Medical intern burnout worsened by Covid-19

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Even prior to the Covid-19 pandemic many medical interns in South Africa had a tough time, often working long hours and with little oversight or support. Spotlight spoke to interns and junior doctors in public hospitals and tag-on Covid-19 facilities, who are performing tasks of porters, auxiliary nurses, and liaising with anxious relatives, instead of getting the required hands-on, supervised learning.

One intern in Gqeberha described their overnight on-call hospital room as ‘a smelly pit’ with no toilet seat, dismal furnishings, and no creature comforts, while being forced to work with insufficient personal protective equipment and at the mercy of work-to-rule nurses.

She said her anxiety was heightened by driving to and from work through a squatter camp in the dark, walking alone between hospital wings and in dingy corridors with security guards declining to accompany her, and pulling long shifts, including overtime, for which she says she’s being underpaid.

All the juniors Spotlight spoke to complained that they had little or no time to eat, even postponing toilet breaks, while they say nurses took three fixed daily refreshment breaks, during which they would often decline doctor requests or refuse to delegate tasks.

“It’s important things, like setting up drips or dispensing meds on time – I even had one end-stage patient not getting their morphine dose in their last hours. We dare not complain because then they shut you out and you’re stymied,” said one intern.

All junior doctors interviewed declined to be identified, citing colleagues who’d gone public only to suffer victimisation. A rare few have claimed victory in lengthy, costly, and debilitating bureaucratic legal battles.

Conflict and burnout

In an incident involving a patient with suspected inhalational burns, a registrar disagreed with an intern’s decision to intubate and was unsure of what sedation to administer while everyone struggled to get a faulty ventilator working.

When the intern posted about the incident on her collegial WhatsApp group, she says hospital management posted pictures of working ventilators, functioning wall suction points, and drugs exactly where they were supposed to be (but hadn’t been). She says she was also upbraided by a consultant, who said, “it won’t do my career any good”.

She said four in her group of 80 interns in the Gqeberha hospital complex had been booked off with burnout, while many others “are toughing it out”.

One junior doctor, working in a close-to-overwhelmed but efficient Cape Metro field hospital in early August, said that despite intense pressure and exhaustion, he still counted his intern years as the worst.

“It’s only when you are away from it, that you realise you accept the unacceptable and are deeply inured to it all. You kind of numb yourself out. Even after [a] good while here, I’ve never experienced anything as bad as internship.

"It’s weird how long you take to recover. It certainly took me a few months to recover after my Comserve year. I still get flashbacks to my two intern years. If I compare it to now, when I have a bit more authority as a doctor, you can’t believe you went through that. You detach from yourself as a coping mechanism. I guess it’s classic PTSD,” he says.

Sucking it up

“It feels like you have to manage 5 000 things a day,” says another young doctor. “If I’ve written up a patient dosage that coincides with a nurse break, they don’t even get someone else to administer it. If you complain about attitude or non-compliance, it rebounds badly on you, so we just suck it up.

"You have to check up on everything and with our pressure, that’s just not possible. A lot of us have given up. There’s no accountability with the nurses,” she said.

While these may well be isolated cases, and while Spotlight’s reporting over the years has found the vast majority of public sector nurses we’ve encountered to be committed professionals, such accounts are nevertheless worth reporting for what it says about conditions at some facilities and how facilities are managed.

Eastern Cape health department spokesman, Siyanda Manana referred Spotlight to the spokesperson for Dr Rolene Wagner, the province’s Head of Department. However, she failed to respond to calls and text messages before deadline.

Spotlight spoke to former superintendent-general of the Eastern Cape Health Department, Dr Siva Pillay, now a foetal medicine sub-specialist in private practice in Uitenhage, in an attempt to throw light on the matter.

Pillay says there has been, “a complete breakdown in the hierarchal structure that used to hold people accountable, and also in consequence management”.

Pillay, a veteran of tumultuous Eastern Cape health politics, was recently invited to serve on the Eastern Cape Premier’s advisory panel and says there’s no line of authority with nurses.

“This results in them doing exactly what they want - there’s been a total erosion of morality and ethics, so people don’t bother now,” he said. "Basically the health department is bankrupt - they don't have enough funds to go beyond September.

A special task team has been appointed to try and appropriate money from other departments and national treasury are deeply unhappy with a whole lot of unauthorised spending.

They're no longer prepared to bail them out. Despite all advice, the provincial health department is not taking on the unions and others about the vitally necessary rationalisation of services - and the salary bill has gone beyond 78% of their entire budget."

But Khaya Sodidi, Democratic Nursing Organisation of South Africa (DENOSA) secretary in the Eastern Cape, is not happy with the singling out of nurses.

“The fundamental problem is the chronic shortage of staff for more than 15 years now,” says Sodidi. “It's a systemic, structural problem which Dr Pillay should know about - without singling out nurses.

"The Eastern Cape health department is in tatters. If there's any nurse neglect of patients, it must be dealt with immediately, but nurses always work in a team environment and this is not their singular problem. We cannot deny that there are problems at the hospitals."

