Isabel [host]: Hello, everyone. I am Isabel Cadenas Cañón, and this is a special episode of De eso no se habla.
These rounds of applause are from March 2020. You may remember them from our first special episode, Radio Silence. I recorded them from my balcony with my recorder. In Madrid, we were in the middle of a lockdown, and most of us couldn’t leave our houses. But every day at 8 p.m., we stood in our balconies or at the windows to applaud. We applauded the healthcare workers: the doctors, nurses, ambulance drivers. Those rounds of applause lasted for several months until they faded away.
People: Long live public healthcare! Long live! Long live the doctors! Long live!
At De eso no se habla, we’ve been talking for a while with primary care physicians based in Madrid. These doctors told us that, when the applause stopped, it all hit rock bottom. The summer was horrible, they said, the summer was desolating: They were understaffed, and nothing had changed for a healthcare system that was already very weak. They told us that nothing had improved since then, and that many doctors and nurses are gradually leaving primary care, looking for other jobs or resigning from their positions. And most of them are doing it in silence.
They also explained to us how this summer, as always, will be a period of crisis in many healthcare centers in Madrid.
That’s why, since we’re now in summer and in the midst of a new wave of infections, we want to give these doctors the space this podcast offers. This episode tells the story of two of them. Their names are Berta and Clara. They are family doctors, as well as friends. We gave Berta a recorder so that she could record herself while she was in her office. As for Clara, we recorded her at home, since she doesn’t have an office anymore: She resigned from her position almost a year ago. Both of them work —or used to work— in Parla, which is the town with the highest poverty rate in the region of Madrid.
So, in this episode, I’ll go silent, and that’s what you’ll listen to: The story of how Clara left her job as a doctor, and Berta’s daily life in an increasingly precarious healthcare system. Their voices take turns to tell the story of what we don’t see, but do suffer, in the healthcare centers of the region of Madrid.
One more thing: Berta and Clara talk a lot about primary care. This term may not be clear to everyone. Primary care doctors are the ones that work in healthcare centers, who know your history and your neighbors and your family. They are primary care physicians, family physicians. They like to say that their job is to take care of people, rather than diseases, and that, in order to do that, they look for “the causes of the causes.” When someone comes into their office, they try to understand not only what they suffer from, but also the reasons why: How housing, working or economic conditions have an impact on their patient’s health. They say that these are values from a different era, because they put the group first, because they use very little technology, because they focus on general aspects. And that’s precisely why they are in danger.
All of this may sound distant to you. However, the reality is, this is probably the story of what’s happening —or may happen— in your closest healthcare center, too.
Welcome to De eso no se habla. I leave you with Berta and Clara.
Clara: My name is Clara Benedicto, and I am a primary care physician. Oh, right. I don’t realize I’m still saying it, you know? But… It’s difficult not to speak in the present tense, isn’t it? I haven’t worked for nearly a year. I am Clara Benedicto. I was a primary care physician, because I resigned in October 2020 after having a bad time before COVID, and a horrible experience during the pandemic. I couldn’t take it anymore. I worked in a healthcare center in the center of Parla, in the old part of town. There are four healthcare centers in Parla — two of them in the oldest part of town. Berta works in one of them, and I worked in the other. The situation at Berta’s healthcare center was even worse than in mine.
PA System: Next station: Parla. End of trip.
Berta: Well… I finally have the recorder in my hands. You gave it to me yesterday. Honestly, it was a relief to have the chance to try to explain the situation. I’m very grateful that you gave us this opportunity, too. I’m worried that I may not be able to explain it properly, and… Well, now I’m on the train on my way to Parla, which is where the healthcare center I work at is located.
PA system: Next station: Parla. End of trip. Connected to…
Clara: Berta and I met when we started our residencies in 2008 because her father chose Getafe by mistake — which was the place I had chosen to do my residency as well. We met at the beginning of our residencies, and we chose tutors from the same healthcare center. That’s how we became friends.
(Footsteps, people greeting, keys jingling)
Berta: This is my office.
(A lock being opened)
(Ringing tone of a telephone)
Berta: Good morning. My name is Berta Herranz. I am a doctor at the Isabel II healthcare center.
Woman: Right, tell me.
Berta: Hello. How are you feeling?
