Why young doctors feel tired

He recalls sleeping the whole night in the hospital ward, waking up at 5 a.m., going to the hostel for a quick shower, and coming back to the ward at 7.30 a.m. It was routine three-four times a week for postgraduate resident doctors on 24-hour on-call duty.

Singh, 29, is now pursuing super specialization in ‘Breast, Endocrine and General Surgery’ at the same institute. But his routine is not good. Apart from assisting in three to four surgeries, he must attend to the patients under his care in the ward during breaks. There is no weekly off and marriage is off the radar for now.

“Life is not altogether miserable,” he assures, adding that the department celebrates birthdays and arranges outings. , AIIMS.

Sadly this is not the case in India. In 2020, when Covid was at its peak, this premier medical institution saw six suicides in two months—three of them by doctors. Worrying part? This problem is not limited to AIIMS. Depression, drug addiction, dropouts and worse, suicides are on the rise among students and junior doctors in medical colleges across the country – all a result of poor mental health. Overwork, anxiety, lack of sleep and exercise, often compounded by a hostile work environment, make junior doctors in the 25-35 age group tire quickly.

The pandemic may have only added to the woes. A 2021 review of the impact of COVID on the psychological health of healthcare workers in India, published in the journal Clinical Epidemiology and Global HealthIt was found that four out of 10 employees suffered from depression and anxiety and three out of 10 suffered from sleep disorders.

And many don’t even seek help for fear of the stigma associated with mental health. The problem usually takes root during residency and persists even when young doctors go on to work in hospitals. While the extent of the malaise remains largely unspecified, it was severe enough for India’s medical education regulator, the National Medical Commission (NMC), to list cases of suicide, dropouts, overwork, refusal of off-days, and ragging by colleges. Asked to do. last five years.

‘The burden will not ease’

In three years of residency, as Dr Singh’s case shows, junior doctors have a grueling schedule handling 60-70% of the workload in government hospitals.

“You are kept working; Dr. Sagar Mundda, Consultant Psychiatrist, Healthspring and former President of Maharashtra Association of Resident Doctors, says, there are no off days. Burnout is common among young doctors, especially in government facilities, he says, leading to the end of students. With clinical depression and suicidal thoughts.

But what makes his ordeal worse is the behavior of his superiors. “Senior doctors often talk disrespectfully to junior residents in the presence of patients. It becomes very embarrassing and painful,” says Mundda.

Dr Pratap Sharan, professor of psychiatry and in-charge of student welfare services at AIIMS, says the workload is inevitable. “Unless the way medical institutions work and their workflow is designed, the burden on residents will not ease,” he says. Also, the doctor-patient ratio in India is not ideal. An allopathic doctor caters to 1,376. people, according to estimates by the World Health Organization (WHO). The body’s prescribed norm is one doctor for 1,000 people. According to the NMC, the ratio is approximately one doctor per 1,194 people. This figure assumes 80% availability of registered doctors.

A resident doctor’s duties can be quite wide ranging from taking patient photos, uploading them into the system, dressing wounds, arranging blood samples and following up with diagnostic tests, says Dr Singh. This workload can be reduced if they have more paramedical staff to help.

stress starts early

In fact, the mental stress faced by young doctors starts from the time they take admission in the medical college. Competition is fierce. There are 19 applicants for one seat in India. Grief counselor and mental health researcher Pooja Priyamvada says, coaching for entrance exams starts from class 7 itself. In many cases, family expectations exceed merit. At a suicide prevention workshop at Delhi’s Jamia Hamdard University, she asks the class how many of them wanted to become doctors as children. Not even half the class raised their hands.

“These doctors have no social life outside the wards, classrooms or laboratories. There is no peer interaction in a healthy way. So, by the time they graduate, they are already struggling with mental health,” she says.

Dr. Kamna Kakkar, Senior Resident, Department of Anesthesia and Critical Care, Safdarjung Hospital, Delhi, says the process of desensitization starts from day one, when students are exposed to a dead body in the anatomy dissection hall. She noted that many of her classmates fainted at the sight of dead bodies, but there was no counseling or training to prepare them for it. In the second year itself, the students get posting in the hospital.

“No one comes into the hospital with a happy face. When you’re surrounded by sad people 24 hours a day, how does one cope? That sadness, that sadness creeps into you,” she says.

