Tomás Cobo, a 59-year-old from Santander, has been president of the General Council of Official Medical Associations since February. He officially took office at the beginning of October in the first joint board of directors that the institution has had in its history. In the week in which the first day of the medical profession is celebrated (Saturday), he reviews the main challenges and problems of doctors in Spain: precariousness, the crisis of primary care, the pandemic, abortion , Euthanasia.
Question. In his inauguration speech he demanded a great pact for healing. What should it consist of?
Answer. We have 20 documents in the last 10 years. All the political forces have to agree to establish a strategy, we have told you a thousand times, we want you to take action and become an executive. A long-term pact is necessary that does not depend on who is in the Administration at any time.
P. With what objectives?
R. The first, pay attention and listen to health professionals. It is especially urgent in the field of primary care, which is mired in a huge crisis. It has a great disconnection with the hospital. And we have a structural problem in our National Health System (NHS) which is salaries, much lower than in Europe. There is a job insecurity that affects 50% of doctors, with contracts sometimes of days. Continuous training must be another of the great axes of this agreement. The pact for health has to defend the model we have: universal, public and free. Do we believe it? If the answer is yes, we are going to see what plan we mark to sustain it, because otherwise there will be progressively a drift towards the private sector, both of patients, who are exhausted from waiting lists, and of doctors. And it would be a catastrophe for social justice: whoever has the most money will leave.
P. Is primary care forgotten?
R. Starting with professional precariousness. You cannot pretend that a doctor with that beautiful title of family and community does not have time to get to know the family or the community.
P. Does it penalize the primary school that is not as showy as the hospitals?
R. Absolutely. One of the things we have done wrong is that excellence, the robot, is taught in medical schools. The primary school has to be embedded in the faculty and give it the importance it has, which is extreme. If you want to be a doctor and take care of the health of others, a holistic specialty is primary. And in the faculties that is not taught.
P. In his speech he also spoke of the “little understandable” differences of the 17 health systems.
R. There are portfolios and services that are different in some communities and others. Those with the most money can offer something more. The spending ceiling that everyone puts it where they want, but the base has to be common. The central administration through the state public health agency could serve as a cushion for this type of measure or scale. There are proposals or plans of the administrations that may not be efficient, but that are conditioned to political pressure, if this is studied and analyzed by a state agency to conclude if this really produces a benefit for health, many sanitary measures could come out of that pressure purely political.
P. Has the management of the pandemic been highly politicized?
R. We did not have a chart. We go through a phase that in medicine we call the golden minute. There were a few weeks of bewilderment. But by politicization I did not mean that. Every time the government changes in a community in the hospitals there is a change of manager, of administration. Again you have to explain the same thing to the medical director and the manager. That is tremendously frustrating. You have to put professional managers, with projects independent of the elections.
P. Are we coming out of the pandemic?
R. Eye. It has come to stay. We have gone from the defense phase to the attack phase with vaccination. But the messages to citizens are being too infantilized. That vaccines supplant three measures that I think are here to stay (masks, distance and hand washing) is counterproductive. The masks in places such as public transport or theaters should continue to be worn. It will be necessary to see if it is attenuated or we go to a hard variant and we return to the same ones. The vaccine has served to defend us from morbidity, but it is not even clear that it will sterilize us, we must still be very cautious.
P. In the future a shortage of doctors is anticipated, how is it solved?
R. There has to be a long-term forecast. The MIR offering has been expanded, but it should have been a forecast from years ago. But we have a pool of 7,500 doctors trained in Spanish universities who have not had access to the MIR and are in limbo. They can work in private clinics, but not in the National Health System. We have to increase the places to start looking for optimal solutions.
P. The deans warn that in five years half of the doctors who teach will retire and there is no relief.
R. There are vets teaching anatomy classes. Why? Because they have time. Doctors, when we finish, we have to do the specialty, the fight to get the place and when you get to be able to apply for a position in the faculty they ask you I do not know how many articles published. But I have not had time. We have done that wrong, because there are many doctors who would be happy to teach and do not have the necessary publications. Instead of doing the doctorate you were operating.
P. How is it possible that a woman who decides to have an abortion due to a fetal malformation has to go to a private clinic because her hospital does not treat her?
R. If it is a benefit of the National Health System (SNS), the most appropriate ways must be organized for it to be attended to. But abortion has more connotations, such as intimacy: in small places everyone knows everyone, it has to be managed discreetly and in the kindest way possible.
P. Is it necessary to review conscientious objection in abortion, as proposed by the Ministry of Equality?
R. Conscientious objection must be taken with great care. It is purely individual, but it transcends clinical management; you have to find the way. In the last 20 years we have removed the problem from us and we have referred it to an external environment. If you are not looking for solutions, each one will do what they want. If an abortion cannot be done in a hospital, the person who must solve it is a manager, not every doctor.
P. Should there be a list of objectors?
R. There may be registration, it is legal and the Constitutional Court has said so. It is a right of the Administration to have it. And from there the manager will be the one who has to organize with the head of service so that this can be addressed and we do not get into pathetic situations.
P. How does the profession deal with euthanasia?
R. We are in the same. With one difference: in euthanasia you enter standing and exit horizontally, which is much more dangerous than privatization. This should stay within the SNS. And it will have to be managed. It is true that from the code of ethics, euthanasia is not a medical act. Doctors do not participate in the death of anyone, but in life. But there is a fine thread between analgesia, terminal sedation, and euthanasia. We have to do a big action about vital testimony, which is essential: say what we want when we are fully conscious.
P. There is already a law that regulates that.
R. There is a regulation that we have to see how it is developed in the autonomous communities. From the profession, which says that euthanasia is not a medical act, we have to favor prior wills. And explain differences between therapeutic fierceness, which is not deontological, analgesia and terminal sedation. The penalty of this law is that it has been called “euthanasia and assisted suicide”, which will be few, very few.
P. It is not a medical act, but euthanasia is going to be practiced by doctors in principle.
R. It is not a medical act, another thing is that it is legal. You will not be able to report to the doctor if you do it. What is not considered is that it is ethical. But we return to this fine thread between one thing and the other.
P. There are cases in which it is very clear. Should a doctor do it?
R. Not necessarily. The doctor will be the one who has to prescribe the medication. Let’s see how it develops. Each case is different. In the case of the poor man who gave his wife the medication … what a tragedy. What if that lady had been well cared for from the social and health point of view? What if she had been cared for all day by the dependency law?
P. There are certain sectors that oppose palliative care and euthanasia.
R. They are not incompatible. Palliative care must be reinforced to the maximum. They are zero implanted. That is why we have started a law on the roof. There is little continuing medical training. We have to make an overwhelming effort and a lot of pedagogy.
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