“After a night in the emergency room, you think: Who told me to become a doctor?
I'm not worth.
Where have I gone?
I am an imposter.
How do you get out from here?".
The first question to a young woman or young intern is how does someone in their twenties, who has just left the university desk after six years of theoretical study and another 12 hours a day devouring the MIR exam syllabus, feel when, for end faces pain and death.
They respond.
Rocío: “I will remember the first person who died for my entire life.”
Zoraida: “There comes a time when I can't handle so much stress.”
Alejandra: “You say to a classmate: 'Give me a little hug.'
And you continue.”
Ismael: “The day before shift I already have anxiety.”
Ana: “You go to the bathroom, cry, wash your face, and come back.”
Clara: “Ripe in minutes.”
Eva: “You assume you are not god.”
Miguel: “You live it with helplessness and frustration.”
Gabriela: “You go from manuals to harsh reality.”
Natalia: “You never get used to it.”
Antonio: “You learn to separate your existence from the tragedy.”
Susana: “You are making a shell of yourself.”
Ana: “It is vital to have a life outside, you cannot be a doctor 24 hours a day.”
Álex: “Yes, but there are patients with whom you empathize so much… that they remind you of your brother, your grandfather, and they go away…”.
Rocío Sánchez, from Córdoba, 25 years old, first-year resident of Anesthesiology, during an intervention at the La Paz Hospital, Madrid. James Rajotte
The remedy for these yogurts of medicine is prescribed by Dr. Ana Martínez Virto, three decades in the profession, emergency coordinator in La Paz in Madrid and tutor and teaching soul of this hospital, which concentrates 700 resident internal doctors in 52 health specialties. , some with the best grades in Spain, but all with the same doubts: “When you get someone out of cardiorespiratory arrest, there is no one in the world happier than you.
I can't describe it.
Without a vocation, you can't stand it.
If you don't have it or don't develop it, this doesn't make sense.
You work for the love of art.
“You are a public service.”
They had an ethereal ideal of helping others, but their manifest destiny was not to be doctors.
The majority do not have any family reference.
They were good students, with 13 points or more (out of a maximum of 14) in the EBAU.
They wanted to go far.
They are very competitive.
But not heroes.
Not even network stars.
In particular, the forgotten family doctors, who are the gateway to 95% of patients and, therefore, the lightning rod for their discontent with the system due to delays in primary care, clinical waiting lists and shortages. From Human Resources.
The aggressiveness of the patient towards the health worker has become a common occurrence that can be sensed in waiting rooms.
Especially after covid.
Between 2021 and 2022, these attacks increased by 38%.
“The patient and his family are no longer passive and ill-informed subjects;
They demand a favorable outcome from you, but it cannot always be.
The patient has changed even more than the doctor in a decade,” explains a veteran specialist.
And that patient, the client, the taxpayer, seems to be clear about what needs to be done to reverse this situation.
According to a 2020 CIS survey, 94.8% of those consulted stated that more financial resources must be dedicated, and 95.9%, staff must be increased.
They are not priests.
Years ago they shed the mantle of infallibility and distance.
Today, to begin with, they have to face unfair competition from the Internet.
For a fifth-year resident: “Many patients arrive with their own diagnosis, which they have seen on a website, and it is difficult to shake them from that certainty.
Before, what the doctor said went without saying;
Now you have to compete with
Dr. Google
.
The other day a man came to the emergency room and told us very seriously: 'I have right lobe pneumonia.'
It was not true.
It was a muscular issue.
And it was difficult for me to convince him otherwise.
We call this new phenomenon cyberchondria.”
For the medical director of La Paz, internist Juan José Ríos, “in the mir exam, artificial intelligence would have better grades than a human;
Therefore, the doctor must have other capacities: empathy, intuition, deduction capacity.”
One of his pupils, Sergio Carrasco, 28 years old, from Murcia and in his last year of Internal Medicine, emphasizes this: “The patient must leave the consultation knowing exactly what is happening to him.
And for that, as a doctor, you must have the curiosity to go to the end in your clinical judgment.
Ask and ask questions and
ask questions
;
Be a health detective.
Many times it is not so much about performing very aggressive tests, but rather listening to him.
But you need time.
And you don't have any left over.”
Marta, a fourth-year resident of Gynecology, during an intervention at the La Paz Hospital.
James Rajotte
They have been removed from the reverential don and doña and have only been left with their first name.
And the youngest doctors, for some patients, are little more than “girls.”
“Sir, I'm not a girl, I'm your doctor,” they respond.
