








































JSSN 2018; 21 (2) 

1 JSSN Journal of Society of Surgeons of Nepal 

Editorial 

Sick Surgeon: Problem and the panacea! 
Bikal Ghimire 

Department of GI and General Surgery, Maharjgunj Medical Campus, Instute of Medicine, Tribhucan University. 

Editor in Chief, JSSN 

Email: drbikalghimire@iom.edu.np 

Gautam Buddha has rightly said ‘To keep the body in good 

health is a duty... otherwise we shall not be able to keep our 

mind strong and clear’. We need clear minds as a clinician 

and more so as surgeon to plan the course of treatment and 

to physically execute it. However, apart from clear minds 

a surgeon should also be physically capable to withstand 

strenuous activities for long periods of time. Daily exertion 

for prolog periods for surgeons leads to poor quality of life 

especially in our subcontinent where health institutions and 

the government do not prioritize the health of clinicians. 

The problem 

The surgeon faces a myriad of health issues related to 

musculoskeletal disorders, cardiovascular diseases, sleep 

deprivation, burn out and mental health issues apart from 

the risks involved in the operation theater. 

A review of ill health in 574 doctors associated  with 

NHS revealed skin related disease, psychiatric illness and 

musculoskeletal diseases and alcohol and drug abuse to be 

very common.1 

With the advent of laparoscopy, focus has always been on 

patient safely and cost but compared with open surgery, 

laparoscopic surgery imposes greater ergonomic constraints 

on surgeons. There is 73% to 88% prevalence of physical 

complaints among laparoscopic surgeons, which is greater 

than in the general working population. Prevalence of 

musculoskeletal disorder (MDS) has been observed to be 

73 to 88% among specialists in minimal invasive surgery 

where as in general occupational population the prevalence 

of backache was 24.7%, muscular pain 22.8%, and neck 

and shoulder pain 23%.  Symptoms  associated  with 

these MSDs mainly include fatigue, pain, stiffness, and 

numbness and such symptoms can affect task accuracy.  
2, 3 A surgeon in pain may not be able to give the 

best possible treatment to their patients. In a review of 

various approaches to prostatectomy, 25% surgeons 

complained that musculoskeletal pain considerations 

impacted their choice of operative approach and 32% 

considered open 

most painful followed by laparoscopic and robotic to be 

the least. 4 

Apart from the strain of physical exertion, surgeons are 

exposed to certain occupational hazards like cuts, needle 

pricks and infections. On average, surgeons report a rate of 

approximately 11 injuries over a 3-year time period. 

Infections due to the exposure to blood, body fluids or 

tissue specimens possibly leading to blood-borne diseases 

such as HIV, Hepatitis B and Hepatitis C and use of CO2 

laser risk infection with HPV (human papilloma virus). In 

the US, of the four million health care workers at risk for 

infection with blood borne pathogens, 25% are surgeons. 5 

Though HIV, hepatitis B virus (HBV) and hepatitis C virus 

(HCV) pose the highest risk of morbidity and mortality, 

there are over 20 blood borne pathogens identified as 

transmissible through sharps injuries. 4B Though HIV is 

dreaded; the risk of seroconversion following exposure 

to HIV from a needle-stick injury is approximately 0.3%, 

and even lower when the exposure is confined to mucous 

membrane or cutaneous exposures. 6 

It supports the need to address the physical health issues of 

surgeons with eagerness. 7 

Apart from physical health, mental health is also an 

important issue. Since time immemorial, surgeons have 

always been stereotyped as brash, arrogant with little in the 

way of human compassion. For many, this may be a way 

of shielding away from the pain they suffer so that they 

can operate with the level of confidence that is required for 

each and every patient and for a few it may be just what 

they are. It has been rightly said that each surgeon carries 

within him burden of a graveyard. (“Every surgeon carries 

within himself a small cemetery, where from time to time 

he goes to pray – a place of bitterness and regret, where he 

must look for an explanation for his failures.’ René Leriche, 

La philosophie de la chirurgie, 1951” ) 

The sheer mental stress imposed trying to save a dying 

mailto:drbikalghimire@iom.edu.np


JSSN 2018; 21 (2) 

2 JSSN Journal of Society of Surgeons of Nepal 

patient and the inevitable failures can be depressing. All 

clinicians are at risk of developing mental health problems 

but surgeons have been found to be the ones least likely to 

seek help.8 

In the UK where the quality of life of surgeons is lot 

better than most developing countries, 10 to 20% become 

depressed at some point in their carrier.9 Suicide is a 

common issue among doctors, and relative to the general 

population female doctors have a 3.7-fold to 4.5-fold 

increased risk of death from suicide, and male doctors 

have a 1.5-fold to 3.8-fold increased risk.10, 11 In a review 

of doctors presenting to the Practitioner Health Program 

(PHP), a confidential London based health service for 

doctors and dentists, it was observed that surgeons had 

myriads of health issues mainly 55% depression and 

anxiety, 30% complex mental health issues and 16% with 

addiction. 

