Exposure of Peregrine Falcons to Halogenated Flame Retardants: A 30 Year Retrospective Biomonitoring Study across North America.

Compared to aquatic ecosystem, terrestrial systems have been subjected to fewer investigations on the exposure to halogenated flame retardants (HFRs). Our study utilized peregrine falcon eggs collected from multiple habitats across North America to retrospectively explore both spatial distribution and temporal changes in legacy (e.g., polybrominated diphenyl ethers) and alternative HFRs over a 30 year period (1984-2016). The results reveal intensive HFR exposure in terrestrial ecosystems and chemical-specific spatiotemporal distribution patterns. The correlations between egg levels of the selected HFRs and human population density clearly illustrated a significant urban influence on the exposure of this wildlife species to these HFRs and subsequent maternal transfer to their eggs. Temporal analyses suggest that, unlike aquatic systems, terrestrial ecosystems may undergo continual exposure to consistently high levels of legacy HFRs for a long period of time. Our findings collectively highlight the effectiveness of using peregrine eggs to monitor terrestrial exposure to HFRs and other bioaccumulative chemicals and the need for continuous monitoring of HFRs in terrestrial ecosystems.

Modelo dinámico para proyectar la necesidad de recursos humanos en salud: anestesistas en Uruguay / Anesthesiologists in Uruguay: dynamic model to project the need of human resources in healthcare

Objetivo Desarrollar un modelo dinámico para simular la oferta de médicos especialistas y estimar la brecha especto a la demanda/necesidad en anestesiología en el sistema de salud del Uruguay. Métodos Se desarrolló un modelo de simulación dinámico determinístico implementado en el programa libre R. Se analizaron las proyecciones en el período 2011-2050 y se estimó la brecha a partir de la situación de equilibrio o desequilibrio entre oferta y demanda/necesidad. Se evaluó la calidad del modelo comparando los valores simulados con los datos históricos, con indicadores de bondad de ajuste, como la raíz del error cuadrático medio relativo (rRMSE). Se realizó un análisis de sensibilidad con respecto a los cupos de ingreso a la especialidady la tasa de crecimiento de la necesidad de especialistas. Resultados Se proyectó la oferta y demanda de anestesistas para el período considerado. Se obtuvo un rRMSE menor a 0,1, lo que sugiere que el modelo propuesto reproduce adecuadamente la dinámica de la oferta real. Para el período proyectado la situación a mediano y largo plazo es de equilibrio. Conclusión El modelo simulado presenta buen ajuste, por lo que la proyección de la oferta de Recursos Humanos (RR. HH.) representa de forma precisa la disponibilidad futura de la fuerza de trabajo. Además, el modelo representa un insumo de interés para la gestión informada sobre la necesidad de recursos humanos y las políticas de salud, dado que permite evaluar las proyecciones bajo diferentes escenarios.

Objectives The aim of this study is to develop a dynamic model to simulate the supply of specialized physicians in Anesthesiology and estimate the gap with its demand, within Uruguay healthcare system. Methods A deterministic dynamic simulation model was developed and implemented using R software. Projections for the 2011-2050 period were analyzed, and the gap was estimated based on the equilibrium state of supply and demand. The quality of the model was evaluated comparing the simulated data with historical empirical data using goodness of fit indicators, such as the relative root mean square error (rRMSE). Results The demand and supply of anesthesiologists was projected for the period under analysis. A rRMSE<0,1 was obtained, which suggests the proposed model adequately reproduces the real offer dynamics. Based on the defined gap criteria, in the medium and long-term the situation is in equilibrium state. Conclusions The simulated model presents a good fit so that the human resources (HR) supply projection represents in a precise way the future availability of the work-force. Given that the model allows to evaluate the projection dynamics under different management scenarios, the model also represents an input of the utmost interest for management knowledgeable about human resource demands and healthcare policy.

The Economic Impact of the SARS-COV-2 (COVID-19) Pandemic in Spain.

