Mental health during the medical internship. Reflections in times of pandemic.

Edgardo Alvarado-Carrasco, Alejandra Valenzuela-Leal


Dear Editor:

Despite being “doctors in training”, medicine interns carry out important tasks within health teams at the places they work, such as: minding the clinical care of patients, interviewing them, giving medical indications (under supervision), communicating with relatives, noting clinical evolutions, attending procedures, and collaborating with clinical plans and decisions.(1)

Evidence generated in several countries has shown that interns are a risk population regarding mental health(2). This is due to many factors: strenuous hospital hours, high levels of stress and anxiety, poor sleep quality, little study time, medical board examinations, earlier start time at the hospital, usually  earlier  than  the  rest  of  the  “staff”  (to find out about the evolution of patients and new admissions), the constant shift between different rotations or “passes” in some internships, a high imposed “self-demand” etc. Therefore, we can point out that this is a known and documented reality since before the pandemic; and it has returned to our student “contingency”,  due to the recent news of the suicide of a 7th year medical intern at the University of Valparaíso, which caused great commotion among medical students in the country, and has generated a request from interns, to university authorities, for more attention to mental health during this stage of the career.(3)

Related to this issue, an article published in mid- March of this year, narrates the experience of the author (Internal Medicine resident) facing the suicide of an intern who rotated through service where he worked as a resident 6 years ago in New  York(4).  We  might  think  that  the  reality of  hospital-care  circumstances  for  interns,  in these countries would be different, but certain aspects   that   are   extrapolated   to   our   context are  described.  The  author  reflects on  the  little time   internship   or   residency   programs   leave for personal development, leisure, sharing with family and friends or for any activity outside the program. He also mentions, that having to face new  professional  responsibilities,  are  possible risk factors for the development of emerging psychiatric diseases or aggravation of pre-existing conditions. Also feeling insecure about their own abilities by constantly being subjected to new clinical scenarios and constant sleep deprivation, among others. contribute to this scenario. What is described above is similar to what happens in our “everyday” reality, but... what if we add the rest of the stressors that this pandemic has caused?

The current coronavirus-2019 (COVID-19) pandemic has greatly affected the world, as well as our country, in several ways (social, economic, psychological,  employment,  political,  etc.)  for over a year; and has also affected medical training, of  both  interns  and  medical  students.  In  first place, most medical schools and hospitals in our country suspended practical activities due to many reasons, but mainly to avoid spreading the virus between students and interns, which could lead to new sources of infection of COVID-19(1,5). Only in some exceptional cases in our country, such as the Pontificia Universidad Católica de Chile, were students and interns offered to attend clinical practice on a voluntary basis in the early stages of the pandemic.(1)

The rest of the great mass of interns nationwide have had their clinical practices suspended for several months, with a consequent load of uncertainty and possible impact on their mental health entailed by this situation. It is in this context that many of the interns in this situation may have had some of the following reflections: what will professional practices be like once interns are authorized to enter hospitals? Will they be just as demanding as in “normal times”? Or will the workload and responsibilities decrease? Will training be the same as someone who has completed their internship “normally”?... A recent publication by the Medical College of Chile has shown that only
39.3% of medical schools nationally, are carrying out clinical practices for their students (which includes interns).(6)

Within our local reality, at the Universidad de La Frontera, some months ago, interns have gradually picked up their practical activities.  Most of the internship programs have had to “adjust” their schedules initially, to meet the capacity and requirements  requested  in  our  training  centers by  the  Intrahospital  Infections  units,  in  charge of supervising this situation. As a difference to a “usual” 8-hour shift in a hospital, plus 24 hours shifts, every 6 days; today we find “part-time” schedules  and  in  some  internships,  shifts  that have  been  initially  suspended  or  have  started again but with shorter hours. The “differences” with  hospital  practical  shifts,  is  that  they  now have been complemented with online classes and conferences with teaching physicians. In addition, in some internships or rotations, a maximum “limit” of patients assigned to each intern has been established (or has been attempted) to establish.

It  is  at  this  point  where  the  reflection arises: will this “new reality” of medical internships happening in our university (and possibly, in many other universities in our country), exist only as long as this exceptional pandemic situation exists? or will certain elements that have been established, be applied permanently?