Though this was lower than that observed with other health 

professionals it could be because surgeons are tailored to 

cope better with stress due to their rigorous training or they 

tend to underreport due to the stigmata attached that might 

risk their career. 12 

Violence against medical professionals is a global 

phenomenon as it involves emotional issues for the patients 

and their families and surgeons are more prone to suffer 

from it. There has been increase in such incidences in resent 

years with a survey amongst doctors by Indian Medical 

Association, reporting 75% observing such incidences at 

work. 13 This adds to the level of stress associated with the 

occupation. 

The panacea! 

The Practitioner Health Program (PHP) is a confidential 

London based health service for doctors and dentists. 

Practitioners presenting to the service have considerable, 

often severe, mental health problems, similar to patients 

who present to NHS mental health services.6 Most 

developing countries lack a system to take care of health 

workers by assessing the problems and working towards 

the solution. It is high time various societies and the 

government work together to have a system to address the 

issue before it is too late. 

Burnout has been characterized by, overwhelming physical 

and emotional exhaustion; feelings of cynicism and 

detachment from the job, a sense of ineffectiveness and 

lack of accomplishment; over identification with work to 

the exclusion of other activities and irritability and hyper 

vigilance. It is imperative that all surgeons are aware of the 

features and seek help at the earliest. 14 

A systematic literature review of PubMed, Embase and 

Cochrane Library in spring 2015  for  comparative  data 

on surgeons’ physical workload with robotic-assisted 

laparoscopy and conventional laparoscopy which involved 

2685 records were screened and 15 articles suggested that 

robotic-assisted laparoscopy is less strenuous compared 

with conventional laparoscopy. However, the widespread 

use of Robotics is limited by the high cost involved and 

availability especially in  our  subcontinent.  Prevention  

of spread of sharp injuries and transmission of infection 

during surgeries requires following universal precaution 

and using safety guidelines. However, the compliance 

amongst surgeons is less, most blaming lack of safe devices, 

urgency of the procedure and lack of dexterity and blunted 

sensation associated with double gloving and other safety 

systems though studies have not provided any evidence to 

support it.15 

In the American College of Surgeons (ACS) report, “Being 

well and staying competent: Challenges for the Surgeon” 

created in 2012, acknowledges that healthcare systems and 

hospitals don’t have an incentive to limit surgeons’ working 

hours and the burnout to be reversible and addresses methods 

to tackle burnout.16 They advice for promoting a culture of 

medicine that values work-life balance, promote the “just 

culture” paradigm during training and most importantly, 

give ourselves permission to be sick and to accept good 

medical care. We should also nurture the religious/spiritual 

aspects of ourselves and get involved in non-patient care 

activities (e.g., research, education, administration). 

In the US, work-hour limitations have been implemented by 

the ‘Accreditation Council for Graduate Medical Education’ 

(ACGME) in July 2003 in order to minimize fatigue related 

medical adverse events.17 In Nepal, the remuneration for 

doctors is one of the lowest amongst other developing 

countries. Hence, doctors tend to work for extended hours 

and are exposed to mental and physical exhaustion, which 

is seen more commonly in surgeons. With the need to keep 

updated with rapidly progressing advances in medicine, 

doctors are in the need of attending Continuing medical 

education (CME) programs, workshops and courses. The 

government is also working on making these activities 

mandatory. In this context, health professionals should be 

allocated a 5 days work day with a day dedicated to perusing 

these activities so that their social life is not compromised. 



JSSN 2018; 21 (2) 

3 JSSN Journal of Society of Surgeons of Nepal 

 

 

 
 
 

Conclusion 

To safe guard the health of doctors, we need  to  study 

their present status including physical and mental health, 

timing of work hours and the morbidity and mortality in 

the community. Societies should work to promote health 

and working conditions of the clinicians and lobby the 

legislature to make rules and regulation to safe guard it. A 

healthy clinician will only be capable of delivering quality 

care to their patients that translates into improved health 

care in the country. 

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