In the final year of medical school, when there are more clinical subjects, students are expected to complete an internship. This happens when the stress and anxiety prescribed in the form of nighttime duties wreak havoc with the circadian cycle, says Kakkar. Fearing stigma, students avoid seeking help or sharing their concerns with classmates. “Interns are paid 12,000-15,000 per month. Hence, they can hardly afford private medical treatment at this time,” says Kakkar.

more prone to suicide

Globally, doctors are 2.5 times more at risk of suicide than the general public. In the UK, 430 doctors ended their lives between 2011 and 2015. While India’s figures are not documented, a study published in 2021 Indian Journal of Psychiatry Based on media reports, 30 doctors committed suicide in the period 2016-19. At least 80% of the deceased were under the age of 40, of whom 22 were medical students. By gender, there were 18 females and 12 males.

“In the US, they lose the equivalent of a medical school batch (about 300) of doctors to suicide every year. I’m sure it’s the same in India. It’s just that we don’t keep track of it,” says Dr Soumitra Pathare, director, Center for Mental Law and Policy, Pune. In any suicide case, factors such as personality, family, community and work environment play a role, adds Plateau.

In addition, the risk is high among doctors due to lack of access to drugs, financial debt and lawsuits arising from patient death or medical complications. Studies also attribute mental health issues to specific personality traits associated with the medical fraternity – such as a high sense of guilt, perfectionism and workaholicism.

bitter pill to swallow

Priyamvada feels that among doctors, the fear of seeking medical help for mental health issues is more pronounced. Also, the belief that they are above such vulnerabilities prevents them from reaching out, she adds. If a doctor admits to having mental health issues, it affects their career development and the way colleagues view them. As a result, many people find easy release in drugs that are within their reach. Substance abuse is more commonly seen among emergency physicians, psychiatrists, and anesthesiologists.

“There are many anesthetists I know who are either using illicit drugs or are alcoholics. Recently, two anesthetists I knew died of drug overdose,” says Kakkar. These specialists handle the most critical cases where the prognosis is already poor. He is tasked with reviving the patient and facing ugly situations if he fails. “There’s poor recognition for the work they do,” says Kakkar.

Doctors treating critical or terminally ill patients also face similar challenges. “These doctors have to witness death on a daily basis. Many are unable to take it well,” says Mundda, whose clients include several doctors.

This was evident during the pandemic. Priyamvada, who works with the mental health helpline Co-Hope, says she has received several calls from health workers. “They were dealing with logistical issues like lack of oxygen. There was nothing they could do about it but it was affecting their mental health,” she says.

“I still remember the stench when I entered the room full of dead bodies wrapped in white sheets. I still remember the faces of patients gasping for air in the ICU even after being given oxygen,” Kakkar shivers.

fear of patients’ resentment

If the pressure of academic and work is not enough, there is always the danger of violence from the relatives of the patients. Dr Roopal Parekh, consultant obstetrician and gynaecologist, doing postgraduate training at KEM Hospital in Mumbai, says, “There are instances when a patient dies and relatives attack doctors, not understanding that the patient is already was serious.” Local goons with political connections also take advantage of the situation.

A study released by the Indian Medical Association (IMA) estimates that 75% of doctors in India have faced some form of violence, most commonly verbal abuse. Other forms of violence include telephonic threats, physical assault, arson and even murder. The IMA said the situation worsened during the pandemic, when patients faced a shortage of beds, oxygen and burial grounds.

needs major reforms

Often, in suicide cases involving doctors, the focus is always on the individual and his or her ability to cope with stress. The system is never questioned but real change can happen only when there are institutional reforms, believe experts.

In 1987, the Supreme Court ordered that the duty hours for resident doctors should not exceed 12 hours per day and 48 hours per week and weekly off was made mandatory. It is yet to be implemented uniformly across the country. Meanwhile, a 2019 study found the average weekly working hours for resident doctors in Mumbai to be 88 hours.

In keeping with the vulnerability of the profession, other countries have annual assessment exams for medical trainees and instructors on a range of issues, including mental health. It is not available in India. Counseling is needed twice a year for all resident doctors, whether they have mental health problems or not, says Mundda. Similarly, doctors should have easy access to mental health support. For example, the American Medical Association has taken initiatives to address the personal and professional risks that lead to physician suicides and has developed a toolkit to identify and support at-risk physicians.

In India, some redressal mechanisms are being worked out. Through its student cell, AIIMS Delhi has introduced recreational activities to reduce stress, set up support systems like e-Lab (a WhatsApp group run by students), made psychologists available for counseling and those who Psychiatrists have been made available for people needing medical intervention. Efforts to de-stigmatize mental health have led to an increase in the number of counseling services from 2% to 10% between 2018-2021, says Dr Sharan of AIIMS.

These are encouraging signs that government hospitals are waking up to the mental health challenges of their young doctors.