{"id":3083,"date":"2024-06-26T18:40:48","date_gmt":"2024-06-26T16:40:48","guid":{"rendered":"https:\/\/www.rivistaeco.com\/?p=3083"},"modified":"2024-06-26T18:40:48","modified_gmt":"2024-06-26T16:40:48","slug":"doctors-and-nurses-where-to-find-them","status":"publish","type":"post","link":"https:\/\/www.rivistaeco.com\/en\/2024\/06\/26\/doctors-and-nurses-where-to-find-them\/","title":{"rendered":"Doctors and Nurses: Where to Find Them"},"content":{"rendered":"

In Italy, there is no general shortage of doctors, but there is a shortage of family doctors and certain specialists. The solution might involve a comprehensive rethink of the medical profession, including the structure and costs of training, while also trying to curb the brain drain. Moreover, the role of nurses needs to be re-evaluated.<\/span><\/i><\/p>\n

Long waits at the emergency room, specialist visits with brief priority times taking months, and people unable to find a family doctor: all these problems are often attributed at least partly to the shortage of doctors and nurses in public discussions. However, according to official statistics, the situation for doctors in Italy does not appear particularly critical. As shown in the figure, our country has 41 doctors per 1000 inhabitants, surpassing the OECD average of 37 and ranking higher than countries like France and the United Kingdom, both with 32 doctors per 1000 inhabitants. It would seem then that there is no shortage of doctors compared to other countries.<\/span><\/p>\n

Active Doctors per Thousand Inhabitants (2021)<\/b><\/p>\n

\"\"
Source: OECD “Health at a Glance” report.<\/figcaption><\/figure>\n

Yet there are significant shortages in some specialisations. For example, the number of general practitioners (GPs) is lower than in other European countries. Eurostat data shows that Italy has 82 GPs per 100,000 inhabitants, a lower number compared to Germany (104), Spain (94), and even more so compared to France (138), the Netherlands (183), and Portugal (233). According to the Gimbe Foundation, Italy lacks over 3,100 general practitioners, with the most critical situations found in large regions in the North like Lombardy, Veneto, Emilia-Romagna, and Piedmont, but also in Campania. Interaction between citizens and general practitioners is much more common and frequent compared to other specialties, and the scarcity of these doctors impacts the public perception of the problem. The data also indicate a potential difficulty in providing primary healthcare services.<\/span><\/p>\n

Active General Practitioners per 100,000 Inhabitants (2021)<\/b><\/p>\n

\"\"
Source: Eurostat.<\/figcaption><\/figure>\n

Another specialty facing a relative scarcity of professionals is emergency medicine. This situation can also affect the perceived quality of care when timeliness is particularly crucial for citizens waiting in emergency rooms. According to the Italian Society of Emergency-Urgency Medicine (Simeu), Italian emergency rooms employ 5,800 full-time doctors while over 8,300 are needed. The shortage of specialists is also very marked in related fields such as emergency surgery, anaesthesia, and resuscitation. The situation is unlikely to improve in the near future because not all available specialisation grants are assigned due to a lack of candidates. A report by the Association of Free Specialists highlights a high rate of vacant or unfilled positions in medical specialty schools in 2021 and 2022. Among the most affected fields are radiotherapy (67% of grants not assigned), pharmacology (63%), emergency-urgency, and palliative care (61% of positions unfilled), and community medicine (57%). These data reflect a structural crisis in recruiting specialists in crucial fields, increasing pressure on emergency services.<\/span><\/p>\n

The Shortage of Nurses<\/b><\/h3>\n

The situation is also problematic when considering data related to nurses. According to the OECD, Italy has only 62 nurses per 1000 inhabitants, significantly lower than the OECD average of 92 and far below other countries: Germany and the United States record 120 nurses per 1000 inhabitants, while France and the United Kingdom have 97 and 87 respectively. Healthcare professionals often lament a dramatic shortage of nurses in both the public and private sectors, particularly in nursing homes (RSAs), where it is increasingly difficult to find specialised staff. This aspect could again impact the Italian healthcare system’s ability to provide adequate and timely assistance.<\/span><\/p>\n

Active Nurses per Thousand Inhabitants (2021)<\/b><\/p>\n

\"\"
Source: OECD “Health at a Glance” report.<\/figcaption><\/figure>\n

Follow the Money<\/b><\/h3>\n

So there is a problem, but what are the causes? First, it is worth reflecting on the salary levels. Doctors’ salaries in Italy are significantly lower compared to other countries with a comparable level of economic development. According to OECD data from 2022, a specialist doctor in Italy earns an average of \u20ac78,044 compared to \u20ac163,384 in the Netherlands and \u20ac148,400 in Germany. Even Belgium (\u20ac117,152) and France (\u20ac86,520) offer more.<\/span><\/p>\n

Average Specialist Doctors’ Salaries (2022 in euros)<\/b><\/p>\n

\"\"
Source: OECD.<\/figcaption><\/figure>\n

The situation for nurses is not better, with an average salary in Italy around \u20ac30,000, while other European countries pay much higher amounts, and in Spain, it reaches about \u20ac40,000 gross per year. Additionally, doctors and nurses often face gruelling shifts with long hours and high stress. The shortage of doctors and nurses fuels a vicious cycle: increased pressure on existing staff leads to further defections, exacerbating the crisis in the healthcare system.<\/span><\/p>\n

