[Training in internal medicine and its specialties: universities' proposals]

Medical School graduates can enter a medicine subspecialty training program upon completion of a 3 year Internal Medicine residency. The Ministry of Health has contributed to postgraduate training by defining the type of physician the country needs, and by financial support of specially (Internal Medicine) training. Before 1995, when applicants began being charged a fee, finding for subspecialty training was provided exclusively by the universities. Currently, 450 training post are available for 550 graduates from all medical schools. Of these, 59 are in Internal Medicine and 58 in its subspecialties. A quantitative analysis of 40 years of training programs in Internal Medicine by the traditional medical schools shows that only the Catholic University of Chile Medical School privileges subspecially training whereas all other schools favor general Internal Medicine training. A high number of Internal Medicine trainees never take final examination. Nevertheless, training through practice, not necessarily in a university setting, accounts for 67% of Autonomous National Corporation for Certification of Medical Specialties. CONACEM accredited subspecialists. About 63% of those who finish an Internal Medicine training program decide to go into subspecialization. It is felt that subspecialization involves technical as well as non-professional aspects, such as a philosophical stance towards the search for truth through research and creativity. An integral education in a subspecialty can only be given by the university. Non-university centers, however, can contribute to subspecialization by allowing trainees to gain access to newer technology or to larger numbers of patients. A critical question is how many subspecialists should exist in relation to the number of generalists and according to the country's health requirements. In my personal view, the proportion of subspecialists is excessive. The decision to subspecialize should not be exclusively a personal choice, but should take into account the interests of all other participants in the process of subspecialization. Therefore, a definition must be reached as to the number and type of subspecialty training programs offered in the country. These programs should be made more flexible, to allow for a shortened specialty training, which in turn depends from the type of pregraduate training delivered. Some of the problems requiring an urgent solution in the specialization process are: 1) finding should be shared in some proportion by all those who will benefit from the subspecialist's action, including private hospitals and HMOS; 2) There should be a clear-cut central health policy, that will be respected by the decentralized State Health Services, with fulfillment of the teaching agreements, respect for the assigned clinical fields, and for the accredited teaching capacity; 3) Unauthorized or "parallel" training must be stopped and the role of scientific societies or of State Health Services must be clarified, 4) The institutional involvement of a number of academicians must be reinforced.