By Dr. George Jacob
Kochi: The Times of India on November 20 published a study conducted by the Research Cell of the Indian Medical Association (IMA) in Kerala, which seemed to suggest that doctors, who are supposed to be professionals helping people to live longer die young compared to the general public in Kerala.
While life expectancy of an Indian is 67.9 years, that of a Malayali (as a native of Kerala is called) is 74.9 years. According to the study by the IMA, the mean ‘age of death’ of a Malayali doctor is 61.75 years. A surprised Dr. Vinayan KP, the Research Cell Convener of the IMA says, “We were surprised by the figures as we expected doctors to live longer, as they know what is good for them.”
The mortality pattern among doctors enrolled with the state IMA’s Social Security Scheme was analyzed In This 10-year old study titled ‘physicians’ Mortality Data from 2007-2017’. Of the 10,000 doctors who were part of the contributory supportive scheme that provides a fixed amount to a diseased doctors’ family, 282 died during the study period.
Of this, 87 percent were men, and 13 percent women. Almost 27 percent died of heart diseases, and 25 of cancer. 2 percent died due to infection, and 1 percent committed suicide.
The study, soon after publication in the print media went viral in the social media, especially among doctors’ groups in the alarmed state.
As might be expected, doctors are supposed to lead healthier lifestyles, and therefore have lower mortality rates than the general population as a result of their ‘medical knowledge.’ However, in some studies, the actual mortality rate among doctors differed according to specialties, while other studies did not validate this observation.
But on the murkier side of things, there are several studies supporting the fact that doctors do not take care of their own health any better than expected. Some studies report that doctors actually take fewer vaccinations, are careless about controlling their cardiovascular risk factors and receive fewer screening tests for cancer than the general population.
An interesting case report about an Australian physician describes how he determined his symptoms on his own and how he was later diagnosed with Lymphoma- a type of cancer!
Why am I writing about this?
I am doing so for two reasons:
(1) I am a doctor myself, who have been working in Kerala as a surgeon for 21 years in a unit specialized in Surgical Gastroenterology which deals with surgical management of diseases within the abdomen
(2) I was struck by a stroke at the age of 39. The stroke considerably weakened my left side, and it wreaked havoc to my career as a surgeon. I was just beginning to blossom into a ‘not- a-bad’ surgeon working in a ‘high-strung’ specialty when the stroke struck out of the blue.
It happened in the afternoon of January 14, 2005. My life turned topsy-turvy in more aspects than just professional. I had just completed an operation that day. At lunch after the operation, I thought I had facial palsy (in which a corner of the mouth deviates to one side) – a common occurrence in stroke, which was confirmed by a colleague of mine who was eating with me. After lunch, I walked up to the Surgical ICU to see the patient I had just operated. There, I fell with a thud near the nursing station. Along with me, my entire life, which was to me ‘a breeze’ until then, came tumbling down, so to say. At 39 I seemed to have lost a dream! The surgeon’s scalpel slipped out of my considerably weakened left hand abruptly.
Soon, a team of doctors led by my boss descended on me, and diagnosed that I had fallen to a major stroke caused by a thrombus (blood clot) that stuck to and clogged a major artery supplying a considerable area of the right half of my brain, resulting in paralysis of my left side. Soon the pressure inside my skull began to increase rapidly having me lose my consciousness and orientation.
Very soon, I landed on the operating table where a neurosurgeon removed a portion of my skull in a jiffy to release the pressure building within that closed unyielding globe of a bone that housed my brain. Surgery followed four days on the ventilator. Thanks to a dedicated team of doctors and Providential grace, I survived the ordeal, and lived to tell my tale.
Off the ventilator, I went through rigorous physiotherapy and a course of Ayurveda, as part of the efforts to restore what I just lost in a matter of seconds. With surgical profession having relegated itself to history quite prematurely, the hospital I worked in was magnanimous to rehabilitate me professionally by employing me to look after patients in the post-operative Surgical ICU, where I have been working since my stroke.
I mentioned in detail the ordeal a 39-year old surgeon had to go through in the morning of his surgical career, as I thought it was relevant to the aforementioned study.
The difference and a significant one is that the massive stroke did not kill me. It could have, if not for prompt medical attention I received. But it certainly left me considerably disabled, and snatched away the scalpel from my hand, and with it, what looked like a promising surgical career at that point in my life. Were it not for the magnanimity of the management of the hospital I worked in, I would have lost my job, denying me significant means to make both ends meet.
What is unique in my case? I had no risk factors to account for stroke. I was no hypertensive or a diabetic. My cholesterol levels were normal. I never smoked. But now, after much water has flowed under the bridge, I can vouch for the fact that although my disease dealt a cruel blow to my life, it has succeeded in making a better doctor out of me. I am now able to relate better with patients I come across in the ICU, as I have been on that sickbed. Quite sick, missing death by a whisker. That thought of course may be part of a mechanism in me to have me count the silver lines!
