A few days ago I was having dinner with a group of close friends who are all doctors, and working in the Portuguese public healthcare sector. One of the topics of conversation was the need everyone felt to carry out additional work in the private sector just to earn a decent income at the end of the month. One of my friends confessed that she only carried out shifts at a private hospital for financial reasons, even though she didn’t enjoy the actual work. Considering that most doctors in Portugal already work at least 35 to 40 hours per week in the NHS, doing additional work in the private sector causes considerable strain to their personal and family life, as well as their health, not to mention whether they are complying with European Working Time regulations. In a way, doctors are no different to the rest of the Portuguese population as it is common to see many people juggling two, three, or even more jobs to make ends meet—and that is for those people still lucky enough to find work.

Even though doctors in Portugal are still thought of as earning a lot of money, I don’t think most doctors would work so hard and in several places if they were paid better in the public sector. Only about 30% of hospital doctors have exclusive contracts that prevent them from working in the private sector, but in primary care, that figure goes up to 70%.

Some doctors working in certain specialties still manage to earn six figure salaries, but juggling several jobs probably adds little or no value to their professional development. It leaves little or no time to reflect on work, to attend courses, or to catch up on the recent medical literature. Perhaps not surprisingly, revalidation is something we are probably not going to see anytime soon in Portugal.

My friends who work in hospital specialties say that when they do private work, rather than focusing on diseases in their specific field of expertise (for example, leukemia), they also have to deal with common problems which are usually more within the realm of primary care (for example, anaemia). I think that hospital specialists’ private work contributes to weakening primary care in the public sector, because it leads to GP’s being deskilled, and more importantly, it generates the public perception that common health problems should be handled by specialists. A lot of standard maternal health and family planning services (for example, follow-up of low risk pregnancy, contraception, cervical cancer screening)  in Portugal are now taken up by private gynaecologists and obstetricians rather than GP’s, and many patients I see don’t consider women’s health to be part of the role of a GP, which is very frustrating.

Juggling work in both the public and private sector also raises a number of other delicate problems, like conflicts of interest and “professional promiscuity.” The Ministry of Health has been trying for a long time to make it compulsory for doctors to choose between working in the public or in the private sector. But this issue is still far from being solved.

The opportunity for many doctors to still be able to work in both the public and private sector reflects  a strong demand for medical care, and job insecurity for doctors, even though that is about to change. Contrary to the overall situation in Portugal, it is still not too difficult for a doctor to find a job, even though it is much harder to develop a fulfilling career with good prospects of professional evolution and development. And there’s a huge difference between just having a job and having a fulfilling career. Most doctors who decide to leave the country don’t do it purely out of financial need. Financial incentives do play a part in the current emigration of doctors abroad, but factors like better specialty training opportunities, better career stability and progression, and professional development are more likely to persuade doctors to leave the country in the coming years. It all comes down to whether you want to accept the tough reality in Portugal and muddle through, or try the overseas dream, wherever that may be.

Tiago Villanueva is a locum GP based in Portugal, and a former BMJ Clegg Scholar and editor, Student BMJ.