The graduate medical training model for medical interns and residents (the MIR system) was introduced in Spain in the 1960s, but it was only fully consolidated in 1978 with the enactment of Royal Decree 2015/1978, which regulated the training of medical specialists by way of residencies in duly accredited teaching hospitals.1 Since then, further regulations have been enforced, the first of which was Royal Decree 127/1984, which regulated specialized medical training and the award of qualifications in specialized medicine.2 The greatest changes, without doubt, were brought in by Act 44/2003 on the Organization of Health Professions (LOPS),3 the second section of which addressed the structure of specialist training in Health Sciences, and the third, educational support structures, including the accreditation of teaching units. The LOPS focused not only on the required content of training programs, but also on the need for assessment of trainee doctors and the creation of specific areas of competency, and specified that the Ministry of Health would be responsible for granting qualifications in these areas that would be valid throughout the Spanish State.

The regulations currently in force are set down in Royal Decree 183/2008.4 This decree identifies and classifies Health Sciences specialties, and develops certain aspects of the LOPS that address the specialist training system, including the characteristics of the teaching units, the profile of the tutor, and procedures for assessing training activities with the use of the medical resident's training log. However, the criteria for accrediting teaching units have not been updated, the implementation of the resident's training log has been patchy, and assessment procedures are far from being properly standardized.

Educational methodology has changed as the regulatory framework has evolved, as reflected by the development of official specialty programs (OSP). The curriculum is changing from a knowledge-based model to a competency-based model, understood as the comprehensive range of knowledge, skills, and attitudes necessary to achieve competency in professional activities.5–7 And this model really does tie in well with the MIR system, which is based on training in a professional environment, that is to say, practice-based learning. If we look at the first OSPs, we can see that they were based on a knowledge-based curriculum model. However, these programs have evolved and, in the specific case of current respiratory medicine program, which dates back to 2008,8 are now entirely practice-based, since they specify not only the areas of knowledge, but also the practical experience required in each area. In addition to the scientific and technical training required, it has become clear that medical students also need to be trained in complementary areas that take into account patient needs, values and beliefs. This aspect is also addressed in the respiratory medicine OSP of 2008, which includes new training areas such as medical management, research and bioethics.

Along with the OSP curricula and training assessments, another fundamental aspect to be taken into account is how our system adapts to European training models in terms of the content and duration of training programs. The 2005 European Directive9 establishes the minimum duration required for specialist training, which in the case of respiratory medicine is 4 years. However, this specific period must be preceded by adequate training in internal medicine. No one questions the need for medical specialists to receive comprehensive training that addresses not only their chosen specialty but also cross-curricular skills and clinical competencies. The “Harmonization of Education in Respiratory Medicine for European Specialists” (HERMES) projects of the European Respiratory Society (ERS) specifies a need for 2 years’ training in internal medicine followed by 4 years’ specific training in pulmonology.10 The figures vary, but many countries follow these recommendations.11 In the United Kingdom, for example, the compulsory training program includes a period of 2 years in general clinical medicine, followed by at least 4 years of specialization in respiratory medicine.12

The Royal Decree 639/2014 of 25 July, which regulates the core curriculum, core respecialization, and specific training areas,13 known as the “core curriculum decree”, developed significant training aspects included in the LOPS: comprehensive competency-based training, assessments, and definition of the specific areas of competency.14 It establishes common generic competency-based training for all health professions. Five major medical specialties (core specialties) were defined with common clinical training for the specialties included in each category, and a curriculum based on specific competencies was to become a general characteristic of all healthcare qualifications. The development of a competence-based curriculum involves setting up training activities that cover all those areas addressed in the official specialty programs, as well as the procedures for assessing each specific activity.

The core curriculum was generally well received by the scientific societies, although they called for the duration of the training period to be increased. Both the National Commission on Specialization in Respiratory Medicine and the SEPAR were of the opinion that if quality training were to be maintained in a context of increasing core competencies and the need to converge with Europe, the training time would need to be increased by 1 year. However the core curriculum sparked considerable protest, mainly from specialty societies not currently recognized as such, or others which aspired to expand their influence. These protests are what really underlie the appeals that eventually led to the repeal of the core curriculum by the Supreme Court,15 although the legal excuse was the lack of an appropriate economic report.

So, now what? There is no doubt that the MIR training system is an excellent model, insofar as it has enabled the Spanish National Health System to achieve its characteristically high level of quality. However, training must be a continuous process that ensures that doctors adapt to the new scientific, technical, cultural, and social demands. It is not enough to keep claiming that the existing system is the best; its adequacy must be assessed and proven. Therefore, with or without the core curriculum, official specialty programs must be updated, and the obsolete criteria for the accreditation of teaching units remain an unresolved issue which must be settled as soon as possible.