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Vol. 14. Issue 3.
Pages 150-154 (May - June 2018)
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Vol. 14. Issue 3.
Pages 150-154 (May - June 2018)
Original Article
DOI: 10.1016/j.reumae.2016.11.005
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Progress of the Attractiveness of Rheumatology Among Medical Speciality Training Candidates (MIR) in Spain
Evolución del atractivo de la Reumatología entre los electores a plazas de médico interno residente
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José Luis Andréua,
Corresponding author
jlandreu@ser.es

Corresponding author.
, Lucía Silva-Fernándezb, Tobias Gallac
a Servicio de Reumatología, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
b Sección de Reumatología, Complexo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, Spain
c Theoretical Physics, School of Physics and Astronomy, The University of Manchester, Manchester, United Kingdom
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Abstract
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Statistics
Figures (1)
Tables (2)
Table 1. Number of Order of Choice of the First Position, Median and Last Position in Rheumatology by Candidates for Medical Specialty Training (MIR) in Calls From 1983 to 2014.
Table 2. Number of Total Positions, Positions Financed by Specialty and Median According to Choice in the Different Specialties by Candidates for Medical Specialty Training (MIR) in Calls From 1983 to 2014.
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Abstract
Objective

To describe the progress of the attractiveness of rheumatology at successive MIR calls, from 1983 to 2014.

Methods

Candidates in the Spanish training system for medical doctors choose their specialties sequentially, ordered by their ranking in the qualifying exam (MIR). The highest, median and lowest rank of candidates choosing rheumatology training positions in every MIR call from 1983 to 2014 was requested from the Department of Management of Specialized Medical Training (General Department of Professional Regulation; Spanish Ministry of Health). To compare, the same data was requested for other specialties. In order to define and analyze the attractiveness of each specialty we introduce an ‘index of attractiveness’, based on the normalized difference of the actual median rank reported for each year and the average median obtained in 1000 simulations in which candidates choose specialties at random.

Results

Regarding the median of the election of rheumatology, the range went from 244th in 1983 to 3394th in 2008, showing a progressive increase over the years in absolute figures. A mathematical simulation allowed quantifying the difference between the observed median and what would have happened if specialties had been chosen by pure chance. Results show a tendency to recover the attractiveness of rheumatology in recent years.

Conclusions

After a sharp decline in the attractiveness of rheumatology during the last years of the 20th century, there seems to be a recovery.

Keywords:
Rheumatology
Specialization
Attractive
Resumen
Objetivo

Describir la evolución del grado de atractivo de la Reumatología en las sucesivas convocatorias MIR de 1983 a 2014.

Métodos

Se solicitó al servicio de Gestión de Formación Sanitaria Especializada de la Subdirección General de Ordenación Profesional del Ministerio de Sanidad español datos de elección de Reumatología de las convocatorias MIR de 1983 a 2014: número de orden de elección de la primera y última plazas de Reumatología, así como la mediana. A efectos de comparación, se solicitó la mediana de elección de otras especialidades. Para definir el grado de atractivo de cada especialidad, se realizó un análisis matemático de 1.000 simulaciones sobre la mediana que habría obtenido cada especialidad si se hubieran elegido al azar y se calculó la desviación entre la mediana observada y la mediana por azar generada mediante las simulaciones.

Resultados

La mediana de elección de Reumatología presentó un rango desde el número 244 en la convocatoria de 1983 al número 3.394 en la convocatoria del año 2008, observándose, en términos absolutos, un progresivo incremento a lo largo de los años. La simulación matemática permitió cuantificar la desviación entre la mediana observada y la que habría ocurrido si las especialidades se hubieran elegido al azar. Se objetivó una tendencia a la recuperación del atractivo de Reumatología en los últimos años.

Conclusiones

Tras un acusado descenso en el atractivo de la Reumatología entre los electores a plazas MIR durante los últimos años del siglo pasado, parece evidenciarse una recuperación.

