3.1. Historical background

The current conformation of the group “physicians in direct contact with patients” and the emergence of the subset “physicians in training” are the result of a planning and historical process in which two facts stand out: a project elaborated in 1959 by the National Commission of Internships and Residencies A.C., and the Medical Movement of 1964-1965.

The project of the National Commission of Internships and Residencies established an educational program for recently graduated physicians and a series of budgetary and operative advantages for health institutions, such as: “continuous attention to patients, emergency services and low disbursement for the so-called “economic aid” to interns and residents” ⁽¹⁵⁾. It should be noted that, at that time, interns, and residents, like interns in their origin, were recently graduated physicians. But, given the labor and economic implications of doing so with graduate physicians, the program was implemented with students. That is, instead of considering hiring physicians who had recently graduated from a four-year curriculum, it was decided to expand the medical school curriculum so that interns and trainees would still be students. The afore mentioned commission justified:

Due to circumstances that are general to all the Schools of Medicine and others that are particular to our Mexican Faculties, We have that the teaching given in school is insufficient for the training of the doctor and that only after having obtained a guided and systematized hospital experience is when an adequate vision of medicine is acquired, and a true medical judgment is formed ⁽¹⁵⁾.

The tendency to use medical students to solve the medical care demands of the population was already being structured; these are the ones that gave rise to the social service in 1936:

The Medical-Social Service of the University, [...] is one of the most important steps [...] to know and seek the resolution of two important problems: the scarcity and, in not a few cases, the absolute lack of medical care in places with few resources, and the concentration of doctors in important population centers because of the poor distribution of these professionals” ⁽¹⁶⁾ (The underlining is my own).

To medical residencies in 1941:

Dr. Aquilino Villanueva Arreola, who instituted [...], for the first time in our country the Hospital Residencies, had the support of Dr. Gustavo Baz Prada, then Secretary of Public Assistance [...] the [...] resident physicians [...] had to remain on duty for 24 hours a day, while the basic medical staff worked two, four, six or eight hours; the care of patients fell, after this period of time on the resident physicians ⁽¹⁷⁾ (Underlining is my own).

And the medical internship in 1959:

At present, no hospital can be considered good if it pretends that its services are satisfactory only from 8:00 to 14:00 hours, but for 24 hours a day, something that has only been achieved with the realization of the system of internships and residencies... ⁽¹⁸⁾ (Underlining is my own).

The Medical Movement of 1964-1965 ⁽¹⁹,²⁰⁾ originated in the face of the role conflict of the students in service (workers or students?) and the first signs that they would not be recognized as workers. Nonconformity was violently repressed and, in the end, the category of “Doctors in training” was imposed and consolidated. That is, although the students fought to be recognized as workers, the health institutions recognized them as students and workers. Thus, President Gustavo Díaz Ordaz (1964-1970):

He considered an apprenticeship contract that would harm the dignity of physicians to be inconvenient, [...] he stressed that the most important thing [...] was that such a contract should be protected by the Federal Labor Law and the Law of Workers in the Service of the State, and that teaching should also be guaranteed in the same way, as a responsibility of the authorities to provide it, and of the physicians to take advantage of it ⁽¹⁹⁾.

Now, the students in service comment on teaching:

The working hours and remuneration of an undergraduate intern are completely outrageous [...]. Welfare work was always prioritized over academic training.... ⁽⁴⁾.

The hospital staff [...] lack many values and consider the interns as vile slaves to be used to getting work done, without any dignified treatment whatsoever ⁽⁴⁾.

From the perspective of human rights, the ambiguity of roles of students in service ⁽¹⁴⁾ who are simultaneously students and informal workers means loss of full rights; and from pedagogy, current medical education in health care units can be considered a craft education ⁽⁶⁾, whose main characteristics are: the coincidence of the roles of student and worker in a single person; the convergence of the role of teacher with that of worker in the figure of the teacher; informal education in a scenario of daily professional work and, therefore, the absence or, if any, in non-compliance with an academic program. Under these conditions and, in general, learning occurs by routine participation in processes, with little or no reflection, without criticism and with few possibilities to modify, innovate and, in the case of medicine, to care for patients according to their biological, psychological, and social diversity.