So then, what caused my stroke when I was only 39? Frankly, I don’t know. One might call it by various synonyms viz: fate, ill luck, God’s will, and many others.
As mentioned in the study, and my experience, why do young doctors fall to major diseases without any warning, killing some of them, or have their lives change drastically, should they survive?
There are numerous causes for the same. As I mention them, I frankly do not know, which one was the villain that wrecked me.
1. Stress: this, without a doubt is the prime culprit.
Doctors are put through a lot of stress, almost as part and parcel of ‘treating the sick’
• The factor of stress probably varies with specialties the doctors practice. Surgeons are known to be under a lot of stress as their work is result-oriented. Any surgical procedure ranging from a simple drainage of an abscess to Coronary Artery bypass, or organ transplant is fraught with complications, unexpected and otherwise. No procedure for that matter is without ‘risk’, and therefore no ‘guarantee’-that favorite commodity patients and their families seek from the treating doctor can be offered. Ever. Simply because what is being dealt with is an ailing human body, which need not respond to treatment along predictable lines, like an automobile does in the hands of a mechanic.
• Doctors, especially surgeons are always result-oriented and are under tremendous pressure ‘to get better than that doctor in the other hospital’.
• They are caught up in a cutthroat competition brought about by mushrooming of hospitals offering quality care, especially in the corporate sector.
• Hospitals, especially those in the corporate sector which runs modern ‘five-star hospitals’ advertise and shout from roof tops through the media of high-end services being offered. This places doctors who actually are responsible of delivering those services under tremendous pressure. This results in a lot of stress on caregivers that doctors are.
• ‘Healthcare’ is no more a noble undertaking. Involvement of money-avaricious private hospitals and over-corporatization of health care have all reduced the art of healing that medicine is supposed to be into pure business undertaking. Monitory aggrandizement by hook or by crook has come to be the bane of healthcare as it exists in India of today. Private hospitals in the corporate sector are the villains in this context. They have ‘targets’ to meet. Targets in terms of number of patients seen as outpatients, number of inpatients, number of surgical and other cost-heavy procedures undertaken, and income generated from in-house laboratories and pharmacies. The hapless doctor, who already is under considerable pressure and a lot of stress to restore health to the ailing under his/her care, is pulled up by managements of these behemoths in the over-corporatized sector to meet targets, most of them financial. Plainly speaking- profit!
• Doctors are also under tremendous stress to keep themselves updated and well-informed of the rapid changes sweeping across the world of medicine. They are required to attend conferences, keeping them away from families and sick patients already under their care. Financial strain on them to subscribe to prohibitively expensive medical journals is not insignificant either.
Patients and their families before consulting the doctor are well-informed of the disease in question and its treatment, thanks to wealth of information available on the internet. This is particularly true in a state like Kerala which boasts of ‘cent percent literacy’. This requires the doctor to be well-informed and well updated, and smart on their feet. What the laymen do not understand is that, while 1+3=4, 2+2 is also=4, as is 5-1 too! In health care, cure or failure to cure does not follow a predictable course.
Doctors these days have the responsibility to brief the families of the patients under their care. It is the sacrosanct right of the people spending for the treatment of the patient to be informed of the treatment being instituted and its results on the patient. This process of briefing families is very much akin to the oral examinations doctors has had to go through as medical students. Doctors can be asked anything by attendants of patients. They need to be smart on their feet, but at the same time honest and down-to-Earth, patient and extremely understanding and empathetic.
There is no place for frayed tempers or raising voices in this communication. There is no place for beating around the bush or dillydallying. After all, proper communication between the doctor and patients’ families, based on honesty, openness and plain truth is the bedrock on which treatment of patients rests. Nobody is appreciated more than a honest doctor.
From the high-end prohibitively expensive treatment being undertaken in private hospitals in the corporate sector, the pendulum of healthcare dispensation swings to hospitals in the public sector. Here, the refrain is ‘we have no facility to treat this patient’. It is a fact. Cash-strapped government hospitals have no facility to sometimes treat even common ailments.
Other factors that make patients reluctant to approach government hospitals, apart from ‘lack of facilities’ are gross shortage of staff in crucial areas like laboratories and other investigative facilities like radiology, a far inferior work culture that functions purely on ‘work to rule’ basis and extreme reluctance on the staff to walk that extra mile, which private hospitals are indeed blessed with.
Doctors working in such an environment function under extreme stress. Even though doctors function in a far inferior work environment caused by poor facilities, expectations of the sick and their attendants remain sky-high. Nothing but a positive result to treatment is expected out of them. Failure to meet this expectation has resulted in umpteen instances of unsavory skirmishes, physical as well as verbal between doctors, other staff and the patients’ attendants. This has showed health care and it’s dispensers under extremely poor light.
