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Do doctors die young, and why?

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Some questions set off by the conclusions of a study among doctors in Kerala

Last month, a national daily published the results of a study conducted by the research cell of the Indian Medical Association (IMA) in Kerala, which seemed to suggest that doctors, who are supposed to be professionals helping people live longer, die young compared to members of the general public in Kerala.

While the life expectancy of an Indian is 67.9 years, that of a Malayali (as a native of Kerala is called) is 74.9 years. According to the IMA study, the mean ‘age of death’ of a Malayali doctor is 61.75 years. Dr. Vinayan K.P., convener of the IMA’s research cell, says: “We were surprised by the figures as we expected doctors to live longer, as they know what is good for them”.

The mortality pattern among doctors enrolled for the State IMA’s Social Security Scheme was analysed in this 10-year study titled ‘Physicians’ Mortality Data from 2007-2017’. Of the 10,000 doctors who were part of the contributory supportive scheme that provides a fixed amount to a deceased doctor’s family, 282 died during the study period. Of this, 87% were men and 13% women. Almost 27% died of heart disease and 25% of cancer. Some 2% died due to infection and 1% committed suicide.

The study went viral in the social media, especially among doctors’ groups.

As might be expected, doctors are supposed to lead healthier lifestyles, and could therefore be assumed to have lower mortality rates than the general population as a result of their ‘medical knowledge’. However, in some studies the actual mortality rate among doctors differed according to specialties, while other studies did not validate this observation.

But there are several studies supporting the fact that doctors do not take care of their own health any better than is to be expected. Some studies report that doctors actually take fewer vaccinations, are careless about controlling their cardiovascular risk factors and receive fewer screening tests for cancer than the general population. An interesting case report about an Australian physician describes how he determined his symptoms on his own and how he was later diagnosed with lymphoma, a type of cancer.

Unexpected turn

I am a doctor who was working in Kerala as a surgeon for 21 years in a unit specialising in surgical gastroenterology that deals with surgical management of diseases within the abdomen. I suffered a stroke at the age of 39. It considerably weakened my left side, and wreaked havoc with my career as a surgeon. I was a ‘not-so-bad’ surgeon working in a ‘high-strung’ specialty when it happened, in the afternoon of January 14, 2005.

My life turned topsy-turvy in more respects than just professional. I had just completed an operation. Then at lunch I thought I had facial palsy (in which a corner of the mouth deviates to one side), a common occurrence in stroke, which was confirmed by a colleague of mine who was eating with me.

After lunch I walked up to the Surgical ICU to see the patient I had just operated. There I fell with a thud near the nursing station. The surgeon’s scalpel slipped out of my considerably weakened left hand.

Soon, a team of doctors led by my boss were attending to me. They diagnosed that I had suffered a major stroke caused by a thrombus (blood clot) that stuck to and clogged a major artery supplying a considerable area of the right half of my brain, resulting in paralysis of my left side. Soon the pressure inside my skull began to increase rapidly and I lost consciousness.

I was on the operating table soon and a neurosurgeon opened my skull in a jiffy to release the pressure building within that closed, unyielding globe of a bone that housed my brain. Surgery was followed by four days on the ventilator. Thanks to a dedicated team of doctors, I live to tell my tale.

Off the ventilator, I went through rigorous physiotherapy and a round of Ayurveda, as part of efforts to restore what I had lost in a matter of seconds. My surgical career having become history quite prematurely, the hospital was magnanimous enough to rehabilitate me by employing me to look after patients in the post-operative Surgical ICU. I have been working here since then.

I mentioned in detail the ordeal that a 39-year old surgeon had to go through in the morning of his surgical career, in the context of the research study findings mentioned earlier.

Of course, the stroke did not kill me. It could have, but for the prompt medical attention I received. But it certainly left me considerably disabled, and snatched the scalpel from my hand. What had looked like a promising surgical career lay in tatters. But for the magnanimity of the management of the hospital I worked in, I would have lost my job, denying me means to make ends meet.

What is unique in my case? I had no risk factors to account for a stroke. I was not hypertensive or a diabetic. My cholesterol levels were normal. I never smoked.

Relating better

But now, after much water has flowed under the bridge, I can vouch for the fact that though my disease dealt a cruel blow to my life, it succeeded in making a better doctor out of me. I am now able to relate better with patients I come across in the ICU, as I have been on that bed. Quite sick, missing death by a whisker. That thought of course may be part of a mechanism in me to count the silver lining!

So then, what caused my stroke? Frankly, I don’t know. One might call it fate, ill-luck, god’s will, and so on.

