“I’ll never forget the complete and utter exhaustion I felt at four in the morning, with a multitude of screaming women in labour waiting for me to see them.
My body was telling me to stop, my brain had nearly completely shut down, and I was seriously contemplating walking out of the hospital, even leaving internship for good, then and there.”
Dr Amy Cupido*, a 26-year-old medical intern at Tygerberg Hospital in Cape Town was describing a shift in the obstetrics ward where she had been on call for more than 20 hours with only a 30 minute break.
At the time, she was working 120 hours overtime a month, even though the legal limit is 80 hours.
Excessive working hours a major cause of stress
South African interns are experiencing extremely high levels of stress, says an article published in the January 2008 edition of the South African Medical Journal.
Difficult working conditions, long work hours and heavy workloads appear to be the hallmark of the South African internship programme.
The average intern is responsible for 20 patients at any one time, says the study. About 40% of interns rated their internship as “overwhelmingly” stressful.
“Working hours are incredibly demanding, and often the hospitals we work under require that we work beyond the recommended overtime hours. I have sometimes found myself working for 32 hours straight!” one intern told Health24.
The study was conducted in August 2005 by the University of the Witwatersrand in Johannesburg. It involved 110 interns from three academic hospitals – Chris Hani Baragwanath, Johannesburg and Helen Joseph/Coronation.
The interns were randomly selected to complete an anonymous questionnaire that evaluated various aspects of the internship year. Of the interns interviewed 54% were female and 79% were single.
Exposed to HIV
The alarming number of interns directly exposed to HIV/Aids imposes a significant toll, both physically and psychologically.
The study indicated that 69% of participants reported exposure to the virus via a needle-prick injury or mucosal splash.
Dr Cupido says there is “no decent system” in place to handle these situations. “When I had my needle-stick injury one busy morning at two am, I had to go on my own to medical casualty where a fellow intern drew the necessary bloods for testing and wrote up my medication. I had to continue working and received no counselling”.
“I had to handle it on my own,” says Dr Themba Ngcobo*, an intern from Groote Schuur Hospital in Cape Town.
He says access to treatment after HIV exposure is good, but the availability of psychological support is non-existent.
Another intern says many of his colleagues who need to take ARVs do not finish the treatment, because they can’t handle the side effects.
Availability of basic supplies in hospitals
Most of the interns considered the availability of basic supplies (gloves, drip stands, needles) to be very poor (63%), and expressed concerns regarding the routine maintenance of basic medical equipment.
The quality of equipment and the environment depends on the hospital, says an intern at Wynberg Military Hospital in Cape Town.
“The military hospital is unlike most public hospitals. The environment is always clean and safe. Basic supplies are always available and our equipment standards are much higher than most public hospitals.”
An intern at Khayelitsha Clinic says on some days even the most basic equipment is not available.
“Some days I could not find basic essentials in the clinic – urine dipstix (essential for detecting a variety of important common medical problems, such as kidney failure and bladder infections), other days there were no thermometers, and at one point there was no working ECG machine (essential for diagnosing heart attacks).
In addition, the clinic was severely short of doctors, and this resulted in additional pressures being placed on the existing doctors.”
Quality of teaching is good
Most interns were happy with the “overall quality of teaching,” but felt that the “quantity of teaching exposure” was insufficient.
Cupido agreed that the quality of teaching, when it did take place, was good.
“Most South African doctors are quite well informed and have a good basis for practising medicine. Of course, due to time constraints and the ever-present pressure to see as many patients as possible each day, the time available for teaching is limited.”
Another intern said he wished that he had better supervision when he was starting off.
“As an intern I'm not always confident of the diagnosis I make, or the management plan I have for all my patients. Obviously if I felt the patient’s life was at risk, I would get a second opinion, but if the condition is not that serious it’s up to me to decide how to manage the patient.”
Interns admit to depression
The most common manifestations of stress were irritability, fatigue, anxiety, fluctuations in weight, loss of appetite and crying.
An intern interviewed by Health24 said his worst experience was spending an hour trying to resuscitate a two-year-old boy and then having to tell his parents afterwards that he didn’t make it.
Interns also mentioned the lack of consideration shown by department heads and hospital managers when they complained about excessive working hours. Often these pleas for help are met with a host of excuses and other avoidance tactics.
More than half of the interns (54%) interviewed admitted to being depressed, and over a third suffered from insomnia or appetite loss.
Alcohol use was relatively widespread with 20 interns admitting to using it as a stress reliever. The consumption of cigarettes and drugs as stress relief mechanisms was reported as infrequent in the study.
Females were more likely to report recent weight changes and crying, and were more likely to acknowledge the negative effects of stress on their personal sense of well-being. This may be due to the isolation and anxiety related to role stress, loneliness and depression, and problems balancing a family and career, the study states.
Despite the poor working environment and high stress levels, some South African interns still find some thing positive in their jobs.
Cupido describes some of her best experiences during her internship.
“Working with children who have been in a coma from tuberculosis – seeing them waking up and starting to smile, singing and playing, when the medication took effect. Also, the rare encounters with patients who are thankful and show genuine gratitude for my helping them.”
Another intern said, “The best feeling is when a patient who was sick or in severe pain smiles at you and thanks you for helping them in their time of need. There is no better feeling than seeing their pure gratitude and relief.”
Comparison with previous study
The study was compared to the findings of a similar study conducted 20 years ago in the same clinical setting. The hours worked were similar to the previous reports.
Despite the additional demands of HIV/Aids, ironically more interns in this study (91%) compared to 66% in the 1986 study claimed to be coping with their internship.
While the scale of this study is small, the researchers believe that the stress levels experienced at other public hospitals is likely to be similar.
Based on the alarming results of the Wits study, the researchers called for an urgent review of intern working conditions, for better protection against occupational HIV/Aids and for increased stress support mechanisms for interns.
Unfortunately, the study also acknowledged that this recommendation was “likely to fall on deaf ears.”
(Thania Gopal, Health24, June 2009)
* Names have been changed
South African Medical Journal, Stress during internship at three Johannesburg hospitals, January 2009, Vol.98 No.1
SA hospital shocker
NHI key details