S. Mahendran (name changed) starts his day at 7.30 a.m. at one of the busiest government hospitals in Chennai. He spends the next 10-12 hours walking to beds of patients in the wards, checking their vital parameters, administering injections and drugs, carrying out routine investigations and coordinating visits of specialists. His working hours get extended if the condition of any of the patients deteriorates.
This has been his routine for the last six months of his Compulsory Rotatory Residential Internship (CRRI). The only change in his schedule comes in the form of a 36-hour-long duty once a week. Sometimes, this gets extended to 40 hours.
Several kilometres away, C. Ravishankar (name changed), a second-year postgraduate (PG) student in a government medical college in southern Tamil Nadu, works for 24 hours during ‘admission day’ at his department. His duty hours continue with the next day being ’operation theatre day’. He leaves the hospital at 4 p.m. only to return after an hour or two of sleep to check on the post-operative care of patients. Another 24 hours of duty await him.
Worsening conditions
Long and erratic working hours, lack of weekly off days or holidays and a stressful working environment may not be new for a PG student or intern (also known as house surgeon) in Tamil Nadu. But, working conditions are worsening, putting many of them under undue stress, affecting their physical and mental health. Some of them are depressed due to work stress.
To top it all, they continue to work in an environment that lacks basic facilities. Some of the hospitals lack duty rooms, drinking water and separate toilets for them. The pay is low and they claim they also face harassment and discrimination in many forms.
Many PGs describe their three-year post graduation period as the most stressful in the life of a doctor. Interns call their year-long CRRI variously as a “curse” and “period of slavery”.
“Internship is like swimming in a tub of hot oil. You can neither swim nor drown,” says Mahendran. Despite court directions and orders from the Health department, there are no prescribed working hours for PGs and interns in the State.
“In simple terms, our work schedule is 24x7 for 365 days. We can count the days when we have all three meals. We are physically and mentally exhausted every single day,” he adds. Since his CRRI stint began, Mahendran has been working without an off-day or holidays. He claims he has lost more than 10 kg in the last six months.
House surgeons at the Madurai Medical College echo a similar sentiment. They state that they work on all days of the year and rarely ever catch a break. One of them adds that the lack of a break contributes to stress. Similar is the state of PG students at Coimbatore Medical College Hospital.
A few students of K.A.P. Viswanathan Government Medical College in Tiruchi term the one-year internship as a curse. “We are usually posted in 24-hour shifts starting and ending at 7.30 a.m. On admission days, which is when the outpatient ward is attended to, or when posted in the emergency ward, house surgeons are not given any safety equipment. We are not even allowed access to gloves,” a house surgeon complains, requesting anonymity.
Risky business
While medical professionals do run the risk of contracting infections, young medicos seem to be at higher risk, because of lack of access to such protection. There have been cases where some of them have been exposed to HIV and hepatitis B-infected blood. One of them contracted tuberculosis during his MBBS course and underwent treatment. “Recently, an intern at Madras Medical College contracted diphtheria after treating a patient. Every doctor goes through this at one or multiple points in their life,” says another PG student.
One intern, who tested positive for dengue, took leave for a few days. “Now, I will have to work for additional days after completion of CRRI to compensate,” he adds.
An assistant professor of Madras Medical College says that the work schedule is indeed hectic for PGs and they cannot eat on time and suffer from lack of sleep. Some of the departments that have a hectic work schedule are general medicine, general surgery, obstetrics and gynaecology.
“The patient load is high in a government hospital. I understand that we cannot get holidays but we should at least be given off days once a month on a rotation basis. We are overworked and burnt out. How will our work efficiency improve?” asks a PG student, working in a government maternity hospital in the city. When the job involves taking crucial life or death decisions, it stands to reason that clarity is of the essence.
‘Treated like slaves’
Postgraduation is a tough time, a student says, adding, “the working conditions have only worsened and there are no signs of improvement. In some medical colleges, especially in the south such as Madurai, Thoothukudi and Tirunelveli, the first question that a PG faces is about caste. If he/she does not belong to the dominant caste, opportunities for surgeries are only a dream. There have been cases in which first year PGs have had to take unit chiefs and other faculty members on tours.”
Another PG student, requesting anonymity, claims surgical departments of some colleges treat many of them like slaves. “I know of a PG student who has to buy tea and snacks from a specific shop for the seniors in the department every day. There have been cases in which married women PGs are told not to get pregnant. Sometimes, if they conceive, they are asked to abort, we’ve heard,” he claims.
However, none of the PG students dare raise objections as they fear being targeted, he says, adding: “We are forced to fall in line or else our senior doctors will not impart surgical skills and deny us opportunities to participate in a surgical procedure. We fear losing marks in the internal examination. There are unwritten punishments that we face. We are not supposed to talk, give our opinions or suggestions,” he says.
It is not just medical work that interns and PG students perform but also clerical jobs. An intern says that sometimes they fill out tons of paperwork, though that is not part of their work schedule. A cross-section of PGs points out that they are forced to do clerical work for the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS). In some hospitals, PGs fill the forms for patients and help them to get the insurance cards. They coordinate the entire CMCHIS work and check cash flow. In the obstetrics and gynaecology department, first year PGs have to do clerical work for LaQshya scheme – Labour Room Quality Improvement Initiative, they said.
Miles to go
While the State government has improved the hostels of several medical colleges in the State, more needs to be done at the workplace for these interns and PGs. Except for a few chairs, many government hospitals do not have proper duty rooms with beds for PGs and interns. In the absence of such facilities, they have no place to rest during long work hours. There are no separate toilets for them. The problem is worse for women PGs, say interns.
Recently, PGs and interns of Chengalpet Medical College staged a sit-in protest demanding some of these basic facilities and a safe working environment.
A. Ramalingam, State organising secretary of Service Doctors and Post Graduates Association, says work-related stress is high among PGs. “A PG has to manage his/her family expenses but is poorly paid. Tamil Nadu has among the lowest salary scales when compared to other States. PGs are in the category of junior residents and should be paid more. In many other States, the pay scale is more than ₹60,000 for junior residents. The government should take concrete measures to improve the remuneration of all doctors,” he stresses.
Teaching institutions try to manage patient care with house surgeons and PGs, G. R. Ravindranath, general secretary of Doctors Association for Social Equality, observes. “They should be considered as students. When they are overworked, there are higher chances of errors and negligence. The Medical Council of India has clearly laid down the work profile of a house surgeon and PG. Despite court orders and a circular from the Directorate of Medical Education on working hours, nothing is implemented in the State,” he says.
The duty hours of PG students should be limited to eight hours so that they can get adequate time for studies, says N. Ravishankar, state secretary of Tamil Nadu Government Doctors Association. “Imposing more working hours on PG students will affect their studies and quality of treatment.”
PGs and interns demand that there be a dedicated grievance redressal mechanism for them. They want rules that stipulate working hours to be implemented in letter and spirit, and ask that they be granted stipends on a par with their counterparts in the Central government.
R. Narayana Babu, Director ( in-charge) of Medical Education, says, “We are implementing the orders on stipulated working hours for interns and postgraduate medical students. We ensure that they are not overworked and provide periodical counselling for them. We also look at their mental and physical well-being.”
“PGs have no separate theory classes and they learn by working. Many of them voluntarily put in efforts and work for longer hours to take care of patients. They cannot follow a 10 a.m. to 5 p.m. working schedule,” he adds.
He says that they have improved the hostel facilities and food for medical students. “We have created the best possible working atmosphere for them,” he adds.
(With inputs from Kathelene Antony in Tiruchi, Sanjana Ganesh in Madurai and Wilson Thomas in Coimbatore)
