THE PERCEPTION OF RESIDENT PHYSICIANS ON THE SUBJECT OF MENTAL HEALTH IN THE THIRD YEAR OF THE MEDICAL RESIDENCY OF A PUBLIC UNIVERSITY IN LIMA-PERU

Cite as: Edgar J. Miraval-Rojas, J. Franco Rodríguez-Alarcón. The perception of resident physicians on the subject of mental health in the third year of the medical residency of a public university in Lima-Peru. Rev. Fac. Med. Hum. July 2020; 20(3):366-373. DOI 10.25176/RFMH.v20i3.2923 ABSTRACT Introduction: Mental health is an issue that has taken on great importance in recent years and has become a substantial part of many training courses around the world. Objective: To determine the perception of resident physicians on a mental health course during the last year of residency. Methods: Observational, descriptive, and transversal study with a sample of 130 students from the Mental Health program of the medical residency of Universidad Nacional Federico Villarreal who were surveyed with a form of 10 questions that sought to know the perceptions of the students on this course. The technique used was non-probability sampling. Results: Of the 130 respondents, 57.69% were women and 13.85% were pediatricians, 57.69% performed a clinical specialty and 58.46% were free-standing. An exploratory analysis was made: on the importance of the course, differences were found with the age range (p = 0.038) and modality of residence (p = 0.05). In addition, regarding the acceptance of the course, differences were found with the age range (p = 0.021) and type of residency program (P = 0.053). Conclusion: Participants in the mental health course of the medical residency have good acceptance of this subject and are considered important.


INTRODUCTION
Mental health is a topic that has become more prominent in recent decades (1) . Its importance has emerged in different aspects of life and contexts, taking priority in the development of communities, families, and workplaces (2) . Thus, stress, anxiety, and depression have become important in the development of policies of work and coexistence in different societies of the World (3) . In addition, the evolution in the importance of mental health has led to the emergence of laws, policies, and rights focused on the development of a balanced environment that seeks the protection of emotions and feelings (3)(4)(5) . Therefore, it has been understood that the elements of a healthy relationship are good interpersonal therapy and empathy (6,7) .
On the other hand, Medical professions must include mental and psychological aspect as an important part in the development of its protocols and working mechanisms (8) . Training in psychological and empathic skills must accompany medical training during all its stages: undergraduate (9)(10)(11) and postgraduate (12) . In this context, medical schools should encourage the training of professionals who can handle stressful situations (13) , establish an empathetic medical patient relationship (14) , and who can solve the mental health problems prevalent in society. According to this, the physician's role is not only to ensure the well-being of his patients but also to all areas involved in comprehensive care (15) . Therefore, it is important to implement the subject of mental health in the academic curriculum of predegree and post-degree programs of the human medicine career for the development of competent and empathetic professionals (16) . Therefore, the objective of this study is to determine the resident physician's perception of a mental health course during the last year of medical residency.

Design and setting
Observational, descriptive, and transversal study in residents of Universidad Nacional Federico Villarreal.

Population and sample
The population of this study consisted of all residents of the different specialties that performed the medical specialty programs at the Universidad Nacional Federico Villarreal during the period from January 18 to February 18, 2020, which constituted a total of 226 resident physicians. Those who attended the mental health class that is taught as a subject of the medical resident's program were included. A survey was applied to study participants at the end of the course. Resident physicians who did not attend the classes where the surveys were administered, as well as those who did not answer the survey nor did so incompletely, were excluded from the study. According to the above criteria, the study counted 130 resident physicians.
The technique used was nonprobability sampling and it was convenient to take advantage of the attendance to the regular classes of the course that were developed in the classrooms of the Hospital Nacional Victor Larco Herrera.

Variables and instruments
The main variable was the perception of the mental health course in the third year of residence. To measure it, we used a survey conducted by the authors and content validated by experts. The survey consisted of 10 objective questions that measured variables such as the importance of course concepts, the importance of mental health in the family and the community, the correct therapeutic approach to mental disorders, mental problems by life cycle, acceptance of course implementation, adequate course introduction, development of the procedural aspect, attitude to the course and perception of mental health reform. The answers were raised following the Likert model.

Procedures
This survey was applied during a class of the mental health course. Participation was openly voluntary and the verbal consent of each participant was requested. Subsequently, the data was processed in a database for which a Microsoft Excel 2016 program sheet was used.

Statistical analysis
Quantitative variables (which showed an asymmetric distribution) were described as age through medians and interquartile ranges, and categorical variables through frequencies and percentages. The distributions of the answers for each question were presented through frequencies and percentages. Also, it was explored the distribution of the different factors according to the answers in the question about the perception of relevance and acceptance of the course. The data were processed using the STATA 14.2 program.

