MIR training in Endocrinology and Nutrition: reflections on its critical points in the choice of the resident

The choice of specialty following the MIR (Médico Interno Residente [Resident Internal Physician]) examination represents an annual milestone, not only for the applicants themselves, but also for the entire medical community, if not at a social level when it is mentioned in the media. Society and the medical community are interested in the shift in the appeal of their own specialties and those of others, and there is a certain curiosity about which specialty is most in demand. Having a clear understanding of the criteria that influence the choice of the different specialties is complicated, although it seems that the medical-surgical specialties have garnered more appeal. In this issue of Endocrinología, Diabetes y Nutrición [Endocrinology, Diabetes and Nutrition], Alfaro-Martínez et al.¹ conduct an interesting analysis of the evolution in MIR places chosen in Endocrinology and Nutrition (E&N) from 2001 to 2022 measured by the uptake index. The number of places in the specialty offered in the MIR tender has increased significantly in that period, from 33 in 2001 to 97 in 2022. This increase has occurred in practically all specialties, so comparing the order number over time between different specialties is not an easy task. Classically, the mean and median have been used to assess the evolution^2,3 of the classifications, but when the number of places available changes, it is difficult to make an appropriate assessment. For this reason, the authors use two parameters (uptake index and uptake order) that objectify the relationship between the offer and the demand for places in a given medical specialty in an MIR tender. An increase in the uptake order implies a worsening of the supply-demand ratio. There is no perfect method to assess the appeal of a specialty, but the strategy proposed in this article may allow us to intuit at least one trend, which does not seem favourable in our specialty. E&N obtained a uptake order of 18 in the last tender-MIR 2022. The top uptake order positions were taken by dermatology, plastic surgery and cardiology, while for other medical specialties, gastroenterology ranked 9 and neurology 10, the rest being behind E&N in terms of uptake order. From 2001 to 2022, a progressive worsening can be observed when considering the specialties overall, with stabilisation since 2018. Regarding the rest of the adult medical specialties, E&N is currently in fourth place, two places below the position it held in 2001. Although it continues to be one of the most coveted specialties in the medical area, E&N exhibits a negative trend in MIR selection according to this uptake order, both in relation to all the specialties offered and in the set of specialties in the medical area. We must ask ourselves what the reasons are for this unfavourable development and also consider whether it is possible to reverse this trend. Some suggestions offered by Alfaro-Martínez et al., and which seem to be correct and necessary, include increasing Endocrinology and Nutrition content in undergraduate teaching, which would allow for greater visibility and prominent relevance in training plans, including a greater offer of placements to allow all medical students to have the opportunity to learn of the enormous possibilities of this specialty and all the associated techniques (such as new technologies applied to diabetes, thyroid ultrasound or morphofunctional assessment in Nutrition). What is not known is not appealing and perhaps E&N is at a disadvantage compared to other more classic medical specialties with a greater presence in Spanish medical faculties. However, this is not an easy issue to approach, and when the curricula in medical faculties are modified, the fight for the teaching "space" and the credits assigned, as well as the number of lecturers is a true take-no-prisoners battle. In this regard, the 2018–2022 strategic analysis by the Spanish Society of Endocrinology and Nutrition [Sociedad Española de Endocrinología y Nutrición (SEEN)]⁴ already includes the need to implement strategies to attract the best medical candidates to work in the specialty of E&N, with actions aimed at medical degree courses by endocrinologist university lecturers and by the SEEN through its collaboration with medical student associations. Here there is no doubt that the actions of the teaching staff have a significant influence, but the ability to convey the appeal of our specialty is very person-dependent and very teacher-dependent, regardless of its intrinsic aspects. The SEEN has also echoed the need to address the challenge posed by the evolution of the specialty in relation, on the one hand, to the growing prevalence of health problems inherent to it (closely related to the progressive ageing of the population and with the unstoppable increase in obesity and other metabolic diseases) and, on the other, to the increasing use of technology in diagnostic and therapeutic processes, and to our greater understanding of the molecular and genetic bases of endocrine diseases. The currently relentless increase in diseases in our field of competence will lead to a greater need for E&N specialists, which should translate into a greater offer of training places. It should also mean that the specialty is more attractive to new doctors, both because of the possibilities of greater job offers (”there will be more work and more contracts”) and also because of the greater appeal that theoretically should be influenced by the incorporation of techniques and new technologies and progress towards personalised medicine. This vision is obviously irrefutable because, in the end, as interesting as the potential job offer landscape and the enrichment of the specialty in terms of content might be, this new vision of the specialty will need to be visible and future endocrinologist candidates will need to receive this information in a way that makes it competitive compared to other specialties, which apparently "know how to sell themselves" very well. The current official programme of the specialty of Endocrinology and Nutrition⁵ requires an update. This challenge to adapt to these new times has already started to be addressed by the Commission. New technologies, artificial intelligence and molecular medicine are already making their mark, playing a role in leading centres today and gaining prominence in our clinical practice. The strategic analysis of the SEEN also reflected the need at the time to take the appropriate steps before the Administration to value all these aspects, validating the diversity and complexity of endocrinological and nutritional diseases at the present time and above all with a view to the medium term, as well as the fact that the new technologies that are being incorporated into our field will require more training time. This approach will most likely require, as an essential requirement/obligation, the extension of the MIR training period for our specialists to five years. The new proposals that have been made by the Spanish Society of Endocrinology and Nutrition4 and by the National Commission for the specialty should make E&N - which, in our opinion, is already highly attractive and is becoming even more so - more appealing to applicants after the MIR exam.⁶ The recognition of E&N as a transversal discipline found at the core of practically all diseases (especially with regard to metabolism and nutrition), and at the heart of healthcare activity both in hospitals, but also with strong connections to Primary Care and health and social care, is also an opportunity to highlight the cardinal role played by our specialty, and to make it more appealing. Endocrinologists and the SEEN will have to make an additional effort above and beyond our commitment of recent years to make ourselves more visible and to value all our professional work. In a mega-intercommunicated world where everything is known almost in real time through social media, our presence must be adequate and our target must receive a powerful and rich message that reflects how powerful and rich our specialty is. Dear medical students and MIR candidates, E&N is a specialty not only with extraordinary relevance in the present, but also for the future. It is gobbling up every scientific development in order to transform it into a product at the service of our patients. It is a specialty where the endocrinologist is the lead protagonist for growing the specialty. We are waiting to welcome you with open arms to this exciting world of endocrinology, metabolism and nutrition so that you can help us continue down the path of medical progress in this field of knowledge that more and more patients are having to rely on. The future is yours and we need you to help us build it.