Employment outcomes of residents of Paediatrics, 2014-2017 period

INTRODUCTION

For years, there has been a shortage of paediatrics in primary care. A proportion of the posts in primary care paediatrics are filled by physicians that are not specialised in paediatrics. This leads to delivery of unspecialised care at the primary level of care that could have repercussions in the management of children.¹ The shortage has been estimated at approximately 30%,² although a recent study calculated a proportion of 25.1%.³

In light of this situation, the Asociación Española de Pediatría de Atención Primaria (Spanish Association of Primary Care Paediatrics), its committee of medical residents and its professional working group set out to investigate the employment destinations of paediatric residents in recent years.

The project started in 2017 with the collection of data for the previous 3 years and was presented as a poster communication at the 65^th Congress of the Asociación Española de Pediatría (Spanish Association of Paediatrics).⁴ We followed this initial analysis with the collection of follow-up data, ⁵ which we present in the current article.

RESULTS

We collected data on the first destination of 75.7% of the residents that finished their training period, corresponding to the employment destination of 1668 residents in the past 4 years (Table 1).

Table 1. Proportions of medical residents for who we collected employment destination data
Year	Number of MIR positions	Number with available data	Percentage
2014	419	278	66%
2015	418	307	73%
2016	413	331	80%
2017	418	347	83%
TOTAL	1668	1263	75.7%

The proportion choosing primary care for employment in these years has decreased from 30.77% to 24.5% (by more than 6%); employment in inpatient care or hospital outpatient clinics has also decreased, in this case from 43.8% to 32.2% (by 11%), while employment in on-call and emergency shifts has increased: comparing the first 2 years to the last 2, by an average of 8.5%, as has employment in private medicine, which increased by 7%. When it came to the mean proportion for the entire 4-year period, the most frequent first destination was employment in inpatient care (37%), followed by primary care (28%) and emergency or on-call shifts (15.5%) (Table 2).

Table 2. First destination of paediatrics residents from 2014 to 2017
	Primary care	Emergency, on-call shifts	Inpatient units	Training: masters. fellowships. etc.	Private medicine	Other
2014	30.77	8.36	43.81	2.34	3.01	4.68
2015	30.29	15.96	41.69	6.19	6.19	2.61
2016	26.20	23.79	30.42	10.84	3.01	5.12
2017	24.5	17.5	32.2	8.5	10.7	6.6
Media	27.94	15.50	37.03	6.97	5.73	4.75

When it came to the employment in primary care by autonomous region in Spain, we found significant differences between regions, with the proportion ranging from 75% in la Rioja and 11.3% in Madrid, and a mean of 27.94% (Figure 1).

Figure 1. Proportion of residents with first employment in primary care, 2014-2017

DISCUSSION

We will address three questions: Is there a demand for training in Paediatrics? Where is the demand for paediatricians higher, in hospitals or at the primary care level? And, could paediatric nurses contribute to solving this problem?

Is there a demand for training in the specialty of Paediatrics?

According to the descriptive report of the Medical Intern Resident (MIR) R1 Survey of 2014,⁶ the “placement system success” is defined as the percentage of applicants that were able to obtain a training spot in their preferred specialty. To calculate it, residents were asked which specialty and facility they would have chosen if they had not been limited by their scores, that is, if all positions and institutions had been available to them. In the case of Paediatrics, the success rate is of 92%, and there is a shortage of spots, as a higher percentage of residents would have chosen this speciality if there had been more spots available (Figure 2).

Source: MIR-R1 survey 2014.

Figure 2. Percentage that chose the preferred specialty, by specialty

Another aspect we analysed was the difference between the desired positions and the selected positions. There are 5 specialties in which residents would have chosen more spots, and among them, the second with the greatest shortage of residency spots, with 5.1%, was Paediatrics (Figure 3), following only Dermatology, which is in highest demand, so that if more spots were offered, all positions would be filled while satisfying the wishes of the residents.

Source: MIR-R1 survey 2014.

Figure 3. Shortage-surplus: percent difference between the desired and the available medical residency (MIR) openings in 2013-2014

Where the demand for paediatricians greater, in hospitals or in primary care?

