PROF KENNETH KAGAME: Medical interns are assistant resident physicians

It is sad how our medical interns are being treated by their own ministry, headed by doctors -minister, permanent secretary, and Director General.

All of the above doctors have been interns and all of them were being paid. So was I, in Jinja hospital in 1978. I have good memories of unimaginable hard work over long hours, but fun unlimited in the very few hours whenever free and decent remuneration.

Perhaps the word intern is no longer appropriate for the current medical interns. Originally the term was “resident physician” or “assistant doctor” to refer to a graduate doctor but one requiring supervised practice to sharpen his /her professionalism and practical skills especially surgical. This was to protect the patient. In 1963, the usage of the term intern was extended to other professions to refer to one under training but acquiring practical experience.

Since then it has been stretched to refer to even high school students trying out different vocations while deciding which one to follow. Today the word intern invokes images of students and new graduates slaving away in industry and offices, trying hard to get noticed by the future employer and working for no pay. To some of us, it brings back memories of Monica Lewinsky happily working “under” President Bill Clinton in White House. This trend, the dilution of the original word, has clouded the way we perceive a medical intern.

The minister of health referred to interns as halfway between doctors and medical students. That is not true, he/she became a doctor when he/she graduated from medical school and even swore the Hippocratic Oath. The press has referred to the interns as medical students and so have some parliamentarians. Perhaps it is high time we reverted to the original term –assistant resident physician.

Due to the widespread exploitation of non-medical interns to do real work for the organisation and industry, to replace paid labour, several countries have written guidelines to specify which interns must be paid versus those who may not.

This considers duration (over 6 months) and type of work. The government of UK guidelines states that: “if interns do regular work (that would have…) been paid for, they are eligible for employment rights (including pay)”. The USA Government has detailed guidelines. Among them are six criteria for when an intern may NOT be paid. I will mention some:

“The internship is only for the benefit of the intern.”

Surely we all know how Mulago Hospital and Regional Referral Hospitals depend on interns. Consultants would go on strike if interns downed their tools for a month.

“The employer derives no immediate advantage from activities of the intern.”

Refer to above. The intern benefits the employer and the patients.

“The internship does not displace regular employees”

Interns displace paid workforce, if they were not there, the hospital would employ medical officers who would cost more, work more regularly, and have fewer hours, therefore, require bigger numbers.

Pretend as they do, the ministry needs those interns for real work and not principally to train them. They should be paid. All the countries I have surveyed pay their medical interns.

Let us take a global perspective. The Global Health Workforce Alliance with the WHO has authored a report titled “A UNIVERSAL TRUTH: NO HEALTH WITHOUT A WORKFORCE” (Nov 2013). It states

“Health workers need to be kept motivated and in an enabling environment”. And, “the health workforce is aging and replacement is a challenge”

Africa has 25% of the world’s disease burden but only 3% of the world’s health workforce. The shortage of doctors is obvious to all of us. Uganda produces about 150 doctors per year, but migration is 30% (Omaswa, 2003).

A study in a number of African countries analysed physician ratio per 1000 population, and inflow and outflow of physicians per 1000 physicians to get the real increase of physicians per year. Inflow means new doctors from our medical schools and expatriates while outflow is loss due to retirement, resignation, dismissal, mortality, and immigration. Uganda was estimated to have 0.08 physicians per 1000 population.

Inflow was 49 while outflow was an average of 47. The net increase was 2 physicians per 1000 physicians per year (kinfu et at, Bulletin of the WHO, vol 87 no 3 March 2009). Plainly speaking, doctors’ numbers are not increasing despite the hard effort of the medical schools. In some African countries, the numbers are dropping. Note that our population is increasing at 2.5% annually, the population is aging and is more aware of their needs hence more demand for doctors.

The reckless neglect and arrogance with which we are handling our young doctors is regrettable.

We have a crisis. We can’t expect to retain a doctor treated like this at the very entry into his career. The intern should be paid, reasonably well too.

The writer is a retired Ophthalmology Professor, Mbarara University of Science and Technology, but currently Medical Director, Dr Agarwal Eye Hospital, Kampala