BACKGROUND: The COVID-19 pandemic has hit both the Spanish economy and the population's health hard. The result is an unprecedented economic and social crisis due to uncertainty about the remedy and the socioeconomic effects on people's lives. METHODS: We performed a retrospective analysis of the macroeconomic impact of the COVID-19 pandemic in 2020 using key indicators of the Spanish economy for the 17 Autonomous Communities (ACs) of the country. National statistics were examined in the search for impacts or anomalies occurring since the beginning of the pandemic. To estimate the strength of the impact on each of the indicators analyzed, we used Bayesian structural time series. We also calculated the correlation between the rate of GDP decline during 2020 and the cumulative incidence of COVID-19 cases per 100,000 inhabitants in the ACs. RESULTS: In 2020, the cumulative impact on the gross domestic product was of -11.41% (95% credible interval: -13.46; -9.29). The indicator for business turnover changed by -9.37% (-12.71; -6.07). The Spanish employment market was strongly affected; our estimates showed a cumulative increase of 11.9% (4.27; 19.45) in the rate of unemployment during 2020. The worst indicators were recorded in the ACs most economically dependent on the services sector. There was no statistical association between the incidence of COVID-19 in 2020 and the fall in GDP in the ACs. CONCLUSIONS: Our estimates portray a dramatic situation in Spain, where the COVID-19 crisis has had more serious economic and health consequences than in other European countries. The productive system in Spain is too dependent on sectors vulnerable to the pandemic, and it is necessary to design and implement profound changes through the European Next Generation program.

Training New Doctors in Mozambique. A Sustainable International Aid Health Program.

The collaborative project between the University of Las Palmas de Gran Canaria and the public University of Mozambique, UniZambeze, aims to strengthen the institutional and training capacities of its Faculty of Medicine located in Tete to provide new medical graduates. The essence of the program, training doctors, has the objective of improving the healthcare system and making it sustainable for the integration of new graduates into the staff of the faculty. In this work, we determine the cost of education for a new doctor and we evaluate the social benefit of the program in terms of the human capital. The program has led to the training of 199 new doctors in the 11 years of operation and is leading the way for 100 more in the next four years. The incorporation of some of them into the faculty's staff will generate new doctor graduates in the near future with a cost below 6000 EUR each in normal circumstances. These results can help to determine how much traditional international aid healthcare programs can save when investing in the education of new doctors. This program is an alternative policy for the international aid financing budgets of donor countries. Supporting teachers and native doctors in the future with private and public patronage programs can raise the efficiency per EUR spent.

Dying at home for terminal cancer patients: differences by level of education and municipality of residence in Spain / Morir en casa pacientes terminales con cáncer: diferencias por nivel de educación y municipio de residencia en España

Objective: To measure and assess differences by educational level in the place of death for cancer patients, and to determine whether patterns of geographical disparities are associated with access to palliative care services in the municipality of residence. Method: We analysed the death certificates of adults (older than 24) who died of cancer (ICD-10 C00 to C97) in Spain during 2015, either at home, in hospital or in a long-term care centre. Of the 105,758 individuals included in the study population, 75.2% lived in one of the 746 identifiable municipalities (more than 10,000 inhabitants). This individual database was combined with three economic databases at municipal level and with a directory of palliative care resources published by the Sociedad Española de Cuidados Paliativos. Multilevel models were estimated to predict the place of death according to individual characteristics. Generalised least squares regression models were then applied to the municipal effects estimated in the first stage. Results: The probability of dying in long-term care centre decreases as levels of education increase; the probability of dying at home, rather than in hospital, is higher for patients with higher education. Dying in hospital is an urban phenomenon. There are large differences between Spanish regions. Access to palliative services is only of marginal significance in accounting for the systematic differences observed between municipalities. Conclusions: Developing specific plans for palliative care, with an active role being played by primary care teams, may help improve end-of-life care in Spain

Objetivo: Medir y evaluar las diferencias por nivel educativo respecto al lugar de muerte de pacientes con cáncer en España, y determinar si los patrones de desigualdad geográfica están asociados con el acceso a servicios de cuidados paliativos en el municipio de residencia. Método: Analizamos los certificados de defunción de mayores de 24 años que murieron de cáncer (CIE-10 C00-C97) en España durante 2015, en el hogar, en el hospital o en una residencia sociosanitaria. Sobre una población total de 105.758 personas, el 75,2% vivía en uno de los 746 municipios identificables (más de 10.000 habitantes). La base de datos individual se combina con datos económicos de ámbito municipal y con el directorio de recursos de cuidados paliativos publicado por la Sociedad Española de Cuidados Paliativos. Se estiman modelos multinivel para predecir el lugar de la muerte de acuerdo con las características individuales. A continuación, se estiman modelos de regresión por mínimos cuadrados generalizados sobre los efectos municipales estimados en el modelo anterior. Resultados: La probabilidad de morir en casa, frente al hospital, es mayor en los pacientes con educación superior. Morir en el hospital resulta un fenómeno urbano. Hay grandes diferencias entre regiones. El acceso a los servicios paliativos solo tiene una importancia marginal en la explicación de las diferencias entre municipios. Conclusión: El desarrollo de planes específicos para cuidados paliativos, con un papel más activo de los equipos de atención primaria, puede ayudar a mejorar la atención sanitaria al final de la vida en España

