Establishing Emergency Medicine as a Specialty in Spain: A Case Study

Federico CAPRILES, Manuel VASQUEZ LIMA, Oscar MIRÓ

Introduction
The establishment of Emergency Medicine (EM) as a specialty in Spain was a long and complex process (Table 1), driven by advocacy (1), strategic alliances, and educational reforms. Overcoming resistance, navigating regulatory challenges, and raising awareness within both the public and medical community were key aspects of this effort. The need for a distinct EM specialty was recognized decades ago as hospital emergency services expanded, and medical emergencies became more complex. In the early 1980s, the first advocates for an EM specialty emerged in Spain, drawing inspiration from models in other European countries, including the UK and the United States (2,3,4).

The Spanish Society of Emergency Medicine (SEMES) was established in 1987 (5). Alongside regional EM societies, SEMES became a leading advocate for the formal recognition of EM as a distinct specialty. The pioneers in these organizations tirelessly promoted specialized training in emergency and urgent care, organizing conferences, courses, and workshops to improve the skills of professionals in the field.

Key Milestones
One significant early milestone was the integration of emergency and urgent care training within the curricula of other medical specialties. However, SEMES, along with organizations like the European Union of Medical Specialists (UEMS), advocated for EM to be recognized as an independent specialty

In 1998, the European Society for Emergency Medicine (EuSEM) declared that EM should be an independent specialty (6). By 2002, a Task Force was established with representatives from 18 national societies, including Spain, to develop a formal curriculum. This curriculum was presented to the EuSEM council and the UEMS Multidisciplinary Joint Committee (MJC-EM) for approval, and in 2008, it was officially accepted and published in Spanish in Emergencias (7,8).

Despite these milestones, the formal recognition of EM in Spain was delayed. In 2008, EM was recognized as a supraspecialty (9), allowing doctors from specific specialties to receive additional EM training. However, this fell short of establishing EM as a primary specialty. In 2014, a Royal Decree designated EM as a supraspecialty, a decision opposed by SEMES. After pursuing legal action, SEMES achieved a victory in 2016 when the Spanish Supreme Court invalidated the decree (10).

Further progress was made through a joint report by Spanish ombudsmen in 2015 and the creation of EM as a specialty within the military sector in 2016. Media campaigns, particularly during the COVID-19 pandemic, helped raise the profile of EM, and interventions in the Congress of Deputies in 2022 and the Senate in 2023 further supported its recognition.

The turning point came on November 12, 2022, when the Spanish Council of Ministers approved a Royal Decree officially establishing EM as a recognized specialty (11). The Human Resources Commission of the National Health System proposed developing a new specialist title in Emergency and Urgent Care Medicine, accessible to medical degree holders in Spain. Following public consultation in June 2023, the Council of Ministers formally approved the Royal Decree in July 2024 (12), with the first resident positions expected in 2025.

Challenges
Navigating the complex legislative and regulatory landscape posed significant challenges. Initial efforts were delayed by resistance from governmental bodies, requiring ongoing lobbying and advocacy to move forward. A major barrier was the absence of standardized training programs for EM in Spain, which hindered the development of a cohesive professional identity and skill set among practitioners. This lack of formal recognition led to a "brain drain," with many skilled professionals seeking opportunities abroad where EM was already an established specialty.

There was also a general lack of awareness about the importance of EM, both among the public and within the medical community, making it difficult to garner widespread support. Opposition from existing medical specialties further slowed progress, as concerns over resource allocation and professional hierarchies created resistance to recognizing EM as a distinct field (13).

Lessons Learned
For countries aiming to establish EM as a recognized specialty, early engagement with key stakeholders—such as medical societies, government bodies, and educators—is crucial. Several key areas should be prioritized:

  • Identifying the Need for EM: Recognizing the long-term benefits of EM, including improved patient outcomes, better emergency care services, and a standardized training system, is essential. Highlighting the need for specialized training for emergency care providers can help build support.
  • Stakeholder Engagement: Early involvement of stakeholders is crucial. Mapping out the necessary legislative and regulatory steps can facilitate navigation through complex systems.
  • Addressing Opposition: Resistance from other medical specialties was a significant challenge in Spain. Addressing concerns over resource allocation and professional hierarchies, while emphasizing the unique value of EM, is vital to overcoming opposition.
  • International Support: Drawing on international models, such as those implemented in the UK and the United States, can provide valuable guidance. Endorsements from organizations like UEMS and EuSEM played an instrumental role in Spain’s success.
  • Developing a Formal Curriculum: Establishing standardized training programs aligned with European Training Requirements (14) was a key step in Spain’s progress, creating a benchmark for the education of EM specialists.
  • Public Awareness Campaigns: Media and public awareness efforts were critical in Spain, helping to build political and public support for the recognition of EM, especially during the COVID-19 pandemic.
  • Long-Term Commitment: Establishing a new medical specialty is a lengthy and complex process. It requires sustained commitment to advocacy, education, and regulatory engagement to achieve formal recognition.

