Medical residency training and university teaching by primary care paediatricians in the Basque Country in 2023: are they satisfied with the recognition of their work as educators?

INTRODUCTION

The Asociación Vasca de Pediatría de Atención Primaria (AVPap, Basque Association of Primary Care Pediatrics) has conducted a survey of its members to determine their involvement in training medical intern-residents (MIRs) in family and community medicine or pediatrics and undergraduate medical students and to analyze the characteristics of these activities.

MATERIAL AND METHODS

Survey carried out by means of a Google Forms questionnaire distributed to the members of the AVPap through its mailing list in May-June 2023. The number of members of the AVPap at the time was 320.

The questionnaire comprised 15 items (Appendix 1). Participation was anonymous and the questionnaire collected data on the province where the respondent was located, the sex and age of the respondent and the characteristics and perceived recognition of their activity teaching medical residents (in pediatrics and family medicine) and/or medical students (in the subject of pediatrics).

Submitting a response was interpreted as providing informed consent to participation.

RESULTS

We received 92 responses, 87% from female clinicians (80 female, 12 male). Most respondents (33%) were aged 51 to 60 years, 31.5%, less than 40 years, 20.5% 40 to 50 years and 15% more than 60 years. When it came to geographical location, 54.5% (50) of respondents resided in Vizcaya, 31.5% (29) in Gipuzkoa and 14% (13) in Álava.

Of all respondents, 52.17% (48) were involved in the training of pediatrics residents and 75% (69) in the training of family medicine residents. Eighty-two clinicians (89% of the total respondents) trained residents, either in family medicine, in pediatrics or both. Fifty-one (55.5%) of respondents trained medical students.

Pediatrics residency instructors

When it came to the type of teaching activity, of the subset of clinicians who reported training pediatrics residents, 1% performed the role of primary clinical supervisors. A majority (39%) were supporting clinical instructors and 28% reported that they provided MIR training but did not have a formal role as instructors. The latter situation was most frequent in Álava, where it amounted to 54% of respondents, and least in Guipúzcoa, where it amounted to 14%. Table 1 presents the distribution by province.

Table 1. Current situation in the recognition of the clinical instructors of medical residents in primary care pediatrics
Province	Primary supervisor	Supporting instructor	No formal role	None	Total
Vizcaya	1	17	15	17	50
Guipúzcoa	0	15	4	10	29
Álava	0	4	7	2	13
Total	1 (1%)	36 (39%)	26 (28%)	29 (32%)	92

Medical school instructors

In the autonomous community of the Basque Country, there are 5 units offering MIR training in pediatrics: Cruces, Basurto, Galdakao, Álava and Donostia. Table 2 presents the characteristics of the affiliation and recognition of primary care pediatricians (PCPs) in each teaching unit.

Table 2. Characteristics of the affiliation of the instructors of students of pediatrics at the different teaching units
Teaching unit	Associate professor	Collaborating clinician (venia docendi)	Certificate	No information	Total
Cruces	0 (0%)	5 (20%)	6 (24%)	14 (56%)	25
Basurto	0 (0%)	10 (66%)	1 (7%)	4 (26%)	15
Galdakao	1 (12%)	2 (25%)	2 (25%)	3 (37%)	8
Álava	0 (0%)	7 (44%)	2 (13%)	7 (44%)	16
Donostia	0 (0%)	1 (4%)	8 (35%)	14 (61%)	23
Total	1 (1%)	25 (29%)	19 (22%)	42 (48%)	87

Satisfaction with teaching residents and medical students and recognition of teaching activity

As can be seen in Table 3, most respondents expressed a low level of satisfaction in regard to their teaching activity in both settings (MIR program and undergraduate medical education).

Table 3. Perception of primary care pediatricians of the recognition they receive for the training in pediatrics provided to undergraduate medical students and residents
Perceived recognition	MIR instructors	Undergraduate medicine instructors	Overall
Sufficient	7 (8%)	7 (14%)	14 (10%)
Indifferent	16 (19%)	16(31%)	32 (24%)
Insufficient	61 (73%)	28 (55%)	89 (66%)
Total	84	51	135
MIR: medical intern-resident.

When we analyzed the level of satisfaction of primary care pediatricians based on whether they provided residency training exclusively to pediatric residents, exclusively to family medicine residents or to both, we found that all considered that they received insufficient recognition. The degree of dissatisfaction varied and was somewhat lower in those who trained only pediatric residents, although the differences were not significant, as can be seen in Figure 1.

Figure 1. Differences in the satisfaction of primary care pediatricians depending on whether they taught residents in pediatrics, residents in family medicine or both.

Other characteristics of teaching PCPs

Of all respondents, 33 (36%) held an official level 3 certificate in Basque language and 13 (14%) had a doctoral degree.

Open-ended questions in the survey

Offering respondents the option to add comments allowed us to learn some aspects that were already hinted at in the closed questions, both in relation to the training of residents in the MIR program and of undergraduate medical students. Below are some of these comments:

Instructors of pediatrics MIR residents

The pediatrics MIR rotation should last at least 6 months split over the first 3 years of the residency. Training for only 3 months, especially considering the rest periods granted after on call shifts and other breaks, is not enough to perform autonomously as a primary care clinician.

