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| MEDICINE AND SOCIETY |
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| Year : 2023 | Volume
: 4
| Issue : 1 | Page : 65-67 |
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Clinical depression amongst surgeons – Is it turning malignant?
Kaushik Bhattacharya1, Neela Bhattacharya2
1 Department of General Surgery, CAPFs Composite Hospital BSF Kadamtala, Siliguri, West Bengal, India
2 Department of Plastic Surgery, Anandaloke Multispeciality Hospital, Siliguri, West Bengal, India
| Date of Submission | 04-Nov-2022 |
| Date of Decision | 13-Dec-2022 |
| Date of Acceptance | 26-Dec-2022 |
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Dr. Kaushik Bhattacharya
G616, Uttorayon, Matigara, Siliguri - 734 010, West Bengal
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JME.JME_137_22
How to cite this article:
Bhattacharya K, Bhattacharya N. Clinical depression amongst surgeons – Is it turning malignant?. J Med Evid 2023;4:65-7 |
| Introduction | |  |
'Surgeons presenting with mental health problems are a hidden minority within a hidden minority' Clare Gerada.
Thirty percentage of Indian doctors go through depression, 17% have experienced suicidal ideation and around 80% of doctors, especially at the earlier stages of their academics and career face the risk of burnout.[1] Surgeons are also not far behind in manifesting all the symptoms of clinical depression. A steady and robust mental health is mandatory for maintaining a successful surgical career without becoming the 'wounded healer'. It was recently found that the overall prevalence of depression is 27% in medical students, 29% in registrars and up to 60% in practicing doctors. Another landmark study on American surgeons in 2001 revealed that 32% of surgeons reported high levels of emotional exhaustion; younger surgeons were more susceptible to burnout, and there was a strong association between burnout and a desire for early retirement.[2] Concerning more serious mental illnesses, such as depression and suicide, studies again showed that although surgeons do not present for care, they most certainly suffer silently! A hidden truth in the career of a surgeon is that due to the high-stress work for long, unpredictable hours, they have some of the highest divorce rates (33%) amongst all the medical specialties.[3] Burnout is also high in oncology, with a prevalence of 25%–35% amongst medical oncologists, 28%–36% amongst surgical oncologists and 28% amongst radiation oncologists. Constant life-and-death decisions, administration of potentially toxic therapies, long work hours (63 h/week), increasing productivity requirements, new information and regulations, loss of autonomy, reduced work–life balance and limited ability to prolong life for many patients all contribute to burnout and depression.[4]
| Professional Stress | | |
The possible risk factors for mental illness amongst surgeons include a heavy and prolonged workload, insomnia, difficult patients with irritated relatives, patients nonresponsive to treatment or unpredicted surgical complications, treatment failures, lack of autonomy in the workplace, financial concerns and constant enigma regarding higher studies.[5] Problematic alcohol use (i.e., symptoms of alcohol dependence or having had ≥6 drinks on one occasion in the last year) was reported by 6.8% of surgeons in a recent study.[6] According to a study in the US, it is estimated that nearly 400 physicians commit suicide per year.[7] All this has ultimately culminated in doctors' life expectancy coming down to 59 years compared to 67.9 years of an average person in India.[8] Another cause for young medical graduates suffering depression is caste-based discrimination and regionalism. In 2007, the Sukhdeo Thorat Committee was asked to investigate caste discrimination at higher educational institutions, and it concluded that 85% of Adivasi and Dalit students at AIIMS felt that internal examiners had discriminated against them when awarding grades.[9]
| Depression Leading to Surgical Error and Burnout | | |
A study showed that those surgeons with symptoms of depression were twice as likely to have committed a surgical error within the last 3 months as compared to their colleagues who were not depressed.[10] These surgeons have been called the 'second victim' and the emotional effects of such errors can be deep and lasting. High levels of burnout, severe stress and distress symptoms are experienced throughout general surgery training leading to a high risk for depression and suicidal ideation amongst surgical residents in the US.[11] The researchers also found that surgeons who showed signs of alcoholism were 45% more likely to admit that they had a major medical error in the past 3 months making them more depressed with burnout symptoms.[12]
| Workplace Violence and Depression Amongst Surgeons | | |
In a study from China on 379 otorhinolaryngologists and 273 nurses, 57.2% were found to have depressive symptoms, whereas, of the respondents who had suffered from physical workplace violence, 71.25% had depressive symptoms.[13] More than half of the doctors reported 'loss of self-esteem', 'feeling of shame' and 'stress/depression/anxiety/ideas of persecution' after the workplace violence incident. There is a complete lack of specific redressal mechanisms in India to address workplace violence. The majority of studies in India on workplace violence on doctors reported an incidence from 35.7% to 78% in the last 1 year leading to insomnia, depression, anxiety and an inability to see their patients without any fear of violence.[14]
| Sexual Harassment and Bullying | | |
In a study on surgeons from Australia, 47% of them (both trainees and practicing surgeons) reported being a victim of bullying and 68% reported witnessing bullying.[15] Bullying at the surgical workplace is a real malady and likely contributes to burnout with depression and faculty attrition. A recent survey by the American College of Surgeons and the Association of Women Surgeons revealed that 58% of women had experienced sexual harassment in the previous 12 months, with female trainees more than twice as likely to experience harassment compared to female attending surgeons.[16] Women frequently suffer from unequal opportunities in clinical, academic or leadership roles, and this can be further represented by disparities in compensation and time to academic promotion. All this leads to workplace stress and depression amongst women surgeons.