The characteristics of artisanal education prevail in most of the medical units that have students in service. For example: over 98% of interns, trainees and residents feel more like workers than university students ⁽⁴⁾; furthermore, 84% consider that in the medical units the care process is prioritized over the teaching-learning process and believe that teachers in the medical unit do not have adequate working conditions to fulfill their educational function ⁽⁴⁾.

For patients, the situation described above entails risks and insecurity. Their right to health is frequently violated, since they are attended by unsupervised medical students in service, who do not yet have sufficient professional competencies. According to a student in service at the end of his internship:

It is not a bad venue. However, it is conspicuous by its lack of teaching in terms of classes. On the other hand, they let you do a lot of procedures. There are very few doctors who take the time to teach you anything ⁽⁴⁾.

To that of an intern at the end of his social service:

During on-call and evening shifts there was no attending or resident doctor on duty leaving all the responsibility to the intern doctor. This was reported to and discussed with the Medical Management, without a favorable response, and was repeated throughout the entire social service ⁽⁴⁾.

In addition, because it is not properly regulated, traditional education predisposes to authoritarianism and a relationship of dominance and subordination that encourages violence ⁽²¹⁾, mistreatment and abuse ⁽²²⁾, which are increasingly evident and frequent in medical education.

3.2 Mistreatment and abuse of in-service students

The general structure of mistreatment of medical students has been described in detail ⁽²³⁾. In Mexico, there is numerous evidence of arbitrariness and abuse of medical students in medical units. For example, in studies carried out in the state of Veracruz ⁽²⁴,²⁵⁾, it is reported that 80% report a lack of cordiality and respect within the medical unit; 54% report having received discriminatory treatment because of their gender, appearance or any other personal characteristic; more than one third report that during the last year they have suffered sexual or other types of harassment by superiors or colleagues, and more than two thirds report having felt anxiety or fear of being punished or dismissed during their stay in the medical unit.

Montes Villaseñor and collaborators ⁽²⁶⁾ found that 87% of residents in the state of Veracruz had had at least one experience of aggression during their training as specialists and up to 50.4% reported psychological violence.

The Human Rights Commission of the State of Puebla (CDH-Puebla) ⁽²⁷⁾ documented that 72% of resident physicians consider that they have been victims of acts of aggression in medical units, 81% have been victims of cruel, inhuman, or degrading treatment, 69% have suffered physical or psychological violence, and 67% consider that their human rights have been violated. In this context, it explains the recommendation that the same CDH-Puebla ⁽²⁸⁾ issued in 2022, regarding the suicide of a medical resident because of workplace harassment, bullying and discrimination suffered in a public hospital in the state.

Derive ⁽²⁹⁾ reports in a group of resident physicians in the State of Mexico that 84% refer to psychological mistreatment, 78% humiliation, 50% punishment guards, 40% being denied teaching, 16% beatings, 35% have been deprived of food, 21% forced against their will to consume alcohol and 21% punished with not being able to go to the bathroom during the guards:

Well, I pissed myself, what was I going to do?”. That was how Manuel, between laughter, used to end his anecdote about one of the many times he was pushed to the limit during his medical residency. His laughter always puzzled me, and once in private he told me that he remembered that time as his “temporary stay in purgatory.” “But that’s the system,” he would tell me resignedly. The only thing that can be done is to break the circle that states that “he who learns the hard way, teaches the hard way ⁽³⁰⁾.

In a study of resident physicians in Mexico City, carried out by Silvia Ortiz-León and collaborators ⁽³¹⁾, it is reported that 98.5% stated that they had suffered at least one harassing behavior during the last six months. The most frequent harassment behaviors were overt intimidation and work discredit. As a result of the above, in the country, it is estimated that 89% of the residents studied have burnout, 71% have depression, 78% have anxiety and 58% accept that they give poor care to their patients ⁽²⁹⁾.

Martín Acosta ⁽¹⁴⁾, has also evidenced the mistreatment and abuse, from a qualitative perspective:

The first day we were received by the head of teaching, and he started threatening us that if we did not comply with the regulations, he would expel us.

