“A bad system will beat a good person every time”
- W. Edwards Deming
“We have met the enemy, and he is us”
- Walt Kelly (Paraphrasing Oliver Hazard Perry)
“I am so sorry, sir. My wife was so sick in the morning.”
Raveendran’s face was wretched with worry, hands pleading. He was supposed to be in the ward at 6.30 in the morning. His wife was pregnant, and she had vomited continuously for an hour early in the morning. He was from another state, and had no friends or relatives.
He was ten minutes late.
“Is your wife, the problem? Then divorce her and come- if you want to be a Neurosurgeon.”
Thus spoke Ravood the ruthless, a legendary dictator in the field, renowned for his puritanical tyranny. When I joined Sri Chirag Thirunal Institute at Trivandrum, he was no longer there, but his aura remained, and his obviously Narcissistic and Psychopathic traits were hailed as characteristics of the ideal Neurosurgeon.
“This Institute is so lame, man.” My fellow resident Raju had said. “Look at the Neurosurgery department at the All-India Institute- three residents committed suicide in the last four years! And see the one at Velpore Christian College. Two suicides and two being treated for resistant depression in the Psychiatry department there. Cool, eh?”
He was counting the greatness of departments by the body counts of residents. Nice metric, no?
When the NMC report came out regarding student and resident suicides, and high rates of burnout, one person asked in a group-
“Is it that people who are inherently week and insecure are getting into Medical School? Or is it something else?”
It is most likely something else (1, 2, 3). Studies show that young people about to join medical school are, if at all, better adjusted to life than other peers. They have similar and better mental health. A few years into medical training, fifty percent show unmistakable signs of burnout, and by residency, the proportion climbs to seventy five percent. This comes down after that, but in all countries studied, levels of burn out among doctors at all levels of their career is at forty to sixty percent (1, 2, 3, 4).
Burned out doctors are cynical, show less empathy, and makes vastly more mistakes. It is not good for them, and it is not good for patients.
There are inherent issues with medicine. The public thinks that it is an exact science, but it is not (5). Many think that physicians have more power in the system than they do. This perception is encouraged by the government, the managers, and the private owners, who at the same time systematically try to undermine the amount of control that doctors have, out of a need to optimise profit, and out of resentment, jealousy, and malice.
Excessive responsibility without adequate control, and a weak and cash-strapped system is a prescription for burnout.
But could there be traits that pre dispose to burnout?
Neuroticism and Introversion are linked to burnout across careers. Specifically for medicine, studies suggest that over-commitment to work (a pattern of excessive striving combined with a high need for control and approval from others) increases the risk of anxiety, depression, and burnout in doctors. There is also evidence from France and the Netherlands that doctors are particularly susceptible to workaholism (a syndrome comprising high work involvement, a strong compulsion to work and low work enjoyment). While excessive involvement in work can improve job satisfaction, a reluctance to disengage from it can limit opportunities for recovery and increase the risk of burnout (6,7,8).
We must start a dialogue about this, especially in India. It has been shown that when the systems are poor, a higher proportion of those that thrive and attain positions of power may have dark triad traits (Psychopathy, Narcissism and Machiavellianism) (9). The mentally healthy, empathic, and earnest doctors might run away and drop out, while very unideal people might flourish.
Raveendran’s wife is not the problem. Ravood, and all he represents, is.
(Jimmy Mathew)
- Stephen Swensen MD MM, Shanafelt T. Mayo Clinic strategies to reduce burnout: 12 actions to create the ideal workplace. Oxford University Press; 2020 Feb 7.
- Brazeau CM, Shanafelt T, Durning SJ, Massie FS, Eacker A, Moutier C, Satele DV, Sloan JA, Dyrbye LN. Distress among matriculating medical students relative to the general population. Academic medicine. 2014 Nov 1;89(11):1520-5.
- Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout among US medical students, residents, and early career physicians relative to the general US population. Academic medicine. 2014 Mar 1;89(3):443-51.
- Kinman G, Teoh K. What could make a difference to the mental health of UK doctors? A review of the research evidence. Gail Kinman, Kevin Teoh- Society of occupational medicine, 2018.
- Kahneman D, Sibony O, Sunstein CR. Noise: A flaw in human judgment. Hachette UK; 2021 May 18.
- Buddeberg-Fischer B, Klaghofer R, Stamm M, Siegrist J, Buddeberg C. Work stress and reduced health in young physicians: Prospective evidence from Swiss residents. Int Arch Occup Environ Health. 2008;82(1):31-38.
- Wu H, Liu L, Wang Y, Gao F, Zhao X, Wang L. Factors associated with burnout among Chinese hospital doctors: a cross-sectional study. BMC Public Health. 2013;13(1):786.
- Rezvani A, Bouju G, Keriven-Dessomme B, Moret L, GrallBronnec M. Workaholism: Are physicians at risk? Occup Med (Chic Ill). 2014;64(6):410-416.
- Corruptible: Who Gets Power and how it Changes Us; Brian Klaas, John Murray Press, 2021.