Dying at home for terminal cancer patients: differences by level of education and municipality of residence in Spain.

OBJECTIVE: To measure and assess differences by educational level in the place of death for cancer patients, and to determine whether patterns of geographical disparities are associated with access to palliative care services in the municipality of residence. METHOD: We analysed the death certificates of adults (older than 24) who died of cancer (ICD-10 C00 to C97) in Spain during 2015, either at home, in hospital or in a long-term care centre. Of the 105,758 individuals included in the study population, 75.2% lived in one of the 746 identifiable municipalities (more than 10,000 inhabitants). This individual database was combined with three economic databases at municipal level and with a directory of palliative care resources published by the Sociedad Española de Cuidados Paliativos. Multilevel models were estimated to predict the place of death according to individual characteristics. Generalised least squares regression models were then applied to the municipal effects estimated in the first stage. RESULTS: The probability of dying in long-term care centre decreases as levels of education increase; the probability of dying at home, rather than in hospital, is higher for patients with higher education. Dying in hospital is an urban phenomenon. There are large differences between Spanish regions. Access to palliative services is only of marginal significance in accounting for the systematic differences observed between municipalities. CONCLUSIONS: Developing specific plans for palliative care, with an active role being played by primary care teams, may help improve end-of-life care in Spain.

Allocation of Residency Training Positions in Spain: Contextual Effects on Specialty Preferences.

In Spain's 'MIR' system, medical school graduates are ranked by their performance on a national exam and then sequentially choose from the available residency training positions. We took advantage of a unique survey of participants in the 2012 annual MIR cycle to analyze preferences under two different choice scenarios: the residency program actually chosen by each participant when it came her turn (the 'real') and the program that she would have chosen if all residency training programs had been available (the 'counterfactual'). Utilizing conditional logit models with random coefficients, we found significant differences in medical graduates' preferences between the two scenarios, particularly with respect to three specialty attributes: work hours/lifestyle, prestige among colleagues, and annual remuneration. In the counterfactual world, these attributes were valued preferentially by those nearer to the top, while in the real world, they were valued preferentially by graduates nearer to the bottom of the national ranking. Medical graduates' specialty preferences, which we conclude, are not intrinsically stable but depend critically on the 'rules of the game'. The MIR assignment system, by restricting choice, effectively creates an externality in which those at the bottom, who have fewer choices, want what those at the top already have. Copyright © 2016 John Wiley & Sons, Ltd.

Economic Crisis, Austerity Policies, Health and Fairness: Lessons Learned in Spain.

This paper reviews economic and medical research publications to determine the extent to which the measures applied in Spain to control public health spending following the economic and financial crisis that began in 2008 have affected healthcare utilization, health and fairness within the public healthcare system. The majority of the studies examined focus on the most controversial cutbacks that came into force in mid-2012. The conclusions drawn, in general, are inconclusive. The consequences of this new policy of healthcare austerity are apparent in terms of access to the system, but no systematic effects on the health of the general population are reported. Studies based on indicators of premature mortality, avoidable mortality or self-perceived health have not found clear negative effects of the crisis on public health. The increased demands for co-payment provoked a short-term cutback in the consumption of medicines, but this effect faded after 12-18 months. No deterioration in the health of immigrants after the onset of the crisis was unambiguously detected. The impact of the recession on the general population in terms of diseases associated with mental health is well documented; however, the high levels of unemployment are identified as direct causes. Therefore, social policies rather than measures affecting the healthcare system would be primarily responsible. In addition, some health problems have a clear social dimension, which seems to have become more acute during the crisis, affecting in particular the most vulnerable population groups and the most disadvantaged social classes, thus widening the inequality gap.

