Time and again resident doctors and interns have reported their problems both to the media and the Government. The pathetic working conditions of resident doctors is an eternal problem globally. These residents are completely exhausted and grossly underpaid. For a long time, these real problems were dismissed citing the shortage of personnel and the need for a strenuous training method to shape up the best of the best.
Plenty of times in the past few years both before and after the pandemic, in various cases, the judicial system had ditched the residents and favored the faulty system. Senior doctors, though they personally feel bad, have never actually stood up for the welfare of their juniors. Most of the work done by these residents are clerical and the prolonged working hours are because these teaching hospitals aren't equipped enough or are technologically far backward.
Time and energy is consumed in running between wards and labs and filling up bundles of paper and registers that end up in a dark room. This exploitation is justified stating that all these are a part of the learning process but are these lessons even necessary in a much evolved outside world. A recent circular from the National Medical Commission has addressed the problem of long working hours of residents and the importance of their mental health. Is it already time to celebrate? What exactly is the problem? What will be the bigger impact? How long will it take to solve?
Let me walk you through the proceedings of a resident doctor on a regular 'Admission Day' in a Government hospital in India. The resident is expected to report as early as seven in the morning. After a quick rounds in the ward and an update on the notes for the day, the team assembles at the out-patient department. The OPD sees a footfall of over a hundred patients every day. Of which some of them are regular patients, some defaulters, a few new ones and a good number of people who have lost their way in the hospital and ended up in the wrong place.
Winding up the OPD is a relay-race with the interns, residents and assistant professors attending and dispersing the patients while simultaneously sorting out people who need hospital admission. All that they can afford to take is a five minute breather and a few sips of coffee in between. The gates close at twelve and the new patients are shifted to the wards after the admission process.
One of the residents moves to the Emergency department for consults while the rest of the team moves to the ward to do thorough history and examination, necessary sampling and image investigations and complete the case sheets. By now, it is already three and the team goes for a quick lunch break. On their way back from lunch, the investigation reports are collected from the various labs and the team gears up for the evening rounds.
Around ten, the pandemonium of shuttling patients and running to the labs cease and it's dinner time. The team splits up to monitor the critically ill patients in the ICU and the emergency department. There is no time-off but only change over to less busier places. As early as five in the morning the team is back to sampling and notes as they get ready for the morning rounds. After the rounds, the scheduled tasks for the day are completed and the team is free to go in the afternoon.
This cycle is repeated twice every week, an occasional double admission day(a lengthier version of the same) once in a month, working on public holidays and absolutely zero vacation. This is not just all. There are regular rounds everyday in the morning and evening, weekly night shifts, insurance claim updates, highly detailed long discharge summaries, terribly boring documentations, thesis projects, and in certain horrible places running errands for seniors.
Additionally, they should also train juniors, do presentations, attend CMEs and conferences, participate in competitions and keep updated in this fast moving world. All for a laborious period of three long years with no breaks. Well, we should not forget that outside the hospital, these normal human beings also have a personal life, family and friends.
How did all this come to be in the first place?
About a hundred years ago, William Osler, a physician, the father of modern medicine devised the first ever residency program by integrating bedside clinical training. Later on William Stewart Halsted, one of the greatest surgeons of his times came up with the first ever surgical residency program. Both of them together were the founding professors of Johns Hopkins Hospital along with two other professors.
They put together a curriculum, followed a system of hierarchy to train doctors from various parts of the world which is very much similar to the modern day residency programs. Does this ring a bell? These are much similar to the Gurukul system of schools followed in ancient India. But, what are we missing? All these programs were the best of their times, times way before the advent of computers and the internet, even before telecommunication was a thing.
Healthcare as a whole is very much advanced today. The social and economic conditions are much different. The way and the number of people who seek medical attention are much different. The mode of education has evolved multiple times. The teacher to student ratio in medical schools is much better now. We live in a glorious era of digitization, where technology seems to be replacing humans. Do the best minds in the country still deserve to undergo such situations just to train for what they love to do?
In a short interview with Dr. Nivetha, a third year surgery resident from Stanley Medical College and Hospital, we get to understand the problem much better. She says, " The core working group of most teaching hospitals are resident doctors. When the entire system is dysfunctional, the core working group gets overburdened. It's not really the shortage of doctors that is causing this problem but the operating system of the hospital."
She fuyther explained how each postgraduate works for around 18 to 20 hours every other day. Even if one colleague doesn't turn up, the burden adds on to the others and this can be both physically and mentally exhausting. She adds, "Most of the time we do clerical work. 80% of which might not require a doctor to do it. I wouldn't say that these are extremely unnecessary but there are plenty of other methods that I can learn it from. A weekly off itself would mean a lot to us.
She also states that as much as experience is important, not all learning happens in the hospital and there are plenty of resources these days. Dr. Nivetha also considers herself very lucky to have supportive faculty and colleagues and points out that this might not be the case with all residents. Her coping mechanism is to celebrate birthdays once in a while with friends outside the hospital.
In another discussion with a consulting physician who recently completed his residency from a private medical college, he states, " There is always a constant comparison that goes between the private and government colleges. I agree that the conditions in a private hospital are much more comfortable. The working hours are more or less similar and there is no guarantee for a stress-free environment. Today, I practise with colleagues who did their residency from Government colleges but see no difference except that they had to undergo such strenuous labor to get trained. The working conditions that they describe are quite a lot to put up with."
Every other research done on burnout cites interns and resident doctors as an example. A good number of people quit their residency due to the toxic working environment. A constant battle goes on in the social media platforms between quitters and survivors. Popular Youtubers and doctor-entrepreneurs have time and again put forth the problems but are ridiculed for the same. What they don't see is a lot of them suffer from mental health issues and some even choose to die.
Years of struggle, plenty of hard work into clearing competitive exams, achieving top ranks to grab their dream choice of residency, only to quit owing to a poor working environment. They are not whinny youngsters but achievers who deserve much better than what they get. If not a celebration, this move by NMC should at least get a cheer. The problem at least got addressed and we have a long road to go until it gets solved.