Berta: Good morning. My name is Berta Herranz. I am a doctor at the Isabel II healthcare center.
Berta: Good morning. My name is Berta Herranz. I am a doctor at the Isabel II healthcare center.
(Telephone keys being pressed)
Answering machine: Your call cannot be completed as dialed.
Berta: Alright, your sick leave starts today then. Since you started showing symptoms on the 9th, and given that you must be in isolation for 10 days, it will run until the 19th.
Berta: Well, yes, the thing is that we are short-staffed, and there’s times that we just can’t answer every call. Tell me, what’s the issue?
Berta: And I just took off my mask. I’ve been sitting here, alone in my office, making calls for who knows how long with the mask on. I forget I’m wearing it.
Clara: When I decided I would quit, I wrote two texts. One of them was addressed to my colleagues at the healthcare center, while the other was a Twitter thread. I’ve had a Twitter account for years, and I use it a lot, right? The profile is pretty public, and I use it in different ways. However, I mainly use it to talk about health and do primary care activism, right? So I kind of felt… I felt guilty and responsible at the same time, right? I feel like I can’t keep working, but precisely to make sense of the fact that I’m quitting, I must continue fighting for it in other spaces, you know? So that I won’t think of it as an absolute failure. So, I put together a thread on Twitter explaining that I couldn’t keep doing it anymore, that I had taken a leave of absence and that I was going to step down, as well as the reasons why. And I didn’t expect such a reaction, you know? The way people shared it and the impact it had, I mean — and thank goodness, because if I had known, I may not have published it.
Berta: So, we’re calling it a day. It’s been rather crazy. Well, I’m going to change my scrubs, white coat, and so on while I talk. And… It’s just that… It’s a bit frustrating, because in the end… In the afternoon, there are only two of us, and one person —a doctor— that works until 6 p.m. Because of that, we are only attending emergencies. We haven’t provided primary care services for a long time in this healthcare center. What’s the problem with that? Well, people obviously need to be seen by a doctor, and in a primary care office, not in the emergency room. So, in the end, you end up seeing them, trying to examine them, trying to carry out a more thorough assessment of somebody you don’t know, putting in a time that you just don’t have… I don’t know. I mean, I really… I don’t know how to explain the desperation, helplessness, and frustration you feel when doing things… If you try to do it right, it obviously takes time, so you have more and more patients waiting. Then, your superiors call — you have to go to a given care unit, and get dressed only to get undressed later. Then you go downstairs, and there may or may not be an emergency call, and… I don’t know. Really, I mean, I just don’t know. It’s a disaster… I don’t know, it’s a silenced disaster, because no matter how vocal we are about how bad the situation is, the answer is just that — silence. “Come on guys, you’re doing great.”
Clara: I tweeted the thread on October 9, 2020, at night, after I finished my last day of work. It’s interesting, I didn’t remember. I had written it beforehand, but I posted it when I got out of work. That’s why it was posted at 9 p.m., because that’s when I leave the healthcare center. And the thread says “Well, today was my last day of work in primary care. I have taken a leave of absence because I literally can’t do it anymore. The working conditions were already bad enough before COVID hit. The working hours that were reduced from my shift haven’t been covered, so I had to see all my patients in three days with the help of my colleagues. In an afternoon shift with 9 doctors, we had three more reductions and a retirement that were not covered.”
Berta: I am on the train back to Madrid city once again. And, well, it’s very representative of the situation we are going through that, out of the 17 doctors that currently are —or should be— in this healthcare center, most of them will move to other locations, and only two people are staying here. Two of those 17 people are staying in this healthcare center — two people that, since they are substitutes, can’t apply to be transferred. It’s the same for nurses, almost everyone wants to leave. However, instead of asking why we want to leave, right? It’s assumed that someone will come. That’s it. There’s no need to ask about it, there’s no need to try to solve it, there’s no need to try and offer more resources… No, someone will come.
