Introduction 

India is witnessing an alarming rise in premature deaths among doctors. This silent crisis is evident worldwide, impacting both lower-middle-income and high-income countries. [1,2] Doctors in India have at least 10 years shorter lifespan than an average individual, evident from the frequent appearance of young doctors' obituaries on social media each week. [3] This alarming trend is attributed to extreme burnout, underpayment, academic stress, corporate hospitals' unrealistic work targets, and patient/relatives' violent attacks, driving doctors to the path of untimely death through suicide. [4] Despite understanding the negative impacts of sleep deprivation and a stressful lifestyle, doctors often struggle to manage themselves in that regard. The small and overburdened cohort of healthcare professionals often finds their voices and grievances unnoticed, impacting not only their lives but also the nation's healthcare system. This article tries to highlight the key factors behind the premature deaths of doctors in India.

Current scenario

It is estimated that there are more than 1 million doctors in India, and annually over 80,000 medical students graduate from 529 colleges. [5] However, most doctors after graduating prefer to practice in private and urban areas (Fig. 1), leaving government and rural hospitals with overworked, underpaid, and burned-out doctors, highly vulnerable to exploitation by corporate sectors. 

Figure 1: Distribution of HWF in India 2018 across rural and urban. [6]

According to a study conducted by the Indian Medical Association’s (IMA) Pune chapter, an Indian doctor’s average lifespan (55-59 years) is almost 10 years less than that of the general population (69-72 years). [3] Findings from a recent NMC survey suggest that, at least 36,000 medical professionals are suffering from mental health issues. In the last five years (2018-2023), 153 MBBS students and 1,120 PG students dropped out of their institutes. Moreover, 122 medical students (64 in MBBS and 58 in PG courses) are estimated to have died from committing suicide. [7]

Every now and then, we see news of doctor’s death broadcasted widely over media. In one such instance, a 25-year-old junior resident doctor from Dehradun ended his life, allegedly due to workplace harassment over his thesis submission [8]. In a similar incident that occurred in December 2023, a 32-year-old postgraduate from Madras Medical College, was found dead at home after reportedly returning from a long work shift. [9] Dr. Archana Sharma, a medical practitioner at a private hospital in Rajasthan's Dausa district, wrote in her suicide note on March 29, 2022, "My death may prove my innocence. DON'T HARASS INNOCENT DOCTORS. Please."; after she faced violence and an FIR under IPC Section 302 (murder) following the death of a pregnant woman at her hospital. [10]

Figure 2: Fear and stress prevalence among Indian doctors according to IMA (2017). [11] (source: The HINDU)

Adding to the misery, the COVID-19 Pandemic made the situation worse for HCPs. Even though there is no clear data available, it is estimated that over 1600 doctors died during the pandemic. 

Figure 3: Doctors died during the pandemic. [12] (source: The New Indian Express)

Under the PMGKP insurance scheme, the Union Government provided Rs 50 lakh coverage to healthcare workers fighting Covid-19. Yet, only 29% of families of doctors who died from Covid-19 during the first and second waves have been compensated by the government [12, 13]. 

Probable Causes

• Among Young Medicos:

  
  

  • Risk-taking behavior:  Medical students, often engaged in risk-taking behaviors typical of their age group, are vulnerable to accidents. The tragic drowning incident on June 5, 2024, which claimed the lives of five medical students, exemplifies this risk. [14]

  • Academic pressure: They also face extreme academic pressure from constantly evolving curriculum; and exams like NEET and USMLE without adequate financial or family support.

  • Ragging: Despite efforts by Anti-ragging Committees nationwide, the existing deep-rooted colonial mindset makes students prone to ragging. 

  • Inadequate and inconsistent pay across states and various institutions: The PG doctors are supposed to receive an average of Rs 45,000, Rs 50,000, and Rs 55,000 for their first, second, and third years, respectively. However, the actual stipend credited to them varies across the nation based on the State and the institution they study. Meanwhile, the residents have to toil and manage the family expenses with the minimum pay, often paid late or no pay for several months adding to the financial burden they face. It has been reported that sometimes they do not even receive  half or 1/4th of stipend making the basic survival of the residents and their families hard. [15] 

  • Unjustifiable working hours: As per NMC PGMER guidelines 2023 “They (residents) will work for reasonable working hours and will be provided reasonable time for rest in a day”; where, the reasonable work and rest time are not been defined. Dr. G R Ravindranath, General Secretary of the Doctors Association for Social Equality, battled a lot to reduce the duty hours of interns and residents from 24/7 to a maximum of 8 hours. Their consistent effort led to a Madras High Court judgment of not to work beyond 8 hours of continuous duty, which the Tamil Nadu Government pledged to uphold. [16,17] Recently, the Tamil Nadu health department also revised the working hours for nursing assistants and housekeeping staff to 8 hours at Government Medical College Hospitals and Primary Health Centers. [18] However, the implementation of this policy all over India remains in question due to inadequate staffing levels. 

  • Systemic toxicity - the toxic work culture during internship and residency: The conventional mindset of the senior doctors/ HODs that “I did work for 72 hours continuously during my days, why can’t you?” even when they are going through physical or mental health issues or pregnancy. The public health system suffers from a shortage of manpower in the public sector. Despite governance and financial constraints, individuals in positions of power often mistreat their subordinates, residents, and interns when they request legally entitled sick or casual leave. They insist that residents find replacements regardless of their health or family issues, particularly during the Covid-19 pandemic. In some cases, clinical departments refuse residents the right to take maternity leave, citing concerns about its impact on their work, rather than advocating for increased staffing from the administration. 