Instructors of family medicine MIR residents

I take on family medicine residents for their primary care rotation 2 to 3 times a year. I do it for the sake of my teaching colleagues and for the residents, so they do not have to travel to a different facility. In the past, they used to notify me of upcoming rotations and requested my agreement and subsequent evaluation. Now they don’t even do that. They don’t acknowledge me in any way.

Instructors of university medical students

As pediatricians, they make us host medical students for a month without any recognition or appreciation.

The hours recognized in the venia don’t even come close to the hours actually spent training the students on site. In addition, each university hospital estimates different amounts of hours for trainees, but this makes no difference in the recognition of the involved clinicians.

I was not allowed to access a university teaching position because I was employed in primary care. I had to file a complaint to have them change the criteria applied to the filling of the vacancy.

I teach 6th year students, and I am not a MIR instructor. I don't know if my role is that of a supporting clinical instructor because no one has told me. I’ve been granted a venia docendi for fewer hours than the hours I actually teach. Nobody is asking me to evaluate the students in any way. I don’t have to report whether they show up to the clinic or not. We do not have a training plan outlining the minimum knowledge and skills that students must gain in the time they spend in our clinic.

I like teaching and I feel it is my duty to do so in the way that I wish I had been taught. I admit that I would like at least a bit of recognition for doing it.

I have previously had students in the clinic without having received any recognition for it, which I felt was deeply unfair, and I have taken this up with the university.

Overall recognition. We must advance in the official recognition and remuneration of teaching in the primary care setting. It should not remain a merely altruistic activity.

It just seems impossible to make any headway in gaining recognition as an instructor…

DISCUSSION

All PCPs in the Basque Country were eligible for participating in the survey. Given that there were 320 in total and we received 92 responses, the survey reflected the views of 29% of the pediatricians in the Basque Country. As regards the different provinces, according to data from the Statistics Portal of the Ministry of Health¹, of the 320 pediatricians in the Basque Country, 169 (53%) are in Vizcaya; 107 (33%) in Guipúzcoa and 44 (14%) in Álava. The distribution was similar in the surveyed sample: 54.5% were in in Vizcaya, 31.5% in Guipúzcoa and 14% in Álava. Thus, the sample was representative in this regard.

The legal framework underpinning teaching in primary care centers in the autonomous community of the Basque Country is based on the existing agreements between the Basque public health system (Osakidetza) and the public university of the Basque Country (UPV/EHU). The earliest one dates from 2008. The scope of this agreement was limited to the practical training of students in specific hospitals, which were from that moment referred to as university hospitals. The hospitals subject to this agreement were the Hospital Donostia in Guipúzcoa, the Hospital de Basurto and Hospital de Cruces in Vizcaya, and the Hospital of Txagorritxu in Vitoria (Álava).²

A further step was taken in 2012, when teaching was extended to primary care centers of the Osakidetza. From then on, the practical training of medical students in the subject of pediatrics was not only carried out by hospital-based pediatricians, but also by PCPs. This agreement came into force in the 2012-2013 academic year. Thus, 106 settings came to be considered “university” centers: the four university hospitals (Álava, Cruces, Basurto and Donostia), the General Surgery and Detoxification units of the Hospital Galdakao-Usansolo Hospital, the primary care centers of Bilbao county, Ezkerraldea-Enkarterri county, Interior county, Uribe county and Donostia county and the integrated care organizations of Alto Deba, Bajo Deba, Bidasoa and Goierri-Alto Urola and Álava county.³ Undergraduate training also started to be offered officially at the network of mental health centers of Álava, Vizcaya and Guipúzcoa and the psychiatry and neurology units of the public hospitals of the Osakidetza.⁴

Ten years later, in 2022,⁵ the agreement was renewed again. One important aspect introduced in the new agreement was the recognition of the work of clinicians training undergraduate medical students. The text of the agreement states: “In recognition of their contribution to undergraduate training, health care professionals who have no existing employment relationship with the UPV/EHU and who regularly participate in such teaching activities shall be entitled to recognition as either 'Academic Teaching Collaborator' or 'Clinical Instructor' (granted teaching authority [venia docendi]) by the UPV/EHU. Such recognition shall be conferred by UPV/EHU in accordance with the regulatory framework governing these positions, and shall be considered as a merit in the competitive scoring system applied to the appointment of Clinical Associate Professor positions as referenced in the sixth clause of this Agreement. Additionally, this recognition shall facilitate preferential access to training programs and services offered by UPV/EHU, and shall be considered in internal promotion competitions and established professional incentive mechanisms.”⁶ This official recognition, which should apply to all PCPs who train medical students in the subject of pediatrics, was actually only granted to 29% of respondents, while 22% reported that they received a certificate for this activity and 48% (which increases to up to 61% depending on the teaching hospital), no recognition at all. The only respondent who reported an official role as associate professor was employed at the Hospital de Galdakao, which does not have a pediatrics department. In all other centers, the only clinicians that had official positions as associate professors were hospital-based pediatricians.