Clara: “The first week of March, I saw an average of 40 or 50 patients. Appointments were delayed by around two weeks, and I was frustrated and under quite some stress. We made many suggestions on how to improve things, but most of them were disregarded. I remember March 11 as a particularly awful afternoon. There were delays, an overcrowded waiting room, rumors of COVID infections, no official information, quite a few people with respiratory problems, so much stress, and so much uncertainty. During the months the state of emergency was in force, we had a hard time, but we did everything we had to do. We organized ourselves as best as we could, we learned new things even when we didn’t have time, and we took care of ourselves as a team. Some of us went to the IFEMA field hospital. A lot of people got very sick. Some died at home, and others died at the hospital — not always from COVID, and not always being well cared for by a saturated system that was focusing on just one thing. There are faces and names that I will never forget.”
(A door opens and closes)
Berta: Okay, so, I’m already in my office. Today is Monday, so we’ll see how it goes. There was quite a long queue of people waiting outside the healthcare center, as well as inside.
Berta: Well, isn’t that great? As if it wasn’t enough, the telephones at the healthcare center have stopped working. Well, we’ll see what we can do today.
Berta: Well, I’m getting tired of this. First, the phone doesn’t work, then neither does the printer, then the computer program stops working… So… yes. Now we just have to wait for things to work, as if we didn’t have anything else to do. This is so frustrating, honestly. In this office, the telephone does work, but the computer doesn’t. In the office I was previously in, the telephone didn’t work, but the computer did work. So… It’s really infuriating.
Clara: “The moment the state of alarm was lifted, it all started to slowly go south. The people waiting with appointments, tests, and surgeries that were cancelled were knocking on our door again, as it’s the most accessible one. Fear, grief, all the pain that had to wait…. More and more calls, more bureaucracy, more new protocols, more people that were angry and confused because they felt abandoned, and with good reason. During the summer, the healthcare center was operating with around 35 to 50 percent of its staff. Clock in early, clock out late feeling your heart pounding in your neck.”
Berta: A colleague of mine just told me that she was in the emergency room today and… She has a patient that I had examined over the phone because her stomach had been bothering her for a while, so I booked her an appointment for a blood test and… Well, the results were completely fine. In any case, my colleague gave her an appointment to see her in the office today because apparently she was feeling a little better, but she still hadn’t fully recovered. And it turns out that… Well, she has an ovarian tumor. They have seen it, and during the examination it was obvious that… Well, in fact, it looked like she was pregnant — that was what they first thought. Later on, when she got an ultrasound at the healthcare center, they determined that she had an ovarian tumor. She’s 37 years old, she’s alone in Madrid, and she doesn’t have family here. And in times like this you just think that you would like to see everyone, call everyone into your office to examine every single problem not to leave anything unexplored, not to leave anyone behind. And these are the cases that… The cases that, of course, we don’t identify… And we are aware. We realize that we have missed them, right? But how many diagnoses have we missed that we will never know about? Anyway, it’s horrible. Oh, and the guilt. The guilt is always there. The guilt of not having seen it, the guilt of having seen it wrong, the guilt of still being part of the charade that is such a collapsed healthcare system, which we can barely keep working. The guilt of staying, the guilt of leaving… The guilt… The guilt!
Berta: I have to say that it’s not easy. Firstly, to own the mistakes, what hasn’t been done right or what could’ve been done better. Secondly, to record it. Thirdly, to transfer it to the computer. Fourthly, to transfer it to the De eso no se habla folder and think that you are going to listen to it or that someone will listen to it. It’s hard.
Clara: “At first, I would arrive an hour or an hour and a half earlier so that I could finish the list of patients, and put a bit of time and affection into each call or visit. After that, I would have more and more rushed appointments, more needs per call: ‘I have several things to tell you, since you never answer the phone.’ One day I left without calling two people because the healthcare center was closing. ‘I’ll call them tomorrow,’ I thought. But the next day, I couldn’t call five. Every day is like that — the uncertainty of not knowing, the lines being saturated, the administrative staff being overworked, the bottleneck that makes it hard to get an appointment, and the certainty that those who need it most have it the most difficult to get access. But at the same time, the inability to fulfill the request to do anything other than to assist the cases that come in. It’s been wearing us out progressively, but I remember the moment when I realized something had broken. One torrid afternoon in early August, after working for several hours with the PPE on, a patient refused to get a PCR test done. She pushed the swab away from her nose, and she accidentally dropped it on the floor. I yelled at her, I scolded her, and I told her that I didn’t have time to deal with that nonsense. I’m not proud, and I apologized afterwards, but to me, seeing the patient as the other is crossing the line.”
