Emergency Room in Italy: The Copernican Revolution
- 1. Department of Emergency Medicine, ASL Valle d’Aosta, Italia
CITATION
PROSPERI PORTA1 H, BALDASSARRE E (2024) Emergency Room in Italy: The Copernican Revolution. Arch Emerg Med Crit Care 8(1): 1065.
INTRODUCTION
Exactly 40 years ago, in Italy, Law 883 of 23 December 1978 established the National Health Service (SSN). The contract of healthcare personnel has been regulated by the National Collective Agreement (CCNL) since 1927 with the promulgation of the Workers’ Charter, but only in 1941 did it acquire legal weight. It continues today, defining working conditions for today’s companies.
After the last contract renewal, the gross salary table of medical and health managers is the same for everyone and equal to 47,015.00 euros gross per year. Some specific allowances are added to this figure, which differ based on the length of service and the roles of the individual medical manager [1].
Practically, in the Italian health system, a doctor who works in the Emergency Room, with the same number of years of service and duties, earns exactly the same salary as a doctor who are employed in less demanding work positions such as dermatology, nuclear medicine, or physiatry.
Starting from the early 1990s, in Italy, the waiting lists in the National Health Service were already beyond the permitted limit, so it became imperative to plan an alternative path. Thus, the individual freelance activity outside of the service commitment was born. The term that was coined was intramoenia, which translates to «within the walls», that is, «within the city», that is, within the company structures identified by the general director in agreement with the board of directors, with the possibility of participation in the proceeds of paid activities, carried out outside of the service commitment, within the company structures. The activity was regulated, in particular, by article 15 - quinquies of Legislative Decree no. 502 of 30 December 1992 [2].
Obviously, the intramoenia, that is, the possibility of supplementing one’s salary with a sort of private activity within the healthcare facility where one works, for obvious reasons, is not the prerogative of all doctors, and above all it is practically impossible for the personnel involved in emergency medicine.
It is obvious, however, that Emergency Medicine represents a sector of vital importance for the Regional and National Health Service and in fact, in the territorial Emergency system of 118 and in the Emergency Departments in Italy 12,000 doctors operate to whom 13 million citizens turn every year.
In this context, the specialization in Emergency Medicine (MEU) was established in Italy by a Ministerial Decree in February 2006 and was placed in the area of Internal Medicine.
In 2012, the Italian State-Regions Conference formalized the need for specialists in Emergency Medicine at 245 specialists per year, and the specialization school in Emergency Medicine (MEU) was activated in 25 university locations, mostly in the centernorth of the country.
As the years go by, the facts are very different. In 2024, 1,020 grants for emergency medicine were issued by the Ministry of University and Research (MIUR) between state and regional contracts, but only 304 of them were assigned, corresponding to a disappointing 30% of the total. In 2023, the data is even more worrying: of the 850 grants available, only 234 were awarded.
To date, many solutions have been sought to make up for the lack of emergency medicine specialists in Italy: use of doctors’ cooperatives, valorization of overtime hours, involvement of territorial medicine, etc...
The figure of the emergency doctor today is no longer that of the young doctor looking for his first job or the pensioner looking for economic integration for his pension, but is a real profession, very distinct from the others, with very high medical-legal risks and the need for constant specific updating. It has become an allencompassing profession that is difficult to replace.
In our opinion, in Italy the time has come to stipulate a specific national contract for doctors who work in the world of Emergency, leaving behind the philosophy of «we are all the same»
For example, in the United States, clearly in another type of Health System, there is a significant variation depending on the specialization, where doctors can earn from 150,000 USD to over 500,000 USD per year.
In October 2024, the average annual pay of a Physician in an Emergency Room in the United States is $370,447 and can go up to $456,447 or down to $263,624, but most earn between $314,532 and $415,463 [3].
The real Copernican revolution of the Italian National Health Service can be born from the Emergency Services, with the restructuring of the Collective Labor Agreements, adapting them to individual specializations and individual territorial realities. The implications of these choices are important but if we do not change mentality by valorizing the doctors employed in the Emergency and Urgency Services especially from an economic point of view, in a substantial way, it is useless to open medical schools without control and spend money indiscriminately on all specializations.
