Anyone who hears the SNS discussed, whether on television or on the radio, can only draw the conclusion that we live in chaos. Now nothing is more unfair. Our NHS continues to be one of the best in the world. Of course, it is experiencing, and not for now, enormous difficulties, the biggest of which is the lack of doctors, felt with enormous impact in filling emergency rosters at various levels of need, and in being able to provide family doctors to more than a million inhabitants. But even some emergencies with full teams are unable to respond quickly, due to too much demand. The shortage of doctors in emergency teams has various levels of demand, they need someone to receive patients and understand the severity and refer them to the most differentiated and specialized ones, who also have to be there in physical presence. To maintain an emergency department operating 365 days a year, 24 hours a day, knowing that the teams have to respect the minimum requirements required by the size of the populations they serve, many more doctors are needed than those hospitals need to respond to the daily needs of their elective activity.
An example in my specialty, the case of surgery. To carry out non-urgent consultations, and to operate on these patients, depending on the number of inpatient beds and the availability of the operating room, I need Specialists and interns in training need a minimum number of annual surgical interventions to maintain their technical skills, just as airline pilots need a minimum annual flight hours to maintain their jobs. If I have too many specialists and interns in the service, I cannot give each one the minimum number of operations that keep them effective. No hospital can size its staff based on emergency needs.
When I started my surgery internship at the so-called Civil Hospitals of Lisbon, there were 7 surgery services in 5 hospitals, but external urgency was only offered at Hospital de São José. There was no lack of human resources to guarantee urgency. But all hospitals, outside of large urban centers, are isolated hospitals, and their staff, designed for elective work, are unable, in the overwhelming majority of specialties, to have the capacity to respond to emergency needs. Let’s look at concrete examples. Beja, Évora, Guarda, Portalegre, Bragança and dozens of other cities need to have their own hospitals, and their emergency rooms open, but it will always be almost impossible to have enough staff to be self-sufficient. Whether in undifferentiated medical resources or in the different specialties required, almost all of these hospitals need to hire doctors to maintain their external emergencies.
This has been the case for a long time, not least because the Order of Doctors requires in many cases a ratio of doctors required to be physically present in relation to the populations they serve, exaggerated numbers, which if not met lead to the closure of emergencies. It was these obvious needs to hire doctors for the task that led to the high dependence on workers and which led to the creation of a parallel system within the SNS based on precarious links and market logic. This situation weakens the state’s ability to plan, direct and retain its own teams, compromising institutional sovereignty and the continuity of public service.
My colleagues who decided to choose a “career” as a laborer, and amazingly it is already 25%, are not committing any illegality, they are just, helped by employer companies that facilitate their placement, taking advantage of the logic of the market. But in addition to this possible 25%, who only work on task, there are many others who complement their jobs in the NHS with more sporadic tasks. Therefore, the workers are not a homogeneous group, they do not represent the same interests, they do not have the same philosophy of life.
A worker who accumulates his activity within an SNS, based on the hierarchy of competence, in multidisciplinary and supervised medicine, with the sporadic exercise of tasks, has at least the advantage of remaining more updated, more competent. The staff member who has practiced medicine exclusively in this way can be useful because his actions help to keep emergencies open, but do not contribute to their quality.
For those who argue that workers should be integrated into the SNS, they forget that they chose exactly the opposite. Even integrated into the new specialty of Emergency Medicine – but with what skills? –, they will never be able to earn what they earn from the task. At this stage, the SNS is, in fact, hostage to this way of working. He is a hostage to the groups that distribute workers to the hospitals that need them, earning millions on a percentage basis. There will never be a career as a profession, even for those who do this way of practicing medicine 100%.
It is incomprehensible to me that this option, which lives solely on the logic of keeping certain emergencies open or closed, can override a logic of quality of the services it provides. A surgeon who decides to just work on a task, being able to operate on a patient who then doesn’t even follow up, who he won’t be able to help in case of a complication, should be banned from existing.
I end with two or three ideas. As an option for the needs of workers. To receive patients in the emergency room we need young doctors at the beginning of their careers. All specialty interns, of all specialties, were required to do 12 hours of external emergency care at all stages of their internships in their training hospitals. Having young doctors, even if they are a minority, not wanting a specialty because they want to opt for a “career” as a staff is depressing.
Not forcing young, recently graduated specialists not to spend a minimum period of two years working in the SNS, other than exclusively, is incomprehensible for two main reasons: because they do not yet have the capacity to be autonomous outside of a work environment with a strong hierarchy of skills, where they can still have supervision that helps them progress, and because they would be a reinforcement of the human capabilities of the SNS.
In my time it was like that. There were two types of experts after successfully attaining the degree after passing the final exam. He was a hospital specialist. To register as a specialist with the Order of Doctors and be completely autonomous, a specific exam was necessary, much more demanding than the Order. And the difference was obvious, in the final exam of the hospital internship no one failed, in the bar exam, even when done years later, the failure rate was huge.
When the Order of Doctors gave up its exam and agreed to the single exam, what was expected happened, the demand was lowered but no one failed it. Forcing young specialists to stay for two years and practice in a hospital setting can resolve the lack of human resources in many specialties, but my dear readers, it continues to guarantee greater competence of these same specialists and a better quality of the medicine practiced. It’s better for the sick.
Let’s look at my personal case. I was a general surgery specialist at the age of 30, and a surgeon on the staff of the then HCL after a public competition in which 84 candidates competed for 12 vacancies. A very demanding competition with three tests, a jury of five members, three of whom must be at the top of the hospital career ladder. I came in second place, but I continued to work in my service, under the supervision of my hierarchical superiors, operating only on patients that my bosses thought I already had the competence to do so. I know those were different times, and I’m not one of those who say that in my time it was good.
Today the criteria are different, but there is one thing that remains the same. Training a specialist, not just in general surgery, is a responsibility of the NHS. There are six years of supervised work, in an environment with a strong hierarchy of skills, but paid work, although poorly paid. There are six years of course and another six or seven, always in NHS hospitals that cost all taxpayers a lot of money. Don’t doctors have any obligation to give back to society? I really think it was a civic duty, a moral and ethical obligation in a democratic society.
Of course, the Medical Association should have a clear position, a constant concern with the quality of medicine practiced in Portugal, and return to giving medical careers the dignity and importance they had in the past. Oppose directly, to what can be imagined as a “career” of workers, synonymous with discontinuity in care, with enormous clinical risk and with a huge impact on the culture of care and teaching.
As I am or was a surgeon, I can’t resist quoting a great HCL surgeon, named Borges de Almeida, who said with irony and great humor: surgeons are like bulls, they are only dangerous when isolated! Today more than ever, quality medicine practiced in isolation is dangerous for patients. This is what we have to face head on. Major structural changes to our healthcare system. We cannot continue to discuss this system solely based on ideological struggles, much less partisan ones. Nobody owns miracle solutions. Wouldn’t focusing on emergencies and worrying about quality be a good principle?
Surgeon. Write with the old spelling