The Italian health system is based on the trainees: young and exploited, now many are leaving

“I’m worried. I do the shift in the wards alone and while I’m there I have to figure out when to give drugs to lower blood pressure or administer sedatives to agitated patients. Nobody checks. What if something happens? I’m still in the first year », one of them writes postgraduate student at the La Sapienza University of Rome. She is studying Anesthesia and Intensive Care and is practicing at the Sant’Andrea hospital in Rome. Her scholarship began in November, she has a handful of months of practice on her shoulders, she feels insecure, she acknowledges that she is not familiar enough to guarantee patients a correct diagnosis, adequate treatment. Despite this he visits the patients, signs the discharge and carries out the anesthetic records on his own, because in the ward there are neither structured doctors nor specialization school professors, no one to ask for advice. It is not an isolated case: this is confirmed by Massimo Minerva, president of the Free Specializing Association, Als, for the protection of young doctors, who has decided to make public the reports of white coats in training and the illegalities affecting specialization schools, for to put a stop to a dangerous drift “for the health and life of patients,” says Minerva, who tells L’Espresso the massive levels of exploitation to which doctors are subjected every day.

The pandemic and poor scholarship management has emptied hospitals of doctors, especially in emergency rooms and surgical rooms. For this reason, trainees – doctors who have completed their degree in Medicine and Surgery and are completing a five-year training course to become specialists – are sent to the departments, often alone, on the front line and exploited to the utmost, with shifts that in some cases exceed 300 hours per month, more than double the legal limit 38 hours per week. The exasperation of the students is skyrocketing, to the point that between November and today 846 young people have abandoned the scholarship: «It is as if every five hours a trainee says goodbye to his career. So far, 99 million euros invested by the state to form future white coats have gone up in smoke, ”comments Minerva.

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The greatest criticality is the overload of working hours. This is confirmed by the responses to a questionnaire that trainees are required to fill out every year, but which is not normally published in its entirety. By mistake, the Almalaurea inter-university consortium, called to analyze the results on behalf of the Ministry of the University, published the full data of the latest survey on its website and it emerged that more than half of the trainees fail to respect the time stipulated in the contract because they are promptly requested to stay longer in the ward. “The quality of life is very low and the dignity of my person is harmed,” writes a young doctor. For example, the students of General Surgery of the University Hospital of Verona were given a shift schedule that exceeds 250 hours per month, violating any European and national directive on respecting breaks and rests. And again in Verona, due to the lack of staff, the trainees are sent to the operating room to take the place of the anesthetists, because the hospital does not have enough staff to keep up with the planning of surgical interventions. The same is true for pediatric surgery, where instead of a structured doctor there is a doctor in training.

The most critical situation is in Emergency room. Since the beginning of the year, 600 white coats of emergency and urgency have resigned. Overall five thousand doctors would be needed to get the ERs up and running, but there is even a shortage of recruits. The Ministry of Health, led by Roberto Speranza, in the autumn had increased the number of scholarships for postgraduates – last year 18,397 were announced, more than double those available two years ago – in order to respond to the lack of hospital staff. However, the young aspirants have chosen the most coveted specialties en masse, further aggravating the situation in the less attractive ones. For example, the grants for cardiology, ophthalmology, plastic surgery, dermatology and pediatrics have been exhausted, while with 1152 places available for emergency urgency, 626 have not been assigned. Same goes for the anesthetists: out of 2,100 scholarships, 166 were not filled.

“As long as the work in emergency urgency is not attractive and economically competitive, these data should not surprise”, explains Fabio De Iaco, president of Simeu, Italian Society of emergency-urgency medicine, who continues: “The work in the emergency room is not attractive from an economic point of view, because there is no possibility of having extra earnings from the free profession; and it has a level of physical and psychic severity that is decidedly superior to other specialties. We need an economic counterpart, a faster career progression and compensation for usury ». At the moment in which five emergency rooms a month are closing in Italy due to a lack of staff, “the trainees are the only reservoir of doctors who could help us deal with this serious crisis”, says De Iaco, even if at the moment his appeal remains a dead letter .