(Sound of footsteps in snow)
Berta: Today is January 11. Now that the snowstorm has passed, the trains to Parla are finally working, so I’m on my way there.
Berta: It’s actually extraordinary to walk around the street without any cars. And well, trying not to fall down while you do.
Berta: So, my colleague Cris and I are coming back from doing ice skating.
Cristina: From somebody’s home.
Berta: And, well, Cristina has already… You’ve already been to a few today, right?
Cristina: Well, I have been to three places. I’ve also attended this emergency call, and my colleagues have attended two more.
Berta: But why… Why has it been so hard or different from other days? What’s happening?
Cristina: Wait, wait.
Berta: Wait, I’m going to fall.
Cristina: Well, because it took us two hours to visit three different homes, since it’s impossible to walk around these streets.
Berta: Everything has collapsed due to the snow, the ice… And, so, at the healthcare center, it was two of us doctors working with a colleague that stayed half the day. Two out of 18. And I think tomorrow is gonna be the same. So, if the healthcare center was already collapsing…
Cristina: Now it’s even worse.
Berta: Now it’s even worse.
Clara: “I’ve had nightmares about work for months. I’ve felt angst thinking about my job on my days off. I’ve suffered anticipatory anxiety on the train on my way to the healthcare center. I immediately run out of serenity and energy to deal with other people’s suffering. Sometimes, I open the appointment list and see 45 names (it’ll be even more throughout the afternoon), and I have trouble seeing them as people. Every single day, there are people that we don’t get to call because we just can’t. I talk freely about how I feel because I’m certain that it’s not a problem of me not being able to cope with it nor about learning new relaxation techniques. Many of my colleagues feel the same way. Some of them have cried. Some of them have expressed their anger. Some of them take medication to cope.”
Berta: Two days ago, we found out that the transferral we requested has been approved. We applied to change healthcare centers. And, a couple of days ago, we found out that it’s coming into effect next Monday, so I’ll no longer be in the Isabel II healthcare center in Parla. I’ll start working in Vallecas. So, uh, I’m… I’m nervous because… On the one hand, there’s the relief of thinking that I’m going to a place where I can work better — not well, but better. I’m sorry that I’m leaving, but I’ve come to a point where I can’t do it anymore. I’m sorry for the people in Parla, I’m sorry for those that depend on our healthcare center, because I don’t know if they will get any more doctors. Six of us are leaving — out of the 18 of us, six are leaving. But there actually may be eight or nine people left actively working. And, well, I hope that more doctors are sent to Parla, because if they’re not… I don’t know, I don’t know how people will manage, to be honest.
Clara: “We’re not burned out. It’s the system that’s been consuming us. It’s the conscious and deliberate decisions to dismantle the primary care system that have been made for years. Now, however, given the burden we carry, they’ve become inescapable. The hope that I had in April has vanished. All that there’s left is insolence after insolence, lies, disrespect from the institutions, being disappointed in management and unions. We can’t take care of our patients, nor can we take care of ourselves.”
Berta: Well, that’s it, it’s over. Today was my last day at the Isabel II healthcare center in Parla, and… The truth is that I can’t help but feel very sad about it. I’m so sad, I feel so sad leaving, for stepping down, for not being able to take it anymore, for… For leaving my patients, and for leaving the colleagues that stay here, who I know are not in a good position right now. But, well, at the same time, I feel relieved, and I think that after almost a year, I’m very enthusiastic about starting a somewhat normal job in a decent office… Or a better one, at least. So, that’s it, this is my last trip on the train from Parla to Atocha. And I share it here.
Clara: “I feel sorry for my colleagues at the healthcare center, who make up a great team, and especially for my group of patients who, by the way, I haven’t been able to treat as they deserve for months. However, I think that the heroism of holding on at any cost helps neither of us. I also feel sorry for Parla, which, like every disadvantaged town, needs the resources more, and receives less of them. The region with less equality, and the one that invests the least money to fund primary care, has abandoned them once again. Every decision is valid: the people that keep working under such conditions, the people that would like to quit, but can’t afford it, the people that have quit or will quit in silence. There are so many of us, and each one fights in silence, in our own way.