This situation is incongruous, as much of the training that medical students receive correspond to activities within the scope of primary care pediatrics, which should be reflected proportionally in the faculty of the medical school.

The situation in other autonomous communities in Spain varies widely. A recent competitive process to fill vacancies in the Universidad de Sevilla did not allow primary care pediatricians to apply for associate professor positions,⁷ while in the Universidad Complutense de Madrid primary care clinicians have been able to access these posts since 2014: “Since 2014, primary care pediatricians have been included as associate professors in the Department of Pediatrics of the Universidad Complutense de Madrid, and  medical students (years 5 and 6) have had the opportunity to have rotations in the primary care pediatrics clinics of the Hospital General Universitario Gregorio Marañón.”⁸

The authors who described this experience in the training of medical students in primary care (PC) concluded with the following reflections: “Medical students rate the PC Pediatrics rotation very highly. They consider that they learn basic aspects of the management of children, families and the most frequent diseases as well as other essential nontechnical aspects. Learning in the outpatient setting is complementary to learning in the hospital and both are necessary to achieve a comprehensive training in Pediatrics. Rotations in PC allow students to learn basic clinical skills with real patients, which are harder to acquire in the hospital, and skills in other areas such as health prevention and promotion or the biopsychosocial approach to disease. Therefore, the PC pediatrics rotation should be included in the medical school curricula of all Spanish universities and integrated with hospital-based rotations with specific objectives. To achieve this, it would be best to integrate the PCPs as professors of pediatrics at the universities.”⁹

This is not what is happening in the Basque Country. In the case of Guipúzcoa, a census of medical specialists with permanent positions and active employment in the Osakidetza health system published in 2020¹⁰ found 16 who held doctoral degrees. Of this total, 5 were PCPs and 11 pediatric hospitalists. Of the PCPs, none had a faculty position in the university, compared to 80% of hospital-based pediatricians.

In our survey, 13 respondents had a doctoral degree (14%); in the Basque Country, to access positions requiring knowledge of Euskera, applicants must have the level 3 language certificate, a requisite satisfied by 33 of respondents (36%), so there would be no barrier in that regard for these clinicians to become university professors, provided the opportunity.

The Strategic Framework for Primary Care and Community Medicine¹¹ proposes that PC professionals teach subjects in medical degree programs and to facilitate their work as instructors. The purpose of Action F.1.3 is to facilitate teaching by PC professionals: “To promote the necessary regulatory changes, in coordination between the Ministry of Health, Consumer Affairs and Social Welfare and the Ministry of Science, Innovation and Universities, regarding the accreditation of university faculty, adapting the criteria to the standards of care in the field of PC and facilitating the incorporation of PC practitioners to the academic staff of universities”. Action F.2.3 states the need to involve PC professionals in university teaching, specifically mentioning Pediatrics: “Review of the educational curricula of the specialties associated with PC (Family and Community Medicine, Family and Community Nursing, Pediatrics, Pediatric Nursing, Midwifery...), with special emphasis on strengthening competence in community medicine and health care equity”.

When it comes to MIR training in Spain, in 2022, at the national level, there were 6612 residency spots in PC (57.5%) and 4906 spots in hospitals (42.5%),^1-12 so the same distribution should apply to the instructors. In addition, there is no legal or organizational barrier for PCPs to be MIR instructors or primary supervisors.¹³ Furthermore, the Strategic Framework for Primary Care and Community Medicine,¹¹ which has been endorsed by every autonomous community, including the Health Administration of the Basque Country, proposes a longer PC rotation. Action F.2.2 in this strategic framework “[proposes] to the National Commission of the specialty of Pediatrics and its subspecialities the inclusion in the official medical curriculum of a mandatory 6-month rotation in PC and the possibility of extending it up to twelve months, on a voluntary basis.”

Primary care pediatrics is isolated from the institutions responsible for medical education at both the undergraduate and postgraduate levels, which is the reason why primary care clinicians are dissatisfied with their teaching activity in relation to both residents and medical students.

These pending regulatory changes and changes in the attitude of the overall field of pediatrics towards PCPs should lead to an increase, in the shortest possible time, in the number of PCPs who are the primary clinical supervisors of pediatric residents and associate professors in the subject of pediatrics.

CONCLUSION

• Primary Care Pediatrics is not represented adequately in MIR training or in the undergraduate medicine curriculum.
• Primary care pediatricians are dissatisfied with the recognition of their work in MIR training and undergraduate medical student training.
• Some university hospitals do not comply with the obligation to grant venia docendi (formal authorization and recognition of the teaching role) to clinicians who collaborate in the training of medical students.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare in relation to the preparation and publication of this article. No funding was allocated to the project.

AUTHORSHIP

All authors contributed equally to the development of the published manuscript.

ABBREVIATIONS

AVPap: Asociación Vasca de Pediatría de Atención Primaria (Basque Association of Primary Care Pediatrics) · MIR: medical intern-resident · PCP: primary care pediatrician · UPV/EHU: Universidad del País Vasco/ Euskal Herriko Unibertsitatea.

REFERENCES

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