To assess whether the employment destinations of residents fit the demand for paediatricians, we took into account the number of positions in each setting and the employment destinations observed in our sample. According to official data from 2016, in Spain there are 6410 paediatricians employed in primary care⁷ and 4154 in hospitals,⁸ corresponding to 60.7% and 39.3%, respectively. This contrasts with the first destinations of new paediatricians, which go in reverse: 52% stay in the hospital setting and 28% enter primary care, which means that the shortage of primary care paediatricians is getting worse.

In a nationwide survey of residents in Spain,⁹ 75% reported that they thought they would work in primary care, with 43% expressing a desire to do so and 55% not minding working in this setting. The problems that they perceived in working in primary care were the low availability of diagnostic tests (30%), the excessive expectations of parents in cases of mild, common diseases (20%) and the wish to continue to do on-call shifts (20%).

There are also residents that are enthusiastic about primary care. One titled a presentation given in a meeting of the AEPap “El residente de Pediatría: entusiasmo por la Atención Primaria” (The paediatrics resident: a passion for primary care)¹⁰, and stated: “My enthusiasm may stem from the fact that we offer comprehensive care to patients and we can participate in their development and growth, tracking the progress of children in our caseload, knowing their individual and family characteristics, so that there is a deeper trust and mutual involvement in the doctor-patient relationship”.

Could paediatric nurses contribute to solve this problem?

Although in 2010 the curriculum for paediatric nursing was established and the professional category defined as “the autonomous delivery of specialised nursing services during childhood and adolescents at every level of care, including health promotion and neonatal care, care of the healthy or ill child or adolescent and rehabilitation services”,¹¹ there are still few paediatric nurses in the Spanish national health care system.

Thus, some of the salient findings of a nationwide survey were that in Andalusia the role of nurses dedicated preferentially to children did not exist, while in Madrid paediatric nurses were only found in 40% to 50% of caseloads. In the Basque Country and Murcia the percentage continued to be low, between 50% and 70%. In Aragon, Castilla-La Mancha, Galicia, Extremadura, La Rioja, Navarre and Valencia it ranged from 70% to 90% and in Galicia it was 81%. In Navarre, most paediatric caseloads have a specific nurse assigned to them, except in some small towns where the nurse divides the time between paediatric and adult patients.  And last of all, in Castilla y Leon, Catalonia, Balearic Islands, Canary Islands and Asturias, most paediatrics clinics (more than 90%) have on staff a nurse dedicated exclusively to paediatric patients.¹² Thus, at present the contribution of nurses to specialised paediatric care is limited.

According to the 2016 report,¹³ the primary care system in Spain employs 34 888 physicians and 29 441 nurses. There should be 0.8 nurses per paediatrician in primary care, a ratio that is not met in most autonomous regions.

The number of spots available each year for paediatric nursing is approximately 130,¹⁴ with nurses gaining employment both in hospitals and primary care centres, which is clearly insufficient to meet the demand for specialised nurses.

There is also a discrepancy between the nurses that care exclusively for children (paediatric nursing) and nurses caring for adult patients as well (family/mixed-care nursing). In a study that included 34 nurses, 11 paediatricians and 1004 parents of children, 99.6% of surveyed parents reported preferring a nurse exclusively devoted to paediatric care. All paediatricians shared this opinion. When it came to the nurses, only 7 (20.6%) preferred a mixed-care model (family nursing), so it is fair to conclude that in this study, a majority of qualified professionals and of the general population preferred a specific paediatric nursing care model.¹⁵

CONCLUSIONS

The percentage of residents that is employed in primary care is insufficient. The quality of the work as a paediatrician is decreasing, with an increase in on-call and emergency shifts. The percentage of residents that seek employment in private health care is increasing.

The only solution to the problem of the deficit in paediatricians is to increase the number of slots for medical residency training (MIR) and, in the case of primary care, to make the openings in the field more attractive to residents that end their training in paediatrics and its subspecialties.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare in relation to the preparation and publication of this article. Preliminary findings on the collected data were presented as an oral communication in the 66^th Congress of the Asociación Española de Pediatría, held in Zaragoza in June 6-9, 2018.

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