Do people think it is an easy life being doctors or that people become doctors only to earn money or that in all other occupations people don’t take money for their services?
The difficulties in training to become doctors
I am a doctor and a teacher in medical college for 35 years teaching undergraduate and postgraduate students both theory and clinical teaching. In the board exam, only those who are meritorious toppers, the top 1%, choose to and qualify to become doctors. The day you join medical studies, life changes forever for you. You have to study harder than any other degree, you have to study longer than any other degree, and you forget about holidays and vacations or even what hour of the day it is.
During undergraduate studies, it is books and wards which will be always occupying all your time and in postgraduate study and life after it, it is patients who will dominate and occupy a big chunk of your time. I have been a teacher throughout my career, and have done the residency as well. Also, so many students were my residents and as an HOD I have seen the residents of all departments. It is an extremely tough 3 year period, especially if it is a clinical branch or any branch that has emergencies. The work is so hectic, it is unimaginable. The Out Patient Dept. (OPD) is very heavy; having 500–600 patients per day and on emergency days there would be continuous flow of serious patients.
First year postgraduate students would be like zombies — no sleep, loads of work, no food timings, no time for regular baths even — and mental stress to add to all of this. But they all endure it. I have seen one or more from each batch developing TB as they come in close contact with patients. They would be exposed to accidental pricks from needles contaminated with the patient’s blood while inserting IV lines and have to take post exposure prophylaxis for hepatitis and HIV. I always saw them running around with patients for their radiology consultation or cardiac consultation etc. When a patient would develop cardiac arrest in the ward, they would give CPR with so much zest. Everybody present will run around to help. I would be touched to see young delicate girl residents climbing on the cot to do CPR and putting all their weight for cardiac massage till they got fatigued. They would keep on trying.
We are all affected by patients’ deaths, particularly when they were young or not suffering from terminal illness. Even if we see death from close quarters, still we are affected by a patient’s death all the time. I tell my students that the day a patient’s death stops affecting you, that day you cease to become a good doctor. I have seen some residents crying over patients’ deaths too. I even read today in about a New York City emergency room doctor so affected by treating COVID-19 patients that she committed suicide. Have we ever seen something like this in any other profession?
Is it easy to study or learn to heal human sufferings? Not at all. Take for example, a simple symptom, headache. Everyone would have had it sometime or the other but let me tell you in brief the causes. Simple causes could be refractory errors, Upper Respiratory Tract Infection (URTI), referred pain from eye, tooth or ear. Slightly more complicated causes could be anemia(low Hb), polycythemia(high Hb), carbon monoxide poisoning, high altitude, hypertension (High BP), postural hypotension, migraine type headaches, acid base imbalance in various forms, premenstrual headaches, those associated with any fever or drugs. And finally, severe cases could be related to meningitis, brain tumors or hemorrhage. The last, lo and behold, common cause may be psychogenic or stress related but you need to rule out serious causes and not stamp a case as that of stress. And I have not even described rare causes here.
Sometimes we need a lot of investigation to find the cause of the symptom like this one. If the investigations turn out negative, the doctor is accused of over investigating but if something turns out positive, he may be given credit to find the diagnosis. But there is always the possibility of both ways. In the same way, sometimes for correct diagnosis or to get protection in court of law in case of court case, physicians have to refer the patients to the corresponding super specialists like cardiologists, gastroenterologists, neurologists or other specialists like surgeons. As it turns out, in the court the judge may ask why the patient was not referred to the corresponding specialist, if facilities were available, and it will be a punishable act. While in others’ eyes, the doctor may be accused of sending the patient to many other doctors for the wrong intentions. Some years back, in a popular TV show the host accused doctors of putting the patients through hell for monetary gain. Now, in COVID-19 times everyone probably would have come to know about the life saving ventilators, which can save critical patients in many other diseases.
It is not simple math
In medicine it is not as simple as 2+2 is 4. There are many more ambiguities and uncertainties. We have to listen to patients, examine,investigate, diagnose and then treat. The story of headaches above, is the same for any symptom. There would be so many causes and so many different presentations. We always have to think of the patient first and believe he is right. That is what I teach the students but believe me all patients are not the same. Their attitude towards a disease, their perception, their communication all vary so widely. Still all the doctors listen to them day after day, daily and treat them. So many patients don’t even give proper history. They will often not volunteer their history of TB even if they have open TB, often not talk about their history of HIV or steroid use or even diabetes unless you ask. So many times they come to the doctor so late even though they would have had serious symptoms since days. The disease would have worsened so much already, but on coming to the hospital they would expect a miracle. If the patient dies by the side of a road due to an accident, it is an accidental death. But, if the patient reaches a hospital and dies immediately, many would think that the doctors did not treat them properly.
The irony is that to understand their mental state and lack of empathy, and not go by their actions, a doctor has to have empathy. This makes empathy one of the most important assets for a doctor.
There are so many diseases that can affect doctors while treating the patients. You may call it a professional hazard. We don’t sign up for these. Sometimes it will affect your family also — for example all infectious respiratory diseases particularly viral infections like influenza, swine flu or H1N1 influenza, SARS or MERS or more recent deadly coronavirus infections. All of us have seen news of so many medical and paramedical staff dying due to COVID-19 worldwide. So many doctors and nurses don’t see their families, afraid to transmit latent COVID-19 infections. No other profession has this hazard of harming your family due to your profession.
