Why are young doctors feeling burnt out?

He recalls sleeping all night in the hospital ward, waking up at 5am, rushing to the hostel for a quick bath and returning to the ward at 7.30am. This was the routine, three-four times a week, for postgraduate resident doctors on 24-hour on-call duties.

Singh, 29, is now doing super specialization in ‘breast, endocrine and general surgery’ at the same institution. But his routine isn’t any better. Besides assisting in three-four surgeries, he must attend to patients under his care in the ward during breaks. There are no weekly offs and marriage is off the radar, for now.

“Life is not all miserable though," he reassures, saying the department celebrates birthdays and arranges outings. “Things could be easier with more helping hands and less patient load," adds Singh, who is a former president of the Resident Doctors’ Association, AIIMS.

Sadly, that is not the case in India. In 2020, when covid was peaking, the premier medical institute witnessed six suicides in two months—three of them were doctors. The worrying part? It is a problem not limited to AIIMS. Medical colleges across the country are seeing a rising incidence of depression, drug addiction, dropouts and, worse, suicide among students and junior doctors—all of which are a fallout of poor mental health. Overwork, anxiety, lack of sleep and exercise, aggravated often by a hostile work environment, is leading to an early burnout in junior doctors, in the 25-35 age group.

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 Health, found that four in 10 workers suffered from depression and anxiety and three in 10 from sleeping disorders.

And many don’t even seek help due to the fear of stigma attached to mental health. The problem usually takes root during the residency itself and persists even as the young doctors go on to work in hospitals. While the extent of the malaise is largely undocumented, it was serious enough for India’s medical education regulator, the National Medical Commission (NMC) to ask colleges to list out cases of suicide, dropout, overwork, denial of off-days and ragging over the past five years.

‘Burden won’t reduce’

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

“You are kept working and working; there is no off day," says Dr Sagar Mundada, consultant psychiatrist, Healthspring, and former president of the Maharashtra Association of Resident Doctors. “Burnout is common among young doctors, especially in government facilities," he says, adding that students end up with clinical depression and harbouring suicidal thoughts.

But what makes their ordeal worse is the behaviour of their seniors. “Senior doctors often talk humiliatingly to junior residents in the presence of patients. It becomes very embarrassing and traumatic," says Mundada.

The workload is inevitable, says Dr Pratap Sharan, professor of psychiatry and professor-in-charge of Student Welfare Service, AIIMS. “Unless there is a change in the way medical institutes function and their workflow are designed, the burden on residents won’t reduce," he says. Moreover, the doctor-patient ratio in India is not ideal. One allopathic doctor caters to 1,376 people, as per estimates from the World Health Organization (WHO). The body’s prescribed norm is one doctor for 1,000 people. As per the NMC, the ratio is about one doctor per 1,194 people. This figure assumes 80% availability of registered doctors.

The duties of a resident doctor can be quite exhaustive too, from taking photos of the patient, uploading them in the system, dressing wounds, arranging for blood samples, and following up with diagnostic tests, says Dr Singh. This workload can be reduced if they had more paramedical staff helping out.

Stress starts early

The mental stress faced by young doctors, in fact, begins early, from the time they seek admission into a medical college. The competition is fierce. For one seat, there are 19 applicants in India. Coaching for entrance exams starts as early as class 7. In many cases, family expectations weigh over aptitude, says Pooja Priyamvada, grief counsellor and mental health researcher. At a suicide prevention workshop at Delhi’s Jamia Hamdard University, she recalls asking the class how many of them wanted to be doctors as kids. Not even half the class raised their hands.

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

The process of desensitization starts from the first day itself when students are exposed to a cadaver in anatomy dissection halls, says Dr Kamna Kakkar, senior resident, department of anaesthesia and critical care, Safdarjung Hospital, Delhi. She noted that many of her classmates fainted at the sight of dead bodies, but there was no counselling or training to prepare them for it. In the second year itself, students get hospital postings.