Ethical aspects
During the development of the study, all ethical standards and principles of research were followed. The participants gave their verbal consent to participate in the project and ensured that their data could not be identified. All data collected for this study was deleted after being processed to meet the research objectives.

RESULTS
All the 130 participants, 57.69% were women. The marital status of the participants was 61.54% single and 27.69% married. The medical specialty with the largest number of people was Pediatrics, representing 13.85% of the total sample. Residents who were trained in clinical specialties accounted for 57.69%, and 58.46% were free-standing. The general characteristics of the study sample are shown in Table 1.

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When performing the bivariate analysis on the relevance of the mental health course, it was found that 62.96% of respondents of ages 25 -35 years considered the course interesting (p = 0.038). In addition, 53.7% of residents matched into a program described the course to be" interesting " and 64.47% of the free-standing residents considered it to be "interesting" (p = 0.005). The other data from the analysis are detailed in Table 3.

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Pág. 370 surgical specialty showed good disposition towards the subject of mental health (p = 0.053) adjusted according to age range, gender, marital status, type of residency, and mode of residency. The details of the analysis can be found in Table 4.

DISCUSSION
In our study, we found that 62.96% of participants of the A group considered the contents of the mental health course important during medical residency. This contrasts with a study done with undergrad students who, after an internship in mental health understood that the human being is not only composed of biological aspects but also psychological, social, cultural, and spiritual (17) . It is interesting to mention the relevance of these findings. Chau and Vilela, a study conducted in 1024 university students from Lima and Huanuco showed that the mental health of the students was determined by variables such as perceived stress, feeling of selfefficacy, career, type of study, institution, among others (18) . Residents within this age group do not only face the job challenges that correspond to the needs of hospital service but also they are exposed to the common problems of their age group. It is for this reason that Ovalle-Peña et. at. tried to understand the most common problems in young adults that could lead them to severe depressive states. A qualitative study of 25 people of 25 -40 years of age was done using the "The State-Trait Depression Scales" and concluded that at this age there is an emotional lack of control, personality problems, a tendency towards depression, and remarkable emotional instability (19) .
On the other hand, 64.47% of the residents who were in the free-standing modality considered as interesting the topics contained in the mental health

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Pág. 372 course. This finding is relevant in the context of the job instability that many of these professionals experience especially at the end of their training years as specialists. Therefore, to affirm that a big interest of the participants is to be able to handle situations of stress or anxiety as a result of the finalization of residency and initiation in the labor field, which in many cases will be their first work experience, is not out of context (20) . In addition, we must add that, among the participants, 27.69% were married. Therefore, in a situation of possible unemployment plus family burden the proper management of depressive or anxious situations takes a special interest in these professionals. This situation was seen by Ponce et al. in residents of a private hospital in the city of Córdoba, Argentina of 159 residents, a percentage of them had developed clinical Burnout syndrome and the others suffered from stress or some degree of anxiety (21) .
In the age range C (46-65 years) 46.15% of participants had a" very good " acceptance of the subject. These results show a reality less explored within the medical field. The acceptance of the course may be a result of the need for professionals of this age to be able to cope with continuous stressful situations in their work. The contact with younger professionals performing the same specialty, family burdens, and pressures of their work centers to obtain a specialty come into play in the emotional stability of this group (22) .
For this reason, when Ortuño et. al. evaluated patients within this age group in a sample of 674 people found that 27.6% had depressive syndromes that required pharmacological treatment and 71% were women (23) .
Based on the findings of this study, it is important to implement strengthening programs of mental health. An example of this was done by The John A. Burns School of Medicine at the University of Hawai'i system which provides individual counseling services. This resulted in a significant decrease in depressive symptoms as well as reported suicidal thoughts in students (24) . Similarly, a much larger program was instituted at The University of California, San Diego School of Medicine, focusing on the mental health of medical students, residents, and faculty physicians. The program was well accepted by faculty members (25) .
Also, it has been reported that doctors with better mental health, are in a position to provide a better service to their patients and strengthen the physicianpatient relationship. They do not only provide a more friendly and empathetic service but also, detect mental health problems that may interfere in the course of the disease, and take the necessary measures in a timely manner (26) .
One of the limitations of our study was the selection bias as the sample was non-probability sampling and was taken for the convenience of a class of the subject of Mental Health. Also, the study did not consider specialists who had just graduated from the residencies. The problems of this population can be explored in future research.

CONCLUSION
Students in their last year of residency in medical school considered the subject of Mental Health important and relevant. It was concluded, that the youngest residents considered the content and procedure of the course to be "good" and "acceptable".