During the H1N1 influenza pandemic and many yearly outbreaks, I would arrange a rotating duty of all levels of doctors in isolation wards where they would work for a certain period and not work in any other ward at the time to avoid infecting other patients. But what about ourselves? Many of us took 3–4 courses of Oseltamivir of prophylaxis every time we got more exposed. But eventually left taking it as these drugs have side effects. The doctors can also get hepatitis B, hepatitis C, HIV, Crimean Congo hemorrhagic fever (which occurs sporadically in Gujarat and doctors have lost lives) due to accidental needle prick or splash of blood while treating or reviving patients. In 1984, so many young doctors lost their lives in Gujarat due to fulminant hepatitis B. This was probably due to contaminated needles as there were no disposable needles available that time. For some diseases post exposure prophylaxis is now available, like for hepatitis B or HIV. Doctors can get infected with TB (even multi drug resistant TB where you have to take 5–6 anti TB drugs for 2 years or more if needed. I have seen countless doctors starting from residents to senior doctors and nurses too suffering from TB due to patient‘s infection. They can get dermatological infectious diseases starting from scabies to measles, chicken pox etc. The radiologist or the doctors who have to use equipment emitting radiation like IITV in operations or cardiologists in the Cath lab are exposed to radiation and related diseases, even cancers. Pathologists can suffer disease while handling infectious samples if they make a minor mistake in handling them. The clinicians can contract diphtheria or meningococcal meningitis while examining patients. Fortunately post exposure prophylaxis is available for these two diseases. All of these diseases can occur many times in spite of precautions.
Fees in medical practice
In India, healthcare is often an out-of-pocket expense. Many proactively choose to avail the medical facilities of the highest-end corporate hospitals for better infrastructure and cleanliness, even though the same treatment is available free of cost at government hospitals. At the end of this all, they still resent the fees for what they chose. In spite of the conflicts on often nominal fees, doctors routinely miss their childrens’ birthdays and many other moments that may be personally precious and once-in-a-lifetime without the batting an eyelid. Doctors do this not to earn more, but because it is their duty to never turn a patient away even if they entered as the doctor switched off the lights for the day.
In fact, in which other profession, even after studying so much, you routinely work 24x7? And be frequently woken up in the middle of the night by patients? Sometimes even for trivial matters, but we still respond courteously.
As I said earlier not only is each patient different but their diseases behave differently too. As we all know some patients with blocked coronaries can pull on for many years and some patients will die in the first attack even before they reach a hospital. For the same illness prognosis varies and depends on multiple factors. It is not in the doctors’ hands. Doctors are judged by results and not by efforts. Patients die sometime even with all treatments given properly. No doctor will think of harming the patient knowingly. It is in our Hippocratic Oath — Do no harm — but doctors are not Gods. If it was so, no doctor would die. Right?
So then why blame doctors for adverse outcomes? They are human too. We read on and off the incidences of violence against doctors in India, which are increasing day by day, more so in recent COVID-19 times (Examples: 1, 2, 3, 4, 5)
How can this be justified? Why doctors or health care workers? They are doing what the higher authorities instruct them to do for the welfare of the public. They are taking risks not only for themselves but for their families also. They are doing their duty in this tough time. So, instead of appreciating them, why the brickbats?
Different systems of thinking?
As well known in psychology and as per the book “Thinking, Fast and Slow” by Daniel Kahneman, there are two modes of thinking. System 1, which is fast, instinctive and emotional. That was the earlier to develop, for survival, hunting and storage of food for famine and it is automatic. Hell, we even have thrifty genes. It is true. These were present as there were cycles of war and famine. So sometimes food was in plenty but sometimes not at all and there is a hypothesis that nowadays we always have food in plenty and the body is not accustomed to the entire overload and so we develop obesity and diabetes. The other type of thinking is System 2, slower, more deliberative and more logical, polished one, which has developed with evolution and is due to the neocortex or orbitofrontal cortex.
So, I think system 1 would come out in individuals who are probably not very educated or have clarity in thinking. They would resort back to the primal attitude. Even educated people in times of crisis behave that way and that is why we see people behaving in most primal ways so as to become selfish enough and to ignore social norms and etiquettes. Maybe this is the type of behavior that prompts them to hurt people. I cannot pinpoint the reason or even if at all there is any reason but why target only doctors? The normal human variability of knowledge, temperament, thinking, communication will be present in the medical fraternity also.
But would I choose anything else?
The situation was not like this a few years back. Patients were always grateful and thankful for saving their lives and considered us doctors as next to God and many would touch our feet though I would tell them not to do so. Even still, the majority of the patients are grateful and it is immensely satisfying for us also when they recover. But, I think in this era of generalized intolerance with abundance of media exposure, knowing half-baked truths, people generally have become more demanding. This has affected their interactions with the medical profession.
Having said all this, would I choose any other profession if I went back in time? No. I love being a doctor and a teacher and love doing what I do and I am what I am because of what I do.