Journal of Medical Sciences and Health

Abstract

The 1st day of the month of July is observed as Doctor’s day in India. It is to honor the legendary physician Dr. Bidhan Chandra Roy (Dr. B C Roy) who was born on July 1st and passed away too on this date. After completing his initial medical graduation from Calcutta, he went on to obtain the MRCP and FRCS degrees in London before returning to India in 1911. He was a skilled doctor, a renowned educationist as well as a freedom fighter who joined Mahatma Gandhi during the Civil Disobedience Movement. He subsequentlywentontobecomethe2nd ChiefMinister of West Bengal and was awarded the Bharat Ratna in 1961 as recognition of his all-around contributions. The Government of India declared July 1 as the Doctor’s day in 1991 as a mark of respect to Dr. Roy.

India has shown remarkable improvements in the medical field over the years, and July 1 pays a perfect tribute to all the doctors who have made relentless efforts toward achieving this goal irrespective of the tremendous odds. These are individuals, who strive to cure illness, extend life, to alleviate pain and suffering and they need to be acknowledged for their commitment and dedication to the health of our community. However, what about the doctor’s health? What happens when they develop a disease and what if the illness is a common yet debilitating mental disorder like depression? A condition that one in every 20 Indians is said to be suffering from,[1] what if the treating doctor is one of them? Let’s take a moment to remember that while doctors provide immense service to society, they’re not invincible. Like popular belief “The doctor might not be a patient like the rest” but what is similar is the illness, and the illness does not differentiate.

Although the rates of depression among doctors are clearly high and the rates of suicide might be the highest in our profession like many people postulate, what makes this issue pertinent is not just its prevalence. The critical issue here is that too many doctors suffer in silence; afraid to seek help because of the fear that they will be penalized professionally, and probably, judged personally as well. Medical education is a privilege, and Doctor’s day could be an occasion for us to reflect on our own health and what we could be doing more for each other. Untreated depression is a significant risk factor for suicide. Current and reliable data on physician suicide are not readily available. A review of 14 studies found that the relative risk of suicide in physicians compared with the general population is between 1.1 and 3.4 for men.[2] Another study found that the rate of suicide is especially raised among female doctors, who are 21⁄2 times more likely than other women to kill themselves.[3] Suicide among medical students and doctors has been a largely unacknowledged phenomenon for several decades, a “skeleton in the cupboard” under the cover of stigma and contempt. Now it’s beginning to emerge from the obscurity, but yet the question remains - why do so many people who want to help others, kill themselves. It’s the ultimate oxymoron. Suicide in anyone is always a tragedy but doctors committing suicide that is a lamentable paradox. Why the reluctance to seek help from one another. Why is it taboo to talk about your mental health? Sometimes doctors themselves do not seek the very treatment options they recommend to their patients with depression. Despite being one of the most informed populations regarding mental health issues, they are also among the least likely to seek appropriate and timely help. The reasons for this are multifactorial. They are partly a consequence of structural barriers, such as being unable to seek help during the long working hours, frequent shift changes at work, and because of frequent migration that makes it difficult to continue care with the same mental health team. One of the other major hurdles to help seeking is the deep prejudice toward mental illness that still exists within the medical community. Physicians might be concerned about confidentiality, the fear of being judged by colleagues, the administration where they work and the fear of being condemned as “weak” on the basis of a mental illness. Some might even be afraid that speaking up might result in illness being documented on their record somehow, be it even through the word of mouth and it will remain a black mark whether it’s with their license or with their hospital or another affiliation with an organization they have. It is important to them that their anonymity is safeguarded, that they remain under the radar and not stand out. To abolish doubts if any privacy and confidentiality are the absolute privileges maintained by psychiatric services. Such confidentiality will always be protected and shall not be broken unless there is potential harm to the doctor or others.

The possible risk factors for mental illness in the medical profession include a heavy workload, sleep deprivation, difficult patients, patient’s nonresponsive to treatment, treatment failures, lack of autonomy in the workplace, financial concerns, and constant enigma regarding higher studies. Doctors work with a human tragedy like death and loss on a daily basis and invariably don’t take time off or debrief after such negative events. Instead, they almost immediately move on to the next patient. It is not uncommon to feel rushed; like there is much to do and not enough time to do it and so it becomes almost routine to put in an extra 2 or 3 h after a 12-h shift because it was just too busy to leave. There is a very thin line between where healthy stress ends and overload begins. The problem, however, has its roots much earlier than this. Even before entering medical school aspiring doctors have a germinal sense of their medical self. They have pledged themselves to a medical career at a much earlier stage and go to tremendous lengths to answer this vocational calling with rigorous and stressful pre- medical coaching. There is tremendous pressure on these students writing these competitive entrance exams. They often experience sleep problems, high anxiety levels, have weight issues stemming from a change in appetite and hardly find time to interact with friends and family. All of which can in itself predispose them to mental health problems later in life.