“Nobody in the hospital comes with a happy face. When you are surrounded by sad people 24 hours a day, how does one cope? That sorrow, that sadness creeps in you," she says.

In the last year of medical school, when there are more clinical subjects, students are expected to complete internships. This is when the stress and anxiety set in as night duties play havoc with circadian cycles, says Kakkar. Fearing stigma, students refrain from seeking help or sharing their concerns with classmates. “Interns are paid ₹12,000-15,000 a month. So, they can hardly afford private therapy at this point," Kakkar adds.

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 the figures for India are not documented, a 2021 study published in the Indian Journal of Psychiatry recorded 30 physician suicides in the 2016-19 period based on media reports. At least 80% of the deceased were aged under 40, with 22 of them being medical students. In terms of gender, 18 were female and 12, male.

“In America, they lose the equivalent of one medical school batch equivalent of doctors (roughly 300) every year to suicide. 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, Centre for Mental Law and Policy, Pune. As in any suicide case, factors like personality, family, community and work environment play a part, Pathare adds.

Moreover, the risk is higher among doctors due to the access to drugs, financial debt and litigations arising from patient deaths or medical complications. Studies also attribute mental health issues to typical personality traits associated with the medical fraternity—such as higher sense of guilt, perfectionism and workaholism.

Bitter pill to swallow

Among doctors, the fear of being judged for seeking medical help for mental health issues is more pronounced, feels Priyamvada. 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 growth and also the way colleagues perceive them. As a result, many find easy release in the drugs that are within their reach. Substance abuse is seen more among emergency physicians, psychiatrists and anaesthesiologists.

“There are many anaesthetists I know who are either consuming illicit drugs or are alcoholics. Recently, two anaesthetists known to me died from drug overdose," says Kakkar. These specialists handle the most critical cases where prognosis is already poor. They are tasked with reviving the patient and face ugly situations when they fail. “There is poor recognition for the work they do," says Kakkar.

Doctors dealing with critical or terminally ill patients face similar challenges. “These doctors have to witness death on a daily basis. Many are unable to take it well," says Mundada, whose clientele includes many doctors.

This was evident during the pandemic. Priyamvada, who worked with mental health helpline Co-Hope, says they received many calls from healthcare workers. “They were dealing with logistical issues like oxygen shortage. There was nothing they could do about it but it was affecting their mental well being," she says.

“I still remember the stench while entering a room full of bodies wrapped in white sheets. I still remember the faces of patients gasping for air even after being administered oxygen in ICU," shudders Kakkar.

Fear of patients’ ire

If the academic and work pressure isn’t bad enough, there is always the threat of violence from the kin of patients. “There are instances when a patient has died and relatives attack the doctors, not understanding that the patient was already critical," says Dr Rupal Parekh, consultant obstetrician and gynaecologist who did her postgraduate training in KEM Hospital, Mumbai. Local goons with political connections also exploit the situation.

An ongoing study 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 situation became ugly during the pandemic, when patients faced shortage of beds, oxygen and burial grounds, the IMA said.

Big reforms needed

Often, in suicide cases involving doctors, the focus is always on the individual and his/her ability to deal with stress. The system is never questioned but real change can happen only if institutional reforms take place, feel experts.

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

Considering the vulnerability of the profession, other countries have an annual assessment test for medical trainees and trainers on many issues, including mental health. This doesn’t exist in India. There needs to be counselling twice a year for all resident doctors, irrespective of whether they have mental health problems or not, says Mundada. Similarly, doctors should have easy access to mental health support. The American Medical Association, for instance, has taken the initiative to address personal and occupational 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-labs (a WhatsApp group run by students), made available psychologists for counselling and psychiatrists for those who need medical intervention. The uptake of counselling services increased from 2% to 10% between 2018-2021 due to efforts to destigmatize mental health, says Dr Sharan of AIIMS.

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