As mentioned in the study, and as seen in my own experience, why are young doctors falling prey to major diseases without any warning?

There are numerous causes.

Stress: This, without a doubt, is the prime culprit. Doctors are put through a lot of stress as a part of ‘treating the sick’. The factor of stress probably varies with specialties. Surgeons are known to be under a lot of stress as their work is result-oriented. Any surgical procedure ranging from a simple drainage of an abscess to coronary artery bypass or organ transplant is fraught with complications, unexpected and otherwise. For that matter, no procedure is without ‘risk’, and therefore there is no ‘guarantee’ — that commodity many patients and their families seek from the doctor. What is being dealt with is an ailing human body, and it need not respond to treatment along predictable lines as an automobile might in the hands of a mechanic.

Doctors, especially surgeons, are always result-oriented and are under tremendous pressure to ‘get better than that doctor in the other hospital’. They are caught up in cut-throat competition brought about by the mushrooming of hospitals offering quality care, especially in the corporate sector. Hospitals, especially those in the corporate sector that are run as modern ‘five-star hospitals’, advertise and shout from the rooftops of high-end services being offered. This places doctors, who actually are responsible of delivering those services, under tremendous pressure. This results in a lot of stress on the caregivers that doctors are.

‘Healthcare’ is no more a purely noble undertaking. The involvement of avaricious private hospitals and the over-corporatisation of healthcare have reduced the art of healing that medicine is supposed to be into a pure business undertaking. Gain by hook or by crook has come to be the bane of healthcare as it exists in India today.

Private hospitals in the corporate sector are the villains. They have ‘targets’ to meet. Targets in terms of number of patients seen as outpatients, number of in-patients, number of surgical and other cost-heavy procedures undertaken, and income generated from in-house laboratories and pharmacies. The hapless doctor, already under considerable pressure and stress to restore health to the ailing under his/her care, is often pulled up by the managements of these behemoths in the over-corporatised sector to meet targets, most of them financial. Plainly speaking, it is all about profit!

Doctors are also under stress to keep themselves updated and well-informed of the rapid changes sweeping across the world of medicine. They are required to attend conferences, keeping them away from families and sick patients who are under their care. The financial strain on them to subscribe to prohibitively expensive medical journals is not insignificant either. Patients and their families, before consulting the doctor, are well-informed of the disease in question and the treatment options, thanks to a wealth of information available on the Internet. This is particularly true in a State such as Kerala that boasts of total literacy. This requires the doctor to be well-informed and updated, and smart on the feet.

In healthcare, cure or failure to cure do not follow a predictable course. Doctors these days have the responsibility to brief the families of patients under their care. It is the right of those spending for the medical care to be informed of the treatment being instituted and its results on the patient. This process of briefing families is akin to the oral examinations doctors have had to go through as medical students.

The many questions

Doctors can be asked anything by the attendants of patients. They need to be smart on their feet, but at the same time honest and down-to-earth, patient and extremely understanding and empathetic. There is no place for frayed tempers or raised voices in this communication. There is no place for beating around the bush or dilly-dallying. After all, proper communication between the doctor and the patients’ families, based on honesty, openness and plain truth, is the bedrock on which the treatment of patients rests. Nobody is appreciated more than an honest doctor. From the high-end, prohibitively expensive treatment being undertaken in private hospitals in the corporate sector, the pendulum of healthcare dispensation swings to hospitals in the public sector. Here, the refrain is: ‘we have no facility to treat this patient’. It is a fact.

Cash-strapped government hospitals have no facility sometimes to treat even common ailments. Other factors that make patients reluctant to approach government hospitals, apart from ‘lack of facilities’, are gross shortage of staff in crucial areas like laboratories and other investigative facilities like radiology, a far inferior work culture that functions purely on ‘work to rule’ basis, and extreme reluctance on the part of the staff to walk that extra mile, which private hospitals are indeed blessed with.

Doctors working in such an environment function under extreme stress. Even though doctors function in a far inferior work environment caused by poor facilities, expectations of the sick and their attendants remain sky-high. Nothing but a positive result to treatment is expected out of them. Failure to meet this expectation has often resulted in unsavory skirmishes, physical as well as verbal, involving doctors, other staff and the patients’ attendants. This has showed healthcare and its dispensers in extremely poor light.

Doctors are asked to work for long hours, often without adequate rest, sleep or relaxation, adding to the stress, burnout and sleep deprivation, with their attendant ill-effects. Shortage of staff is sought to be made up by ‘squeezing’ extra work and man-hours out of those available, adding to their fatigue and burnout. Doctors, after busy night shifts, are more often than not required to continue into the next day’s schedule without a break, placing them under extreme stress. This is rampant in the private sector unlike in the public sector, where doctors enjoy adequate days off from work, to unwind and to restore their bearings.

