The traumatic toll of medical education in India

Nearly a year ago, Sugirtha Selvakumar, a 27-year-old anaesthesia postgraduate, died by suicide by injecting herself with a muscle relaxant in Tamil Nadu. In her suicide note, she mentioned having to work 20 hours a day under immense psychological pressure from seniors. Her death sparked outrage and dialogue, but the furor eventually died down without any fruitful action.

A Right To Information filed in 2024 showed that in the past five years, almost 58 postgraduate medical students have ended their lives. An online survey done the National Medical Council reveals that almost 37,000 medical students have self-reported mental ailments with suicidal risk.

How many students filled this form is unknown and therefore to tell what percentage of students reported poor mental health is not possible. As an insider in the medical education system who has witnessed how it functions, I have reason to believe that these staggering numbers are just the tip of the iceberg.

A high-stakes trap

A postgraduate seat, in essence, can be likened to a toxic relationship – in that, leaving could be just as dangerous as staying. Acquiring a postgraduate seat gate kept by a single three-hour exam is uniformly nerve-wracking. The over-glorification of postgraduate medical education in Indian society leads to a situation where a student, once admitted to a medical college for their postgraduate degree, finds it hard to leave.

This situation is worsened considerably by the excessive seat-leaving fees levied on students who wish to exit. The fines begin from Rs 5 lakh and can rise to almost Rs 40 lakh, something most students cannot afford. While the National Medical Council has now requested states and union territories to do away with the seat leaving fees, no concrete measures have been put in place as of now.

‘Fill in the gaps’

For one, residents or postgraduate doctors are not just doctors. They are a skilled labour pool that has been used to fill in the gaps, wherever they may be found. An average resident, along with their studies and patient care responsibilities, is invariably also responsible for umpteen odd jobs – carrying samples to the lab, ensuring radiology technicians get scans done, pushing patient trolleys around when paramedical staff isn’t around – the list goes on.

They may also take on some responsibilities for their seniors – helping with their research, covering their classes or presentations, and even attending to personal favours.

“I feel my life would be so much easier if everyone else just did their job – from ward boys and lab technicians to assistant professors and professors,” said an internal medicine resident who did not wish to be identified. “It just seems like everyone in the system knows that they can slack off and not be accountable because the PG doctor will come and pick up the slack anyway.”

“Leave is not a right”, is a statement the average resident doctor is inured to. It is reinforced that their taking a leave would mean that they would be a burden on their colleagues who would have to do more work. “Why don’t the colleges then hire more doctors if there is such a deficiency in manpower?” another resident anesthesiologist wondered. “There are, after all, innumerable post-MBBS doctors looking for employment and exposure. Why can’t there be more senior resident and non-PG resident posts?”

Mythological ‘toughness’

“My seniors used to get upset if they found out that I had had breakfast that morning,” said a general surgery resident. “If they notice some sign that you have showered, or god forbid, a trace of eyeliner, they will make snide remarks about you having the luxury for personal care,” she added.

Unfortunately, this seems to be the attitude across the board. “They expect you to be above basic physical needs like sleep and food. And they treat you as somehow less worthy just because you need those things.”

It might be relevant here to note that residency as a method of training was introduced by Dr William Stewart Halsted, who was infamously known to have been able to work constantly without food or sleep, and expected his trainees to be the same way. However, after his death, it was discovered that Halsted was able to accomplish these feats as he was addicted to cocaine. One would then logically need to question the need to continue a system that requires doctors to overwork as though they are cocaine-addled.

“I was made to feel extremely guilty for taking leave even when I was sick, ” said an internal medicine resident. “A senior even told me to find a replacement for duty before I went on my sick leave. However, I was too sick and needed to go in for admission, so thankfully I resisted.”

“I am glad I had that experience because it opened my eyes to how unreasonable all of this is,” she added.

Inefficiency, danger

One of the myths perpetrated by people in the system is that the only way to adequately learn is to be ground through the mill of overwork. However, there is a lot of evidence pointing to the opposite. A large-scale study in BMJ, analysing almost 4,85,000 patient records, shows that internal medicine doctors trained for fewer hours treated patients just as well in their first year of unsupervised practice as doctors trained for more hours.

“There is no structured learning in residency anyway,” said another internal medicine resident. “We almost never have lectures. We learn through the caseload we have, if and when we have time to read about our patients. Most of our seniors are uninterested in teaching. What kind of learning can even happen when you have not eaten or slept for many hours?” she asked.

“Sometimes, I want to scream, this is a course,” she continued. “I have paid money for you to teach me things, not for you to overwork me like a dog and leave me no time to sit down with a book.”