El baremo académico en el acceso a la formación médica especializada en España / The academic grade in access to specialist medical training in Spain

INTRODUCCIÓN: La selección en la formación sanitaria especializada de los médicos (MIR) se basa en la equidad interpersonal que premia a los candidatos según su esfuerzo. El rendimiento académico, a través del baremo, refleja el 'esfuerzo de fondo', mientras que el examen MIR mide el 'esfuerzo sprint'. Este artículo discute los pros y los contras de mantener el baremo académico, que actualmente pesa un 10%. Por un lado, mide capacidades y habilidades más allá del mero conocimiento que aporta el examen; pero, por otro, puede tener problemas de validez, no modificar elecciones debido a su bajo peso o no ser coste-efectivo. MATERIALES Y MÉTODOS: Registro de adjudicatarios de plazas MIR 2012-2013 (Ministerio de Sanidad, Servicios Sociales e Igualdad) y encuesta propia a los MIR-1 2012-2013. Modelo multinivel para estimar el efecto universidad en el baremo académico de los candidatos. Resultados. Hay diferencias sistemáticas en el baremo de los candidatos atribuibles a la universidad de procedencia cuando se comparan todas las universidades, españolas y extranjeras (correlación intragrupo: 47%), pero no hay diferencias significativas entre universidades españolas (correlación intragrupo: 7%). El 62% de los candidatos sube o baja menos de cien puestos en el ranking. Al menos el 1% de los candidatos cambiaría su especialidad elegida si se suprimiera el baremo académico, lo que supone un coste máximo de 576 euros por cambio. CONCLUSIONES: El baremo académico es válido para las universidades españolas, pero no para las extranjeras. Su supresión modificaría marginalmente el orden de elección y las asignaciones MIR

INTRODUCTION: The selection on specialized health training of doctors (MIR) is based on interpersonal fairness that rewards candidates by effort. Academic achievement, through the average grade, reflects the long-distance race, while the MIR test measures the sprint effort. This article discusses the pros and cons of maintaining the academic grade, that currently weighs 10%. On the one hand, it measures skills and abilities beyond the mere knowledge that provides the test, but on the other, it may have problems of validity, it could not change elections, given their low weight, and/or it could be not cost-effective. MATERIALS AND METHODS: Database of MIR 2012-2013 (Ministry of Health, Social Services and Equality ) and own survey of MIR-1 2012-2013. We used a multilevel model to estimate the effect of the university on the candidate's academic grade. RESULTS: There are systematic differences in the grades of the candidates attributable to the university when all universities, Spanish and foreign are compared (intragroup correlation: 47%). There are no significant differences between Spanish universities (intragroup correlation: 7%). 62% of the candidates move less than a hundred places in the ranking if the academic grade would be suppressed, and at least 1 % of the candidates would change their chosen specialty. It represents a maximum cost of 576 euros per change. CONCLUSIONS: The academic grade is valid for the Spanish universities but not for foreign universities. Its suppression would marginally alter the order of choice and MIR assignments

Respuesta de los autores: Acerca de las implicaciones de las facultades de medicina en la medicina de familia / Reply: About the implications of medical schools in family medicine

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Real waiting times for surgery. Proposal for an improved system for their management / Los tiempos de espera reales en cirugía. Propuesta de un sistema mejorado para su gestión

Objectives In Spain, official information on waiting times for surgery is based on the interval between the indication for surgery and its performance. We aimed to estimate total waiting times for surgical procedures, including outpatient visits and diagnostic tests prior to surgery. In addition, we propose an alternative system to manage total waiting times that reduces variability and maximum waiting times without increasing the use of health care resources. This system is illustrated by three surgical procedures: cholecystectomy, carpal tunnel release and inguinal/femoral hernia repair. Methods Using data from two Autonomous Communities, we adjusted, through simulation, a theoretical distribution of the total waiting time assuming independence of the waiting times of each stage of the clinical procedure. We show an alternative system in which the waiting time for the second consultation is established according to the time previously waited for the first consultation. Results Average total waiting times for cholecystectomy, carpal tunnel release and inguinal/femoral hernia repair were 331, 355 and 137 days, respectively (official data are 83, 68 and 73 days, respectively). Using different negative correlations between waiting times for subsequent consultations would reduce maximum waiting times by between 2% and 15% and substantially reduce heterogeneity among patients, without generating higher resource use. Conclusion Total waiting times are between two and five times higher than those officially published. The relationship between the waiting times at each stage of the medical procedure may be used to decrease variability and maximum waiting times (AU)