The head of service even broke my notes in front of everyone. And that is a humiliating situation.

It should be noted that the problems described above are not exclusive to medical education in Mexico. Fabiana Reborais ⁽³²⁾ cites this type of problem in Argentina, Brazil, Canada, Colombia, Chile, Spain, Finland, Japan, Nigeria, Pakistan, and the United Kingdom. Derive ⁽³³⁾ refers to studies on the subject in Saudi Arabia, Argentina, Australia, Canada, Chile, United States of America, France, Ireland, India, Japan, Mexico, Nigeria, New Zealand, Pakistan, and United Kingdom. In a meta-analysis including 51 studies written in English, Fnais et al. ⁽³⁴⁾ estimate the prevalence of bullying among students to be between 52.0% and 66.7% (95% CI). The review by Abate and Greenberg ⁽³⁵⁾ concludes that verbal, sexual, racial and gender discrimination is widespread in undergraduate and graduate medical education in the United States.

3.3. Violence in medical education

How to understand the extraordinary tolerance of medical students in service to violence? Violence according to the World Health Organization is:

The intentional use of physical force or power, in fact, or as a threat, against oneself, another person, or a group or community, that causes or has a high likelihood of causing injury, death, psychological harm, developmental disturbance or deprivation ⁽³⁶⁾.

According to Christophe Dejours ⁽³⁷⁾ it is “acting on someone or making them act in a way that, without their knowledge, puts their life or the lives of others at risk”.

It should be specified that the violence that students consent to and allow is hegemonic internal violence ⁽³⁸⁾ and neural violence ⁽³⁹⁾. Internal violence is the one that students in service “as members of the medical field, must accept, incorporate and naturalize” ⁽³⁸⁾. This is tolerated because it is lived with during training and is, as we will see below, justified, and normalized. Neural violence refers to that which is immanent to the current socioeconomic system and to the individuals themselves; that is, violence to which there is no resistance because it is self-generated and self-imposed for the sake of efficiency and productivity.

The commonality of violence in medical education may mean that it is useful and functional to health systems. What is achieved with violence towards students in service, fear with hegemonic internal violence, self-exploitation with neuronal violence. The fear generated by internal violence is necessary to generate the subjugation characteristic of dominance-subordination relationships and thus impose work overloads ⁽⁴⁰⁾; enough fear to accept mistreatment and abuse and not be rejected by the group and see their motivations and desires to have a title of general practitioner or specialist, and receive the corresponding social recognition, frustrated.

On the other hand, self-imposed neural violence is not perceived as such, but as a challenge. Admission to medical school and medical specialties is highly selective. Those selected form a minority who, in general, enjoy high self-esteem and social recognition. To them, violence and mistreatment are presented as challenges to their abilities and competencies. It is therefore not unusual, for example, for them to engage in competitions to see who can spend the longest time in the hospital or the most hours without sleep. This is what Dejours ⁽⁴⁰⁾, from an occupational health perspective, calls a collective defense strategy, which tends to minimize, if not deny violence.

On the other hand, violence has a legal basis; it is indicated in the regulations themselves. For example, the official norms establish that the complementary clinical practices of the students (guards):

On working days, they begin at the time the morning shift ends and conclude at the time established to begin the following morning shift, in accordance with the regulations of the health institution [...] Their duration on Saturdays, Sundays and holidays must be for a maximum of twenty-four hours, beginning and concluding activities as specified in the regulations of the health institution. The intern who finishes his complementary clinical practice on a working day should continue the activities described for the morning shift in the operative program ⁽¹⁰,¹¹⁾.

In other words, students in service are ordered to workdays in the medical units that officially last 32 hours, with an annual average, as already mentioned, of 80 hours of work per week. In fact, interns’ and residents’ workdays in hospitals frequently exceed 100 hours per week ⁽⁴,²⁴,²⁵⁾. In the words of one intern: “Although we have an established schedule, we exceeded the limit and worked around 36 hours not so much in academic tasks but in things related to patients” ⁽¹⁴⁾. Thus, it is the regulations themselves that force in-service students to perform professional activities in conditions that put their lives and those of the patients they care for at risk ⁽⁴¹,⁴²⁾. In the words of one resident: “It requires us to know all 80 patients 100%; two residents and three or four new interns and the truth is that no matter how much you want to, you can’t” ⁽¹⁴⁾.