Clara: “Even in these conditions, being able to step back for a while is a privilege. There’s no leave of absence, there’s just a void for professionals with precarious positions. There’s no plan B for many of our colleagues who have families to care for, there’s no flexibility possible. Nor are there alternatives for many of my patients, who live similar or even worse situations of stress and exploitation, with a much lower salary or social prestige than the ones family medicine provides. But the roots of such mistreatment are the same. I want to thank those of you who have put up with me or helped me decide. And those who have supported me, and given me love and affection from a distance. I am leaving for a while, but not in silence. In fact, I’m doing it with a thread that may be too long, because it’s our responsibility to point out the causes of the causes here, too.”
Clara: I hadn’t read it since. Oddly enough, I think that, despite the hard time that I was going through, I must have had very clear thoughts to be able to articulate all of this. I think I would have a harder time if I tried to write it now.
Isabel: Berta and Clara’s story is not only about a work-related problem. It’s not a problem about Parla either. Investment in primary care has been declining for years: Our public healthcare system is increasingly being more privatized, and fewer people have access to healthcare despite the fact that in our country —in theory— everyone has the right to universal healthcare.
Spain has a decentralized healthcare system, which means that it’s the different regions that decide how and how much they invest in healthcare. Madrid is the Spanish region that invests the least on healthcare per GDP, and it‘s also the one that invests the least on primary care.
Since the 2008 crisis, primary care has grown half as much as hospital care. At the same time, job positions are increasingly more precarious: In 2017, for example, only 6.9 % of family physicians had indefinite contracts.
Comparing primary care with hospital care is not a whim: Many studies claim that primary care is the healthcare system resource that reduces the population’s mortality the most. A robust primary care system largely prevents us from going to the hospital later on. It’s also much cheaper than hospital care, so why the lack of investment?
And one more thing: It is estimated that, in the last 10 years, 19,000 family doctors have finished their specialty, but very few have joined primary care. As of today, only 13 % of primary care physicians actively working are under 40 years old. There’s not much data on where the rest of them are, but there are signs: In those 10 years, there have been more than 30,000 applications to obtain the certificate required to work abroad.
This data comes from an article published by Clara and another family physician, Bea Aragón, in the journal of the primary care association Sociedad Madrileña de Medicina de Familia y Comunitaria. Clara, Bea, and Berta are part of the Resisters, a group of family physicians who started to get together to support each other during the pandemic, and continue to do so. Clara and Bea’s article, by the way, is titled “De eso no se habla” (We don’t talk about that).
…Or else we do.
If, after listening to this episode, you wish to know more or do more about it, we have posted links to many associations and groups on the additional materials section of our website. There, you will find more information about the topic and who you can collaborate with.
The production, script and editing of this episode were done by me, Isabel Cadenas Cañón. Vanessa Rousselot did the script editing and Paula Morais did the production assistance and communication. Marcos Salso did the final mix, and our studio is Isolé División Sonora. Our theme music is by Alva Noto and Ryuichi Sakamoto. The illustration is by Carmen Cáceres.
Thanks to the Resisters, who have trusted us so much to do this episode, and especially to Berta, Clara, and Carmen Fando. Thanks to all the people who have helped us make this episode a better one: Laura Casielles, who has finally taken a vacation, María San Miguel, Ernesto García López, Óscar Martín García, Chiara Giacco, Cris Ortego, Carmen Cáceres, Teresa Flores, Alberto Muñoz, Concha Calatayud, Manu Maroto, Javier Padilla, Haizea Miguela, Patricia López, Nerea Pérez, and the Cadenas: Paz, Blanca, Godo, and Mari Luz. And thanks to Lourdes Lancho and Valentina Rojo, from the A vivir que son dos días program, for wanting us to be on it. You can find the link to the radio broadcast in the description of the episode.
If you liked this episode, please recommend it to your friends and subscribe to our channels. You can also leave a rating on Apple Podcasts or Ivoox. You can also subscribe to our newsletter on our website, www.deesonosehabla.com. And, if this is the first time listening to us, you can listen to our first season: 8 episodes about silences, and how we break them.
This special episode of De eso no se habla was produced, as usual, in the proud neighborhood of Lavapiés, in Madrid.
Thanks for listening.