Stress, anxiety, depression, SARS-CoV-2 infections and deaths, dry eye syndrome, and gastrointestinal diseases feature among the problems that medical interns have reported. These problems result from the workload they experience during their clinical internship and from carrying out activities that were not their responsibility.
Healthcare professionals told Medscape Spanish Edition that although there are programs for detecting and addressing symptoms related to mental health in a timely fashion, it is urgent that doctors in training stop being viewed as cheap labor. These professionals must come together to denounce any abuse against them so that it does not go unpunished.
Who Cares for Interns?
Jesús Moreno, MD, recently completed his clinical internship in a rural area in Linares, Mexico. In addition to giving 20-minute consultations to an average of five to 10 people per day and cleaning the clinic, he participated in canine vaccination days.
Overseeing the medical unit soon took its toll. Although he was used to living alone, the lack of interaction with colleagues and with patients caused anxiety and stress because he did not know whether he was doing his job well. His immediate bosses rarely went to the first-level hospital.
This situation, as well as the lack of learning, motivated the young man to undertake rotations in an urban unit. There he treated an average of 15 to 25 patients, although the established limit is four, and he was without the supervision of assigned doctors to guide him. The clinician found pros and cons in his situations, but not a happy medium that would allow him to prioritize his physical and mental health. It got to the point where he needed to undergo treatment for depression.
"In terms of workload, urban needs are greater than rural needs regarding patients. However, when it comes to administrative and cleaning activities, rural needs are much greater, because an individual takes care of everything. In urban clinics, I didn't have to clean toilets, I shared reports with another colleague, I practiced a little more. For example, I started in August, and by January, I had to start [treatment with] antidepressant drugs due to stress and the burden of running a clinic, and my personal situation added to that," said Moreno.
The doctor pointed out that, like him, other colleagues began taking antidepressants or anxiolytics to be able to carry out the activities assigned to them and to achieve the health goals established for the state of Nuevo León.
"The worst thing is not that they send us to the front line with no weapons or that we are cheap labor but that there is no concern for patients, for knowing their illnesses, and treating them. As for us, there was no help to deal with the stress we were subjected to. There is talk of strategies, of institutional support, but it's not put into practice. In addition, getting a permit for anxiety, stress, or depression is very difficult... To start with, who diagnoses it? And if you get a permit, maybe they give you 1 week, but there is no follow-up on the problem."
Sol Durand, MD, who is affiliated with the Ramón de la Fuente Muñiz National Institute of Psychiatry, lamented that there is a national lack of information on the mental health of medical staff and that such problems are greater among doctors in training.
She added that receiving a diagnosis of depression, anxiety, or professional burnout syndrome is not what is most difficult; rather, the real battle is to attend to these conditions and get the union to recognize the disability. The problem is largely due to the stigma of "weakness" that prevails among those who report these conditions.
"How are we going to get recognition of a disability due to depression, anxiety, professional burnout syndrome, or stress if just saying it out loud makes us look like the weakest, like those who can't put up with anything? It's easier to hide, pretend that nothing is happening, look for alternate routes, but never in the hospital where you work, because there is an enormous fear of being singled out. If we don't correct this, the repercussions on our health will never go away," she said.
Fighting for Change
On January 4, 2021, intern Jorge Alejandro López died in the emergency department at the Ecatepec General Hospital in front of colleagues who could not revive him, although they tried for more than 40 minutes.
Almost a year and a half later, the Human Rights Commission of the State of Mexico determined that the medical unit should respond to the incident by compensating and rehabilitating the victims. Dr R, who asked to be named this way to avoid reprisal, commented that as long as the conditions in which they work do not change, there will be no justice for her friend or for colleagues Mariana Sánchez, Eric Andrade, and thousands more who suffer abuse during their training.
"We watched Jorge die. There was no good oxygen outlet. We had no protective equipment. There was a lot of terror. The hospital wanted to distance itself. When the National Autonomous University of Mexico withdrew its students, it said that Jorge was not at risk, but many of us are still in that hell. I know that a long time has passed, but I still shy away from speaking publicly, and I know that this must change, that perhaps I have to go out and say my name out loud, openly speak about everything that we have been through in our practices, but my income is not fixed, and although more and more of us are trying to achieve a change, the need to have a job is very great."
Dr R provides her services in two public hospitals in Ecatepec. Her days are split between work, family, and attending private psychological therapy sessions to deal with anxiety and the posttraumatic stress disorder that she experienced not only through the death of her colleague but also from caring for patients with COVID-19 during the most critical stages of the pandemic.
Andrés Castañeda Prado, MD, coordinator of the Nosotrxs Cause for Health and Welfare, argued that it is not necessary that Dr R share her identity. He affirmed that there are many cases such as hers, and not only among interns but also among professionals who did their residency during the first and second waves of the coronavirus pandemic.
He recalled that in the group that he leads, surveys were carried out involving doctors in training. Among the results, he highlighted the union's concern for not having the necessary tools to deal with the COVID-19 pandemic, complaints due to lack of personal protective equipment, for not having received the SARS-CoV-2 vaccine, and for not receiving support from academic or hospital institutions.
