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Supplement: Cardiologists in Spain

An article from the e-journal of the ESC Council for Cardiology Practice

Today in Spain there are two types of cardiologists : those working outside the hospital only, called “cupo” cardiologists, and others working in and outside of the hospital, the so-called “jerarquizado” cardiologists. Since 1983, however, only "jerarquizado" cardiologists are coming into the workforce. The working conditions of "cupo" cardiologists, in the meantime, are not being improved.

I - Before the 1980’s

Before 1983, there were three ways of working as a cardiologist:

  • Attending both outpatients and patients in the hospital: outpatients being public care patients who had been in the hospital in the past and returned there for check-ups.
  • In “Ambulatorios” (ambulatory clinics):  special clinics for first step attendance of public care patients.These included general practitioners and specialists. For further exams/tests, patients went to the hospital.  These acted as a filter to determine which patients had to move on to hospitals.

Once the patient had been in the hospital they usually used both systems: outside patients going into the hospital usually once a year for a check-up, while regular follow-up was done by the cardiologists working in the “Ambulatorios”.

  • In private clinics or in private apartments either outside or inside the hospitals with cardiologists using their own equipment and some of them working together.

For insurance, besides Social Security, patients usually had an affiliation to one of the numerous Private Medical Care companies that existed then, through which they received very cheap private care.

However, these companies underwent major change during the 1980’s especially with regard to size. When companies by law were obliged to have a very high money deposit regardless of their size, they were driven to merge and in so doing lost their “family” flavor and prices increased. Today these have become large international groups such as SANITAS (BUPA in England).

Patients today mostly can afford to use private doctors because they are insured with private insurance companies, and must do so anyway because there are not enough cardiologists working in the public practice. 

II - Since the 1980’s

Today there are two kinds of Cardiologists :

  • In “Ambulatorios”, with cardiologists working there exclusively five days a week. These cardiologists have passed their exams and acquired their position before 1983. They are called “Cupo” cardiologist. They are not related to any given hospital.
  • In “Ambulatorios” and in the Hospital.  They are in the "ambulatorios" part of the week with outside patients and spend the remainder of their time in the hospital : They are called “jerarquizado” cardiologists. They are closely dependant and related to their hospital of reference. During their days in the hospital,  “jerarquizado” cardiologists visit hospitalised patients and sometimes do the complementary studies for their "ambulatorio" patients. They may also go around into different areas of cardiology (treadmill, echocardiography) and comment with other colleges on their outside patients.

III -  The working conditions of “Cupo” Cardiologists

In 1983, the public health minister decided that the specialist organization had to stop having the outside and hospital medicine relation and created the jerarquizado status (a doctor would spend some days in the hospital and others outside, for more hours, and his boss would be in the hospital).

The administration however could not change the “cupo” cardiologists’ contract as it was obtained by public exam but decided not to renew them, and have since not improved their working conditions.  “Cupo” cardiologists’ wages were determined when they began to work 25 years ago; this wage has not since been reviewed.

Cupo cardiologists are paid for two and a half hours per day of working time regardless of the number of patients they have. However, they often need more than 2 and a half hours to see their patients because

  • The number of patients programmed for them changes depending on the area they work in. In some areas, for example, in Pozo Del Tio Raimundo, in Vallecas, in Madrid, thirty seven patients were assigned to be treated in two and a half hours. In such cases, “CUPO” cardiologists are paid for two and a half hours and work more than four hours
  • They have had a growing number of patients with much more to do - older, more chronic conditions, fewer days at hospital, more time needed for explaining everything and signing, etc. 
  • It is a personal doctor-patient relationship, many of their patients are elderly (multi-pathology), but they are not able to refer them to be controlled by their primary doctors. 

Yet, if "cupos" complain about this situation, it can happen that the number of patients they are assigned are diminuished and therefore they could experience a cut in their wages.

Finally, in the last 4-5 years, the administration has not given the “cupo” cardiologists the “extra payment” that the “jerarquizado” cardiologists have received for “fixed” productivity. Additionally, they have no possibility to take time off for training sessions, to receive extra input, etc. All their time is devoted to seeing patients. They do request certain things from the health authorities, but rarely receive them.

Most of them have no choice but to continue because many of them will be retiring soon and if they do not remain in their jobs, they will lose all rights to their pensions. Many have been working many years and cannot afford to lose these rights now, at the end of their working life. Furthermore, they have been working for 30 years on their own, so it would be difficult to admit change at this point in time.

 “Jerarquizado” cardiologists are assigned many patients but since they are paid the same amount of money regardless of how many patients they see, patients face long waiting lists. “Jerarquizado” cardiologists are paid for seven hours per day of work. They have twenty eight patients programmed on average per day- depending on the different areas.
Both types of Cardiologists can be members of our Spanish Clinic and Extrahospitalary Section of the Spanish Cardiac Association.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.


Vol4 N°28 Supp

Notes to editor

*Dr. N. Murga and Dr. J.L. Alvaro Cuesta, Madrid, Spain,*Bilbao, Spain

Dr. JOSE LUIS ALVAREZ CUESTA is a cardiologist in Madrid and has been working since 1980 in the same area with public care patients. He won his position 25 years ago. He ranked number one in his exams to become a cardiologist in 1981 (one needed to rank among the first to get a place as a cardiologist). 

"The part of Madrid in which I work with public care patients - I also have my own private clinic - is one of the poorest (Pozo Del Tio Raimundo, in Vallecas, in Madrid). Some patients do not know how to read or write, and I enjoy helping my patients both in the social realm as well as in the medical realm. That is why I work four or more hours every day, even though I am only paid for two. I have worked there for twenty five years and I enjoy a good relationship with my patients.

I keep up to date with the latest issues in cardiology by going to all the meetings and conferences that I can (especially in Spain, Europe and the United States), and I use all of my free days in my public practice (1 month of holidays/year, 5 special free days, 6 congress days) to maintain a high level of scientific knowledge in my field.

I hope that in the near future our Health Ministry will help the “cupo” cardiologists. With the help of associations such as the Spanish Cardiac Association and our Clinic and Extrahospitalary Association especially, I am sure that we will make the Spanish Government consider and solve our difficulties.”

Besides his work in the ambulatorio, Dr. Jose Luiz Alvarez Cuesta is in his private clinic from 2 pm until nearly 10 pm from Monday to Friday.

Dr Nekane Murga is a "jerarquizado" cardiologist.

Dr. Jose Luiz Alvarez Cuesta's e-mail is: All your comments and ideas will be welcome.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.