To change the country, not to change the country

The situation of medicine students in Italy


In Italy there has been a strong debate about the faculty of medicine over the last few years: students asking for more places and a different admission exam, the government that has to control the public deficit and citizens demanding more from an efficient health system. Now, the government wants to modify the recruiting system for medical students: will it win the challenge?

The Italian Minister of Education wants to change the admission rules to the faculty of medicine in order to tackle some problems, such as the high number of old doctors, the unfair admission method and the population getting older, without forgetting the high public debt (130% of the GDP).

Figure 1.1 Physicians by age

First of all, let’s have a look at the distribution of the physicians by age (figure 1.1 and 1.2): from 2000 to 2012, the percentage of physicians who were under 30, between 45-54 and over 65 years old diminished a little, whereas there was a strong decrease of those who were between 35-44 (-18.68%) and a risky increase of those who were 55-64 (+31.98%).

Figure 2. Medical graduates
Figure 1.2 Medical graduates

The aging can be problematic if the number of graduates is lower than doctors going to retirement, as the number of physicians will decrease in the future. This phenomenon can be explained by the low level of new graduates in medicine (figure 2): from 25.28 graduated students per 100.000 people in 1980 to 11.51 in 2000. Over the last decade, this figure has been stable, even though it has diminished a little, reaching 11.14 medical graduates per 100.000 people in 2012. In absolute values, this means that in 1980, 14,264 students managed to graduate, whereas in 2000 and 2012 respectively only 6,552 and 6,631 students succeeded.

Figure 2. Medical graduates

A future challenge that the national health system will have to consider is the aging of the population: in 2013, 21.40% of the Italian population were over 65 and 6.40% over 80. In 2050, this figures will raise significantly, as over 65 will represent 34% of the population and the over 80 14%. An older population means that Italy will have to increase its healthcare budget, also hiring new medical workers.

Over the last few years, the different governments tried to reduce or to control the public expenditure, hitting also the education and in particular the faculty of medicine. The Italian State has to bear every year about € 1.5 billion to finance the studies in medicine. This means that the State spends € 248.000 .000 for the first six-year-education, as the cost per capita is € 24.800 per year and the students are about 10.000 each year. Then, for the whole specialization the State spends € 128.000 for each student.

To solve this financial problem, in Italy there is a low closed number of admission and in the last years a cutting of the scholarships for the specializing students. The immediate effects are the aging of the physicians, the risk that the new doctors will be less than those going to retirement and the escape of students abroad to do the specialization.

This last problem is quite interesting as the state finances the first six years of training and then, reducing the scholarships, induces students to finish their studies abroad and likely to work there. The result is that Italy finances the medical formation for foreign health systems. Hence, is it a really efficient way to cut expenditure or would increasing the scholarships be a better solution in financial terms?

Over the last few months, the Italian Minister of Education has been trying to change the system of medicine faculty. She proposed to adopt the so called French system: free access to the faculty and selection at the end of the first year based on the marks. Then, in this project a common first year between medicine and other similar faculties, such as pharmacy and biology, is provided. However, this idea has been criticized by students to not be realistic, impartial and a solution for other problems.

First, if government does not have enough money to finance scholarships, how is it possible to create new spaces for all new students? Or new places? Only to give you an idea, 10,000 students pass the admission test that is tried by 60,000 each year. This also implies 50,000 students not passing the first year would lose an year, so time and money.

Another problem is that without a national test, the selection could not be impartial as based on the marks of professors who could help someone in some cases, above all, if we consider that most of the exams are oral. Then, the study programs are different among the Italian universities, creating in this way an heterogeneous context.

Concerning the admission exam, in Italy it has always been criticized for its structure. Above all, there are questions about general culture such as: put in order the following mounts in order of height. Is it a fundamental question that a doctor is supposed to answer? So, a good idea would be to test basic scientific knowledge or psycho-attitudes.

Another way to reduce costs for the public system would be reducing the length of studies and increasing the number of hours in practical training (teaching hospitals), conforming to the European system. This would allow students enrolled in the final part of their studies to work in the hospitals. In this way, they would be more productive and make more experience in their fields.

Then, the decrease of the scholarships for the specialization is a really big issue, as students are forced to go abroad to study. However, the most important problem is the limited number of places for the specialization that forces students to go abroad or to wait for at least one year. Note that a graduate student can work only as a volunteer or in other fields, as the pharmaceutical, but he/she will never be hired without a specialization in the hospitals. This means that continuing the studies is a compulsory choice in this case.

In conclusion, Italy has the opportunity to not destroy an efficient health system thanks to a better formation system. Hence, it would be great rethinking about the number of places and scholarships, the inefficient allocation of resources and the unfair selection system. Hopefully, the change will be more respectful about public spending, families’ students taxes and the right to have an efficient health system. A special thanks for their suggestions to my friends Francesco, Marta and Roberta, students of medicine.

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