LegalMD Newsletter - May 2018

19 May, 2018

Medico-Legal Newsletter
        May 2018, New Delhi




Along with money, health and relationships, job strain is one of the most common causes of stress, which can occur in any work place. However, this risk is high in the medical profession due to the nature of work, patient load and expectations, the current healthcare system, and the strains right from the early days of medical training. The process of becoming a doctor and practising, in its entirety is stressful.
Indian doctors are among the most stressed in the world.  
According to a recent survey by IMA reports:

  • 82.7 % of doctors in India feel stressed out in their profession
  • 56% of doctors do not get a comfortable 7 hour sleep most days of the week
  • 46.3 % fear violence is the main cause of stress in many doctors
  • 24.2% doctors fear being sued
  • 13.7% fear criminal prosecution most days of the week
A study published the results in the Indian Journal of Critical Care Medicine:
  • 21% of all doctors consume alcohol in copious quantities
  • 18% are on antidepressants
  • 14% smoke heavily
  • doctors as well as nurses who work in the ICU routinely report auditory hallucinations
Some experts call the burn out “inevitable,” given the high-pressure environment in which they must make potentially life-saving, and almost always life-altering, choices on a constant basis. 
Research shows that doctors experience emotional, physical, and psychological burnout from their jobs, and the consequences are no different for them than they are for people in other occupations.
  • 90% PGI doctors stressed, most of them don’t ask for help
  • Just 60 doctors (13%) have sought psychiatric help with nearly 86% replying in the negative when asked if they have been counselled. The reason, 57% feel, is the stigma attached in asking for help and 61% say they fear being labelled as weak
  • 45% of Indian physicians show at least one symptom of burnout such as a downward spiral of physical, emotional and spiritual energy
  • burnout was worse among female and senior doctors which is the result of exhaustion, disengagement in the form of cynicism and self — doubt and loss of expectations or reduced sense of personal accomplishment and acknowledgement
  • The most common mental illnesses among doctors happen to be affective disorders like depression and bipolar disorder, alcoholism and substance abuse and the most common method of suicide is the use of firearm or lethal medication overdose
  • 67% affected by long working hours, 53% (each) by lack of recognition at work and no leave. About 48% were stressed because of their inability to avail leaves and being blamed for mistakes they had not made or for minor mistakes
The result of a cross sectional survey that appeared in the Indian Journal of Critical Care Medicine shows the scenario among doctors who work in critical care units of India:

1. Between two fifths and three fifths of the doctors are moderately to severely stressed

2. 242 respondents participated in the survey out of which 85% of them were male. They were either intensivists for full time or specialists who would spent at least half of their day in critical care units

3. The study reveals the percentage of doctors under high stress levels in different specialties:
  • Padiatricians-57%
  • Anaesthetists-44%
  • Pulmonologists-39%
  • Intensivists- 38%
  • Practitioners of internal medicine- 37%
4. The study also notes that the highest levels of stress were found in-surprisingly or not
  • the heads of departments- 50%
  • directors- 45%
  • consultants- 41%


  • Poor doctor-patient ratio
  • Long working hours
  • Quantum of work
  • The enormous pressures
  • Corporatization of hospitals
  • Pressure on the heads of various departments to deliver profits 
  • In case of difficult patients who refuses to trust the doctor, explaining procedures and recommending treatments can be nearly impossible
  • Fear of attacks and criminal prosecution
  • Lack of sleep
  • Time management is one area where a lot of doctors suffer. It can be self-imposed or through the institution due to staff shortage
  • Psychological pressure from families and loves ones of the patient
  • Seeing so many sick and hurting patients can be hard, both mentally and emotionally. Keeping a sense of perspective and stay positive can be extremely difficult at times
  • Doctors tend to forget to take care of themselves between patient calls and documentation, taking time out for exercise or even to listen to music does not come naturally for them which adds to the stress levels




1. Among students, the reasons for suicide may be:
  • lack of competence, frustration and depression because of poor performance and repeated failure in the examinations
  • problems with English language — the study medium
  • inability to cope with work related stress
  • use of drugs/alcohol

2. Among residents:
  • stress and strain of long working hours during residency
  • harassment by seniors
  • failure to get speciality of choice
  • use of drugs/painkillers/alcohol
  • early burnout
  • knowledge about and easy access to lethal drugs

3. Among senior doctors:
  • continuous long exposure to professional stress and strain
  • loss of professional reputation
  • failure to recognise depression and resorting to self-medication
  • overindulgence with drugs/alcohol


What is needed is a comprehensive programme addressing all the important factors and laying adequate emphasis on preventive as well as curative aspects, on the following lines:

1. Assessment of students:
To prevent a mismatch between the student’s competence and the requisite competence, there should be a system of assessing the academic as well as psychological suitability of the student at the time of admission. A low calibre or emotionally fragile student, in any case would be no good for the patients, even if he does become a doctor.

2. Cap the amount of work you take on voluntarily

3. Activities:
Recreational activities can be organised to deal with stress effectively. Doctors should also be encouraged to practice yoga, meditation and other relaxation techniques as well as physical exercises to maintain a healthy, stress-free lifestyle.

4. Breaks:
Hospital authorities must ensure that doctors are provided with the appropriate amount of physical and mental breaks from work. Overworked doctors sometimes have to work 24 to 32-hour shifts without breaks which ultimately leads to burnout.

5. Access to drugs:
Easy access to lethal drugs is a major cause of suicide among doctors, students and residents. There should be a strict system that monitors usage of these drugs to prevent their misuse.

6. Do not compromise on seven to eight hours of sleep

7. Make use of technology for proper data management

8. Educating doctors in order to arm them with stronger social and leadership skills, as well as some untraditional strategies, including teaching mindfulness

9. Improving the doctor-patient relationship may also help. In other words, making health care more satisfying for physicians and patients may be a group effort, and that’s something that doctors aren’t quite used to yet

10. Recruitment:
Lack of manpower leads to the few available doctors having to work for long hours and do jobs that are not their responsibility – which leads to frustration. There should be an adequate number of interns and doctors to ensure that work is divided equally and the staff is not overworked.

11. A physician can avoid burnout if they are aware of the stress when it arises. There are some proven methods which if followed effectively could protect against burnout.
  • Physical exercises/sports (often neglected) can be very effective in improving mood
  • Organised recreational activities to break the monotony
  • Stress-busting measures such as meditation, yoga, relaxation techniques, and hobbies
  • Social support from peers, friends and family is crucial to maintaining good mental health
  • In case of serious depression, especially with past history / family history of depression, one must seek professional treatment

12. Counselling Services:
Availability of timely help/counselling from agencies such as Support Centres, Suicide Prevention hotline can prevent many suicides.

13.Programme of Prevention of Depression and Suicide among medical professionals may be organised in every medical college / medium/large sized hospital.
  • The programme must include deliberate efforts to educate the students and residents about the problem of burnout and depression and the ways and means of preventing/coping with it in a healthy manner
  • It should aim at removing the stigma and other barriers to reporting and treating depression and encourage the students to come forward and seek timely counselling and help
  • It may include a programme of discrete monitoring of behaviour of students and residents by the faculty as well as peers, so as to detect and render help at early stages
  • Use of prescription drugs — particularly painkillers, is related to depressive symptoms and suicidal thoughts and behaviour in college students. The programme may include a system of monitoring by the faculty, the use of such drugs by the students/residents
  • Starting websites that allow students to screen themselves anonymously for depression and taking help of counselors who may encourage them to come in for evaluation/treatment, observing full confidentiality
  • The programme should include a change in the culture of medicine that contributes to and/or stigmatizes depression among its members
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