Responding to the claims about nurse behaviour from a Western Cape perspective, Dr Saadiq Kariem, Operational Chief of the Western Cape Health Department, says, “Nursing agencies have to follow our Department of Health prescripts in terms of working conditions such as tea or lunch.

"Our full-time staff have oversight over the agency staff and ensure that these prescripts are followed. If this is not the case, I would encourage any of our staff members to raise this with us and we will certainly take action against it.

National Department of Health spokesperson, Popo Maja, says such incidents are unfortunate and not the norm nor a reflection of our health system.

“Admittedly, Covid-19 has stretched our health systems globally. However, countless health professionals (including nurses) continue to save lives on a daily basis. We should celebrate their exploits,” he said.

The South African Nursing Council declined to provide comment for this article.

Top psychiatrist ‘shocked’

Professor Christoffel Grobler, Head of the Clinical Unit at the Elizabeth Donkin Psychiatric Hospital in Gqeberha, says that if you are a doctor, your chance of developing anxiety is about 5 to 10 times higher than the general population. The disassociation one doctor spoke of, he says, is a classic symptom of trying to cope with anxiety and depression.

Grobler says local research on depression and anxiety implies that the chances of a doctor developing burnout range between 59% and 100%, “so I suppose for most of us it’s a matter of when not if”.

He cited studies showing a 59% prevalence of burnout, anxiety, and depression in medical doctors working in KwaZulu-Natal, and 76% (suffering the same maladies), in Western Cape rural clinics and district hospitals.

“I’ve developed a lot of compassion for young doctors,” says Grobler. “They come to my hospital as interns and comserves and I hear these horror stories of bullying from them.

"It’s absolutely shocking.”

Grobler says an impending SA Medical Journal article would show that doctors aged 24-29 were the most distressed, with a shocking 46% clinically depressed.

“Most say they’ll leave the public service the first chance they get. It’s totally unacceptable when half our young doctors fulfil the criteria for depression.”

Intern curators’ failing?

Dr Akhtar Hussain, Chairperson of the SA Medical Association’s Public Sector Doctor Advocacy Forum says by law there is supposed to be an intern curator at every teaching hospital, but in practice the job is doled out to busy consultants, many of whom who see it as an irritant.

“The big academic hospitals have 70 to 100 interns and one curator. How do you manage them? It’s a full-time job that the medical manager should do, or appoint somebody to do, full time. Instead, he delegates it to somebody else and nothing gets done,” says Hussain.

A proper intern curator should know how many interns had drug, or mental health problems, family travails, security hassles, or road accidents, he says.

“Instead, the interns are pulling bloods and running to the labs or doing skivvy jobs when they’re supposed to be learning,” says Hussain, questioning how well the Health Professions Council (HPCSA) is fulfilling its role as the oversight body in checking interns’ logbooks and addressing clinical teaching issues. 

Veterans bemoan lost nursing skills

SAMA chairperson Dr Angelique Coetzee says pushing interns into the Covid-19 frontline is not teaching. She backs their complaints about nurses not fulfilling their roles.

“It’s a can of worms ever since the nursing colleges closed down and it’s in the private sector as well. You need to send an investigative team into the ICUs to see how many sisters are on call and how many enrolled nurses are being used.

"Your young doctors are 100% correct. If the nursing staff don’t like you or you’re not senior enough, they won’t do anything and will leave the patient. There’s no accountability. And too often, the moment you get upset, it can become a race thing.

"It’s so sad when actually it should be about whether [or not] you did your work. We have a huge problem with poor nursing skills and qualifications and the adequately qualified nursing cohort is getting older and older,” she adds.

Janine Roos, Director of the Mental Health Information Centre of SA, herself a long-serving nursing sister, says doctors dared not risk ordering nurses around.

“Today’s nurses work a 40-hour week. They bring food, pray, sing for an hour and eat.  Doctors have no time to do any of this. Then they, (nurses), work double shifts for extra cash and some sleep on night duty.

"Everyone is understaffed and there are simply not enough registered nurses – they cost too much, so they appoint low-qualified people who can’t do the job,” she says.

Interventions

Kariem said Metropolitan Life was partnering with the Western Cape Health Department to provide individual and group mental health counselling for healthcare workers, on and off-site.

“After our very traumatic second wave, we instituted an ‘intentional process of healing and grieving’ across the platform to allow us to experience the grief, hurt, and pain and deal with the pressure. It’s helped a lot, especially with the junior doctors,” he says.

Konrad van Staden, a Gqeberha-based clinical psychologist who counsels doctors, told Spotlight that the quality and knowledge of interns coming through in more recent years was “phenomenal, but we haven’t looked at how to help them overcome the emotional and psychological and to feel safe”.

“The system doesn’t allow that,” he says.  

“Everybody is just trying to keep their heads above water in normal circumstances, but with Covid coming along, it’s an absolute nightmare.

"The medical students I’m seeing know about self-care and are willing to take medication. However, from consultants to medical students, every one of them is isolated in some way.

"Isolation breeds disconnection, and that continues into further isolation,” he warns.

*This article was produced by Spotlight – health journalism in the public interest.

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