Palabras clave:
Reumatología
Especialización
Atractivo
Full Text
Introduction

Rheumatology is the specialty that concerns the study, prevention, diagnosis and treatment of medical diseases of the musculoskeletal system and systemic autoimmune diseases (SAD). The definition of the specialty is provided in the order from the Spanish ministry that regulates the training that residents should receive to be granted official accreditation as specialists in rheumatology recognized by the Spanish government.1

Rheumatology practice has undergone significant changes in recent years, including the introduction of biological therapies or the widespread implementation of musculoskeletal ultrasound in routine clinical practice. On the other hand, the presence of rheumatologists in the body of professors teaching undergraduate and graduate medical studies appears to have shown a substantial increase in the last few years. Thus, it is to be hoped that there will have been greater exposure to the specialty by the most recent classes of medical undergraduates and graduates.2

The choice of a position for specialization using the ranking in the qualifying examination for Spanish medical residents (MIR) represents a unique and accurate observatory of the preferences of Spanish physicians toward the different specialties—medical, surgical and procedural—offered annually in the successive MIR calls.

The objective of this report was to describe the changes in the attractiveness of the specialty of rheumatology in successive MIR calls from 1983 to 2014, and to compare them with those observed in other specialties.

Methods

Every year, the Spanish Ministry of Health announces a call for specialized medical training. Both the total number of positions offered and those available for each specialty change from one year to another. The choice of a position on the part of candidates is sequential, according to the ranking of each in the year that the call is posted. Thus, once all of the positions in a specialty have been chosen, this option is no longer available for candidates whose rank is higher.

The median rank of the candidates who choose a certain specialty in each call could be understood to be an indicator of the popularity of said specialty in that year. The median is the rank of the candidate who chose the position in rheumatology that occupied the mean position of those places offered for said specialty. For example, if there are 50 available positions for a specialty in a given year and the 50 best candidates in that call choose that specialty, the median rank for that year would be 25. In practice, the real median would typically be higher, as it is not very likely that all the best candidates would choose the same specialty. In general, it can be understood that the lower the median rank of a specialty indicates a greater attractiveness of that specialty in that given year.

It is necessary to be cautious in properly interpreting this estimator of attractiveness. For example, if, for a certain specialty, there are 100 positions one year and 50 the next, the median in the case that all the best candidates chose that specialty would be 50 and 25, respectively. This indicates that the median by itself is not a valid quantitative indicator of attractiveness for comparing the popularity of specialties over the years.

To rectify this situation, we created a normalized popularity index based on the difference between: (1) the mean median obtained by 1000 computer simulations in which the candidates chose the specialty at random and (2) the real median of each specialty for each year. This difference was appropriately normalized in relation to the total number of positions for each year.

To carry out this simulation, we asked the Department of Management of Specialized Medical Training of the General Department of Professional Regulation of the Spanish Ministry of Health, Social Services and Equality to provide data on the choice of the specialty of rheumatology in the MIR calls from 1983 to 2014. Specifically, we requested the number of positions of rheumatology offered each year and the highest and lowest ranks, as well as the median rank, of candidates choosing rheumatology in each MIR call. To enable comparisons with other specialties, we also asked for the number of positions offered and the median rank for cardiology, dermatology, endocrinology, internal medicine and allergology, as well as the total number of positions offered encompassing all of the specialties in each call (Ntot). The simulation shows the choice of the best Ntot of the MIR candidates for each year. In the simulation, the candidates choose a specialty of among the 6 named above on which they had data, and a seventh option referred to as “other”, which includes all the other specialties available for the MIR on which there was no data, and including those candidates who opted for not choosing a position in each call.

In the simulation, the candidates chose the specialty at random. The possibility of choosing a certain specialty, including “other”, concludes when all the available positions for that specialty have been chosen. From that point on, the random selection in the simulation is restricted to the other specialties. At the end of each simulation round, each candidate of the Ntot will have been assigned a specialty (including the possibility of “other”).

After each simulation, the median rank for each specialty was calculated. As the choice was random, this median varied from one simulation to another. Subsequently, we calculated the mean of the medians of 1000 independent randomly assigned simulations. This generated a mean median for each specialty for each year.

