RADIOLOGY IN PAMPLONA,

Ben Whitlow PAMPLONA, SPAIN

• Capital of the autonomous community of Navarra • Population 201,311 • Best known internationally for the San Fermín festival with the running of the bulls in July every year CLÍNICA UNIVERSIDAD DE NAVARRA

• Hospital associated with Universidad de Navarra • Part of Spain’s private healthcare system which exists alongside public system • One of the top ranked private hospitals in Spain • Best hospital in Spain for oncology • Medical students at the University of Navarra do their clinical rotations both at CUN and in the public hospital TOPIC OF INTEREST

• National healthcare system in Spain • Training of radiologists in Spain • Practice of radiology in Spain HEALTHCARE IN SPAIN

• Tw o s y s t e m s – public and private • Public healthcare system – Sistema Nacional de Salud or SNS • 1978 constitution guaranteed healthcare as a right for all citizens • SNS is made up of 17 regional healthcare systems • Each is administered independently by the autonomous communities • Funds from central government in Madrid • In Navarra, public system run by the Servicio Navarro de Salud SISTEMA NACIONAL DE SALUD

• Statistically, SNS normally does well in many areas • Longest life expectancy in the European Union • 83.3yr in 2014 vs 80.9 for EU, 79.3 in US • WHO ranks health systems by efficiency • Spain #7. USA #37 • Reached 99.5% coverage of population in 2010 • May have decreased since due to 2012 law revoking full coverage for illegal immigrants CHALLENGES FOR SNS

• Long wait times for nonessential care • Rising costs, especially with economic difficulties over past decade in Spain • Disparities between autonomous communities • May offer different benefits, leads to internal medical tourism • Majority of top ranked public hospitals are located in Madrid or Barcelona • Different regions have applied 2012 law on illegal immigrants differently • Continued full coverage for illegal immigrants in Navarra • Emergency care only in La Rioja, Castilla y León, Castilla-La Mancha PRIVATE HEALTHCARE IN SPAIN

• Available to anyone who pays for private insurance, people who choose not to contribute to SNS. Also an option for government employees • Nicer facilities and shorter wait times • CUN used by professional La Liga soccer players due to shorter wait times for imaging/diagnosis/surgery • Overall comparable quality of care to SNS, but cutting edge technology will go to private system first • Intraoperative MRI for neurosurgery at CUN is 1st in Spain • CUN also has many clinical trials in oncology MEDICAL TRAINING IN SPAIN

• Medical school begins after high school and lasts 6 years • All students in Spain take a test called the MIR following medical school to determine specialty and hospital for residency • Radiology residency in Spain lasts 4 years • Unlike in US, no radiology fellowships are available in Spain. Residents can go abroad or gain more experience by working/studying in a specific subspecialty PRACTICE OF RADIOLOGY IN SPAIN

• Overall, very similar to US • Salaries for private practice radiologists in Spain were lowest in developed world in 2016 study - $68,000 vs $400,000 in US • Public hospitals have slightly easier hours • Private hospitals allow more emphasis on teaching, research • Residents and attendings at CUN were preparing for the European Congress of Radiology in Vienna • Private hospitals may have more cutting-edge technology before it becomes standard of care • Intraoperative MRI at CUN DAILY LIFE AS A SPANISH RADIOLOGIST

Daily schedules in Spain are very different

Medical students Radiology residents, attendings

9am – Arrive at hospital 9am – Arrive at hospital Noon – Coffee break Morning conference 2pm – Leave hospital, lunch 10am – Begin day in reading room 4pm – Class Noon – coffee break 7pm – Home 2pm – Lunch 10pm – Dinner 3pm – Resume work 5-7pm – Home MOST PROFOUND CLINICAL/ACADEMIC EXPERIENCE

• Interesting radiological techniques and procedures, some of which were uncommon in Spain • Intraoperative brain MRI with neurosurgery • Close relationship between radiology and primary care • Primary care teams come to reading room to discuss cases more frequently than in US • Chest radiologists do daily radiology rounds with MICU staff MOST PROFOUND CULTURAL EXPERIENCE – BASQUE COUNTRY

• Major cities – Bilbao, San Sebastián • San Juan de Gaztelugatxe • Pintxos, txakoli • Unique • Servicio Navarro de Salud = Osasunbidea in Basque REFERENCES

• Interview with Dr. Alberto Benito, abdominal radiologist at CUN

• Radiologist income, receipts, and academic performance: an analysis of many nations. Acta Radiol

• https://www.ncbi.nlm.nih.gov/pubmed/26924837

• Health systems in Transition – Spain. WHO.

• http://www.euro.who.int/__data/assets/pdf_file/0004/128830/e94549.pdf

• Health at a Glance: Europe 2016. How does Spain compare? OECD.

• https://www.oecd.org/health/health-systems/Health-at-a-Glance-EUROPE-2016-Briefing-Note-SPAIN.pdf

• Measuring Overall Health System Performance for 191 Countries. WHO.

• http://www.who.int/healthinfo/paper30.pdf

• Healthcare coverage for undocumented migrants in Spain: Regional differences after Royal Decree Law 16/2012.

• https://www.ncbi.nlm.nih.gov/pubmed/26948703

• Which country has the world's best healthcare system?

• https://www.theguardian.com/society/2016/feb/09/which-country-has-worlds-best-healthcare-system-this-is-the- nhs