Objetivos En España, la información oficial sobre tiempos de espera para cirugía está basada en el tiempo desde que se indica la cirugía hasta que se realiza. Nuestro objetivo es estimar el tiempo de espera total considerando también la visita al especialista y las pruebas diagnósticas previas a la cirugía, y proponer un sistema alternativo para gestionar tiempos de espera totales que reduce la variabilidad y los tiempos máximos sin incrementar los de recursos. Se ilustra para tres procedimientos quirúrgicos: colecistectomía, reparación quirúrgica del túnel carpiano y de la hernia inguinal/femoral. Métodos Con datos de dos Comunidades Autónomas, se ajusta mediante simulación, una distribución teórica del tiempo de espera total, asumiendo independencia de los tiempos de cada etapa del proceso asistencial. Se muestra un sistema alternativo donde el tiempo de espera para la segunda consulta se establece condicionado al esperado previamente en la primera consulta. Resultados Los tiempos de espera totales medios para la colecistectomía, túnel carpiano y hernia inguinal/femoral son 331, 355 y 137 días, siendo los oficiales 83, 68 y 73, respectivamente. Utilizando diferentes correlaciones negativas entre los tiempos de espera de consultas sucesivas se reducirían tanto los tiempos de espera máximos (entre el 2% y el 15%) como la heterogeneidad entre pacientes, sin mayor uso de recursos. Conclusión Los tiempos totales de espera son entre dos y cinco veces mayores que los publicados oficialmente. La relación entre tiempos de espera en cada etapa del procedimiento puede utilizarse para reducir la variabilidad y los tiempos máximos de espera (AU)

Importantes diferencias entre facultades de medicina. Implicaciones para la medicina de familia y comunitaria / Important differences between faculties of medicine. Implications for family and community medicine

OBJETIVO: Contrastar si hay diferencias significativas entre universidades en la proclividad a elegir medicina de familia y comunitaria (MFyC), dadas las restricciones impuestas por el número de elección. Contrastar la hipótesis de que las facultades que tienen la MFyC como asignatura obligatoria en el grado (3 de 27) presentan mayor predilección por esta especialidad.DiseñoEstudio observacional sobre el archivo de datos individuales de elección de plaza MIR en las convocatorias 2003-2011.EmplazamientoEspaña.ParticipantesTodos los que se presentaron al examen MIR en las convocatorias 2003-2011.Mediciones principalesPosición en el ranking de cada candidato, plaza elegida (especialidad y centro), código postal de residencia, sexo, nacionalidad y universidad en la que se ha formado, y código postal del lugar escogido para la residencia.ResultadosPorcentaje de elección de MFyC está muy correlacionado con la posición en el ranking: 8% de los licenciados por la «mejor» universidad, y 46% para la última. Hay diferencias muy notorias y consistentes en la preparación para el MIR entre las 27 facultades de medicina. Ranking en el examen, sexo femenino y ser extranjero ayudan a pronosticar la elección de MFyC. La obligatoriedad de currículum de MFyC de 3 universidades no parece influir en la elección de la especialidad.ConclusionesLa conveniente competencia por comparación entre las facultades, su currículum de MFyC, así como la insistencia en los atributos más atractivos de la especialidad pueden contribuir a la necesaria renovación de la MFyC

OBJECTIVE: To determine if there are significant differences between universities in the proclivityto choose Family and Community Medicine (FCM), given the constraints imposed by thenumber of choice. To test the hypothesis that the Schools of Medicine that have the FCM as acompulsory subject in the degree (3 of 27) had the highest preference for this specialty.DESIGN: Observational study on the data file of all the individuals taking the MIR examinationbetween 2003 and 2011.Location: Spain.Participants: All those who sat the examinations called by MIR 2003-2011.Main measurements: Position in the ranking of each candidate, elected position (specialty andcenter), post code of residence, sex, nationality and university in which they studied, and postcode location for the residence chosen. RESULTS: The percentage electing FCM is highly correlated with the position in the ranking: 8% ofgraduates for the 'best' college, 46% for the worst. Very noticeable and consistent differencesin the preparation for the MIR among the 27 medical schools. Ranking in the exam, femaleand foreigner, help predict the choice of FCM. The FCM compulsory curriculum from threeuniversities does not seem to exert any influence. CONCLUSIONS: The convenient yardstick competition between the schools of medicine, FCM intheir curriculum and the emphasis on the most attractive attributes of the specialty can contributeto the necessary renewal of FCM

Real waiting times for surgery. Proposal for an improved system for their management.