The popularity index was generated by comparing the median obtained at random with the real median for each specialty for each year. If the real median was lower than the randomly produced median, it could be considered that the specialty was popular; otherwise, if the real median was higher than the randomly generated median, it could be considered that the specialty was not popular.

To achieve a normalized quantitative measure that can be compared over a period of years, we utilized the following popularity index:

It could be that the outcome numerical measure of the simulation would change if we utilized the data relative to all of the specialties included in the “other” category. However, we would not expect changes in the shape of the curves. As a measure of verification, we calculated another simpler popularity estimator that consisted in dividing the negative median of each specialty by the number of total positions available each year. We observed that the qualitative behavior (curves) of this simpler index was similar to that obtained by simulation.

Results

Table 1 shows the number of the first position chosen, the median and the number of the last position chosen in the specialty of rheumatology in the calls from 1983 to 2014. The best rank in the order of choice of the first position in rheumatology was in the 1984 call, in which number 2 of the MIR candidates chose that specialty, whereas the call in which the first position in rheumatology was highest was that of 1999, in which the first position chosen was number 995. With respect to the number with which the last position offered was chosen, it ranged between number 629 in the 1984 call and number 4913 in the calls of 2007 and 2012. Concerning the median, the range falls between number 244 in the 1983 call and 3394 in the call of 2008; it can be observed that, in absolute terms, there is a progressive increment over the years.

Table 1.

Number of Order of Choice of the First Position, Median and Last Position in Rheumatology by Candidates for Medical Specialty Training (MIR) in Calls From 1983 to 2014.

Call  First  Median  Last 
1983  244  648 
1984  297  629 
1985  22  361  770 
1986  109  346  649 
1987  100  614  1258 
1988  30  615  1538 
1989  232  1077  1955 
1990  107  1147  2133 
1991  64  1073  1772 
1992  152  1810  2591 
1993  157  1612  2836 
1994  11  1517  3488 
1995a  949  2131  2489 
1996a  2156  2621 
1997a  31  1975  2431 
1998a  729  2140  2733 
1999a  995  2219  2643 
2000a  757  1926  2436 
2001  46  2382  3010 
2002  159  2626  3415 
2003  338  2656  3882 
2004  654  2704  3552 
2005  963  2814  3903 
2006  70  3014  4221 
2007  26  3203  4913 
2008  489  3394  4760 
2009  287  3117  4714 
2010  194  2835  4184 
2011  12  2785  4830 
2012  56  2678  4913 
2013  34  2470  4683 
2014  324  2682  4858 
a

In these years only the positions assigned in the general call were taken into account, excluding those assigned in the specific calls for family and community medicine, which were directed to those who graduated from medicine after January 1, 1995.

As the median is influenced not only by the attractiveness of the specialty among the MIR candidates, but by the total number of positions and the number of positions offered in each specialty, the mathematical simulation utilized enabled the quantification of the deviation between the median observed and the one that would have resulted if the specialties had been selected by pure chance. Table 2 shows the total number of positions offered, the positions offered in each specialty and the medians according to choice in rheumatology, as well as dermatology and cardiology (currently considered to be highly attractive among MIR candidates), internal medicine (a specialty that was often chosen in the 1980s), endocrinology (a medical specialty that currently has a somewhat greater attractiveness than rheumatology, but less than dermatology and cardiology) and allergology (a specialty that has a moderate attractiveness at present). Fig. 1 shows the change in the differential of the median observed as opposed to that calculated with random selection in rheumatology versus the other specialties analyzed. There is a trend toward recovery of the attractiveness of rheumatology after a nadir seen at the end of the 1990s. From a graphic point of view, there are 2 upward slopes: one very steep starting around 2000 and the other, with a shorter duration, that started in 2008 and with an apparent plateau effect that commenced in 2010.

Table 2.

Number of Total Positions, Positions Financed by Specialty and Median According to Choice in the Different Specialties by Candidates for Medical Specialty Training (MIR) in Calls From 1983 to 2014.

