In March earlier this year, three medical students took their lives in different medical colleges in Gujarat, all within three days of one another.

Even while the medical profession is widely regarded as one of the most stressful, the mental health of doctors and nurses remains a hushed subject.

An Indian pharmaceutical news portal found that, globally, the risk of suicide is 2.5 times higher among medical students and doctors, with those in the age group of 24 to 37 years being the most vulnerable.

Another study among clinicians in India found that 45% of respondents scored high on emotional exhaustion, with 87% of the doctors scoring low on ‘personal accomplishments’.

Dr Manish, president of the Federation of Resident Doctors’ Association, in an interview with The Citizen said that the stressors for resident doctors and medical students in India have remained largely the same over the last few years, and have also been systematically ignored by public authorities.

“There are around 250 patients at a time in an OPD, and there is only one doctor to look after the patients. So they are very much stressed,” he explains.

The starving of funds for preventive and primary healthcare and the lopsided concentration of doctors and hospitals in cities has led to congestion and overburdening.

“Many resident doctors came into my office and threatened that they would commit suicide,” says Manish, describing the pandemic. “Because they are not going to work like this. They have been working for 48 hours at a stretch… They are also human, and you cannot treat them like this. And still the government is not doing anything.”

“These resident doctors in the hospitals are working for 48 hours, and moreover they are not getting leaves to go home and meet their parents. For the last two and a half years, ever since the pandemic, they are hardly getting leaves to go spend time with their families. So these things are building up the pressure and mental stress… Many doctors have committed suicide in the last year.”

He says that despite their protests to hasten the NEET-PG examinations last year, the situation is still the same, with the government refusing to take any action in this regard. The exams continue to be postponed, delaying the process of counselling and admissions all over again.

“Despite the new doctors having joined, we are still falling short of manpower in our hospitals,” says Manish. “The Ministry has again postponed the NEET-PG examination. It was supposed to happen in January, then they postponed it to March. From March they postponed it to May, and I got to know that they are planning it for September now.”

“I don’t know why the government is doing this. Again, they are repeating the same – they are forcing us to come onto the road again.”

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*Kalpana Mitra, 24, recently finished her medical internship, and is currently preparing for her NEET-PG exam.

“The line is stressful, and you will have to keep studying, till the end of time. And about the stress - you know this is going to be there since the first year of college. It is a part of your curriculum and the portion is never ending. I feel we sign up for this when we go into medical school.”

She explains that a batch of junior doctors who would have as a matter of course been promoted to a higher ranking, could not be promoted, since their subsequent juniors, the next batch of residents, had not yet been admitted into the colleges. The current date for the exam announced by the Union Health Ministry is May 21.

Mitra was in her final year of medical school when the pandemic hit. “So JR-1 (junior residents) had to do two years of JR shift because their juniors didn’t come… That was a real bad situation, yes… I saw the residents work so hard.”

She says the counselling (placement) rounds for 2021, which had already been delayed, finally closed early in May. Since much of the counselling was happening simultaneously with the ambiguity regarding the NEET-PG exams, many were torn on whether they should focus on the last few rounds of counselling, or dedicate the time to studying for the as yet uncertain exams.

“We didn’t get time during our internship to study for this NEET. It is difficult to sit and study after completing a shift for 12-13 hours, unless you are a genius… I would rather have my one year prep, than this ambiguous thing.”

“Right now we are not able to understand what do we finish. We have 19 subjects, so we have to revise everything, give question papers, mocks and everything else.”

So she says, purely because of the stress of the subjects and the time available for preparation, the students are split on whether the exam should be postponed. “It’s like - do you focus on one subject and give them 20 days each, or do you just make some revision notes? Because you are competing with people who have been studying for 2 years.”

The point is echoed by Dr Santanu Sen, council member of the World Medical Association, and state secretary of the Indian Medical Association in West Bengal. Sen was president of the IMA in 2019 when its Doctors for Doctors (D4D) initiative was launched. This was a mental health initiative intended to help doctors, residents and medical students to cope with the pressures and burnout in the profession.

He agrees that the study load is something that students are largely aware of. And cites another reason for the stress and depression among medical students. “With students they have tremendous pressure of studies, but I think that they can overcome. But the main problem that they often fail to overcome is the pressure from the patient parties. When they are in their third year, sometimes they face such bad behaviour from the patient parties…”

“Sometimes they get humiliated, sometimes they get physically assaulted in the hospitals. Because junior doctors are the pillar and backbone of any government hospital or any big institute.”

Sen says that junior doctors are at the highest risk of facing such abuse. “In any hospital, in a medical college, junior doctors and medical students, they are the first line service providers… They often face these confrontations whenever anything happens. The patient parties’ first targets are these junior doctors and students.”

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A recent study of English language press reports found that 30 doctors in India took their lives between 2016 and 2019. 22 of the deaths were reported from medical educational institutions.

19 of these reports mentioned that the doctors were depressed when they took their own lives. Harrassment was one of the other main reasons identified, besides bullying and marital discord.

“So sometimes they get shattered physically, mentally, emotionally, psychologically, everything. So they need to be treated and counselled first… If we cannot treat our doctors, if our doctors are not healthy enough, how can they treat the patients in the society?” asks Sen.