| Work Depression and Job Dissatisfaction | | |
In a study from India, 76% of doctors were found to be dissatisfied with their job and 48% of them were stressful. Doctors were found to be least satisfied with their job on physical working conditions, workload, rate of pay and benefits, safety and security, professional growth, autonomy and adequate resources.[17] Another study showed the mean number of work hours amongst doctors was 9.7 ± 2.7 h/day, and the mean number of night shifts was 5.6/month. About half (49.6%) of the doctors were dissatisfied with the average amount of work hours/day. Dissatisfaction was significantly more in those who had an average of >8 work hours per day and who had > or = to 8-night shifts per month. About half (45.6%) of the doctors considered their salary as “bad,” and this was significantly more amongst unmarried doctors, interns and those who had > or = 8-night shifts per month. More than half (55.2%) of the doctors were dissatisfied with their choice of profession, i.e., being a doctor, as compared to other professions.[18]
| Depression after Postoperative Complication | | |
During any surgical error, 'Knowing that you have caused something by your own hand' was reported as a particularly painful experience for the operating chief surgeon. A sense of direct responsibility for the care that surgeons provide possibly makes the experience of surgical adverse events more personal and emotional than in other medical specialties.[19] A study showed a complete lack of institutional support in such a situation, and worse there exists a strong institutional blame culture if there is any inadvertent surgical complication.[19] It boils down to the fact that serious complications also often make surgeons more conservative or risk-averse in the management of patients, which can be detrimental and counterproductive in patient care.
| Medical Negligence Consumer Cases and Depression | | |
A study on general practitioners (GPs) from Australia who had current medicolegal cases against them, reported increased levels of disability in work, social or family life, as well as a higher prevalence of psychiatric morbidity, compared to those GPs with no cases.[20] Male GPs with a current or past medical negligence claim had significantly higher levels of alcohol use than GPs with no experience in medicolegal matters. The medicolegal processes of complaints, claims and enquiries that follow can be distressing and irritating for the treating surgeon regardless of the cause or the outcome. A well-publicised malpractice case in the print media or social media today can ruin the surgeon's career, reputation and practice.
| Surgeon's Depression During COVID-19 | | |
COVID-19 brought in a new type of depression amongst surgeons due to fear of contracting the virus in the operation theatre accidentally, the prolonged lockdown putting a stop to regular elective surgeries with the resultant decrease in salary or practice, the daily media news of the death of medical colleagues or surgeons due to COVID-19 and the exhausting discomfort of wearing personal protective equipment with N 95 mask and face shield and doing surgeries in that unaccustomed environment for long hours with the chance of causing surgical error being very high.[21]
| Corporate Hospital Culture and Depression | | |
A study from Maharashtra reveals an ongoing 'reprofessionalisation' within the private medical sector in the corporate hospitals where personal indebtedness, performance targets and constraints placed on professionals lead to trends in cost inflation, medical malpractice and distrust in doctor–doctor and doctor–patient relationships. The corporate hospital management always favours senior hospital specialists and 'star doctors' who contribute to the corporates' brands and generate maximum revenue for the hospital leading to undue anxiety and stress in them while the status of senior 'nonstar' GPs gets diminished or ignored, and this leads to feelings of poor self-worth and depression.[22]
| Escape from Depression – The “Way Out” for The Surgeons | | |
Very few hospitals and doctors admit the necessity of having a mental health department to guide them. Moreover, as such, there are very few studies in India that highlight this problem. However, the few studies that have been done, have amply shown that the mental health of doctors from residents to superspecialists is in a precarious condition and in urgent need of redressive measures.
It should be a routine and mandatory feature that every doctor see a therapist at least weekly or biweekly depending on the stress scale that he/she is subjected to. Moreover, such communication should be strictly treated as doctor–patient privileged communication so that the doctor is not stigmatised or maligned by it. It is up to the doctor community to understand and place this demand, and maybe even the medical councils and the state health departments should consider issuing recognition and licenses, respectively, only if this facility is set up. Once it becomes routine, seeing a therapist will no longer be a 'frowned upon' event.
Surgeons need to find a work–life balance. Long hours and little rest have been consistently shown to increase errors. Either voluntarily or with institutional nudging, work hours need to be optimised. Then, the surgeon will have time to engage in a hobby such as gardening, photography, reading books, chatting with friends and going on small vacations which all have been shown to relieve stress. Another major factor that improves mental health is moderate exercise at least five times a week. Going to the gymnasium, playing outdoor sports or indulging in aerobics and dancing are proven stress busters and must be encouraged.
Surgeons need to understand that the problems or unexpected complications they face do not happen to them alone. They should be willing to discuss the issues with their friends and mentors and now with online chatting becoming so seamless, it can be used to enhance knowledge and obtain new ideas to deal with problems.
It is high time for the government and the health departments to also give doctors the respect and importance they are due. Starting from an internship where it is considered normal to work 72 h without a break and head back to dingy, cramped hostel rooms, to the rural posting without any basic infrastructure and support/security where the doctor faces the wrath of the village goons alone, to the stressed out corporate specialist who perennially works with the axe of a malpractice suit or dismissal when targets are not met, hanging over his neck, doctors, the lifesavers who should have been the most venerated people, are the most illtreated and 'taken for granted' race. Hence, it is the urgent need of the hour, to look holistically at this problem, understand the system and infrastructure problems that are causing stress, dismay and hopelessness in surgeons and start taking remedial measures. More studies aimed at assessing the true incidence of the problem of depression, substance abuse and suicides amongst doctors and especially surgeons should be undertaken. The first step in that direction is to admit that yes, depression amongst doctors is fast becoming a malignant problem.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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