Call  Total positions  RheumatologyCardiologyDermatologyInternal medicineEndocrinologyAllergology
    Positions  Median  Positions  Median  Positions  Median  Positions  Median  Positions  Median  Positions  Median 
1983  1486  24  244  19  334  19  235  98  375  15  174  13  438 
1984  1353  30  297  17  150  14  219  95  302  11  229  12  359 
1985  1335  36  361  17  205  20  163  93  465  15  129  12  484 
1986  1734  18  346  23  238  27  295  70  666  16  222  38  569 
1987  2288  37  614  30  385  38  212  90  986  27  183  35  416 
1988  3060  40  615  40  249  42  301  174  1753  33  378  34  628 
1989  3928  33  1077  50  424  42  282  182  1998  33  596  39  1012 
1990  4025  40  1147  60  390  43  133  192  1988  34  272  43  1017 
1991  3886  32  1073  65  331  41  427  196  1866  35  224  38  1235 
1992  4277  40  1810  76  347  43  307  203  1967  42  178  42  1922 
1993  4306  42  1612  83  241  45  518  212  1619  40  265  43  2309 
1994  4442  33  1517  88  365  46  425  212  1733  31  244  42  2641 
1995a  3907  42  2131  75  170  47  323  211  1561  35  444  45  2381 
1996a  3333  40  2156  75  207  48  457  217  1513  31  424  42  2445 
1997a  3170  40  1975  97  232  49  393  217  1474  28  290  41  2166 
1998a  3194  42  2140  97  289  51  376  224  1413  30  448  44  2221 
1999a  3201  40  2219  97  355  52  403  228  1782  29  368  47  2378 
2000a  3526  37  1926  101  208  54  343  229  1941  34  579  49  2424 
2001  5242  39  2382  102  259  56  347  232  2093  44  861  49  2895 
2002  5417  39  2626  104  284  57  327  238  2264  47  826  47  3099 
2003  5661  41  2656  114  318  57  297  239  2542  52  808  49  3359 
2004  5480  43  2704  111  284  54  217  247  2797  51  768  48  3591 
2005  5717  43  2814  119  304  58  237  261  2782  55  721  54  4285 
2006  5804  44  3014  129  330  64  536  265  2835  56  792  51  4435 
2007  6216  48  3203  144  422  69  326  293  2624  62  1151  56  4625 
2008  6706  48  3394  153  481  74  282  324  3339  68  1448  58  4707 
2009  6941  51  3117  158  624  76  306  342  3575  75  976  59  4911 
2010  6873  49  2835  158  534  83  391  345  3282  75  1419  60  4933 
2011  6704  52  2785  156  557  81  402  338  3477  75  1431  57  5036 
2012  6349  50  2678  153  427  77  430  313  3238  76  1915  44  4705 
2013  5920  48  2470  151  447  77  312  300  3050  73  1485  46  4617 
2014  6017  50  2682  154  611  79  354  294  2695  72  1458  37  4492 
a

In these years only the positions assigned in the general call were taken into account, excluding those assigned in the specific calls for family and community medicine, which were directed to those who graduated from medicine after January 1, 1995.

Fig. 1.

Changes in the differential of the median observed as opposed to that calculated with random selection in rheumatology versus the other specialties analyzed.

(0.13MB).
Discussion

The system for the choice of MIR positions is characterized as being centralized, is absolutely meritocratic and is extended throughout all of Spain. This selection system, governed by the order of preference of the candidates, represents an extraordinarily precise vantage point from which to view the attractiveness of the different specialties among physicians who graduated from Spanish medical schools, who represent the main body of candidates for MIR positions. Our study demonstrates a severe crisis in the attractiveness of rheumatology, which appears to be recovering in recent years.

It is difficult to define the causes responsible for the profound deterioration in the attractiveness of the specialty that commenced at the end of the 1980s. Rheumatology went from being an attractive specialty, that was chosen by MIR candidates who ranked among the very first, to be one of the least demanded specialties. This all occurred with no relevant change in the content of the specialty. The lack of interest in rheumatology that started to take shape at the end of the 1980s had a clear impact on the advice that recent medical graduates received from residents and young rheumatologists, immersed in an imminent future of unemployment and precarious contracts.3

The specialty of rheumatology is essentially clinical. There are no complex techniques, like digestive endoscopy or bronchoscopy. It is based on the specialization of the work, as in other medical specialties like dermatology, endocrinology, allergology, medical oncology and neurology. It has the added attractiveness that the field includes the management of SAD,1 and is the medical specialty that specifically trains its residents in the management of the complex situations presented by patients diagnosed with those processes.

