Reportage. Physicians trained abroad make up 0.9% of the total in Italy. Training new professionals takes years. Italian hospitals could hire doctors from abroad, but the rules and low salaries keep them away.

In Italy there is a shortage of doctors, but foreign ones can’t work

On Tuesday, the Lazio Regional Council approved a resolution that opened up participation in competitions for jobs in the public health sector to foreign doctors, but only for fixed-term appointments. The rule concerns physicians who have been in Italy for five years and are registered with the respective professional order.

“We are at war, and we must use all the forces available, whose professional training is recognized by the registration in the professional order,” said the Regional Councillor for Health, Alessio D’Amato.

It will be only an emergency measure, and limited to one region. However, the problem of the shortage of doctors in Italy is a structural one. This is demonstrated by the fact that, even with 80% of the population vaccinated, each new wave of COVID is forcing hospitals to suspend ordinary activities for lack of resources. Doubling the number of beds in ICUs does not automatically mean multiplying the care capacity. In addition to beds, intensive care physicians and nurses are needed, but their numbers have remained about the same. Taking into account retirements and new specialists currently in training, the union of resuscitators and emergency physicians, AAROI-EMAC, predicts that by 2025, there will be 500 fewer workers than today in Italian ICUs.

Increasing the number of anesthesiologists in the immediate future is not easy, because training one requires five years of postgraduate specialization. In competitions, especially in the south, there are often fewer candidates taking part than the number of available positions. The only way to increase the number of specialists in intensive care and other departments in the short term is to hire from abroad. But very little of that is done in Italy. According to OECD statistics, physicians trained abroad make up 0.9% of the total in Italy. In France they make up 12%, in Germany 13%, in the United Kingdom over 30%. Only in Turkey, among OECD countries, are there fewer foreign doctors than in Italy.

The reasons why foreigners are staying away from Italy are various, according to AAROI-EMAC secretary Dr. Alessandro Vergallo, an anesthesiologist at the Spedali Civili in Brescia. “First of all, all things being equal, in Germany or France you earn about 50% more,” he explains. “Then, there are greater risks of legal disputes: lawsuits are more frequent here, and Italy is one of the few countries in the world where you risk a criminal trial. Finally, the European norm that sets minimum rest periods for health workers is rigidly enforced here, and this prevents intensivists from supplementing their regular activity with additional work.” These factors do more than repel foreign physicians: “In parallel, there is a hemorrhage of Italian physicians, especially to France, Germany and the United Kingdom.”

Added to these contextual conditions, there is another barrier. In public competitions for physician jobs, the vast majority require Italian citizenship or citizenship of an EU country. And this cuts off a large number of professionals who thus have no hope of a career in the public health sector. In other countries, in addition to mobility within the EU, physicians are also drawn from more distant countries. In the United Kingdom, almost half of the foreign physicians come from the Indian subcontinent. In France, there is an important influx from the Middle East and North Africa. Germany attracts many physicians trained in former USSR countries.

In reality, there are enough doctors in Italy, but they are kept on the sidelines by the practices being followed in recruitment. “There are about 77,000 foreign health workers in Italy, of which 22,000 are doctors,” explains Foad Aodi, a doctor of Palestinian origin and secretary of the Association of Doctors of Foreign Origin in Italy (AMSI). “They are all registered with professional orders, but only 8-10% can access public jobs.” However, Italian laws do not set any conditions regarding the citizenship of healthcare professionals.

The 2001 Consolidated Civil Service Act places such constraints only on professions that affect national security. The “Cura Italia” Decree issued in March 2020 to address the emergency goes even further, as it explicitly says employment in the public health sector is available to “all citizens of non-EU countries who hold a residence permit that allows them to work.”

However, the decree has been ignored in the vast majority of cases. Hospitals and health authorities have preferred to keep the European citizenship condition for the recruitment of health workers. Or even the condition set out in a Prime Ministerial Decree from 1994, declared illegal but never repealed, which reserved managerial positions (such as those of hospital physicians) to Italian citizens alone, excluding even European ones. Not all regions have applied such protectionist norms. Before Lazio, Umbria and Piedmont had already opened their competitions to physicians of all nationalities after the protests from AMSI. But the tangle of laws seems tailor-made to impede this process.

“The result is a flight of physicians from Italy,” Aodi says. “Here, quality-related requirements, such as licensure, are often confused with nationality. France, on the other hand, gave French passports to foreign doctors who helped during the pandemic.” AMSI considers the decision by the Lazio region “a step forward,” but now the goal is getting the provision into the coming omnibus bill. “The government should commit to ensuring that the single text and the Cura Italia Decree are being respected,” Aodi says.

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