OBJECTIVES: In Spain, official information on waiting times for surgery is based on the interval between the indication for surgery and its performance. We aimed to estimate total waiting times for surgical procedures, including outpatient visits and diagnostic tests prior to surgery. In addition, we propose an alternative system to manage total waiting times that reduces variability and maximum waiting times without increasing the use of health care resources. This system is illustrated by three surgical procedures: cholecystectomy, carpal tunnel release and inguinal/femoral hernia repair. METHODS: Using data from two Autonomous Communities, we adjusted, through simulation, a theoretical distribution of the total waiting time assuming independence of the waiting times of each stage of the clinical procedure. We show an alternative system in which the waiting time for the second consultation is established according to the time previously waited for the first consultation. RESULTS: Average total waiting times for cholecystectomy, carpal tunnel release and inguinal/femoral hernia repair were 331, 355 and 137 days, respectively (official data are 83, 68 and 73 days, respectively). Using different negative correlations between waiting times for subsequent consultations would reduce maximum waiting times by between 2% and 15% and substantially reduce heterogeneity among patients, without generating higher resource use. CONCLUSION: Total waiting times are between two and five times higher than those officially published. The relationship between the waiting times at each stage of the medical procedure may be used to decrease variability and maximum waiting times.

[Important differences between faculties of medicine. Implications for family and community medicine]. / Importantes diferencias entre facultades de medicina. Implicaciones para la medicina de familia y comunitaria.

OBJECTIVE: To determine if there are significant differences between universities in the proclivity to choose Family and Community Medicine (FCM), given the constraints imposed by the number of choice. To test the hypothesis that the Schools of Medicine that have the FCM as a compulsory subject in the degree (3 of 27) had the highest preference for this specialty. DESIGN: Observational study on the data file of all the individuals taking the MIR examination between 2003 and 2011. LOCATION: Spain. PARTICIPANTS: All those who sat the examinations called by MIR 2003-2011. MAIN MEASUREMENTS: Position in the ranking of each candidate, elected position (specialty and center), post code of residence, sex, nationality and university in which they studied, and post code location for the residence chosen. RESULTS: The percentage electing FCM is highly correlated with the position in the ranking: 8% of graduates for the 'best' college, 46% for the worst. Very noticeable and consistent differences in the preparation for the MIR among the 27 medical schools. Ranking in the exam, female and foreigner, help predict the choice of FCM. The FCM compulsory curriculum from three universities does not seem to exert any influence. CONCLUSIONS: The convenient yardstick competition between the schools of medicine, FCM in their curriculum and the emphasis on the most attractive attributes of the specialty can contribute to the necessary renewal of FCM.

Specialty choice in times of economic crisis: a cross-sectional survey of Spanish medical students.

OBJECTIVE: To investigate the determinants of specialty choice among graduating medical students in Spain, a country that entered into a severe, ongoing economic crisis in 2008. SETTING: Since 2008, the percentage of Spanish medical school graduates electing Family and Community Medicine (FCM) has experienced a reversal after more than a decade of decline. DESIGN: A nationwide cross-sectional survey conducted online in April 2011. PARTICIPANTS: We invited all students in their final year before graduation from each of Spain's 27 public and private medical schools to participate. MAIN OUTCOME MEASURES: Respondents' preferred specialty in relation to their perceptions of: (1) the probability of obtaining employment; (2) lifestyle and work hours; (3) recognition by patients; (4) prestige among colleagues; (5) opportunity for professional development; (6) annual remuneration and (7) the proportion of the physician's compensation from private practice. RESULTS: 978 medical students (25% of the nationwide population of students in their final year) participated. Perceived job availability had the largest impact on specialty preference. Each 10% increment in the probability of obtaining employment increased the odds of preferring a specialty by 33.7% (95% CI 27.2% to 40.5%). Job availability was four times as important as compensation from private practice in determining specialty choice (95% CI 1.7 to 6.8). We observed considerable heterogeneity in the influence of lifestyle and work hours, with students who preferred such specialties as Cardiovascular Surgery and Obstetrics and Gynaecology valuing longer rather than shorter workdays. CONCLUSIONS: In the midst of an ongoing economic crisis, job availability has assumed critical importance as a determinant of specialty preference among Spanish medical students. In view of the shortage of practitioners of FCM, public policies that take advantage of the enhanced perceived job availability of FCM may help steer medical school graduates into this specialty.

