Posted By
IMAlive, Posted on August 29th, 2019
Author: Dr Priya Radhakrishnan, MD, FACP,Chief Medical Officer at HonorHealth, Arizona, US
As we celebrate Doctor’s Day in India, we have to take a hard look at our profession, our practice and the systems of care around the delivery of our health and ask ourselves whether we are truly committed to health and wellbeing. Or do we have a commitment to disease? Our practice of medicine has come to a crossroads with violence against physicians, increasing concerns about the well-being of our physician community and ultimately a disconnect between what we as physicians set out to do and what we are doing.
The World Health Organization defines "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." It goes on to define “Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.
Our goal for health has not extended to the healthcare team. As we look at the newspapers across the world, the workplace has significantly changed. Once revered and placed on a pedestal, today’s physicians are increasing practicing in environments that are tumultuous, fast-paced and far removed from the idealist world that many of us had dreamt about practicing in. Perhaps the biggest leveler has been the easy availability of information due to the internet. Increasing financial pressures- both from health systems, as well as personal pressures due to lifestyle aspirations have changed the practice landscape over the last few decades. Within many countries, there are increasing reports of violence against physicians: in India with violent mobs and angry relatives, in the US due to the opioid epidemic and in Africa- with attacks on relief workers. Governments have contributed to the epidemic of burnout experienced by physicians across the world- from an increase in the numbers of laws mandating and regulating the profession and encouraging the expansion in the scope of practice by allied health; to apathy in supporting medical practice.
Medical Schools and postgraduate training programs in India have largely turned a blind eye to the wellbeing of physicians. Early in medical school, exposure to ‘ragging’ or hazing sets the expectation for the fresh-eyed youth to harden and withstand the onslaught from seniors- who feel justified in sharing the pain, despite the activities being illegal. As the medical students enter the clinics, seasoned professors and faculty grill the students and residents on medical knowledge, setting a “game of thrones” scenario where only the ‘best’ survive and the weak are sidelined. The examinations and viva voce are similarly structured. The end result is a training system that focusses on the disease rather than the patient and on the system rather than the individual physician. The final end product is a physician who has learned the hard way to succeed: the ultimate type A personality. In 1938, Dr Irving Bell wrote “The doctor has long been considered an individualist; in some quarters he is still so regarded”. 81 years later- this is still true.
During the process of education and practice, physicians often lose the empathy, compassion, their listening skills and often, the instinct to heal. As young physicians graduate and enter the workforce the very aim of the practice of medicine seems to be far from the profession of healing. This spills to personal lives and the pursuit of the career becomes all-encompassing. The end result for some is depersonalization and burnout and sometimes, the ultimate: physician suicide.
The purpose of this essay is not to highlight the dark aspects of the practice of medicine but to showcase the need for change from within and demand the change from the systems that we work in. Across the world, especially in India, doctors are still highly respected and trusted. It is estimated that about two-thirds of physicians are largely satisfied with their jobs. The question for my colleagues is whether two-thirds is good enough? An estimated 12% of males and 19.5% of females in the medical profession suffer from depression, and it is even more common among medical students. About 15-30% of students and residents screen positive for depression. Studies also show that 1 in 16 trainees report suicidal ideation. My own medical school class has lost several classmates to suicide.
The research into wellbeing and burnout is new. Until recently there was low to medium quality of evidence in the current literature. Given the magnitude of this problem, there have been an increasing number of studies that are examining the problem. There have been two approaches to this study- from resilience and wellbeing to a burnout and prevention perspective. Health systems, physician organizations such as American College of Physicians, American Medical Association, Accreditation Council of Graduate Medical Education, to name a few in the US and many other countries are examining this problem. Early initiatives include measurement of the problem, and developing educational programs focusing on the joy of medicine. Measurement of resilience or burnout, can be performed using scales. It is important to note that many of these scales have not been validated in the Indian population.
Health systems and professional organizations like the IMA and MCI and medical schools and PG training programs must assign resources to examine this problem both nationally as well as locally. Once the measurement has been performed, the next step is to design programs that address the problem. For most but specially, junior doctors and trainees, there must a focus on the working conditions. Following Maslow's hierarchy of needs basic requirements during shifts- food, water, bathroom facilities, call rooms, attention to number of hours and time off must be addressed first followed by self-actualization and goal-directed programs.
Fig 1 – Maslow’s Hierarchy of needs represented as a pyramid with the more basic needs at the bottom. The most important aspect and the hardest to change is the Culture of Medicine. In this area each of us has a role to play in this crisis. Our medical education programs: medical colleges and PG training programs need to develop structured faculty development and clear expectations for professionalism. The era of throwing scalpels in OTs and shaming students have been clearly shown to be detrimental to patient care as well as learning. We need to ensure that our students have a safe training environment and access to mental health services. This is particularly true for female and minority students who are faced with specific harassment. There is good evidence that faculty development is key to effective medical education. Faculty are often burnout and require specific assessment and interventions for their wellbeing. Access to mental health counseling must be offered and normalized rather than stigmatized.
And lastly, but most importantly, the narrative of medicine has to change to be patient-centered. It is when we show empathy and compassion, that our expertise is revered. In Osler’s words, “the good physician treats the disease; the great physician treats the patient who has the disease”.
An estimated 12% of males and 19.5% of females in the medical profession suffer from depression
