The demographic profile of national medical examiners in Spain

During the last few decades society has been subject to major changes and transformation, as has the medical collective within it. The national medical examiners in Spain (CNMF) for its initials in Spanish) has been party to these changes and this evolutionary process. A brief contextualisation and glance at the development of these changes is therefore in order. Firstly, the scarcity of physicians and the progressive ageing of those who were incorporated into the labour market in the 1970's and 1980's are notable. This deficiency appears not to affect all specialities equally, and it is a subject for debate that has become particularly keen in recent years. This unpredictable pendulum phenomenon is shared by other Western countries that may find it difficult to cover their needs in upcoming years.¹

Secondly, the increase in the number of female medical professionals and consequently in the CNMF, is a reality. Although there is yet much ground to be covered, the position women occupy worldwide affects any area of society and may therefore be extrapolated to our profession. In Spain, the number of female physicians has increased considerably. According to data from the Organisation for Economic Cooperation and Development,² in Spain the percentage of women within the medical profession is above average (estimated to be 48.2%). In the year 2000 this accounted for 36.8% of the whole medical profession, progressing to up to 55.2% in the year 2017. However, this proportion does not appear to be reflected in the main positions of responsibility, as has been made apparent in several specialities, such as, for example, cardiology.³ Other authors highlight that these significant differences between men and women lead to the phenomenon known as “leaking pipes” which consists of a disproportionately low number of women who rise to top medical positions in their profession.⁴

Thirdly, the legislative change which came about with Organic Law 7/2015, of 21st July, cannot be overlooked. This modified Organic Law 6/1985, of 1st July, governing Judicial Power,⁵ which included the demand for the speciality of Forensic Medicine as a requirement for access to the CNMF (article 475). This demand will be made effective when authorised by the Ministry of Justice (7th transitory provision) and imposes regulation on access to the speciality in Legal and Forensic Medicine (EMLYF for its initials in Spanish) through the residency system and also the determination of the profile or characteristics of those belonging to the profession in relation to this new demand.

Progress has been slow. On 17^th June 2011 a conference was organised in Barcelona on the Importance of Legal and Forensic Medicine. The reason behind it was the Dr Pere Mata annual celebration in the Official College of Doctors of Barcelona, as the second centenary of the birth of the creator of the CNMF and of the Chairs of Legal Medicine.⁶ The conference put the Ministries of Justice and the Ministry of Health into contact for the first time and began with studying the possibility of converting the EMLYF into a speciality to be accessed through the residency system, similarly to the other specialities, with the alumnae system consequently disappearing.

It was at this time that initial estimation of the demographics of the CNMF was made, requested by the Ministry of Health. Data revealed 719 professionals as at 31^st December 2009 with a higher proportion of women (54%) due to the high female percentage in ages under 50 which counterbalanced the prevalence of men aged over 50. Above all, it highlighted a major female representation (77%) of people under 40 years of age. It was noted that almost 40% of the CNMF fell into the age group of 50-59 years. Those over 60 at the time were a scarce 5% (4.8%).

Since that time until today, all teams responsible for forensic medicine in the Ministry of Justice have firmly believed in the importance of incorporating the EMLYF into the system of residency training and the access requirements to the body of national medical examiners. They have defended it and worked intensely towards this aim. The Forensic Medical Board, which was founded in 2014,⁷ demonstrated its relevance by dedicating its first report to the defence of the EMLYF.⁸

We are hoping this long trajectory may draw to a close in the last quarter of 2019 with regulation on EMLYF access through the residency system. For this to occur the Ministry of Justice, which has already driven the 2015 reform of the LOPJ, has worked closely with the Ministry of Health, Consumption and Social Wellbeing. This Ministry is responsible for processing the Royal Decree by which access to the title of physician/specialist in legal and forensic medicine through the residency system is granted, the draft of which has already been submitted to previous public consultation⁹ and to public audience and information.¹⁰

In this context and aware that data may not be totally precise, given the difficulty of personal contact arrangements between the Ministry of Justice and some of the autonomous communities, the current demographic situation of the CNMF has been assessed. The following data were presented previously in the First Equality and Justice Seminars organised by the Ministry of Justice and the Centre for Legal Studies in Madrid on 27^th and 28^th February¹¹ and partially, on 22^nd May 2019, in the hearing procedures and public consultation of the before mentioned draft royal decree.

At present, the CNMF comprises 813 staff, with an average age of 53 years, 67.4% are over 50 years of age and 28% are over 60. As in all other medical professions, forensic medical examiners born between the 1950's and 1960's account for the vast majority of retirements which will occur in the next decade.¹ This ageing phenomenon may be appreciated mostly in those over 60 years of age, since in 2011 they scarcely accounted for 5%, but at present they are 28%. The 50-59 age group remains stable, representing 40% of the group. Care needs to be taken to anticipate the right mechanisms of replacement (such as regular appointment of residents, medical examinations or measures to allow one to continue in the profession up to the age of 70) so that the system does not reach crisis point, particularly in those areas where recruitment of medical staff is already complicated.

Women account for 59%, which is 5 points higher than that observed in 2011. In the group over 50 years of age, women account for 49.8%, whilst in the group under 50 years of age they are 78.1%. However, this proportion is uneven since in the case of managerial posts (managers and assistant managers of the Institutes of Legal Medicine and Forensic Sciences) women represent 41.1%, in the case of medical chiefs of staff (services and sections) they account for 38.2% whilst in all other positions their representation is 65.1%.

This inequality of the sexes in managerial positions and chiefs of staff reflects here what is already common in other specialties and areas.^3,4 Inequality in chiefs of staff may be related to several interconnecting factors. As we have already seen, in 2011 men predominated in the age groups over 50. These positions are appointed through specific meritorious systems where the most experienced professionals have greater opportunities to obtain them through their length of service and the consequent development of their career. Women very frequently take a break from their professional career to have children and take care of them. This gives them less of a change when applying through specific meritorious competitive procedures. Furthermore, regarding gender inequality, it has been reported in Spain and throughout the world that the main concern of female medical professionals is the lack of reconciliation between their professional and family lives.³

With regard to the CNMF profile it is not known how many of its members are also EMLYF. Through the ordinary procedure, between 1992 and 2014 the Ministry of Health offered 455 specialised medical training places for EMLYF. The extraordinary procedure for obtaining the appointment was regulated by Royal Decree 1497/1999, of 24^th September,¹² but as yet there are no published data on the number of specialists.

To conclude, the increase in the number of women in the CNMF is a fact, as occurs in other areas, and it is not improbable that in the next few years 3 out of every 4 forensic medical examiners will be women. Almost one out of every three medical examiners will retire over the next few years, which will require appropriate planning by the administrations to avoid situations of crisis. Lastly, we firmly believe that the transformation of the EMLYF into a specialty via residency and as a requirement for being a forensic medical examiner will adapt the training of future forensic doctors to the training reality of the other doctors in Spain and also add appeal to the forensic medical profession which, as we all know, is a fascinating one.