To comply with official regulations and silent disagreements, a context favorable to coercive power is required. Power relations in hospitals have been described from various perspectives. Consejo and Viescas-Treviño ⁽⁴³⁾ approached them from the perspective of Foucault and Bourdieu; Villanueva ⁽⁴⁴⁾ and Reiborais ⁽³²⁾, from the framework of total institutions developed by Goffman ⁽⁴⁵⁾. From the perspective of artisanal education, hospitals create scenarios characteristic of total institutions: they are places in which apprentices are stripped of their previous identity and roles; the activities are rigorously scheduled; All their time, dedication and effort are required; In them, students in service carry out and share work, educational and social activities, consequently, they must renounce other interests, commitments and obligations. The fact that 74% of students are in medical units more than 80 hours a week and more than 97% consider that their stay in the hospital interferes with their social and family life ⁽²⁵⁾, supports the idea that for students in service, medical units are like total institutions. In his own words:

To the family, I knew I was going to let them see. I knew that I was going to live only for the hospital and for the specialty... ⁽¹⁴⁾.

My courtship little by little deteriorated to the point of having to take a decision. These situations are so complex and complicated, and everyone decided to take their own path… ⁽¹⁴⁾. As for my friends, I no longer keep track of them, nor do they keep track of me, for obvious reasons... ⁽¹⁴⁾.

On the other hand, the entrance to these spaces is characterized by initiation rituals, which are tests or challenges to which those who enter are subjected and whose overcoming means acceptance and integration into the group. Derive ⁽³³⁾ describes the similarities between initiation rites and the mistreatment of residents. According to testimonies collected by Acosta-Fernandez ⁽¹⁴⁾: ‘He told us: you, clean up! Then we started to pick up the garbage and move the typewriters that were on the table. He pointed his finger at us and said: ‘you are the new ones, and you must understand your place as new ones’“. In a context such as the one described above, it is feasible to violate and overload students with work; in addition, fear, simulation, silence, competition, and deterioration of interpersonal relationships, among other things, are generated ⁽³⁷,⁴⁶⁾.

Thus standardized, contextualized, conceptualized, and understood, violence, both by medical personnel and by the students themselves, is easily acceptable and even pedagogically desirable: doctors must be trained with the character and skills to attend patients whenever necessary and under any circumstances, capable of making decisions under adverse conditions, pressure and uncertainty; Reboiras calls it the “heroic model” ⁽³²⁾.

Certainly, such a narrative does not stand up to the slightest analysis. Accepting violence for didactic purposes implies complicity with the perpetrators and willingness to exercise and reproduce it for that purpose. That is, accepting to be violated to become part of the medical profession justifies that, in due course, medical students may be violated. This explains the resistance to change and the fact that students in the higher grades violate the newcomers or those in lower grades, justifying themselves with sentences such as “that’s the way it has always been” or “that’s the way it was for me, and it was good for me”. According to the residents:

They are unfair mainly most of my fellow senior residents. Right now, I have suffered harassment and bullying from them (I am not the only one). Very few members are disrespectful and unfair. However, there are those who just let you down even if you haven’t made any mistakes or missed work. [...] The older residents are the ones who squeeze us under the water, exploit us and demand more, without you being able to give your opinion because things are worse for you ⁽⁴⁾.

The atmosphere among internal medicine residents is very arbitrary since the most senior residents are the ones who determine the punishments. Reprimands and many times, it is without supervision of an assigned person. There needs to be greater oversight by seconded physicians over how senior resident physicians interact with junior residents ⁽⁴⁾.

From a human rights perspective, the mistreatment of students in service is one more manifestation of violations of the right to education, the right to work, the right to personal integrity and safety and the right to dignified treatment. And given the interdependence of human rights, it is to be expected that the health of the students in service ⁽⁴²⁾ and that of the population they serve will be affected.