Brain Drain<\/b><\/h3>\n

The pay gap and difficult working conditions push many trained and qualified doctors and nurses in our university system to move elsewhere in search of better economic and professional opportunities. According to recent data from the National Federation of Orders of Surgeons and Dentists (Fnomceo), about 20,000 doctors will leave Italy in 2024 to settle in countries like the United States, Germany, France, and the United Kingdom. Ninety percent of them are between 35-40 years old. Thus, we have a problem of qualified personnel leaving the country, which besides worsening the shortage of certain professionals, represents a net loss for public finances since training a nurse and even more so a doctor costs much more than the university fees paid. Most of the education costs are indeed borne by taxpayers. In the United States, one of the preferred destinations for “escaping” doctors from Italy, university education costs are significantly higher, with fees that can exceed $70,000 per year, often covered by students and their families through savings or loans that must be repaid. Given the difference in training costs, it is no surprise that doctors’ salaries in the US are much higher than in Italy, reaching about $350,000 per year on average with significant differences between specialties. A system that heavily subsidises the training of doctors and other professionals but offers relatively low remuneration is unsustainable when there is high international mobility. This is why some countries condition scholarships or training incentives on subsequent service for a few years. If beneficiaries decide to move elsewhere, they might have to repay the funds received.<\/span><\/p>\n

The “repayment” model aims to balance public investment in education with the need to derive a collective benefit. Under these conditions, investment could even be strengthened, for example, through an extended scholarship program that fully covers living expenses during studies: this would reduce the importance of the socio-economic background of the students. There are already examples pushing for the adoption of similar conditions in Italy. For instance, for the medicine and surgery course in English for the 2024-2025 academic year, the autonomous province of Bolzano finances some of the annual university fees of \u20ac18,000 on the condition of a commitment “to work in the South Tyrolean health service for four years within ten years of completing subsequent specialist medical training or specific general medical training.”<\/span><\/p>\n

In addition to high outbound mobility, Italy has a limited capacity to attract talent from abroad. Since training new doctors and nurses takes many years, recruiting professionals from abroad can in principle offer a quicker solution to address immediate shortages. Unfortunately, within the OECD, Italy has one of the lowest percentages of doctors trained abroad, under 3%. Attracting professionals to our country is a complex operation that would require intentional interventions and significant efforts. This topic deserves to be explored separately.<\/span><\/p>\n

Removing the Test Keeping the Selection<\/b><\/h3>\n

Another crucial issue is access to medical schools. In April 2024, the government introduced a proposal to modify the restricted number system with admission conditional on the results of a national entrance test. The proposal eliminates the initial filter, allowing all interested students to enrol in medical courses. The new selection mechanism comes at the end of the first semester and is based on academic results. Essentially, the concept of a restricted number is not abolished, but the selection is shifted further into the course of studies.<\/span><\/p>\n

The proposal has some merits, considering that once they start their studies, many students might have a greater awareness of what studying medicine entails compared to the knowledge they have at the end of high school. However, the change also raises several issues. One of the most significant problems is the universities’ ability to manage a substantial increase in initial enrolments. Many institutions will find themselves with inadequate structures and teaching staff for the large number of students in the early months of the course. There is also the issue of how to ensure uniformity in selection criteria during the second semester. If each faculty adopts different standards based on its academic results, the consistency and fairness in how students are evaluated and selected would be undermined.<\/span><\/p>\n

It would also be worth reflecting more broadly on the balance between the number of trained doctors and the needs of the national health system. Incentives for specialisation in fields where shortages are greater or enhancing training capacities in less served regions to distribute qualified human capital more equitably could be considered. Of course, this should be done with a forward-looking perspective, considering the needs that will emerge when these individuals actually begin their service.<\/span><\/p>\n

Specialised Nurses<\/b><\/h3>\n

To address the shortage of doctors, the role of specialised nurses could be enhanced, for example, by drawing inspiration from the “Registered Nurse Practitioners” model in the United States. With advanced and specialised training, these professionals are authorised to perform many functions traditionally reserved for doctors, such as diagnosing and managing various medical conditions, prescribing medications, and conducting autonomous treatments. In Italy, introducing or expanding the role of nurses with advanced skills could alleviate pressure on doctors and improve the accessibility and efficiency of healthcare services. Specialised nurses could operate in areas such as primary care, chronic care management, and assistance in rural or underserved areas where doctors are often harder to find. This would allow doctors to focus on more complex cases.<\/span><\/p>\n

Implementing such a change would require a revision of regulations defining professional profiles in the healthcare sector, accompanied by significant investment in nurse training. Closer collaborations between universities, hospitals, and other healthcare institutions could facilitate the creation of specific training paths for specialised nurses, ensuring the maintenance of high-quality care.<\/span><\/p>\n

The shortage of doctors and nurses is a complex problem that needs to be addressed from multiple perspectives: those already trained need to be incentivised to stay, return, or come to work in Italy; those still in training will be called upon to make specialisation choices aligned with needs; and those who have yet to decide on their professional path. This issue intersects with many others, from technological development (will artificial intelligence reduce the need for radiologists? Will personalised medicine require more attention to individual patients?) to technical-administrative support (how to prevent a doctor from spending 5 out of the 20 minutes dedicated to a visit inputting data into the system?) to investments in structures and equipment (community health centres, telemedicine, and more).<\/span><\/p>\n

In the face of such complexity, the only certainty is that there are no simple and immediate solutions.<\/span><\/p>\n

Bio<\/em><\/p>\n

Mario Macis<\/strong> is a professor of economics at the Johns Hopkins University Carey Business School and the Johns Hopkins Berman Institute of Bioethics and a research associate at the National Bureau of Economic Research (NBER) Economics of Health Program.<\/span><\/em><\/p>\n

Mirco Tonin<\/strong> is a professor of economic policy at the Free University of Bozen-Bolzano and director of the Institute for Public Policy Evaluation \u2013 Bruno Kessler Foundation Trento.<\/span><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

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