Nobody applauds them on the balconies anymore.
They are hardworking.
And in the case of the mir, eternal trainee workers in hospitals and health centers, who sign annual contracts with the autonomous communities and, in addition, are evaluable students whom the system requires to acquire certain capacities, skills and abilities, up to achieve some objectives.
They rotate continuously and transversally through other services, hospitals and countries;
They receive courses in augmented reality, communication of bad news or to detect gender aggression;
they perform simulations;
They do no less than six shifts a month, attend to emergencies and wards, and debut as R1 (first-year residents) with a salary similar to the interprofessional minimum: 1,280 euros gross.
To which add about 500 euros for the night guards.
“The kind where you come out devastated, you've slept three hours in a
warm bed
, you're full of adrenaline and your schedule has changed.
And the next day it's almost worse.
The guards are our imbalance.”
In the last stages of that long path (four or five years depending on the specialty), as R4 or R5, they will not earn more than 2,500 euros.
And when they conclude their residency, that hospital bubble in which they have remained during that time will explode and their contract with the State will be
extinguished
.
“It's the moment when you think: 'I must have done something wrong to see myself on the street,' explains Miguel, an Interna resident at the Príncipe de Asturias hospital in Alcalá de Henares.
The mir is not an opposition to use.
It is organized every year exclusively by the central Administration on the same day in January and with the same 200 questions throughout Spain, but passing it does not entitle you to a place in the National Health System.
It gives access for a limited time to a specialization program in teaching units accredited by the Ministry of Health, whose places are awarded according to the grade obtained.
And, when they finish it, they will have to begin a painful pilgrimage of temporary employment waiting and searching for a decent contract and, in the future, a disputed property position, which is almost a chimera.
That another doctor dies, retires or requests a leave of absence.
“Meanwhile, you're handing out your resume around the clinics and hospitals as if you were leaving it at Zara,” says Alejandra Vaquero, 29, who finished her residency last year and is a temporary doctor in the emergency department and chief resident of La Peace (the link between the mir and the hospital).
“And, in that moment of uncertainty, many think if they have chosen the wrong profession.”
Michael, third-year resident of Pulmonology, in the La Paz Emergency Department.
He already makes decisions.
James Rajotte
Others will decide to emigrate.
An option that they describe as undesirable and that is carried out for economic reasons and, to a lesser extent, for the acquisition of knowledge.
As 5% of young doctors have already done to OECD countries (Organization for Economic Cooperation and Development): around 8,000 professionals.
“I don't rule it out, but it would make me very angry,” explains Álex Marcelles, 28, R4 of internal medicine at the San Carlos Clinical Hospital in Madrid.
A drain of talent, of very well-trained people, of a system that needs them like never before: according to the
Supply-need study of medical specialists 2021-2035
,
by the EcoSalud team at the University of Las Palmas, the Spanish health system will have in 2027 a deficit of 9,000 doctors and in 2035, 17,765.
“The increased life expectancy and the unstoppable aging of society, with a large percentage of chronic diseases, multipathologies and complex health needs, make a greater number of professionals with different profiles necessary.
We need, for example, more geriatricians and care specialists,” describes Silvia Calzón, medical epidemiologist and Secretary of State for Health during the pandemic.
“Not counting the extensive retirements of
baby boomer
doctors , which we knew were coming our way.
The authorities had been clear about this for a long time.
And nothing was done.
There was no demographic or sociocultural planning.
Especially after the cuts made by the PP governments starting in 2009, when 20% less was invested in public health.
No thought was given to the size, composition or distribution of health personnel for a future that was upon us.
And you don't invent a doctor overnight: it takes 12 years.”
It was not until 2020 when around 2,000 more mir places began to be offered each year than during the aftershocks of the 2008 financial crisis. At this time, the annual offer exceeds 8,700 places, compared to the meager 5,956 in 2015 and successive years, with a strong strengthening of vacancies for family doctors.
At the other end of the system, half of the professionals are already over 50 years old and 21% over 60. They are on the verge of retirement and there is beginning to talk about making their retirements more flexible, at least until they are 70. .
Silvia and Marta, first-year residents of Family Medicine, face their first cases in the Emergency Department, in which they must assess the severity. James Rajotte
“The real problem is not the lack of doctors.
There are some, and they are very well trained, what is missing are decent contracts,” summarizes Manuel Quintana.
Intensivist, teacher, liaison of his hospital with the Autonomous University of Madrid and director of the Advanced Simulation Unit of La Paz.
