Doctors' Day: Even the healers need healing

“Burnout happened to me at 29. I was overworking, and obsessing about everything in the hospital, trying to fix all kinds of medical and non-medical problems to help dying patients. I could not understand my limitations as a junior doctor in a broken health care system despite the best efforts of concerned seniors. I socially isolated myself and gave up my hobbies while having irregular, unhealthy meals. I became emotionally flat towards patients and hostile towards my colleagues. There were written complaints about my behaviour. Ideally, I should have been suspended. But my professor was very kind and gave me a break while asking me to see a counsellor. I was told that I had a possible burnout. I researched on burnout extensively and that gave me more insights about the factors causing it, and the poor coping methods I had adopted."

The experience of Dr Murtuza Ghiya, an assistant professor of Emergency medicine, is not singular. While burnout, which WHO recently described as an occupational syndrome, is part of every profession, for medical professionals, the effects are manifold.

“Burnout in IT professionals, artistes and corporates have been talked about for a long time and addressed. We doctors have been addressing work management for others but never gave a thought for ourselves. The fact that doctors are also human beings facing the same challenges has been overlooked," says Dr Nilima Kadambi, chairperson, IMA National Standing Committee for Emotional Well-being of Medical Students and Doctors in India.

Burnout she says is caused by continued ongoing chronic stress and lack of adequate rest and sleep. "Some stress ('Eustress') is good. We perform well with a very sharp focus under short-term stress. But doctors undergo repeated chronic stress on a daily basis as a part of their work. From that intense focus, body and mind need to recover. We are not letting our body and mind recover adequately from that stress,” she says.

Caregiver burnout stems primarily from stressful working conditions. In fact, closer home, there is no dearth of such conditions. The attack on a doctor at a hospital in Kolkata by the relatives of a patient only vouches for it.

“Burnout results from overworking because of doctor-patient ratio, frequent 36-hour-day shifts, inadequate sleep at night, constant exams, financial and safety pressures. Added to it are the lack of healthy coping mechanisms and poor awareness, a broken public healthcare system, flawed health education system and unrealistic expectations and perceptions of doctors. If you have a wet floor due to a leaking tap, how do you fix it? Individual and institutional factors are the wet floor while policies and governmental factors are the leaking taps," explains Dr Murtuza.

Young doctors and nurses, he points out, have the highest risk of burnout.

“Moreover, entrance exams to medical schools are extremely competitive and medical courses are stressful and expensive," he adds.

Why burnout happens

Pointing to work-life imbalance as a primary factor, Dr S Venkatesh, lead interventional cardiologist, Aster RV Hospital, says, “For the large majority of doctors in India, money earned is equal to the number of patients treated. At the beginning of the career, doctors have less practice and therefore have to run around between clinics or hospitals to make ends meet. Once they become experienced, more patients seek them and they are unable to wind down their practice hours. It’s a vicious spiral leaving them no personal time, family time or even time for fitness and hobbies,” he says.

He cites the nature of the job as another factor.

"Dealing with illness, pain, empathising with sick and dying patients and their families takes an emotional toll. The job is uniformly joyless and interaction with colleagues also leads to exchange of descriptions of morbid illnesses and are not pleasurable. In addition, long hours of work, calls on weekends and holidays including festivals when hospitals do not close also lead to burnout,” he says.

Moreover, “today patients are in a hurry, judge doctors for the slightest delay, a misplaced word of frustration or a genuine diagnostic dilemma or error in judgment. While compliance to tests and adherence to the treatment advised is a prerogative of patients, and the latter cannot be confirmed, the patient’s expectations about cure rate are uniformly high.”

“Slightest deviation of behaviour or under-or over-treatment -- both of which are possible due to the unique biology of each patient -- leads to discontent and aggression by patients. Therefore, doctors are on the edge and this constant on-guard behaviour leads to burnouts,” adds Dr Venkatesh

Describing medical education as archaic and has no relevance to clinical practice, he says, "while the undergraduate medical programme teaches doctors about a hundred causes of headache, it doesn’t really give them a route map as to what tests or treatment have to be advised for a patient who walks into the hospital. All of that has to be learnt on the job. This cluelessness leads to frustration, heuristic prejudices and a fear of missing important diagnosis."

Medical education also lacks in the teaching of empathy, appropriate communication skills, knowledge of legalities of the practice of medicine further undermining the confidence. A serious deficiency of our education is not reaching how to deal with death or dying patients."

He details that often, medical students alternate between professional learning and preparation for entrance exams and higher studies.

"In effect, time for socialisation is severely curtailed leading to the production of brilliant doctors with very awkward social skills. These deficiencies in our education throw doctors unprepared into the society and this leads to doctors putting on masks of knowledge, lack of emotions and professionalism. This constant role-play is emotionally draining and contributes to burnout,” points out Dr Venkatesh.

Corporate vs government service

“Higher remunerations in the corporate sector are offset by expectations of impeccable results as well as higher financial productivity. While some corporate groups are hands-off in terms of how doctors treat patients, it is well known that many corporate doctors come under the pressure of financial targets both because of their corporate obligations as well as their personal desire to lead lavish lifestyles,” he says.

Doctors in government service, he says, are cursed with lack of basic treatment facilities, humongous patient loads, fear of transfers, bureaucratic and political pressures and lesser salaries compared to corporate colleagues.

"Gender discrimination, casteism and regionalism are rampant in government service. Professional aspirations in terms of advanced care for patients and quality research are nearly impossible in government service except in select institutions and leads to gross frustration and sense of professional inadequacy in government doctors," he says.

Resident doctors' life

Meanwhile, Dr Nilima highlights the problems of resident doctors. She says that when a person is doing a job as a resident, he/she is studying and working and there is a lot of pressure to perform to unrealistic expectations from society, family and patients.

"During recovery, they need a quiet place to rest, some healthy food options and safe drinking water, a bathroom to take a shower, and a clean toilet. None of this is provided at the hospital casualty and residents' quarters," She adds that when a skilled and hardworking medical student walks away due to burnout or gets into depression and commits suicide, it is a loss to the society and the country.

All this leaves a lot left to be desired and much room for improvement. “In India, we do not have strict guidelines or regulations on how much a doctor should do or not do," says Dr Nilima.

Added to the burgeoning problems is the fact that only 1.5 per cent of GDP is spent on healthcare as Dr Murtuza puts it. He regrets the fact that the healthcare system is broken because of "excessive privatisation of health care 'business' and poor infrastructure in government hospitals."

Coping with burnout

Throwing light on the coping mechanisms, Dr Venkatesh says one should "apportion enough time for family, social and personal times even if it means contentment at lesser earnings, government and employers should provide protection against physical threats and financial insecurities."

"Investing in activities of physical fitness, psychological de-stressing and hobbies. There should be access to better technology to treat patients and material to update oneself periodically about the advances in medicine. Change in the pace of practice with time, acquire communication skills, learn how to deal with distressing clinical scenarios, seek professional help and counselling when the pressure appears to get out of hand,” he adds.