts may help you, over time, to accrue points and obtain an interinidad, although the path towards becoming an interino is very much subject to regional variation. Often there is a list of hopefuls held at provincial level, again arranged in order of merit according to some local rating scale. In other areas it's more of a free-for-all involving knowing the right people, to the extent that, in some areas, for general practitioner interinidades completion of general practitioner training attracts no points at all.
So what do you have to do, in administrative terms, if you want to embark on this? The grim details are discussed in 2, but I would emphasise that it is this bureaucracy, rather than the MIR or the oposiciones, that is the main obstacle you must be prepared to face if you want to work here. There are very few foreign doctors in Spain, and nobody quite knows what to do with them and their non-standard pieces of paper. Furthermore, as most of the people behind most of the desks that you are queuing at (in the heat) have got their plaza en propiedad, nobody really cares. The whole process is tiring, frustrating, and, above all, time consuming - a year out working in Spain is not an option.
There will come a point when you become extremely disorientated by the whole process. Senior male doctors will suffer most, whereas women will more quickly recognise that “glass ceiling” feeling, when nobody blatantly turns round and says “forget it” but a distinct lack of progress is being made. Much has been written about EC directive 93/16/ EEC,(2)(3) and if David Maclachlan is right this seems to run smoothly in Germany. However, Spain is not Germany, and the less assiduous, “So what are you going to do about it?” attitude to the application of EU norms, combined with a massive historical problem of medical unemployment, means that foreigners must expect obstacles.
And if you make it, what's it actually like? Hours are 8.30 am to 3 pm, and the workload, especially in hospitals, is not arduous as there are plenty of doctors. Litigation is extremely rare, although regular histrionic arguments with patients and their entourage of relatives are considered normal by all concerned. Many of your colleagues will be well trained and nothing less than heroic given the difficulties the system flings at them. That said, 40 years of fascist dictatorship do not pass without some impact, and you will encounter individuals whose notions about the purpose of the game will in no way coincide with your own. Besides this extreme, the oposicion process means that, in a department or health centre, many doctors and other staff may not have particularly wanted their posts and existing doctors will not have had any say in the selection of newcomers; thus, team spirit, like-mindedness, and cohesion are not features of the Spanish working environment.
The structure of the Spanish health service is similar to the British NHS, but obtaining work is very different - interviews and curricula vitae don't figure
High medical unemployment makes it difficult to get a post
Transfer part way through training is not possible: complete general practitioner or specialist training before arrival or be prepared to start from scratch
Some regions run their own health service; others come under the Madrid based, formerly country wide health service, the Insalud. It is important to ascertain the situation in your particular region when looking to obtain a post
Doctors' salaries and status are lower than in Britain, and hospital specialists have limited promotion prospects - the progression to consultant does not exist
No formal language requirements exist, but the bureaucratic maze acts as a highly effective screening procedure(2)
Work is available in private clinics; this is easier to obtain, but pay is poor and standards vary widely, so check carefully before committing yourself
So why would anyone choose to live and work in this exasperating, illogical country? Like I said, it's hot nearly all the time and people hardly do any work.