“You have very good people, but you can't keep them and they end up stumbling.”
Quintana makes this reflection in the Polytrauma and Burns ICU, where a patient has just been admitted after a very serious motorcycle accident, and another burned.
Ismael del Val, 25 years old, from Fuenlabrada and a resident of the first year of intensive care, does not detach himself from it.
“Since I was a child I wanted to help others and I feel happy here.”
Along with Quintana there are also two young associate doctors, Claudia and Alba, whose employment hangs in the balance.
They have had years of unstable and temporary contracts: “You end up living day to day.”
Polytrauma and Burns ICU of La Paz.
Three doctors on duty: from left to right, Claudia, deputy;
Raquel, fifth-year resident, and Alba, assistant. James Rajotte
Others at the end of their path will try their luck in the increasingly widespread private care, which a third of the Spanish population already attends (especially in specialty consultations).
However, it doesn't seem like a real alternative.
Citizens are stubborn in their defense of the public system.
According to the CIS of December 2023, 71% of Spaniards prefer consultations with their primary care doctors in public hospitals, and 75.4% prefer hospitalization in public hospitals, although they criticize the waits and delays that exceed seven in primary days.
Faced with this public demand, more than a third of Spanish doctors' contracts are temporary.
More than 85,000 professionals (doctors and nurses) are waiting for the regularization of their situation under the magnifying glass of the European Commission, and waiting for the 1,000 million from Component 18 of the Recovery, Transformation and Resilience Plan of the Pedro Sánchez Government, especially in two of its key points: “Strengthening primary care” and “reducing temporality.”
The reality is that some young doctors out of morbidity collect the hundreds of payrolls for half-days, days and weeks that they have accumulated: covering sick leave, participating in clinical trials or earning their daily wages as guards.
And that causes hopelessness and demotivation.
According to a survey by the General Council of Official Colleges of Physicians, 35.3% of Spanish doctors declare themselves dissatisfied with the practice of their profession, “with the most influential factors being the workload/care (65.2%) and the level of demand (32.9%)”.
43.6% have conciliation problems.
55.7% feel emotionally tired.
Intervention at the La Paz Hospital.
In the background, without a green coat, on the right, Rocío Sánchez, a first-year resident of Anesthesiology, along with her tutor and head of her section, Elena Gredilla.
In this operation, all the professionals (surgeons, nurses and anesthetists) were women. James Rajotte
And who takes care of the toilet?
Who takes care of your mental health?
Apparently, no one.
“You look for a life.”
“With the pandemic we hit rock bottom.
We all came out touched.
It was a debacle: 120,000 dead.
You were talking to three patients in the emergency room, and 20 minutes later they had died, and their beds were full again and a hundred more were waiting in the gym.
You came home overwhelmed.
You were afraid of infecting your children.
We all caught covid.
We fell like pigeons.
How do you manage that emotional burden?
There is no body that can withstand it,” explains a veteran doctor who puts words to a feeling that surfaces in many conversations.
The mir promotions that lived through the pandemic will never be able to forget it.
OECD figures speak of a post-pandemic situation of up to 46% of doctors with anxiety and up to 37% with depression in their territory.
The report concludes with these words: “They have often felt abandoned and undervalued by their organizations.
“All these problems have led to greater pressure on their mental health.”
A scenario that many professionals still find difficult (and afraid) to recognize, and that leads some to self-medication, depression and even suicide.
Ismael del Val, 25 years old, first-year resident of Intensive Medicine, in the Polytrauma and Burns ICU of La Paz. James Rajotte
“The doctor has always been very undemanding,” explains Sheila Justo, a family doctor and vice president of the AMYTS union.
“He has never considered his working conditions, he considered them part of his job.
The town doctor was available 365 days a year.
But now professionals aspire to reconcile [partly due to the unstoppable feminization of the profession] and have a life.
And the system has to adapt to that doctor, because all he wants is to be a better doctor.
It can and should be reconciled, but now it causes you to overload your colleagues and feel terrible.
Even pregnant doctors feel guilty, because they leave their colleagues at the horses' feet.
It is one reason for the delay in maternity in the sector.
The problem is that there are very few staff.
But we are no longer silent, as we have done with the four-month primary care strike in the Community of Madrid.
Nor has anyone taken care of our emotional part, which is very complex.
But that is changing with the new doctors.
There is another generation of residents entering the scene,” explains Sheila Justo.
For example, Gabriela, 29 years old, R3 of pulmonology at the Gregorio Marañón Hospital in Madrid: “I chose this specialty for quality of life;
“I want to start a family and have a stable life.”