Studies have documented high levels of stress in medical schools.[4,5] Research suggests that hostile environment of requirements in medical colleges can ultimately have a negative impact on the student’s academic performance, physical health and psychosocial well-being.[6,7] Medical training teaches us to “endure it all,” so help-seeking is not a conventional skill among doctors. Because the majority of doctors are overworked, fatigued and discontent, they don’t usually consider themselves as outliers. They are habituated to these stress levels and inevitably underplay the misery. Many lack the awareness that they are suffering from depression and are oblivious to the symptoms. During the process of passing through medical school; graduates drift into a profession that essentially sees itself as special and often a cut above. This is reinforced by society’s view of doctors, and the classic paradigm of the supreme healer. There is also a romanticization of the profession through TV shows and movies. This is also consolidated every day at work, in communication with peers and with patients, even through a simple act of introducing oneself as a “doctor.” This elevated sense of self could cloud their objectivity in the need to approach psychiatric services. There are certain thought processes and personality features commonly seen in doctors that might be a double-edged sword. They tend to be very perfectionistic in their attitude toward work, employ a sense of compulsiveness of not giving up on a task till they have finished it. Common diathesis of thinking includes “I care for my patients more than myself, and my needs are trivial compared to theirs” and “people who need help are failures. If I seek or accept help, I am a failure.” These beliefs further encapsulate their reluctance to validate their own mental health issues.

A depressed physician might enter a downward spiral. They are more likely to resort to unhealthy coping mechanisms like excessive alcohol consumption and abuse of other drugs. A problem further compounded by the professional’s easy access to drugs. Spouses can feel overwhelmed and bewildered by changes in the depressed person’s behavior, which may lead to separation or divorce. The symptoms might also alienate their children especially if they are really young. Professional consequences include academic performance decay, decline in empathy and ethics, academic dishonesty, negative influence on their choice of specialty and high incidence of medical errors.[8]

A three-fold approach can be employed to help physicians cope with depression and other similar mental illnesses. First, it is important, we destigmatize seeking help. We must make it easier for these individuals to ask for help and that can be done through investing in strategies aimed at changing the culture of medicine specifically agendas targeting education. Educating the entire medical fraternity about how to recognize the warning signs of depression and how to refer colleagues who might need help is of prime importance. Periodic training sessions and workshops can be conducted for this purpose for both students and staff. Every health professional can be a gatekeeper for mental illness, and we must acknowledge that the mental health team of the country comprises not just of psychiatrists or psychologists but also of every single doctor irrespective of their specializations. Second, we must provide doctors diagnosed with depression prompt and targeted mental health assessments, adequate psychoeducation regarding the nature of the illness, potentiate their social support system including peer support and use pharmacological and psychological treatment if required. It would also be worthwhile to have in-house counseling services and mentorship program at medical colleges for early detection and treatment of mental health related issues in student’s and postgraduate residents. Third, prevention is always the best form of intervention, and we must work toward reforming intensely busy work schedules by restricting work hours, the cost of mental health treatment, and the difficulty of finding resources during non-work hours, which by itself is much curtailed.

We must remember that if we are experiencing the symptoms of depression, we owe it to ourselves, our families and our patients to get professional help. It is imperative to understand that it is difficult to look after others if we can’t look after ourselves first. This is a condition that can have detrimental consequences not only on your medical career but also your personal life. Though there might be several barriers in coming forward, an unwillingness to seek help should not culminate in adverse outcomes such as self harm and suicide. Irrespective of the consequences of disclosure of illness, they are far better repercussions than those of untreated depression. It is estimated that about 400 physicians commit suicide every year in the United States.[9] This is almost 3 times the strength of our average MBBS class. Although similar studies are not available from India, the rates could definitely be high. According to the WHO globally, more than 300 million people of all ages suffer from depression and the organization projects that by 2030 it will be the leading cause of the global burden of disease such that the amount of disability and life lost as a result of depression will be greater than that resulting from any other condition, including accidents, war, suicide, cancer, and stroke.[10] The reality is that it will affect each of us directly or indirectly. The best-case scenario is that we won’t personally be affected but we will see this in our colleagues or residents, and we will be in a situation to recognize and intervene. We will be in a position to make a difference, which for most of us was the driving force behind choosing the medical career in the first place.
It’s high time for the medical fraternity to recognize that mental health is our collective responsibility and doctors who spend so much of their lives caring for patients are often suffering in silence. They are not immune and effective interventions for improving care for them will better the medical system as a whole and would serve as a quintessential avenue for improved patient care.