  • Systemic Injustice: The medical profession is marred by systemic injustices such as financial burdens, lack of privileges, and exploitation. For instance, exorbitant costs for publishing articles or becoming a member of professional associations put additional pressure on doctors. This financial strain is compounded by disparities in salaries and stipends across different states. 

On other hand rural – urban disparity and rich-poor inequalities leading to the difficulty of pursuing medical education by first graduate, from low-income families and rural backgrounds. In turn paying huge fees for NEET coaching centers and education loan adds to the existing financial burden.

Systemic injustice to female doctors in giving clinical and administrative opportunities, untold tragedy of harassment by male doctors, difficulty in availing maternal and menstrual leaves, lack of safe accommodation[19] and other gender disparities– need a separate article to be discussed in length.

• Among Medical professionals:

  
  

  • Profit pressure in Private sector: Pressure to meet unrealistic targets in a profit-driven environment. Pressure to meet unrealistic target, focusing on profit more than affordable healthcare, puts the doctors in ethical and moral dilemma. Conflict between one’s own humanitarian approach and financial insecurity, forces them to do unjustifiable investigations and unnecessary treatment, which exploits the patients in return. 

  • Work Pressure in Public Sector: Catering health services to huge population in a resource limited situation, strains the healthcare workers (HCWs) and the quality of care to patients. 

  • Violence and Lack of Security: Attacks by patients' relatives and lack of protection for healthcare workers (HCWs). Mob lynching and false allegations even lead to suicide out of guilt, [10] [20] especially in this digital era where anything can be made out of context and viral in a short span of time. 

  • Lifestyle disorders:  Due to their sedentary lifestyle, lack of physical activity and dietary pattern, it is found that doctors are at higher risk for CVDs as compared to nurses as well as general population, adding to the cause of premature death and decreased longevity among doctors. [21]

Why do we need data for Physician Mortality Rate?

Regarding mortality rates, WHO quotes that “Measuring how many people die each year and why they have died is one of the most  informative ways of assessing the  effectiveness of a country’s health system”. [22] For the Cohort of physicians and Healthcare workers, what indicators determine their mortality and morbidity pattern? 

When we have detailed data about their deaths, we can find their, [23]

• Personal health habits and their influence on patient counselling,

• Lifestyle choices and overall health,

• The impact of socio-economic status and environment on their well-being.

Moreover, this data can shed light on the effects of occupational safety, exposure to hazards, workplace stress, and burnout, which can contribute to suicides.

Impact on Healthcare System

Figure 4: Impact of premature death of doctors on the healthcare system

Each premature death of a doctor exacerbates the already strained healthcare system. It creates a vicious cycle of overworked doctors in a country with doctor population ratio of 1:1800. [24] Doctors are essential in turning research into action, bridging healthcare policies with beneficiaries. The death of a single doctor can create a significant gap in research to action. Exodus of Doctors – Brain drain: The lack of job security, overwhelming competition, and inadequate support drive many doctors to seek opportunities abroad resulting in brain drain. [25]

Possible measures to be taken:

1. Data Collection: Comprehensive data on doctors' deaths to understand the scope and scale of the problem and can compare with Physician Mortality Rates of other Countries to support better policy making. We need thorough data to substantiate the hypothesis of rise in physician mortality in the past decade is a significant or not. 

2. Adequate, standardized and consistent Pay – Along with standardizing the pay across Nation, need to ensure the consistent and adequate pay, adjusting the inflation rate.

3. Addressing Toxic Work Culture: Reforming workplace culture to eliminate abuse of power & exploitation and ensuring proper grievance redressal.

4. Security Measures: Enhancing security and protection for doctors against violence.

5. Support Systems, annual health checkups: Establishing mental health support for physicians and promoting ethical practices.

6. Government and Healthcare System Role: Enabling a balanced lifestyle through systemic changes rather than placing the onus solely on healthcare workers.

7. Gentle Mentoring and Education Reform, with strict 8-hour work per day: The medical community needs to adopt a more compassionate approach towards mentoring. The intense demands of medical education and the inhuman work schedules during internships and residencies need reform. Ensuring that the advice doctors give to their patients about healthy living is also applicable and to be adopted in their own lives. Ensuring 8 hour work may not be possible for a country with physicians per 1000 people of 0.8 [26], but it is completely possible in places like Tamil Nadu, Delhi, Karnataka, Kerala, Goa and Punjab-  where physicians per 1000 people is 4, 3, 1.5, 1.5, 1.3, 1.3 respectively, [27] which have more than 1:1000 of WHO guidelines. Possible solutions also include creating more posts to accommodate more doctors.

Conclusion: 

Healthcare force forms the essential vertebrae to the Nation’s backbone. Ensuring doctors' well-being is crucial for a healthy nation. Without a safe work environment, fair hours, and adequate pay, advising healthcare professionals on work-life balance is hypocritical. Systemic changes with proper regulatory guidelines defining the work hours are needed to improve conditions, support mental health, and protect against violence to reduce premature deaths among doctors. Adequate recruitment, ensuring 8-hour workdays, and addressing systemic injustices are urgent needs.

While the NMC is taking possible measures, effective implementation of these measures is essential to translate it in action, not just in papers. [28] The UK's 4-day workweek trial showed significant benefits, such as increased revenue and job satisfaction. [29] Although this model may not be feasible for public sectors, increasing healthcare spending from 3% to closer to the USA's 16.6% of GDP can improve conditions. [30] 

Instead of glorifying doctors as "God's messengers”, it is imperative to provide them with a better health-related quality of life. We need to implement annual health checkups, wellness schemes, and sabbaticals to help them recover from burnout before it is too late.

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