Or Carolina, 31, a family resident in Arganda del Rey: “My thing is people.
And I am happy with the patients, even though the doctor's conditions seem horrible to me.
I aspire to work in a small town, meet the kids and the grandparents.
“I like the social sense of medicine.”
Domingo Antonio Sánchez, an oncologist in Murcia, who finished his residency two years ago and is the representative of young doctors on the Council of Official Colleges, summarizes: “Our generation has other priorities: a balance between work and life;
between your care work and your training.
We are digital natives;
We have professional concerns, languages and masters, but the system causes our disenchantment.”
Marta, first year resident of Family Medicine, with a patient recently admitted to the La Paz Emergency Room. James Rajotte
As soon as they sign their mir contract (with its corresponding confidentiality clause on the data they handle), they receive their green pajamas and an identification card and go from being a university student to being a doctor in hours.
From there, they learn as they go, by osmosis;
They are required to be sponges with a high absorption and assimilation capacity.
Not only do they internalize the increasingly complex techniques and procedures, and assume the heavy bureaucratic burden;
They must also develop the capacity for empathy, teamwork, leadership, resource management, efficiency, intuition and communication.
And in the early morning, a time to study and catch up on a profession that constantly evolves.
And, if necessary, party with your “co-R” until your body can handle it.
“You give everything you have and then you completely disconnect.
Our hangouts are mythical.
Half is rolled with the other half.
You end up being inbred, because no one else understands this life,” explains a mir.
First-year residents in a Cardiopulmonary Resuscitation class at La Paz Hospital. James Rajotte
According to rheumatologist Eugenio de Miguel, president of the La Paz Teaching Commission, “the profile of the current doctor must be a professional who combines technical quality with human skills.”
To achieve this, residents must observe their tutors, their references, seasoned specialists, with a special sensitivity for teaching, who follow and mentor a maximum of five pupils per year, and do not receive a single euro for this dedication.
And, sometimes, they also serve as psychologists and tear cloths.
“The tutor must be empathetic, close to the field, with knowledge, leadership skills and constant availability,” explains Juan José Ríos, medical director of La Paz.
“They should dedicate themselves exclusively to the monitoring, planning, supervision and evaluation of their residents (which is already enough), but the care overload prevents this.
And they have to be involved in many things.”
In the shadow of these tutors, throughout the years of residence, the R's acquire responsibilities and demand less supervision from their
elders
(as they are still called in hospitals; the new ones are the
little ones
).
They learn on the spot, not in master classes.
They will scale from the minimum responsibility of R1, “who assists and observes”, to the maximum of an R4 or R5, “who executes and reports”.
Everything is in writing: accredited and audited by the Ministry of Health.
When they are R3, they will think they know everything, and when they are R4 or R5 they will think they know nothing.
They will be ready for launching.
According to Celia Gómez, general director of Professional Regulation of the Ministry of Health, there are 32,517 residents in Spain.
To which we must add the 8,700 Medicine graduates who passed the last mir test, on January 21, and of which 65% are women.
They will join in June, after being awarded a place in descending order according to their qualification.
The most sought-after specialties are dermatology, surgery, plastics, cardiology and endocrinology, which are supposed to have good opportunities, demand in the private sector, fewer guards and offer a better quality of life.
These 32,517 young doctors are the backbone of the health system.
The key to its sustainability.
“Without them, this would fall apart,” says one veteran.
Resuscitation Class at the La Paz Advanced Simulation Unit. James Rajotte
Ten in the morning.
In the La Paz operating room, a dazzling high-tech space, there are six women gathered around the operating table.
They wear red surgical pajamas and hats printed with emoticons.
They are going to address a tumor through laparoscopy.
It is a risky intervention.
The hat of Rocío Sánchez, 25, from Córdoba and a first-year Anesthesiology resident, has sharks on it.
That of her tutor, Elena Gredilla, head of her section, cherries.
The resident moves through a maze of cables and tubes.
She manages all the information through a large computer screen at the patient's feet, where the ultrasounds, vital signs, and analgesia parade before her eyes.
Her tutor doesn't take her eyes off of her.
Rocío chose Anesthesiology because she likes “the operating room, working with her hands, having contact with patients” and feeling that she is “useful.”
For her tutor, “this does not mean that they know (because study is mandatory), but that they act with warmth, care, respect and prudence.”
She adds: “You are in a public system and you are a resource manager.”