Forecasting the need for medical specialists in Spain: application of a system dynamics model.

BACKGROUND: Spain has gone from a surplus to a shortage of medical doctors in very few years. Medium and long-term planning for health professionals has become a high priority for health authorities. METHODS: We created a supply and demand/need simulation model for 43 medical specialties using system dynamics. The model includes demographic, education and labour market variables. Several scenarios were defined. Variables controllable by health planners can be set as parameters to simulate different scenarios. The model calculates the supply and the deficit or surplus. Experts set the ratio of specialists needed per 1000 inhabitants with a Delphi method. RESULTS: In the scenario of the baseline model with moderate population growth, the deficit of medical specialists will grow from 2% at present (2800 specialists) to 14.3% in 2025 (almost 21 000). The specialties with the greatest medium-term shortages are Anesthesiology, Orthopedic and Traumatic Surgery, Pediatric Surgery, Plastic Aesthetic and Reparatory Surgery, Family and Community Medicine, Pediatrics, Radiology, and Urology. CONCLUSIONS: The model suggests the need to increase the number of students admitted to medical school. Training itineraries should be redesigned to facilitate mobility among specialties. In the meantime, the need to make more flexible the supply in the short term is being filled by the immigration of physicians from new members of the European Union and from Latin America.

[Imbalance between the supply and demand for cardiologists in Spain. Analysis of the current situation, future prospects, and possible solutions]. / Desequilibrio entre la oferta y las necesidades de cardiólogos en España. Análisis de la situación actual, previsiones futuras y propuestas de solución.

Planning cardiology provision in Spain requires knowledge of the resources available and the demand, both now and in the future. In this report, we present the results of a study carried out by the Spanish Society of Cardiology on the availability of and demand for cardiologists in the country. The current situation is characterized by an imbalance of around 14% between the number of active cardiologists and the estimated number required. The demographic distribution of cardiologists shows that they are predominantly male and middle-aged. Expectations are that the situation will get worse until the year 2020. To correct this imbalance, alternative forms of training or clinical department organization, or both, are required. Some possible alternatives are presented in the final part of this document, as proposals for open discussion.

Desequilibrio entre la oferta y las necesidades de cardiólogos en España. Análisis de la situación actual, previsiones futuras y propuestas de solución / Imbalance between the supply and demand for cardiologists in Spain. Analysis of the current situation, future prospects, and possible solutions

La planificación de la cardiología en España requiere el conocimiento de los recursos disponibles y las necesidades, no sólo presentes, sino también futuras. En el presente informe se recogen los resultados de un estudio llevado a cabo por la Sociedad Española de Cardiología sobre la necesidad y la disponibilidad de cardiólogos. La situación actual en España presenta un desequilibrio entre el número de cardiólogos en activo y los que serían necesarios, desequilibrio que oscila en torno al 14%. La pirámide poblacional refleja una población envejecida y mayoritariamente masculina. Las previsiones futuras indican que la situación empeorará desde ahora hasta el año 2020. La corrección de este desequilibrio requiere el desarrollo de alternativas diferentes de las actuales en formación y/o organización de los servicios asistenciales. Algunas de estas alternativas se recogen en la parte final de este documento, en forma de propuestas abiertas al debate

Planning cardiology provision in Spain requires knowledge of the resources available and the demand, both now and in the future. In this report, we present the results of a study carried out by the Spanish Society of Cardiology on the availability of and demand for cardiologists in the country. The current situation is characterized by an imbalance of around 14% between the number of active cardiologists and the estimated number required. The demographic distribution of cardiologists shows that they are predominantly male and middle-aged. Expectations are that the situation will get worse until the year 2020. To correct this imbalance, alternative forms of training or clinical department organization, or both, are required. Some possible alternatives are presented in the final part of this document, as proposals for open discussion