“Proper counselling is needed, and it is absolutely needed for doctors. So that they can be morally charged and emotionally and psychologically stronger so that they can face all kinds of situations and serve the society better.”

However, the National Medical Commission is far from implementing any such measure in the medical curriculum.

“Definitely, psychological counselling should be strongly included in the medical curriculum. There are still certain vacuums, and this is one of those important issues… Medical students from first years onwards, should be given this type of training and this kind of counselling,” Sen emphasises.

With an estimated 80,000 medical students from over 500 medical colleges graduating each year, why haven’t such measures been included in the curriculum?

“See, medical colleges run their course as per the direction given by the National Medical Commission.They don’t have the right to include something extra in their curriculum, until and unless it is being provided from National Medical Commission… So until and unless a directive or initiative comes from that end, no individual medical college, be it government or private, can take any step.”

Dr Manish is of the same opinion. “There is no provision or counselling options for the students… This conversation has been going on for a long time, but still nothing has happened. Everything is on paper. Practically it’s not happening at all.”

And anyway, “After 48 hours of work, they are not going to have time to attend the counselling sessions. After 48 hours, koi bhi kisi halat mein nahi jayega,” he explains, speaking of the resident doctors’ challenges with fatigue.

He shares that there are many doctors who seek therapy independently to cope with the pressure, but they are not comfortable going on record about it due to the stigma attached to this notion. “That is why they do not opt for therapy in their own hospitals, they look for it outside.”

Sen suggests that we cast off the stigma. “There is no question of stigmatisation, no question of discrimination. We should forget these age-old thoughts. In the 21st century, we must be much more scientific in our thoughts and our actions. So we must forget those age-old concepts of discrimination.”

Mitra agrees that counselling for medical students is a very real need, recalling her recent college experience. “My college, the teachers were good enough for anybody who went there and sought help. I know a couple of people who were suffering… But in my experience, our teachers were really good. You just had to seek help.”

Of one of her peers in particular who needed therapy, she says the student in question went to the teachers who arranged for a counsellor for her, since the college did not have one on their faculty.

“I feel UG (undergraduate) students are really susceptible to the stress,” she says, as the sheer possibility of not excelling as a medical student, or performing poorly, tends to demotivate students to a dangerous degree.

From her perspective as an intern, she says, the pandemic was very hectic, but a valuable learning experience. As the resident doctors were overworked, the interns were made to engage with a lot more work and duties than they otherwise would have been.

Manish adds however that while counselling might help, it will not take care of the real problem.

“Yes, it’s going to help. But if you are not going to give proper relief to the resident doctors and not improve the working hours of the doctors, nothing is going to improve. You have to improve the working conditions of the doctors,” he says.

“Now the government has no excuse at all. In fact, last year also the government had no excuse. Pandemic was just an excuse to avoid the examinations. Like AIIMS conducted the examinations, PGI Chandigarh conducted the examinations, why not the central government? Elections happened last year, this year also elections are happening,” he points out.

“Our health minister is busy campaigning, but he is least concerned with the health sector.”

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Mitra recalls that something similar happened with the NEET undergraduate exams. It was decided that there would be one unified exam for all undergraduate medical students organised by the Centre – which intimated this to the students just one month before the exam. As a result, those who had been preparing with the state curriculum found themselves hung out to dry.

“Our Indian education system, and Medical Council needs to understand… You can’t keep postponing exams or not giving us a definite answer, because that definitely builds stress for everybody… I mean a medical students’ duty is to study and they are doing that but don’t put on the stress of thinking about when the exam is going to be,” says Mitra.

She adds that many incoming students are unfamiliar with the profession.

“When you’re entering this, people should be given a background… I think schools and institutions glorify this profession a lot. But people have to be counselled about what it is, how much there is to study, and the fact that it is not going to be easy. If you are studying five hours to get into a medical college, you have to study twenty hours to get into a PG college.”

Last year it was also reported that a number of students appearing for the NEET took their lives in Tamil Nadu, with entrants alleging that the pressure on students is huge. The central exam has provoked a political tussle in the state, with the DMK government calling it discriminatory against students from rural areas and those not educated in English.

Meanwhile, a study last year by the National Library of Medicine on suicides among medical students found that India had seen 358 suicide deaths of medical students from 2010-19, wherein 7 of 10 suicides happened before the students had turned 30.

Sen is of the opinion that it is purely the negligence of the NMC that has prevented ameliorative measures being implemented in medical colleges, despite the pressing need for many years.

“There are certain issues like these in medical colleges, like the psychological counselling. These basic medical ethics, how to build up proper doctor-patient relationships – these are some important issues that are not taught in the medical curriculum. And these are loopholes.”

“I strongly believe that today there is hardly any person on this Earth, who is not having any psychological problem,” he says. “Psychological problem does not mean you are a psychiatric patient. Some emotional or psychological imbalance, some emotional upset, it is being experienced by each and every person on this Earth! And doctors are also human beings! It is quite natural that sometimes they also need counselling, and they also need a grievance redressal system.”

*Name changed

Photographs DANISH PANDIT for The Citizen