Alienating intern doctors is a naive and ill-advised costs saving strategy

While internship is part of one’s training towards being a licensed doctor, in practice, it is how care is delivered in training hospitals across the country

COMMENT | Dr Bruce Tumwine Rwabasonga | On Friday, May 12^th, government issued a newly proposed policy to address what now appears to be a rite of passage for all Ugandan doctors, intern strikes. According to Prime Minister Robinah Nabbanja, “Internship is going to be part of the medical school degree and therefore, a university medical student will be studying an extra year. This is contrary to the present where a medical student has to first graduate before doing a mandatory one-year internship”. This is a move that is geared towards eliminating salaries for some interns and significantly reducing salaries for all interns across board.

As I share below about my experience as an intern doctor, while internship is part of one’s training towards being a licensed doctor, in practice, it is how care is delivered in training hospitals across the country. The argument that government is making that interns are merely trainees shadowing a senior doctor is a misconceived one as they are more like on staff doctors with tyrannic shackles that require them to show up and perform in sometimes impossible situations or risk not getting licensed.

Though it has been more than a decade, I vividly remember my first day of internship. After driving in late on Sunday night, onboard a rented minibus with eight of my colleagues from Galloway Hall to Mbale hospital, I reported to the Chief of Obstetrics and Gynecology (OBGYN) on Monday morning, alongside two of my colleagues that had been assigned OBGYN as their first rotation. Our understanding was that there would be at least a week or two for orientation. We were in for a shock!

After quick introductions, the OBGYN chief ushered us to the gynecology ward, where he rounded on the 30 admitted patients in an hour or less. After the ward round, I was assigned to the emergency gynecology unit. The emergency gynecology unit, as the word emergency implies, is a high stakes place of life and death. One must expertly triage, examine patients while developing and executing their treatment plans. To ease me into the work, the OBGYN chief joined me, introduced me to the staff and reviewed some of the patients with me. After about an hour, with a smile on his face, he said, ‘Doctor, you can now take over!’ That is the last I saw of him that day. Barely two hours into my internship, I was the only doctor in a regional referral hospital, seeing all emergency gynecological cases!

The unit had ten beds and a couple of long benches outside, where all the women sat, as they waited for their turn to be seen. By lunchtime, the line outside the unit had sprawled out to the veranda. Over the following weeks and months, I would realize that was just a typical day that would get worse on on-call days where one sometimes didn’t sleep for literally 36 straight hours.  Over the next three months, I independently conducted over 150 cesarean sections and countless other obstetric and gynecological procedures. My story is not an anomaly. The picture above is what an intern doctor in Uganda experiences. They are without doubt the heart and soul of care delivery within the country!

Currently, there is a record high number of 1,900 pre-medical interns waiting to be deployed. While this might present financial constraints today, it also provides a big long-term opportunity for the country.

Despite the United States GDP per capita and medical spending being seven and ten times respectively higher than Cuba’s, Cuba has comparable outcomes on many health indicators particularly life expectancy and infant mortality.  While there are many factors behind this phenomenon, the central one is Cuba’s famously high doctor to population ratio (8.4 per 1000 in 2018) – the highest in the world by a margin! This high supply of doctors has ensured that Cuba’s primary care clinics are available in every neighborhood and that specialists in various specialties are available in hospitals. This phenomenon allowed Cuba, a country with scarce resources to within a space of two generations move from life expectancy rates of a developing nation to that of the United States.

As H.L. Mencken famously said, ‘For every complex problem, there is an answer that is clear, simple, and wrong’. While not paying intern doctors salaries presents significant cost savings for government, it is not only ill conceived but presents unforeseen long term systematic harmful ramifications. Intern doctors are the present and future of the country’s health system.

Today, their return on investment (ROI) on the little that government pays in salaries is paid back in plenty – probably the highest ROI of any government employee! Instead of alienating these young doctors, whose impact the country can reap for the next half century, government should prioritize a strategic doctors workforce development plan with the necessary recruitment and retention incentives, including financial and working conditions ones.

This strategic plan begins with government leaders conducting gemba walks (Japanese term for going to where the work happens) to gain a better grasp of the issues interns and the health system, as a whole face. Then hopefully, many of these intern doctors will consider long term careers in their communities and consequently put Uganda on the path that Cuba underwent to attainment of world class health outcomes within a relatively short span of time!

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Dr. Rwabasonga, MBChB, MPH, MHA is the director of strategy and innovation at Optum, part of UnitedHealth Group and the largest employer of physicians in the United States. Opinion expressed here doesn’t reflect that of Optum

Email:  mande166@umn.edu