The image of six healthcare professionals (surgeons, anesthetists and nurses) taking over an operating room would have been unthinkable 20 years ago.
The first graduate in Medicine in Spain, Dolors Aleu, dates back to 1882. In 1965 there were a thousand women.
And a quarter of the total in the eighties.
Today, 57% of the total members are women;
as are 65% of the mir and 70% of the students of the faculties of Medicine.
The average age of these female members is 45 years, five less than men.
Today two men retire for every woman and two women for every man enter the system, which will mean the feminization of the profession in a very short time.
Although, for the moment, the professorships and a large part of the service heads (up to 70%), and the positions in property (55%) are in the hands of men.
“But, at least, that stale perception of society in which men healed and women cared has changed,” summarizes María Jesús de la Iglesia, mental health resident internal nurse (EIR).
Miguel Ángel, first-year resident of Cardiology and fifth best grade in Spain in access to the mir of 2023, waits for the subway after leaving guard in La Paz. James Rajotte
Three p.m.
It's a bad day at the La Paz Emergency Service.
The dozens of beds in its five wards are full.
Nursing professionals circulate among themselves with skill.
The atmosphere is thick.
The majority of patients are older people: the reflection of society.
Dr. Ana Martínez Virto directs the orchestra.
Next to her, two first-year residents, Silvia and Marta.
They talk to patients, prepare their medical history, order tests and try to discern those who are serious from those who can wait on a scale from 10 to 240 minutes.
They confess that sometimes they feel overwhelmed.
Your job is not to give an exact diagnosis, but to assess the urgency.
The senior resident is Michael, R3, Ecuadorian, pulmonologist.
He already makes decisions: “In an area as chaotic as this, where everything comes to you, you develop skills and learn to manage your emotions.
The problem is that the more care overload you suffer, the more mistakes you can make.”
A dull alarm sounds and the young men and women rush towards the resuscitation area, where a young man with a serious heart attack has just been admitted.
Like this for 12 hours on call.
Meeting of the first-year residents of La Paz at the Taberna Murciana, in Madrid.
There are 120. 40 attend, from all specialties.
The majority are women.
Their problems are low salaries and finding an apartment.
James Rajotte
The R1 meeting is at the Murciana Tavern.
Spread the word through their WhatsApp group.
At nine there are no less than 40. There are no tutors or elders.
Croquettes and broken eggs emerge from the kitchen and the beers circulate quickly.
Some of them can be seen by their tired expression as they come out on guard.
Others will enter the next morning, “to see if the adrenaline lets us sleep.”
They are very young people, women are overwhelming in number, and their
look
is very varied, from formality to
trapper
aesthetics .
It sounds reggaeton.
They are pleasant and spontaneous.
They talk about their work.
There are several couples.
Many share a flat.
The apartment search is your via crucis.
And the guards, their emotional roller coaster and their salary lifeline.
They make circles by specialties.
Anesthesia and intensive care, next to the bar;
in front, those of pediatrics (this year there are 20 women);
On the left, a mix of three trendy specialties: endocrinology, dermatology and rehabilitation.
In the background, the seven from gynecology mixed with several from family, a pediatric surgeon and one from preventive.
Why did you choose those specialties?
Most had doubts;
Some did not get the grade for their first option and chose on the fly.
Most did it by discard.
“You are looking to combine quality of life and making money with performing a good public service,” says María, the only R1 in urology.
“I took it because it is very complete and has a component of helping others.”
Inmaculada, of preventive and public health, which works with data, seeks to “plan policies to improve health.”
Paloma, from gynecology, wants to “solve problems in the moment” and Micky, the fifth best grade in Spain, opted for cardiology: “You are a complete doctor, you know about kidneys, lungs, you are like an internist at heart.
And it is very good in private.”
Antonio Rueda and María Alameda, 28 years old, fourth-year Oncology residents at La Paz Hospital. James Rajotte
Twelve in the morning.
La Paz Oncology Plant.
María Alameda, from Madrid, and Antonio Rueda, from Málaga, are 28 years old and are R4.
She goes in on guard and he goes out.
Why did María become an oncologist?: “After Covid I questioned many things, and I decided that I wanted something that would fulfill me, make me live intensely, and make my hair stand on end.
Give my best.
And it is the moment of my life in which I have grown the most as a person.”
Antonio adds: “Our patient is complex scientifically, clinically and humanly.
You have to be next to him.
Accompany him.
He adds an emotional burden to us, but you have very good moments.
If you can help him, you already have a reason to continue in this.
It's worth it".
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