"The lack of personal protective equipment was never a secret; more than 90% of the doctors interviewed reported it. Although COVID-19 vaccination began in the health sector in December, by March 2021, 50% said they did not know when they were going to receive the second dose, 68.7% said they did not feel prepared to deal with the pandemic, and, in cases of getting infected, 47.3% indicated that they did not receive support from the medical unit. This is a clear example of the reality that exists in public health services, specifically with doctors in training, and it's because they are still considered cheap labor and are at the bottom of the chain, so to speak."
Prevention Is Key
Guillermo Blanco Govea, MD, state commissioner of mental health and addictions of Colima, is convinced that prevention is one of the greatest allies against depression, anxiety, professional burnout syndrome, and suicidal behaviors. In August 2021, the implementation of an early detection and mental health care program for undergraduate medical interns and clinical interns was announced in the state.
The central objectives of this program are to prevent healthcare professionals in training from making attempts on their lives, detecting the conditions mentioned in the questionnaire on psychosocial risks at work (SUSESO-ISTAS), and giving timely follow-up to the students.
"We hope that intern doctors and those who carry out medical residencies do not experience these unfortunate events, that they are accompanied, and that this myth that the doctor is superhuman and has no feelings or emotions disappears. Therefore, doctors must receive care. Those situations that make them vulnerable must be detected and avoided. Only in this way will we be taking care of them," he stressed.
He also explained that the first step was to classify the groups with respect to low, medium, and high risk. On the basis of the results, intervention and psychoeducation strategies are granted and counseling for self-care of mental health is offered. In addition, activities related to self-care, both recreational and familial, are recommended.
For the moderate-risk group, he specified that they are working with communication workshops in which self-care of health in food and rest is prioritized.
"It is very necessary that we learn to rest, that doctors in training know that they cannot work as if they were robots, that their sleeping hours must be prioritized, because if they do not, there are consequences, such as dry eye syndrome, sleeping cycle disorders, and discomfort ranging from gastrointestinal to emotional as a result of this."
For high-risk doctors in training, the indication is to carry out a more individual and thorough assessment for a possible mental-emotional disorder to make a more precise diagnosis. The next step is either individual psychotherapy with a specialized healthcare team or, if they are assessed as needing pharmacologic treatment, referral to outpatient management or hospitalization.
"It's important to highlight that this program has a follow-up; it's not only passing through, but that first diagnosis is made, and 6 months later, a new assessment needs to be carried out to see the impact with the strategies initiated. It must be understood that the doctor is not exempt from suffering from some psycho-emotional condition. Even the very demanding nature of the course and its duration make the staff being trained in this area of health vulnerable, and therefore there is an imminent risk that a more delicate situation may occur, such as suicide. That is why we must work to prevent these situations," he said.
The state commissioner emphasized that to carry out this type of program, a team specialized in mental health and in the use of preventive measures, such as individual assessment, is required. But he recognized that some communities do not have enough specialists.
"It is evident that doctors at some point will be attached to a health service, they will dedicate themselves to caring for other people. To do so in the best way, it is essential that they have psycho-emotional well-being, that they know how to detect and how to channel patients who have some problem, but not only those they care for, but for themselves, that they know when they are going through depression, anxiety, psychosis and have the tools to know how to act and achieve good care," he concluded.
What Can Be Improved?
Moreno recalled that during his clinical internship in Nuevo León, the strategy for dealing with situations related to the mental health of doctors in training consisted of channeling patients on the verge of suicide to individualized care. He considered that in addition to the structural flaws in the healthcare system, another Achilles' heel is that healthcare professionals minimize the symptoms of any pathology for fear of being criticized.
"Sometimes we don't sleep and do not give it importance until we end up with irritated, inflamed, and light-sensitive eyes. If we have problems of anxiety, stress, or we are overwhelmed by work, we try to show ourselves that we can do it, no matter if we have diarrhea, if our intestines are inflamed, or if we hallucinate due to lack of sleep. I think we also have to learn to take care of ourselves, look for coping strategies, because we cannot wait for the authorities to want to help us," said Moreno.
Castañeda celebrated the existence of strategies such as the one implemented in Colima and affirmed that they should be maintained and be extended, but he stressed that they are insufficient if the healthcare system continues to depend on doctors in training to attend to the health of Mexicans.
"The underlying problem is that doctors in training are cheap labor, so these strategies are not going to be used, they are not going to be expanded because no one can afford to promote them if it is going to reduce the workforce in a hospital that is saturated. More budget and hiring of qualified doctors is needed to attend these first-level clinics in urban and rural areas. We are waking up as a society, as a union. Months ago, there was talk of resignations in nursing homes, the person resigning is very respectable, who prioritizes their health, but it shouldn't have to be like that, no one should have to give up their dreams, because we live in a system that has normalized malpractice. We have to cut those chains and fight for a more dignified and equitable health system for all," he concluded.
Moreno, Durand, Alejandra, Castañeda, and Blanco have disclosed no relevant financial relationships.
This article was translated from the Medscape Spanish edition.
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Cite this: Workload and Extra Responsibilities Affect Interns' Health - Medscape - Aug 26, 2022.