On the anesthetists front, the president of Aaroi-Emac, Alessandro Vergallo, if on the one hand he hopes that the number of fellows will remain high in the next few years, in the hope of solving the shortage of anesthetists and hospital resuscitators, on the other he points out that specialization schools are not ready to welcome more than three times the number of young doctors compared to previous years: «We need an adaptation of the training system». The confirmation comes from Federica Viola, a young doctor and president of Federspecializzandi: «Up to 2019 the scholarships put out to tender were very few, no more than six to eight thousand a year, out of a pool of about 16 thousand applicants. The training funnel was punctually created », that is, half of the medical graduates, who had failed to access the specialty, were left in limbo: awaiting future competitions or forced to migrate abroad.

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“The increase in scholarships has eliminated this problem, but now we are dealing with a large loss of education caused by the pandemic and aggravated by the failure to adapt schools.” In the hardest months of Covid-19 the surgical rooms remained closed for a long time and the trainees did not practice surgery and «the increase in the number of scholarships was not followed by an adaptation of the training offer. There are young trainees without tutors, without reference professors, often used to fill out resignation folders and letters and who, at the end of the course, will have done very little practice. This is serious, especially for the health of patients ».

To identify the less performing schools it is sufficient to analyze the responses of the trainees to the annual questionnaire. One of the questions asks “how satisfied are you with the graduate school?” and a third of the 988 schools do not reach the pass. About fifty schools received a rating of less than four: vote one at the School of Occupational Medicine in Verona and at the Cardiac Surgery in Rome Tor Vergata, vote two at Urology in L’Aquila and Vascular Surgery in Pavia. One could guess the lack of appeal of some schools also from the levels of abandonment and from the requests for authorization, which in some hospitals exceed fifty percent. “This is information that the National Observatory for specialist training could use to improve the quality of the training offer, but which is absolutely not taken into consideration,” says Minerva. The Observatory is a body made up of three representatives from the Ministry of the University, three from the Ministry of Health, three deans of the Faculty of Medicine and Surgery, three representatives of the Regions and three doctors in training. However, during this year the three postgraduates were no longer nominated: “The Observatory should protect the educational quality of the specialization schools and in recent months it is continuing to take important decisions, such as the accreditation of the schools”, says Federica. Viola by Federspecializzandi.

To draw attention to the numerous irregularities committed by the Observatory in the accreditation of training schools, Massimo Minerva is sending all the members of the Observatory and some journalists a daily letter to report a new anomaly every day. For example, the Federico II of Naples declares to have an Emergency and Urgency department, while it does not even have the Emergency Room. At the Vanvitelli Hospital of the Campanian University, the school of Gynecology and Obstetrics claims to perform a thousand deliveries, while according to data from Agenas, the national agency for regional health services, there are 850 births. Even the University of Bari does not reach the minimum number. of births, but the specialty of Gynecology was accredited. In Salerno, where a resident accused his professor, Nicola Maffulli, director of the school of Orthopedics, of forcing students to do push-ups if the young doctors showed up late in the ward, the minimum number of interventions is not reached.

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Are approximately about a hundred accredited specialization schools despite the lack of teaching staff, the training network and the minimum care volumes, yet the observatory continues to accredit these schools: «It happens because the hospitals belonging to the university do not want to lose the advantages deriving from having postgraduates. A specialization school gives prestige to the hospital and allows for free labor in the wards, since the scholarship (1,650 euros per month) is paid by the university. Even the university has an interest in not losing accreditation, because these doctors pay around two thousand euros a year in university fees, ”explains Minerva.

Despite constant reports, the observatory, chaired by Eugenio Gaudio, former rector of the Sapienza University of Rome, and absorbed in the headlines for having renounced the post of extraordinary commissioner for Health of the Calabria Region the day after his appointment for family reasons, continues to confirm schools not up to standard. And in recent weeks the members of the observatory are preparing a modification that would allow schools to obtain a validity no longer one year, but two years for accreditation. The students would have objected, but in the Observatory they no longer have a say, because no one seems to have the time to name them.

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