Official recognition of subspecialty training is a goal that should be dealt with at the European level, a clinician says.
Jorge L. Alió
Ophthalmic care meets population needs in Spain, with a good balance of
public and private service delivery, according to Jorge L. Alió, MD,
president of the Spanish Association of Technology and Implant Surgery,
Refractive and Cornea.
Ophthalmology, like health care in general, in Spain is under a national
health system (NHS), which is managed by 17 autonomous regional governments.
Overall spending on health care amounts to 15% of the national budget, Dr.
Alió said. Of that, 95% comes from income tax and 5% comes from social
security contributions made by workers and employers.
All Spanish workers have access to free health care, regardless of their
type or level of employment. About 20% of Spanish residents, mainly in large
cities such as Madrid and Barcelona, prefer to purchase private health
insurance coverage rather than using the NHS. Approximately 5% of health care
services are provided solely on a private basis — mainly procedures, such
as refractive surgery, that might not be covered by the NHS or some insurance
companies because they are considered nonessential.
“The NHS provides high-level, efficient services to cover all the
basic needs of medical assistance. In the case of ophthalmology, it provides
primary care as well as standard medical and surgical treatment for all ocular
pathologies and age-related disabilities,” Dr. Alió said.
“However, services are area-based, meaning that the hospital and doctors
you are referred to depend on your place of residence, and you have no choice
in who will take care of your needs.”
This lack of physician choice drives some people in Spain to pay for
private insurance schemes, which usually require patients to obtain care from a
list of specialists and public or private centers. Patients seeking premium and
elective procedures, such as refractive surgery and cosmetic oculoplasty, must
pay for private treatment.
There are 3,200 ophthalmologists in Spain, 3,000 of whom belong to the
Spanish Ophthalmological Society. Only 25% work full time in public hospitals.
Approximately 60% have appointments in the public system as well as part time
in private practices, and about 15% work exclusively for private practices.
Private practices have been growing steadily due to the increasing
market for refractive procedures, including lens surgery with premium IOLs.
These procedures are in the domain of private insurance and private care, where
they are likely to remain. Most ophthalmologists in Spain, including Dr.
Alió, agree with this arrangement.
“The standard for everybody has to be provided by the government,
but if you go beyond standard, you should provide for yourself,” he said.
“However, we expect private practices to become more accessible in future
years. There is a growing competition, and these procedures will become
The ratio of men to women among ophthalmologists is currently 50-50.
Female medical students already outnumber their male counterparts, so the
proportion of women will grow in future years.
The geographic distribution of ophthalmologists corresponds well to
population needs. No area is unattended, although 60% of ophthalmology
residents are trained in Madrid, 20% in Barcelona and the remaining 20%
“We train about 120 ophthalmologists per year. They undergo a
4-year program where, unlike in some other European countries, surgery is done
from the first year and there is no separation between medical and surgical
ophthalmology,” Dr. Alió said. “Like everywhere else in
Europe, there is no subspecialty degree, and this is a limitation that is
becoming increasingly evident in our system.”
Spanish ophthalmology faces challenges on three levels, Dr. Alió
said. The first is financial, due to Spain’s looming economic crisis that
will likely affect the health care budget in the next 5 to 10 years.
“Because of financial constraints, hospitals will offer fewer
contracts to ophthalmologists, which means fewer options for the patients,
decreased efficiency and level of services. Also, there will be less money to
spend on technological equipment, and there is a risk that public health will
be unable to keep pace with the fast evolution of modern ophthalmology,”
The influx of optometrists into medical practice is the second main
challenge that will create controversy in the future. Currently 10,000
certified optometrists practice in Spain. Because job opportunities for them
are scarce, they sometimes encroach into ophthalmology’s field of
expertise, some ophthalmologists say.
“Wherever there are optometrists, they are fighting to expand their
scope,” Dr. Alió said. “Drawing a line is mandatory, to
prevent unlawful intrusions and malpractice. Medical care and surgical
procedures, including laser, must remain strictly beyond the scope of
Obtaining official subspecialty certification within university training
programs is the third major challenge that needs to be dealt with at the
“Ophthalmology subspecialties have never been formally introduced
in our system. Most of us are in fact trained in specific subspecialty areas,
but there is no official certification to guarantee the level and quality of
our training and to clearly direct patients’ choices,” Dr.
One of the consequences is that patients may receive a suboptimal level
of eye care because they do not know where to go for their specific pathology.
They often go to the general ophthalmologist who is nearest to them but might
not have the specific competence or the appropriate technological equipment to
care for their condition.
“There is no way to identify subspecialties by the average patient.
At the same time, not all ophthalmologists are so professionally and ethically
correct to give up a patient and redirect him or her to the colleague who can
best deal with his or her specific condition,” Dr. Alió explained.
“It’s a major problem in Europe. ‘Hidden’ subspecialties
should have visibility for the patient and official recognition by education
authorities.” – by Michela Cimberle
- Jorge L. Alió, MD, PhD, can be reached at Vissum Corporation,
Avenida de Denia, s/n, 03016 Alicante, Spain; +34 965150025; fax: +34
965151501; email: email@example.com.
- Disclosure: No products or companies are mentioned that would require