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José Luis Jiménez, a doctor in Colmenar, treats Pedro Palomo at his home. Migue Fernández
Rural doctors in Spain: a more human side to the medics who treat us
Health

Rural doctors in Spain: a more human side to the medics who treat us

They would not swap their country job for one in the city, but replacing older doctors with younger ones is hard due to poor incentives and little career progression

Susana Zamora

Malaga

Friday, 24 May 2024, 12:49

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It is ten o'clock in the morning and there is only one person manning the desk of the health centre in inland Colmenar; there is no one in the consultation rooms and the rehab gym is empty. It is time for phone consultations and home care. Here there is no waiting list to get an appointment. José Luis Jiménez (64) is one of the three doctors working in these medical facilities which are no worse than those in busy Malaga city or on the Costa del Sol.

Don José, as they call him, is getting ready to visit Pedro at his home. The patient has ankylopoietic spondylitis, a hereditary autoimmune disease, and his health has been complicated by knee surgery. He has a prosthesis and his left leg often swells up. He can barely walk and his high temperature in the past few hours had been worrying his wife, who has contacted the regional health ministry's Salud Responde unit to make an appointment.

"It's Thursday today and they've given it to me for Monday, so I called this morning to see if they would bring it forward," Ana María Mérida explains, while thanking Don José, who came to see her husband less than an hour after the call. "I can't thank him enough for the good way he always treats us," she says about the doctor who has been working in the small Axarquía town of slightly over 3,000 residents for a decade.

On his way back to the health centre, he stops to chat with the elderly residents, who take the opportunity to greet Don José. "I will never forget how attentive he was when he examined my daughter after I brought her in with a 40 degree fever from Covid," says Josefa Palomo.

Juan Alexander Ávila is a family doctor in Alozaina.
Juan Alexander Ávila is a family doctor in Alozaina. SUR

Don José has been a village doctor for 30 years. He likes this label, although family doctors who work in "particularly isolated areas" in Malaga province are nothing like those professionals of old who used to set up practice in their own homes, with meagre resources and 24/7 availability. Now working conditions are different, though they still require vocation and commitment, closeness and trust, respect and admiration - values that are diluted in doctor-patient relationships in cities due to haste or overcrowding but which, in rural medicine, are the driving forces that move these doctors.

Long commutes

These values are the compensation for a job that requires them to travel many kilometres each day, to pay for their commute and to often have to work alone. "We need to make the profession more attractive, with incentives that attract doctors starting out," says Jim Jiménez, who highlights another important issue. He questions why family doctor and rural doctor vacancies are not being filled in Spain.

In many cases, it is because of the conditions that these professionals work in: with many patients to see on a daily basis and in a short period of time, but he also thinks it is due to lack of career advancement. "It's unacceptable that universities have no family medicine course and this would be a first step," he points out.

This is further supported by Juan Gabriel García, head of the organising committee of the fourth Rural Medicine Conference held by the Spanish Society of Spanish Society of Primary Care Physicians (Semergen) in Jaén last April.

At the conference, some 500 doctors discussed the profession's present and future situation; the difficulties they face and the issue of young doctors not choosing to practice in these areas, and therefore, the lack of generational replacement. "Those who choose to do so have to accept a more limited use of new technologies, harder travel due to the lack of infrastructure or adequate transport in these isolated areas, and the care of an aging population, which has greater complexity and requires more resources," Juan Gabriel García, a rural doctor himself, explains to SUR from Sabiote (Jaén).

He insists on the need for labour incentives, with a different evaluation of seniority when working in rural areas. For example, rewarding more points for the time spent working there when it comes to the merits section of competitive examinations, giving housing aid and promoting measures to improve work-life balance.

Juan Alexander Ávila (37) has been working at the health centre in Alozaina for a year. Despite the inconveniences, it was a personal choice. Every day he commutes from his home in Malaga to this village in the Sierra de las Nieves, with slightly over 2,000 residents.

"It's around 45 or 50 minutes, depending on whether you run into a flock of sheep crossing the road that day and get delayed," Ávila jokes, adding that in a village, a doctor does not just look after the patient, but the whole family, and knows each member's medical background.

Despite the inconveniences, "5G internet has also reached villages and small towns, and we can do minor surgery, infiltrations, physiotherapy treatments, ultrasound scans... We are not as disconnected from the world as you might think," he points out. In his presentation on new technologies at Semergen's conference, Ávila highlighted the usefulness of many specialised mobile apps for doctors and nurses, who can sometimes avoid referring the patient to hospital if it can help them find a solution. On the recommendation of their doctors, these apps can also be very useful for patients, to follow up on diets or treatment.

"But familairity is such that they don't wait for an appointment to consult you, so if they run into you at the petrol station or in a shop, they don't hesitate to ask you about their treatment or mediation, without taking into consideration that this is not the right place; they only see their doctor," he says.

The negative aspect of this globalisation is also reaching these areas, Ávila points out, in reference to stressful situations experienced by the rural population. "It's not exclusive to cities; it's less frequent here, but it also exists and benzodiazepines are often abused."

In spite of everything, none of them would change their current job for one in the city. "Patients are always very respectful and the relationship that's formed with them is one of familiarity. When you spend so much time in this role, you've taken care of half the family, - from pregnancy care, you follow up on the little ones when they come to the pediatrician and you continue to see them when they are older. That closeness and knowledge of patients' growth is what always attracted me to this profession," says José Luis Jiménez, who hesitated at the start about whether to go into journalism or medicine. He now edits a magazine published by Malaga's College of Physicians.

Dr Nérsida Fernández and nurse Antonio Fernández visit Elisa Ortega at her home in Cañete la Real.
Dr Nérsida Fernández and nurse Antonio Fernández visit Elisa Ortega at her home in Cañete la Real. SUR

Six years ago, Dominian-Repuplic-born Nérsida Fernández came to Cañete la Real and since then she has earned the affection, trust and admiration of this village of 1,600 people in the Guadalteba district of Malaga provinc.. "I know them all," says this doctor, who deals with patients with an average age from 70 to 95.

She works from Monday to Friday from 8am to 3pm in the village's consulting room, where she is joined by a nurse and another family doctor, who comes every day for two hours - from 8am to 10am - and a pediatrician who comes twice a week. But such is the relationship with her patients that they avoid going into the surgery when she is not there. "The colleague who stands in for me when I'm on holiday or on a break always tells me how quiet it's been," says Fernández, who divides her time between early morning face-to-face consultations, telephone consultations and scheduled appointments, "although patients know that, when I'm alone, if an emergency arises during a face-to-face consultation, they have to wait or return the next day. Unfortunately, emergencies are common because it's a population with many cardiovascular conditions, who have falls in the street or cancer. Those who wait are used to it and are understanding."

Familiarity and respect

"To them I'm 'Nersi'. There's so much familiarity that sometimes when I'm in the office they ask me for my car keys to leave me a little something, like that day when I turned to the back seat and saw that they'd gifted me three rabbits. It's not often that I come home empty-handed, from olives to eggs... It's their way of thanking us for the service we give them, but it's simply our obligation, our job," says this family doctor, who previously worked in different health centres along the Costa and now would not change her patients "for anything". "They even tell me that they won't take the medicine prescribed in the hospital until I see and approve it. Maybe it's an exaggeration, but all of that allows you to practise integrative medicine.

"Sometimes they come with the excuse of an ailment and end up talking to you about a personal or family problem that makes them uneasy. That's when a kind word cures more than medicine itself," says the doctor.

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