Regarding online classes, they were an unexplored option in our reality; but nevertheless, current technological tools clearly make it possible. Undoubtedly,  certain  practical  activities  cannot be completely replaced by this format (examples: physical examination, suture workshop, cardiopulmonary resuscitation, etc.); but the theoretical classes (which turn out to be the vast majority), perfectly can. Regarding the advantages of education on an online format, literature mentions the possibility to record the audiovisual material of the classes so it could be reviewed when deemed appropriate, therefore there would be less travel time to the university or hospital (it is worth mentioning that there are certain disadvantages: possible internet connection problems, especially for students living in rural areas; or students with fewer economical resources, resulting in less availability of technological elements such as a personal computer or cell phone(1,5). Although there are many different opinions about this modality, online classes have become an unavoidable educational tool, and must be complemented with traditional medical teaching methods.
It is interesting to study the mental health of medical  students  and  interns  as  detailed  above but given the current context in which interns nationally are gradually resuming their practical activities, it is necessary to further research this topic. Perhaps the comparative results of both pre- and post-pandemic mental health realities, will create interesting evidence that could be useful for academic authorities.

Additionally, we believe that another interesting focus  of  attention  are  students  who  are  yet  to enter  the  medical  internship  program  (4th  and 5th  year),  who  have  had  much  fewer  options to resume face-to-face practices, unlike current interns... and that, however, will have to return to the hospital once start their 6th year of training, regardless of the possible “clinical skill gap”. Let us remember that the first approaches to patients occur in the 3rd year of training, with clinical practices (semiology rotations). From that moment on, experience in health care centers is essential to develop clinical reasoning, as well as clinical skills and abilities that ensure that the quality standards necessary for the professional and technical practice of medicine are met(6). It is likely that in this group of students mentioned, this situation is resulting in repercussions in their mental health, as a consequence of the associated uncertainty. Nationally, only 25% of medical schools have 5th year students participating in clinical practices.(6)

Finally, we estimate that it is possible to harmonizehigh quality education with better mental and affective health of medical interns (better sleep quality, less stress, more time to carry out other personal activities, more time to study included, etc). Some of the new measures applied and mentioned in our internship´s reality, such as limiting   hospital   hours   and   shifts,   including online classes and limiting the number of assigned patients; can help carry this out. We emphasize that it is necessary to further investigate this situation in order to assure these claims with more evidence. From a reflective point of view and based on the above, as a medical community we must stop “normalizing” that medical internships are assumed to be a period of great learning, but at the cost of “suffering”, both physically and mentally. Perhaps because of this unexpected global circumstance, it is time to rethink the “old paradigms” of our medical training, in pursuit of the well-being of our future doctors.

REFERENCES


  1. Ballart  MJ,  González  J,  Larraín  S,  Muñoz  F, Pérez S, Andresen M. Experiencia del internado de medicina durante la pandemia por Covid-19. ARS  MEDICA  Revista  De  Ciencias  Médicas. 2020;45(3):72–5.
  2. Kobus V, Calleti MJ, Santander J. Prevalencia de síntomas depresivos, síntomas ansiosos y riesgo de suicidio en estudiantes de medicina de la Pontificia Universidad Católica de Chile. Rev Chil Neuro- psiquiatr. 2020;58(4):314-23
  3. Litoral  Press.  Suicidio  de  alumno  de  Medicina
    genera  conmoción  en  la  UV;  20  de  mayo  del
    2021 [Internet]. [Citado el 11 de julio del 2021]. Disponible   en:   https://www.litoralpress.cl/sitio/ Prensa_Texto?LPKey=3UITT56ZXRBMMU4V5
    MWZ4P67YASAPBZNZW7XOQEUNY66D2PJ US7A
  4. Leiter    RE.   My   intern.   N    Engl   J    Med.
    2021;384(11):986-7.
  5. Abreu-Hernández  LF,  León-Bórquez  R,  García- Gutiérrez JF. Pandemia de COVID-19 y educación médica en Latinoamérica. FEM. 2020;23(5):237-42
  6. Colegio Médico de Chile. Declaración pública. Una preocupación país: el acceso a las prácticas clínicas de estudiantes de pregrado del equipo de salud; 7 de julio del 2021 [Internet]. [Citado el 11 de julio del 2021]. Disponible en: https://www.facebook. com/ColmedChile/posts/559579022090230


HOW TO QUOTE?


(2023). Mental health during the medical internship. Reflections in times of pandemic. .Journal of Neuroeuropsychiatry, 57(4).
Recovered from https://www.journalofneuropsychiatry.cl/articulo.php?id= 98
2023. « Mental health during the medical internship. Reflections in times of pandemic. » Journal of Neuroeuropsychiatry, 57(4). https://www.journalofneuropsychiatry.cl/articulo.php?id= 98
(2023). « Mental health during the medical internship. Reflections in times of pandemic. ». Journal of Neuroeuropsychiatry, 57(4). Available in: https://www.journalofneuropsychiatry.cl/articulo.php?id= 98 ( Accessed: 6diciembre2023 )
Journal Of Neuropsichiatry of Chile [Internet]. [cited 2023-12-06]; Available from: https://www.journalofneuropsychiatry.cl/articulo.php?id=98

 

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