• Doctors are asked to work long hours, often without adequate rest, sleep and relaxation, adding to the stress, burnout and sleep deprivation, with their attendant ill- effects. Shortage of staff is made-up by ‘squeezing’ extra work and man-hours out of those available, adding to their fatigue and burnout. Doctors, after busy night shifts are more often than not required to continue into the next day’s schedule without a break, placing them under extreme stress. This is rampant in the private sector unlike in the public sector, where doctors enjoy adequate days off from work, to unwind and to restore their bearings.
• Yet another important factor that plays a part in these diseases affecting the doctors like any other group of people is Genetics. People born into families in which premature death has resulted from vascular diseases have a high chance of falling to heart attacks and stroke. Even cancers like those of the large bowel and breast run in families. The ‘Cancer Family Syndrome’ is a condition in which cancers run in families.
• Like genetics, racial factors too play a prominent role in the development of certain diseases. People from Kerala are known to be have higher incidence of heart attacks. This is also true in Malayalees who have migrated to other countries. Race and genetics therefore constitute two non-modifiable risk factors for the development of vascular diseases and certain cancers.
• Last but not the least, is the self-inflicted tendency among doctors to lead a flashy lifestyle, rife with swanky cars, palatial homes, undertaking expensive holidays, putting their children into expensive educational institutions, especially professional ones. all of these add to their stress. Stress definitely knocks on the doors of those who strive to live beyond their means, or to get better than a so-called ‘rich’ and upbeat neighboring colleague, who leads a life that looks straight out of a Karan Johar Bollywood mega blockbuster!
Stress adds up and leads to diseases, especially cardiovascular, like myocardial infarction (heart attack) and stroke.
2. Cancer this has figured prominently in the study by the IMA, as a causative agent for premature death among doctors. Though cancer has figured in the study prominently, a direct relationship between doctors’ premature death and cancer need to be examined more precisely through well-conducted studies. Theoretically doctors are exposed to various occupational and environmental factors that may increase risk of cancer. Doctors are a unique group of individuals who are routinely exposed to multiple carcinogens, such as ionizing radiation and various chemicals.
Exposure to high doses of diagnostic and therapeutic ionizing radiation is known to increase various cancers, like that of the thyroid and ovary. High Incidence of differentiated thyroid cancers among doctors specialized in various disciplines of radiology is testimony to this. Even young postgraduate students in the specialty are reported to be associated with higher incidence of cancers. Besides radiation and chemicals, the other factor known to cause cancer among doctors is stress itself. Stress caused by a heavy workload, burnout syndrome, compassion fatigue and short sleep can cause cancer. Studies have shown that surgeons (82.5%) did not recommend that their children follow in their professional footsteps!
3. Suicide has figured among causes leading to premature death of doctors, though not to the extent posed by stress and cancer. Doctors are prone to suicide owing to stress, high incidence of depression, and concomitant substance abuse. Doctors are one group of professionals who have easy access to addictive and habit-inducing drugs.
Having come this far, this peculiar phenomenon of Malayali doctors meeting with premature death calls for a proper well-conducted prospective study to examine and dissect into the validity of the observations made in the study by the IMA, before conclusions are drawn from it.
If the study indeed is validated, doctors deserve to be ‘handled with care’. They also need to ‘handle themselves with care’
• Hospital managements, especially those in the corporate sector must do away with their tendency to arm-twist doctors, and to squeeze performance out of them, to meet inflated, and often unreasonable targets. Doctors must not be seen as geese that lay golden eggs!
• The government must see to it that facilities existing in public hospital are upgraded to meet the patients’ expectations, and provide doctors with state-of-the-art facilities and equipment that is required to treat complex diseases at more affordable costs.
• Doctors must be provided with personal security and an atmosphere of security, well shielded from a marauding public who do not hesitate to physically and verbally assault treating personnel in the event of an untoward incident such as death of the patient during treatment or an unexpected clinical worsening of the patent, especially after large amount of money have been spent on treatment.
• The government must consider putting in place a comprehensive health insurance for its citizens, so that a great deal of financial stress on the public while seeking services of doctors and hospitals for their health needs, especially in emergencies is cushioned to a large extent.
• The onus is on the doctors to take responsibility of their own health. They must not be reluctant to seek advice from specialists among their colleagues, and not attempt to treat themselves. Those known to be genetically prone to vascular diseases must pay attention to address modifiable risk factors and effect lifestyle changes that contribute to ward off catastrophe. Those known to have cancers running in families must subject themselves to stringent cancer screening programs.
• Doctors must function humanely doing justice to the nobility of their profession, not sidestepping their responsibilities and accountability toward patents. They must keep the channel of unconditional communication founded on honesty, truth and readiness to accept responsibility, with patients and their families open.