INTRODUCTION

The medical internship consists of pre-professional practices during the last year of medical school ¹. After this year, medical interns (MIs) take the National Medical Exam (ENAM). Completing the the internship and passing ENAM are requirements to become a member of the Peruvian Medical Association and practice medicine in Peru ².

In March 2020, the Peruvian government took measures to control the spread of COVID-19, including the suspension of educational activities ³. Thus, universities and hospitals suspended all undergraduate academic activities ⁴. As of May 2020, the Peruvian authorities had not set the conditions, nor the date of a possible resumption of the internship. This study aimed to describe the MIs’ perceptions on the suspension of medical internship during the COVID-19 quarantine in Peru.

FINDINGS

A total of 381 participants answered the survey, 28 were excluded (9 did not sign informed consent, 14 had previously participated, and 5 were not MIs). Finally, data from 353 MIs (94.0% of the total) from 41 Peruvian universities were analyzed (Appendix 2). The median age was 25 years (IQR: 23-26), 230 (65.2%) were students from private universities; 257 (72.8%) had health or accident insurance, 196 (55.5%) were receiving remuneration, and 232 (65.7%) declared to live with people at high risk of infection by COVID-19 (Table 1).

The majority (74.8%) of the MIs agreed with the internship suspension; 81.1% agreed or strongly agreed with the suspension because hospitals did not guarantee biosecurity measures; 76.2%, because it was a risk for family members or people close to them; 62.0%, because they were still students; 38.5%, because they did not feel qualified to face a pandemic; and 37.7%, because they did not receive a salary. On the other hand, 53.1% agreed or strongly agreed against the suspension because it was a good learning opportunity; 48.0%, because the MI provides essential work; and 51.4%, because the health system would collapse without the MIs. At the time of the survey, 70.0% agreed to continue in quarantine.

Of the participants, 91.5% reported feeling very or moderately uncertain about the restart of the internship, and 85.1%, very much or moderately uncertain about its completion. On the other hand, 90.3% felt moderate or very uncertain about the date of the ENAM (Figure 1). The majority (85.6%) participated in virtual classes to prepare for ENAM (Figure 2).

Figure 1 Uncertainty perceived by medical interns participating in the study 

Figure 2 Academic activities carried out by medical interns participating in the study during quarantine by COVID-19. 

Regarding biosecurity measures and equipment not being guaranteed, only 11.9% agreed or totally agreed to return to hospitals during quarantine. Under these conditions, 29.6% agreed or totally agreed to return in the event of a collapse of the health system. If biosecurity measures and equipment were guaranteed, 54.9% agreed or fully agreed to return to their hospital sites during quarantine; and 72.9% if the return was after quarantine. However, 24.9% agreed or totally agreed not to return to the hospital despite the guarantee of biosecurity measures (Figure 3). When asked about their position on recovering one month of internship in January 2021, 41.9 % agreed or strongly agreed, and 48.2 % disagreed or strongly disagreed.

Figure 3 Perspectives on the return to medical internship in the studied population. 

DISCUSSION

Less than half of the MIs agree to return to the internship if biosecurity measures are not guaranteed. This perception increases when biosecurity measures are guaranteed and the quarantine ends. On the other hand, there is great uncertainty about the restart and end dates of the internship. In turn, most respondents invest their time in preparing for the ENAM.

During the internship, MIs are exposed to develop mental disorders, suffer aggressions, and work accidents ^{1 , 8 , 9}, in addition, the scarcity of protection equipment and the lack of adequate biosecurity training are highlighted ⁸. The 2020 MIs carried out their activities for more than two months and probably observed limitations in the health systems. Perhaps because of this, almost all of them feel great uncertainty about the availability of biosafety equipment and do not agree to return to their activities if their protection is not guaranteed.

Previously, MIs groups suspended their activities for some weeks demanding better working conditions ¹⁰. During the 2009 AH1N1 pandemic, MIs continued their activities normally ¹¹. However, the COVID-19 pandemic resulted in the interruption of several months of internship, with the possibility of suspending the entire academic year. In the face of this, MIs have felt uncertain about their education. On the other hand, prolonging the internship would postpone the 2020 ENAM and begin the internship in 2021. However, half of the MIs would not support the extension of the internship.

Other countries are facing their own reality during the pandemic. Mexico also suspended the internship due to lack of biosafety equipment ¹². However, other countries involved MIs or seniors in the fight against the pandemic ¹³. Thus, degree processes were earlier in some universities in the United States ¹⁴, Colombia ¹⁵, and Ireland ¹⁶, prioritizing the number of available personnel over formal education of MIs. It is important to consider that in these countries MIs start to work midyear and at the time of the pandemic they were close to completing their internship.

During quarantine, MIs spend their time mainly studying through virtual classes for the ENAM. This is probably due to the recent obligation to pass the ENAM to become a member of the Peruvian Medical Association ², and because many students perceive that the knowledge provided by their universities is not sufficient to take the ENAM ¹⁷. On the other hand, more than half of the respondents used virtual classes or conferences for their education, not necessarily related to ENAM but probably in the context of the pandemic ¹⁸. Despite this, trainings at their universities or hospital sites are not frequent. This was a missed opportunity, as virtual clinical discussions could have been held and MIs involved in virtual orientation to the population and identification of risk groups ¹⁹.

The limitations were the following: the sample was not representative of the MI population in Peru, since the selection of participants was not randomized. The sex variable was not included due to an error in the design of the survey. A non-validated instrument was used, with the possibility of a particular interpretation by each participant; however, with the realization of the pilot, the intention was to diminish this possibility. These conditions could underestimate the results of the study. Despite these limitations, this is the first report of MIs’ perceptions on the pandemic in Peru that evidences an intention to return to medical internship, but under appropriate conditions. In addition, it provides insight into the uncertainty that MIs are currently experiencing regarding their academic future.

In conclusion, in a sample of MIs from Peru, the intention to return to boarding school increases if biosecurity measures are guaranteed and the quarantine is terminated. On the other hand, there is great uncertainty about the dates of return and termination of the internship. In turn, most interns invest their time in preparing for the ENAM. We recommend that universities encourage virtual training by focusing on the resolution of real clinical cases. In addition, hospital centers, in coordination with universities, should guarantee the safety, well-being and health coverage of MIs if they intend to return to their hospital sites.