It’s a chain. If a health center does not cover sick leave or vacations for professionals, there are fewer doctors for the same number of people. Each of them has to deal with a long list of consultations and the time they can spend with patients decreases. From 10, to seven, to five, to two minutes. Faculty and citizens are frustrated. Everything is on the run, the Primary Care service is gradually deteriorating and the majority union of doctors (Amyts) call an indefinite strike ―which will soon be three weeks old― to try to stop the infinite overload. But in the chain, there is a link that cannot be added to unemployment and that increasingly sees its training and job expectations diminished: the Internal Resident Physicians (MIR) of Family and Community Medicine. In the last two years, 443 professionals have completed their residency in this specialty in Madrid. So only 37 of them have accepted the contracts offered by the Ministry of Health.
“We are the future of Primary Care. If they don’t want us here, we’ll have to go where they offer better conditions. But we will do it with a lot of sorrow”, says José Manuel Portal, a fourth-year resident (R4) at the Monterrozas health center, on the outskirts of the Madrid municipality of Las Rozas. He is 36 years old and is from Salamanca, although he moved to Madrid in 2007 to practice as a nurse.
It was not his first choice. He wanted to study Medicine, but he did not reach the cut-off grade. He liked nursing and he dedicated himself to it for 12 years, until he decided to try his luck again. This time yes. He combined his degree with work, took the MIR exam and started his residency. He only has six months left to finish it, but the saturation that health centers have been suffering for years is affecting their training: “The tutors have very tight schedules, and that means they can’t take care of us well. We cannot ask questions because there is no time to solve them. Or they have to do it in a hurry and running to be able to continue with their care work”.
It’s not the only problem. The chaos derived from new plan for reopening extra-hospital emergencies ―80 centers launched with half the staff―, has caused many of those known as Continuous Care Points (PAC) to be operating without a doctor. These centers include the 41 Rural Care Services (SAR), where fourth-year family medicine residents must do at least one shift per month. Without a doctor who assumes the supervision, the MIR cannot cover that shift. “It is day by day. If you’re lucky, there’s still, if not, nothing. We have to call every time to see if it’s a yes or a no. When it comes to the second, you look for your life, because that night in many cases you don’t get it back, ”says Portal. The loss is double: formative and economic.
“Sometimes we go to the center, we see that there was no doctor and we have to go home. There are many hours invested in coming and going, because the SARs are far away. And a large part of the salary of the residents is the guards”, complains Pablo Martínez, 29 years old and R4 in a health center in Torrejón de Ardoz, east of the capital. On average, residents must do between five and six guards per month.
Per hour, they charge 17.85 euros on holidays or if they are 24 hours they go up to 19.94 euros. For example, in a 12-hour rural guard, a resident would earn 214.20 euros. If he can’t do it, he loses them. “If you take away guards from us, the salary at the end of the month to live in Madrid will be just a thousand euros. We can’t do that,” criticizes Portal. Martínez adds: “There are also many hours of training that disappear and that we can only do the fourth year of residency. We want to help patients and families, and we want to do it right, but we lack outside support.”
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It refers to the lack of investment. “I always have in my head the phrase of a professor of the career: ‘The key to a good functioning of medicine is a good investment in Primary Care’. That has not happened, Primary Care is not attractive”. Health expenditure per inhabitant in Madrid is 1,521.8 euros, which makes it the second community with the lowest investment, according to the Ministry of Health. Of that amount, 162.2 euros are for Primary, 10.7%, the lowest percentage registered in the capital in the last 20 years. The regional government has committed to allocate 25% of health spending to Primary Care in the regional budgets of 2023.
“We are extremely well-trained professionals and it is a shame that we are treated like this in Spain, and especially in Madrid, because we have shameful salaries,” laments a third-year resident of the Guayaba health center, in the Carabanchel district of the capital. She prefers not to say her name so as not to compromise her professional future, which she defines as uncertain: “When you finish your residency, all the contracts are temporary, even for a single day. Some doctors work in the morning in one center and in the afternoon in another. That’s zero stability.”
Martínez feels the same, tiredness and fear. “What is heard in the corridors of my health center is that this strike is historic [Sanidad calculó un seguimiento del 30% el primer día]. But it is exhausting to see that the Community is not listening or moving a finger to improve the situation. You begin to wonder if it is worth continuing with the specialty. It’s hard for me to say, because I like it, but you have doubts, ”she says.
At the Carabanchel outpatient clinic, they see an average of between 60 and 80 patients a day, says the 27-year-old resident: “When you leave the day you find yourself in such a state of stress and disappointment that you live in frustration constant. You feel like an automaton.” The workload means that fewer and fewer doctors want to commit to acting as tutors, because they do not have time. In the Community of Madrid there are seven Family and Community Care Teaching Units, according to data collected on the website of the Primary Care Management. These units have the capacity to train 1,016 residents and have 848 accredited tutors.
“Tutors must have a limited number of patients per day and even with the reduced number it does not allow them to dedicate time to their resident. They not only teach you what is related to the disease, in Primary Care a number of bureaucratic or social aspects must be taken into account. Only a doctor who has spent years in a consultation can train you in that. But the more load, less time and worse learning”, explains Martínez. Family Medicine was not his first choice, but after four years she has fallen in love with the specialty. Now, about to finish the training period, he doesn’t know whether to dedicate himself to it. He sees his surroundings and wonders: “Is something so beautiful going to end up burning me so much? It’s a bit of a sad future.”
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