I translated this into English for everyone to read. This is written by an orthopedic surgeon colleague in Spain, but I know my American colleagues will appreciate the text an similarities to challenges we face here 1/ The Asymmetry in Medicine in Spain: Responsibility Without Authority (I) Opinion Francisco J. Guitián Lema The Asymmetry in Medicine in Spain: Responsibility Without Authority (I) “There is irrefutable empirical proof of this asymmetry: the doctor can replace anyone; no one can replace the doctor,” states Francisco J. Guitián Lema, a Vigo-based traumatologist specializing in orthopedic surgery There is a truth so elementary that it feels uncomfortable to state it: a hospital exists solely and exclusively to cure the sick. It is not there to provide jobs or to justify organizational charts. Nor to feed bureaucracies or to experiment with organizational theories. It exists so that a sick human being leaves it less sick or, at the very least, having received the best possible treatment. From this premise follows a logical consequence that the Spanish healthcare system seems determined to ignore: in that healing process, there are only two absolutely indispensable figures. The patient, who is the reason for the entire structure’s existence, and the doctor, who possesses the knowledge to guide that process. Everything else — and this is not disdain, but taxonomy — is support structure. Necessary, valuable, often heroic, but auxiliary. The doctor is the only professional capable of performing the core act that justifies the hospital’s existence: diagnosing the disease and establishing the treatment. Without a diagnosis, there is no possible direction. Without a therapeutic indication, there is no meaningful action. An orderly transports the patient, but it is the doctor who determines where and why. A nurse administers medication, but it is the doctor who decides which, how much, and when. A technician performs a test, but it is the doctor who orders it and interprets its result. This functional hierarchy is not a social convention or an inherited privilege: it is a direct consequence of training. Six years of medical school plus four or five years of MIR specialization produce a professional capable of integrating knowledge of anatomy, physiology, pathology, pharmacology, and a thousand other disciplines into a diagnostic synthesis that no other healthcare professional is trained to perform. There is irrefutable empirical proof of this asymmetry: interchangeability. A doctor can, in case of need, perform the functions of any other hospital professional. They can push a stretcher, insert an IV line, draw blood, take vital signs — in Germany, doctors routinely perform these functions. The reverse is not true. An orderly cannot diagnose pneumonia. A nurse cannot order a surgical intervention. The doctor can replace anyone; no one can replace the doctor. Recognizing this reality does not imply disdain toward anyone. Nursing care is essential. The orderly’s work ensures that hospital flow does not stop. Everyone deserves respect and fair compensation. But respect for personal dignity cannot be confused with functional equivalence. In an operating room, the surgeon is not worth more as a human being than the assistant; but their function is irreplaceable in a way that the assistant’s is not. This distinction, obvious in any other field, has become taboo in Spanish healthcare. The prevailing egalitarianism has managed to make an evident functional truth be perceived as a moral offense.