The Jakarta Post
Two resident doctors from Airlangga University (Unair) in Indonesia's COVID-19 epicenter – Surabaya, East Java – had been on track to wrap up years of studies in the next few months.
However, following days of intensive treatment at their teaching hospital Dr. Soetomo Hospital, where they had been training and serving patients for years, they succumbed to COVID-19.
Internal medicine chief resident Miftah Fawzy Sarengat died from the virus on June 10 after tending to COVID-19 patients in Surabaya, marking the first fatality reported among residents in Indonesia.
Less than a month later, on Sunday, pediatric resident Putri Wulan Sukmawati died from the virus, though Soetomo Hospital, also a COVID-19 referral hospital, insisted that she did not work in a COVID-19 isolation room and that the management was already "contact tracing internally".
"At the hospital, there is no space that is safe from COVID-19. Even if we do not work in the COVID-19 [isolation] room, we can be infected by our colleagues," an Unair resident who requested anonymity told The Jakarta Post on June 23.
He said that, up until May, the teaching hospital had failed to provide enough personal protective equipment (PPE) for residents working in the emergency room, prompting them to rely on PPE donations. It was only in June, after reports caught the public's attention, that the hospital allowed residents at the ER to ask for a new set of PPE for every four hours, he said.
"There is much worry among fellow residents. It is not only about fears of contracting the virus and potentially infecting families at home, but also about prolonging our education, whether we want it or not,” he said. “Adding one more semester means paying tuition fees for one more semester and more living costs for six more months.”
Seventeen universities in Indonesia offer residency programs with an estimated 13,000 students, according to the Academy of Medicine of Indonesia (MKKI), the Indonesian Medical Association's (IDI) council overseeing medical education.
These residents are assigned to teaching hospitals, many of which are being used as COVID-19 referral hospitals. They work long hours with little to no pay, and when they do receive a salary it is way below the living wage.
Indonesia’s university-based system for its residency programs meant that residents were considered university students who had to pay tuition fees, said MMKI chairman David Perdanakusuma.
The fees range in the millions to the dozens of millions of rupiah, although there are scholarship options, with program duration lasting four to 12 semesters.
This is in contrast to the hospital-based system applied in other countries, in which residents are considered workers who receive salaries throughout their training.
"One of the ways to be able to survive being a resident is to be rich," the Unair resident joked, adding more seriously that being a resident might not only lead to financial constraints, but also physical and mental issues.
A 2011 research study that polled 117 University of Indonesia pediatric residents at Cipto Mangunkusumo Hospital in Jakarta found that 23.9 percent of students had experienced depression two weeks prior to their interviews. The study, published in Sari Pediatri, a journal from the Indonesian Pediatric Society’s (IDAI) publishing agency, also found that 59 percent of them had experienced depression more than once, with a majority of them relating it to their programs of study.
As a result of the pandemic, some residents of pulmonology, internal medicine and anesthetics, among other fields, have been asked to directly tend to COVID-19 patients at ERs, wards and intensive care units under the supervision of specialist doctors.
Hospitals and medical workers have had to limit services to non-COVID-19 patients, who have declined in number over virus fears, and reduce polyclinic activities and elective surgeries.
This disrupted training among residents, as they were less exposed to cases that would help them meet the required competencies to complete their studies, David of the MKKI said.
A resident at Brawijaya University in Malang, East Java, who wished to remain anonymous, said his teaching hospital of Saiful Anwar had seen a "boom" of COVID-19 patients, meaning there was a high possibility of prolonged training.
"[Hospital] departments are now requesting for tuition fee relief [...] We are certainly financially concerned because we rely on our own money and scholarships, and we cannot work [while taking residency]," he said on Sunday.
Joni Wahyuhadi, the president director of Soetomo Hospital and curative management head of East Java's COVID-19 task force, told the Post on June 26 that the hospital made sure there was an adequate stock of PPE and that it was processing incentives for residents. He said it was restructuring its ER.
At the time, he said nine residents were treated for COVID-19 at the hospital, with one admitted to the ICU. On Monday, Joni said one resident was treated for the disease at his hospital and three others at Unair's infectious diseases hospital. Joni did not respond to questions on the total number of infections among residents.
Unair has promised a 50 percent cut in tuition for residents providing care to COVID-19 patients. It has also waived their tuition while they take temporary leaves of absence from their study programs.
Meanwhile, David said the government had now rolled out incentive policies for residents via teaching hospitals, which were expected to register residents with the Workers Social Security Agency (BPJS Ketenagakerjaan) to access the benefits.
"There is a possibility for a hospital-based residency system. Consequently, there needs to be an adequate teaching staff and hospitals that meet the teaching requirements,” he said. “There also needs to be support [from policymakers] in the form of regulations and laws on the inception of hospital-based systems.”