Genetic factors

Yet another important factor that plays a part in the diseases affecting doctors like any other group of people is genetics. People born into families in which premature death has resulted from vascular diseases have a high chance of falling to heart attacks and stroke. Even cancers such as those of the large bowel and breast, run in families. The ‘Cancer Family Syndrome’ is a condition in which cancers run in families.

Like genetics, racial factors too play a role in the development of certain diseases. People from Kerala are known to have higher incidence of heart attacks. This is also true among Malayalis who have migrated to other countries. Race and genetics therefore constitute two non-modifiable risk factors for the development of vascular diseases and certain types of cancers.

Last but not the least, is the self-inflicted tendency among doctors to lead a flashy lifestyle, rife with swanky cars, palatial homes, undertaking expensive holidays, putting their children in expensive educational institutions, especially professional ones. All of these add to their stress. Stress definitely knocks on the doors of those who strive to live beyond their means, or to get better than a so-called ‘rich’ and upbeat neighbouring colleague, who leads a life that looks straight out of a Bollywood mega blockbuster.

Stress adds up and leads to diseases, especially cardiovascular, like myocardial infarction (heart attack) and stroke.

Cancer has figured prominently in the IMA study as a causative agent for premature death among doctors. However, a direct relationship between doctors’ premature death and cancer need to be examined more precisely through well-conducted studies. Theoretically, doctors are exposed to various occupational and environmental factors that may increase cancer risk. Doctors are a unique group of individuals who are routinely exposed to multiple carcinogens, such as ionizing radiation and various chemicals. Exposure to high doses of diagnostic and therapeutic ionizing radiation is known to increase the incidence of various cancers, like those of the thyroid and the ovary. High Incidence of differentiated thyroid cancers among doctors specialised in various disciplines of radiology is testimony to this. Even young postgraduate students in the specialty are reported to be associated with higher incidence of cancers. Besides radiation and chemicals, the other factor known to cause cancer among doctors is stress itself. Stress caused by a heavy workload, burnout syndrome, compassion fatigue and short sleep can cause cancer. Studies have shown that surgeons (82.5%) did not recommend that their children follow their professional footsteps!

Suicide has figured among causes leading to the premature death of doctors, though not to the extent posed by stress and cancer. Doctors are prone to suicide owing to stress, high incidence of depression, and concomitant substance abuse. Doctors are one group of professionals who have easy access to addictive and habit-inducing drugs.

Having come this far, this peculiar phenomenon of Malayali doctors meeting with premature death calls for a proper, well-conducted prospective study to examine and dissect the validity of the observations made in the study by the IMA, before any conclusions are drawn from it.

Handle with care

If the study is indeed validated, doctors deserve to be ‘handled with care’. They also need to ‘handle themselves with care’. Here is a possible check-list.

Hospital managements, especially those in the corporate sector, must do away with their tendency to arm-twist doctors and squeeze performance out of them to meet inflated and often unreasonable targets. Doctors must not be seen as geese that lay golden eggs.

The government must see to it that facilities in public hospitals are upgraded to meet patients’ expectations, and provide doctors with state-of-the-art facilities and equipment required to treat complex diseases at affordable costs.

Doctors must be provided with personal security and an atmosphere of security, shielded from marauding members of the public who often do not hesitate to physically and verbally assault treating personnel in the event of an untoward incident such as the death of the patient during treatment or an unexpected clinical worsening of the patient’s condition, especially after a large amount of money has been spent on treatment.

The government must consider putting in place a comprehensive health insurance scheme for its citizens, so that a great deal of financial stress on the public while seeking the services of doctors and hospitals for their health needs, especially in emergencies, is cushioned.

The onus is on doctors to take responsibility for their own health. They must not be reluctant to seek advice from specialists among their colleagues, and not attempt to treat themselves. Those known to be genetically prone to vascular disease must pay attention to addressing modifiable risk factors and effect lifestyle changes that could contribute to a catastrophe. Those known to have cancers running in families must subject themselves to stringent cancer- screening programmes.

Doctors must function humanely, doing justice to the nobility of their profession, not sidestepping their responsibilities and accountability towards patients. They must keep open the channel of unconditional communication founded on honesty, truth and readiness to accept responsibility, with patients and their families.

earaly@hotmail.com

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Printable version | Jan 23, 2020 11:30:30 AM | https://www.thehindu.com/opinion/open-page/do-doctors-die-young-and-why/article21381601.ece

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