Doctors in distress

How prolonged stress and competition can lead to depression, anxiety, substance abuse, even suicide, among doctors, and why attention to mental health should start before medical college

October 08, 2018 03:46 pm | Updated 04:47 pm IST

Pressure cooker  Not only is the job exhausting, but the threat of being physically assaulted also looms large

Pressure cooker Not only is the job exhausting, but the threat of being physically assaulted also looms large

“I sit in the OPD and tell my patients to eat a healthy diet, go for a walk every day, take breaks, set aside time for vacation, spend time with their family. I never do it myself,” says Prof Sandeep Grover, Department of Psychiatry, PGIMER, Chandigarh. He begins work at 7.30 am and usually has 12-hour days, teaching, mentoring, attending to patients, and doing research work. Dr Grover is not the exception.

Most doctors across our country work these hours, some seeing up to 400 patients a day, in facilities that at times lack basic infrastructure. And while we rile at the quality of care, doctors say they want to do more, but there is a payoff between quantity and quality. “Doctors say that just the guilt of not spending enough time with patients kills them,” says Prof Pratap Sharan, who is in the psychiatric department and heads student welfare in AIIMS, Delhi. He isn’t joking.

Last year, a study by the Indian Medical Association (IMA) in Kerala found that doctors die approximately 10-12 years before the average person in Kerala, and seven years before the average person in India. Earlier this year, six doctors checked into the psychiatric ward at AIIMS at the same time, even as the IMA declared physician suicides “a public health crisis”. How did we go down this road?

It begins in school

Pressure begins to mount from Class IX onwards, when parents may push children into medicine, even though children themselves are unsure of their own interests. “Earlier, the focus was on values; being a good person was important. Today, it’s all about being someone else,” says Dr Harjit Singh Bhatti, the president of the Resident Doctors’ Association at AIIMS, Delhi. “Become Dhoni is not something you should tell a child,” he says. He may swagger around with a bat, but may not have the capability to be a cricketer at all.

Just getting into medical college can be a struggle: In 2018, 13,26,725 candidates registered for NEET (the entrance exam) and only 7,14,562 made it through, as per CBSE data. Which pushes children into hectic coaching classes. “Students today don’t respect teachers, because coaching classes are all about paying money for a service and getting marks,” says Prof Grover. This has a two-way impact: students reduce institutions to a transactional relationship and don’t see the teacher as a part of a support system, while professors feel the stress of lowered respect.

It continues in college

As more and more teens move from villages to bigger towns, cultural challenges play a large part in feeling unsettled. “These do not themselves result in depression and anxiety, but layered with other pressures, they may,” says Dr Sharan. Students often end up living in cramped, windowless, pocket-size spaces. They may have been toppers in school, but may be just scraping through in college. They may have studied through school in a local language and have to now switch to English. Plus, there’s the isolation of technology and its all-pervasive nature, sometimes driving already-lonely teens into isolation.

After a basic MBBS degree, a doctor then begins to explore a specialisation. Again, the number of seats funnels down, and with it the thought of going abroad bringing on additional academic and monetary pressure. The 2017-18 batch had just 35,117, as per a Press Information Bureau release last year.

It is at this level that doctors may work 40 hours at a stretch, working, studying, reading research papers – never mentally switching off. “An engineer may feel settled by about 25; a doctor feels this only at about 35,” says Prof Grover. Burnout, alienation, facing disease and death daily, getting pulled up by senior doctors, demoralisation may push a student into depression and anxiety. “Rates of addiction to alcohol and drug abuse in the medical field remain high, indicating that their coping mechanisms are far from healthy,” says Madhuri Krishna, a psychologist with Sangath.

And into careers

Most doctors in their first few years feel the need to prove themselves. If they’re setting up their own practice, he says there are so many legalities that a doctor cannot handle it himself, forcing him to be more than just a doctor.

Today, with depleted doctor-patient trust, being physically assaulted by patients’ relatives is a reality, says Dr Bhatti. Legally, a senior doctor is responsible for patients. “The quality of doctors is being diluted, with many who have neither the interest in the subject nor the temperament,,” says Prof Grover.

The future

AIIMS has this year instituted a Student Wellness Centre that has a dedicated staff of three psychologists, working with the psychiatry department. In addition, there’s a 24-hour helpline that connects with a psychiatrist. The Students’ Welfare Programme has a mentorship facility for UG students. There is also an initiation programme that helps ease students into college life. It also offers courses in English and Hindi. PGIMER also has a helpline and a mentorship programme. The NIMHANS department of psychiatry has a Student Welfare Team.

However, healthcare pros say that while these are good, there has to be an overhaul of the system. In the UK, for instance, doctors can work a maximum of 72 hours in any seven-day period, reduced from 91. They can do a maximum of eight consecutive shifts, with a 48-hour rest period after.

But it goes beyond that. It really starts with parents letting their children take a call about picking a branch of study that they are inclined to. “Stop thinking of a medical degree as a mark that your child is brilliant or as a mark of success. Encourage the young person to interact with medical students, have brief internships where the young person can shadow others through the drudgery of medical studies and work ( not just the glamorous bits). Help them understand that every doctor does not have to be a cardiologist or a neurosurgeon. That family physicians are most important. That fields like psychiatry, preventive and social medicine , public health, palliative care, are equally valuable,” says Prof Prabha Chandra, Department of Psychiatry, NIHMANS, Bengaluru.

Other measures she says will help are: a focus on communication skills, a discussion on doctor-patient relationships and the values and ethics of being a doctor, the elimination of capitation fee and a one-fee structure for all. Most importantly: to give doctors a space, the facilities, and the encouragement to relax during a work day.

Why docs don’t ask for help

Stigma is the biggest reason. “The pressure to perform can be psychologically debilitating and doctors also fear that they will be seen as less competent than their peers should a mental health issue be disclosed,” says Krishna. Doctors need a dedicated occupational health approach because they may seek help informally from colleagues, or self-medicate, but because they don’t go the formal route, they may not get full treatment unless we reach out to them in myriad ways, says Dr Sharan.

Why they need it more

“The nature of their work requires them to address others’ health concerns and trauma, often ignoring their own. Healthcare professionals who are constantly digging into their well of personal (psychological) resources to attend to their patients can only benefit from seeking help to address their own mental-health concerns and making sure that their self-care strategies are in place,” says Krishna.

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