An obstetrics and gynecology resident said: “As a resident doctor, I am required to assess my patients accurately, and at times I have to make life-saving decisions in the moment. Given how sluggish I feel when I have not slept well, I am 100% sure that my brain is not functioning well at all during those moments.”

“Patients should insist on being treated by a non-sleep deprived doctor for their wellbeing,” the resident doctor added.

A large-scale study done in the United States found that once physician work hours were restricted, patient adverse outcomes and human errors fell by a third.

Students or staff?

The postgraduate medical education suffers from the fact that the postgraduates are a group of people who are in the grey area between students and staff. A postgraduate resident is expected to take care of patient responsibilities like a staff member, without any benefits that come with formal employment – such as a provident fund, bonuses and paid vacation leave. Many postgraduate students are not even awarded free healthcare by their colleges and might have to pay out of their pockets to avail of the same.

They are expected to take care of their commitments to their course, such as a thesis and compulsory research work, while also managing what is essentially a full-time job. There is also variability in pay scale across the states, suggesting that some medical residents receive very small stipends as compensation for their labour.

“This is probably why there is a deficiency in manpower. Colleges are trying to minimise their investment in faculty. Why hire someone formally for whom you have to provide benefits when you can exploit PG students?” the anaesthesia resident concluded.

Emotional abuse

While the systemic failures and lack of any form of labour protection are huge issues, what causes the most suffering is the emotional toxicity that exists within these departments. Seniors routinely engage in non-professional behaviour – insulting resident doctors in front of patients, calling them names, passing untoward comments, and bullying – all in the name of teaching.

“A senior I worked with once told me that I wasted a seat and he wasn’t sure how I got through the entrance,” said an internal medicine consultant who ended up remembering this comment long after her residency period ended. “I was shocked. In a professional environment, even senior colleagues must be held to a standard of decorum when it comes to communication. Expressing displeasure at mistakes must also be done courteously.”

The pediatrics resident said when doctors ask for breaks or for assistance from seniors, “they make it sound like we do not care about our work or our patients”. “Some of us chose this field to help people, and the implication that we are shirking off work or actively harming our patients is a painful one to hear. Every single resident I know has been taken on this guilt trip by their departments.”

The general surgery resident concurred. “They make us feel guilty for even personal milestones like getting married or having a baby. The entire department was icy when they realised I was pregnant and did not hesitate to bring it up every time I made a mistake.”

Why not complain?

If it is that bad, then why don’t resident doctors complain? “Well, because I am scared that my HOD [head of department] or thesis guide will not sign off on my thesis, for one,” said the anaesthesia resident.

“There is an environment of fear. People are scared that they may be failed in their internal exams if they antagonise some senior and will end up having to stay a year longer in an environment they already despise,” she said.

She added: “The other fear is that the bullying will intensify against the complaining resident without any measures being taken against the person being complained about. The consensus is, do not complain because it will make life worse for you. Just keep your head down and finish the course.”

The obstetrics and gynaecology resident pointed out that struggle is often glorified. “People see it as a rite of passage,” she said.

“If I complain, or even raise concerns, people will act as though I am the weak one for being unable to cope in the system,” she continued. “They will say I am not fit to do the PG course, and who wants to be thought of that way?”

What can be done?

While the problem is multifaceted and the collective traumatisation of hordes of young doctors must end soon – measures to do so have not yet been conceived. The newpostgraduate medical education guidelines released in 2023 have not addressed any issues regarding mental health problems and burnout among postgraduate residents.

There are a few tangible steps that need to be taken urgently. Removing the seat-leaving fees seems to be the logical next step so that no one is financially coerced into completing a degree they no longer want. Other steps include hiring non-postgraduate residents and senior residents so that there is no lack of manpower, and ensuring that employed staff performs their duties adequately.

Measures to strengthen infrastructure in colleges are essential to ensure that patient care systems in hospitals are not run on the backs of postgraduate students. The systematic exploitation of resident doctors to fill in the gaps in manpower must be done away with completely. In the future, introducing some labour protection and making postgraduate stipends uniform and adequate across states may be explored.

There is also a need to understand that a postgraduate degree is a service availed by the student from a college, having paid the stipulated fees. The college has a responsibility to provide a well-structured education to the students in a professional environment, without resorting to overburdening young doctors. Having disciplinary bodies at the level of the colleges, states and the centre is also necessary to ensure that students can safely raise their concerns without fear of persecution.

With work done on all these fronts, hopefully, post-graduate medical education in India can create not just efficient doctors, but better carers of health. If the healthcare system does not pay heed to the call of its students, who will?

Christianez Ratna Kiruba is a physician, patient rights advocate and the Deputy Editor at Nivarana.

This article was first published on Nivarana.