Factores predictores del inicio y consolidación del consumo de tabaco en adolescentes / Analysis of factors related to smoking initiation and continued smoking in young adolescents

Objetivo: Analizar los factores que determinan la adquisición y posterior consolidación del consumo de tabaco en los jóvenes adolescentes. Material y método: Estudio longitudinal de 3 años de duración (2000-2002) sobre jóvenes estudiantes de enseñanza obligatoria, con una edad al inicio del estudio de 13-14 años. Los datos fueron recogidos mediante encuesta individual, cuyo ámbito de estudio era la isla de Gran Canaria, con una muestra final de 745 individuos. Se estimaron modelos de elección binaria condicional de efectos fijos para datos longitudinales, para determinar la probabilidad de probar por primera vez el tabaco («modelo de inicio»), así como sobre la probabilidad de ser fumador ocasional o habitual («modelo de experimentación»).Resultados: En el último año, el 57% de los adolescentes encuestados ha tenido contacto con el tabaco alguna vez, un 25% más que en el primer año, algunos de ellos (el 9%) de forma diaria. En el «modelo de inicio» los determinantes del consumo de tabaco son el interés por el colegio (odds ratio [OR] = 0,27; intervalo de confianza [IC] del 95%, 0,08-0,87, y OR = 0,14; IC del 95%, 0,03-0,58 para los que manifestaron bastante y mucho interés por el colegio, respectivamente), el consumo de tabaco por parte del mejor amigo (OR = 7,44; IC del 95%, 2,59-21,4), el consumo de alcohol (OR = 11,82; IC del 95%, 4,96-28,2, y OR = 15,42; IC del 95%, 4,68-50,7 para los que beben alcohol de manera ocasional o frecuente, respectivamente), y el dinero disponible (euros semanales) (OR = 1,13; IC del 95%, 1,07-1,19). Para el «modelo de experimentación», el consumo de tabaco por parte del mejor amigo (OR = 7,01; IC del 95%, 2,96-16,5), el consumo de alcohol (OR = 5,71; IC del 95%, 1,98-16,4, y OR = 5,22; IC del 95%, 1,56-17,5 para los que beben alcohol de manera ocasional o frecuente, respectivamente) y los años que lleva como fumador (OR = 1,44; IC del 95%, 1,11-1,86). Conclusiones: El estudio destaca, principalmente, los efectos del grupo de amigos, el consumo de bebidas alcohólicas y el poco interés por los estudios como factores asociados al consumo de tabaco

Objective: To analyse the determining of the acquisition and later consolidation of the tobacco consumption in young adolescents. Material and method: Longitudinal study of three years of duration (2000-2002). Subjects were students of secondary education between 13 and 14 years old at the beginning of the study. The research was performed in Gran Canaria Island with a final sample of 745 subjects. Models of conditional binary election were considered for longitudinal data where the dependent variable reflects decisions of the adolescents through time, with regard to the probability of beginning to smoke, «beginning model», and the probability of being occasional or habitual smoker, «experimentation model». Results: In the last year, 57% of the young teenagers surveyed use tobacco, a 25% more than in the first year, some of them, 9% on a daily basis. In the «beginning model» the determining of the tobacco consumption are interest in studies (odds ratio [OR] = 0.27; 95% confidence interval (CI), 0.08-0.87 and OR = 0.14; 95% CI, 0.03-0.58 for the students having enough and much interest in studies, respectively), to have a smoker as the best friend (OR = 7.44; 95% CI, 2.59-21.4), the alcohol consumption (OR = 11.82; 95% CI, 4.96-28.2 and OR=15.42; 95% CI, 4.68-50.7 for youngs who drink alcohol occasionally or frequently) and having more pocket money (euros per week) (OR = 1.13; 95% CI, 1.07-1.19). For the «experimentation model», to have a smoker as the best friend (OR = 7.01; 95% CI, 2.96-16.5), the alcohol consumption (OR = 5.71; 95% CI, 1.98-16.4 and OR = 5.22; 95% CI, the 1.56-17.5 for youngs who drink alcohol occasionally or frequently) and the number of years since the student started smoking (OR = 1.44; 95% IC, 1.11-1.86). Conclusions: Our study emphasizes, peer group effect, drinking alcoholic beverages and lack of interest in studies as factors associated to the tobacco consumption