Over the last 20 years, there have been substantial changes that may be responsible for the apparent recovery of the attractiveness of rheumatology: the introduction of ultrasound in rheumatic diseases and of biological agents, as well as a greater presence of rheumatologists on medical faculties.

The extraordinary efforts of the school of ultrasound of the Spanish Society of Rheumatology (SER) have added a sixth sense to the examination of the musculoskeletal system performed by rheumatologists,4,5 adding arthrocentesis, capillaroscopy, guided injections, the study of microcrystals and synovial and salivary gland biopsy, a technique that many rheumatologists consider to be essential to our activity,4 although it is not recognized as such by the official training guidelines.1

Another point of inflection is the introduction of biological therapy, which has revolutionized the management of diseases like rheumatoid arthritis, ankylosing spondylitis, nonradiographic axial spondyloarthritis and psoriatic arthritis. The utilization of biological therapies has signified a profound change in the prognosis of our patients in terms of control of symptoms, quality of life and intermediate and long-term prevention of structural and functional deterioration.6 For the first time in the history of the specialty, the administrators of hospitals have focused on rheumatic patients as a budgetary problem to be taken into account. But, for the present purposes, it has meant that medical students have witnessed the clinical role of a specialty with enormous potential to modify the outcome of many patients.

This takes us to the last factor of the equation: the perception that medical students and future MIR candidates become acquainted with the specialty of rheumatology throughout their training. In this respect, the presence of rheumatologists on the undergraduate teaching staff is fundamental. Their comportment with undergraduates and what they transmit to students results to a great deal in conveying the attractiveness of rheumatology among MIR candidates. If rheumatologists are capable of transmitting its added value, their enthusiasm and its health outcome, it is unquestionable that the attractiveness of the specialty will continue this upward trend, as recent data seem to indicate. For this purpose, programs like Reumacademia, endorsed by the SER, are of maximum strategic importance when it comes to promoting the presence of rheumatologists on the faculty of medical schools.2

The reduced attractiveness of the specialty of rheumatology is not a question involving Spain alone, and has been the subject of reflection in Canada, the United States and the United Kingdom.7–10 Surveys in different countries have demonstrated that the opportunity of being able to complete a rotation in rheumatology during the period of core studies in residency or while in medical school increases the probability that residents or students ultimately choose rheumatology as their definitive specialty.7,8 In fact, it seems to be important that exposure to rheumatology occurs as soon as possible since interest in the specialty wanes the longer this contact takes to come about.9,10

We do not know the distribution by age and sex of the candidates, or where they are from. Their expectations in terms of professional and economic aspects and hopes of future contracts are also unknown, as is the need for certain requirements for access to specialized training. It is not possible to speculate on the influence of other determining factors that might have modified the attractiveness of rheumatology over the course of years.

In short, our study indicates that the attractiveness of rheumatology among MIR candidates is recovering, and that a realistic and enthusiastic transmission to medical students and, in the future, to residents during the period of medical core studies, showing what the specialty signifies for patients, is probably the best recipe for consolidating and enhancing this recuperation.

Ethical DisclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that no patient data appear in this article.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Conflicts of Interest

The authors declare they have no conflicts of interest.

Acknowledgments

We wish to thank the staff of the Department of Management of Specialized Medical Training of the General Department of Professional Regulation of the Spanish Ministry of Health, Social Services and Equality for their indispensable help in acquiring the data on the numbers of candidates for medical specialty training (MIR) who chose the different specialties, total number of positions offered and those presented by specialty.

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Please cite this article as: Andréu JL, Silva-Fernández L, Galla T. Evolución del atractivo de la Reumatología entre los electores a plazas de médico interno residente. Reumatol Clin. 2018;14:150–154.

Copyright © 2016. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
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