Conclusion
The recognition of EM as a specialty in Spain mirrors global trends in medical specialization, positioning the country as part of a broader movement toward more effective emergency care. The perseverance of SEMES and its supporters underscores the importance of specialized training in improving patient outcomes in critical care settings. The formal recognition of EM not only validates the efforts of practitioners but also enhances the overall effectiveness of emergency healthcare services in Spain. Although the journey was fraught with challenges, the recognition of EM as a specialty marks a significant step toward improving the quality of emergency care in the country.

 

References

  1. Martinez, L. & Rodriguez, P. (2015) ‘The Role of Advocacy in Establishing Medical Specialties’, Medical Education, 49(4), pp. 321-328.
  2. Royal College of Emergency Medicine (1972) Establishment of Emergency Medicine in the UK.
  3. Smith, J. & Brown, R. (2010) ‘The Evolution of Emergency Medicine in Europe’, Journal of Emergency Medicine, 45(3), pp. 203-210.
  4. American Board of Emergency Medicine. History of Emergency Medicine Certification in the US. 1979. Retrieved from ABEM Official Site.
  5. Spanish Society of Emergency Medicine (SEMES) (1987) Foundation and Advocacy Efforts.
  6. European Society for Emergency Medicine (EuSEM). Position on the Establishment of Emergency Medicine Specialties in Europe. 2023. Retrieved from EuSEM Official Site.
  7. Vázquez Lima, M.J. (2009) ‘Plan Europeo de Estudios de Medicina de Urgencias y Emergencias’, Emergencias, 21, pp. 456-470.
  8. Öhlèn, G., Petrino, R. & Vázquez Lima, M.J. (2009) ‘La formación en Medicina de Urgencias y Emergencias’, Emergencias, 21, pp. 401-402
  9. Spanish Ministry of Health. Creation of the Specific Training Area in Emergency Medicine. 2008. Retrieved from Ministry of Health Official Site.
  10. Boletín Oficial del Estado. Sentencia de 12 de diciembre de 2016 de la Sala Tercera del Tribunal Supremo. Retrieved from Official Site.
  11. Spanish Government (2022) Royal Decree Establishing the Specialty of Emergency Medicine.
  12. Spanish Government (2024) Final Approval of the Specialty of Emergency Medicine.
    Spanish Ministry of Health (2008) Creation of the Specific Training Area in Emergency Medicine.
  13. Spanish Society of Emergency Medicine (SEMES) (2019) Public Awareness Campaigns and Media Relations.
  14. Union Européenne des Médecins Spécialistes (UEMS) (2024) European Training Requirements for Emergency Medicine.

 

 

Table 1: Time line for Recognition of EM as a Speciality in Spain

1987:

The Spanish Society of Emergency Medicine (SEMES) was founded, marking the beginning of organized advocacy efforts for the specialty in Spain.

1992:

The Union Européenne des Médecins Spécialistes (UEMS) recognized EM as an independent specialty in Europe

1998:

The European Society for Emergency Medicine (EuSEM) declared that EM should be an independent specialty.

2002:

EuSEM established a Task Force with representatives of 18 countries to develop the first core curriculum for EM, officially accepted in September 2008.

2008:

The creation of the Specific Training Area (ACE) in EM was planned, allowing doctors from certain specialties to receive added training in this field.

2010:

The Inter territorial Council of the National Health System agreed to start procedures for the creation of the EM specialty.

2013:

The European Board Examination in Emergency Medicine (EBEEM) was created, to evaluate competencies in EM at the specialist or consultant level in Europe.

2014

The government of Spain approved the Royal Decree considering EM as an ACE. SEMES appealed this decision, leading to the Supreme Court of Spain annulling the decree in 2016.

2015:

A joint report by the Ombudsmen highlighted the importance of establishing EM as a specialty.

2016:

Creation in Spain of the EM specialty in the military sector.

2022:

The Council of Ministers approved the Royal Decree on November 12, 2022, setting up the EM specialty.

2023:

Interventions in the Congress of Deputies and the Senate of Spain supporting the establishment of the EM specialty. A public consultation of stakeholders, including medical professionals, academic institutions, healthcare organizations, and the public was done.

2024:

On July 2, 2024, the Council of Ministers gave final approval to the Royal Decree standardizing the training of emergency doctors, with the first resident positions planned for 2025.