The Tribune, Chandigarh, India

Mental health and work
By Dr Narendra N. Wig

ONCE again we will be celebrating World Mental Health Day on October 10. This event is organised by the World Federation of Mental Health and celebrated in many countries, including India. This year's theme is "Mental Health and Work".

Work has a very close relationship with mental health. Healthy and creative work produces good mental health while good mental health, in turn, is essential for the good quality of work. It is now well recognised that stress at work is one of the important factors in the causation of many kinds of physical and mental disorders.

On the other hand, mental disorders are one of the frequent reasons for absenteeism, resulting in enormous losses in business and industry. Other related issues in mental health and work are matters like child labour, which deprives children of healthy growth of mind.

Equally important is the issue of social stigma and discrimination at the workplace which deprives the mentally ill of the right to work and hampers their recovery and rehabilitation.

1. Stress at workplace:
As a psychiatrist, I am often struck by the frequency with which patients talk about the stress in their work. It may be the unhappy relationship with the superior or the colleague or it may be the quantum of work and long hours which the individual is unable to cope with. It may be job insecurity or certain unethical practices which the person resents or it may be the sheer boredom of the repetitive and uninspiring work.

The stress at work comes in many shapes and forms. In the present times, one of the worst-affected groups is that of working women who are expected to perform efficiently both at home and at work but often have to suffer gender insults and sexual harassment in many forms in a male-dominated workplace.

2. The Working Environment and Health:
In recent years, there is growing awareness that the work environment is very important for the workers' physical and mental health. Many architects now recognise the "Sick Building Syndrome" — a condition in which a proportion of the occupants of a building experience varying degrees of low-level non-specific sickness or discomfort dominated by sensory reactions.

The components of a bad environment may be excessive heat, humidity, dust, poor lights, lack of fresh air, overcrowding, excessive noise and many other factors.

Once a depressed patient, who was a tailor's assistant, told me how he shuddered at the thought of going to work every morning. His place of work was a low attic in a shop where there was not even enough space to stand and he had to spend 10 hours crouching over his work.

3. The Impact of Information Technology:
The Information Technology (I.T) revolution of the last two decades has affected all spheres of life. The work situation is no more the same as it used to be. The computers and the Internet have infiltrated into all fields of life. Of course, there are many advantages to the working persons with the new technology; it makes things happen much faster and you can plan your own routine and work at your own place but it has also brought new tensions. The difference between office — a place to work at — and home — a place to relax at — is getting blurred. The computer is now right in your bedroom beckoning you to work all the time and the laptops and the cell phones literally go with you in every holiday travel. For most of the workers, information technology means routine, repetitive and boring data-filling tasks.

There is a small lucky minority that are in the higher echelon of the programme and software development who are enjoying unparalleled success and wealth. Their life is also very hard. They overwork and have to use their mental faculties all the time in work.

The cut-throat "hyper competition" makes life very tough. There is no time to relax. The worse thing which the computer does is to isolate you from social life.

The computer chat-rooms are no substitutes for real people. These new patterns of business behaviour have serious mental health implications.

Work is not only the job people go to; it is a community they belong to, a location where they meet and see friends, a place where they develop a sense of self-respect and strength of purpose in life. The computer age is changing all that.

4. The Cost of Job Stress:
In 1992, the United Nations identified job stress as a "20th century epidemic". The World Health Organisation called it a "Worldwide epidemic". The US National Institute for Occupation Safety and Health reports that stress-related disorders are rapidly becoming the most prevalent reason for worker disability. Recent research shows that nearly 40 per cent of employee turnover in the USA is due to on-the-job stress. It is estimated that the cost of job stress to American industry is something like 200 to 300 billion dollars annually owing to related factors such as absenteeism, diminished productivity, employee turnover, accidents, direct medical, legal and insurance fees and workman compensation awards.

The figures for India are not readily available but there is not much doubt that job stress is costing our industry very heavily in terms of financial loss and human suffering.

5. The Effect of Stress of Health:
The effects of stress on the body and the mind are well documented. One of the common reasons for people to consult doctors is due to the effects of stress. Headache, pain in the back of the neck, lower backache, pain in the limbs, stomach upset, excessive gas formation, palpitation, pain over the heart region, weakness, tiredness, and many other physical symptoms without any physical disorder on investigations, mostly turn out to be stress-related.

On the psychological side, there is often poor sleep, poor appetite, lack of sexual desire, poor sexual performance in males, imaginary fears, being anxious and tense on minor things, the misuse of alcohol and drugs, hysterical fits in women and so on.

The list of stress-related symptoms is very long indeed! Some of the diseases, however, require special mention and one of them is depression. It is a very common illness but, unfortunately, often missed by patients, and even doctors, who are not well-trained in psychological medicine. Apart from some of the symptoms listed above, there is a feeling of sadness, the inability to enjoy oneself, the lack of interest in work, family and friends, irritability, self-blaming, feelings of hopelessness and even thoughts of suicide. The person feels trapped in his/her circumstances with neither the will to fight nor the capacity to run away from it. Luckily, it is mostly a treatable and curable condition. With appropriate modern medical treatment, the course of the disease is cut short.

Chronic stress of long duration often leads to more serious problems because of the lowering of the body immune processes which are nature's defence system. It can contribute to conditions like persistent rise of blood pressure, heart attacks, diabetes, allergy, repeated infections and many other disorders.

6. Work as a Part of Good Mental Health:
Work is not always a stress-producing activity. In fact, happy and healthy work is the best tonic for good mental health. The key is to be able to do work that is to your liking and within your capacity. Challenge in work is the real thrill of work. Work without challenge tends to get boring and repetitive. It was probably Einstein, who once said that "The secret of happiness is doing a task which is difficult but not too difficult". Unfortunately, the right level of difficulty varies from individual to individual and there is no universal level of work about which every one will be happy.

It is important that the place of work should be made conducive to mental health. Unfortunately, very little attention is being paid to this aspect in our offices and factories. In view of the rising cost of mental illness because of stress at work, it is high time the senior management in offices and industry paid attention to this aspect. The following are some of the suggestions for de-stressing the modern workplace:

1. Modify the pressure placed on the working people by a healthy environment and sound management policies and practices.

2. Keep the mental health of the workers as an integral part of the business agenda and regularly brief the senior management about it.

3. Improve interpersonal communication at all levels.

4. Provide recreational facilities for workers.

5. Arrange regular sessions to teach workers how to reduce stress by techniques like yoga, relaxation and exercises.

6. Organise professional help by counsellors and such other persons for the vulnerable members of the staff at an early stage.

Dr N.N. Wig is Professor Emeritus of Psychiatry at the PGI, Chandigarh, and an internationally known mental health consultant.

Vagaries of medical malpractice
By Dr Surendra Kumar Jindal

Undoubtedly, law is the custodian of any civilised society. Seeking legal remedy is the final recourse which an aggrieved person is likely to take. Incidentally, an increasing number of patients suffering from inadequacies of treatment are also seeking remedies in courts. Doctors, on the other hand, have always found this practice obtrusive to the delivery of good treatment. There are several issues where medical and legal opinions and actions are rather contradictory. This discussion involves only the acts and judgements of doctors' practice in good faith and with honest intention. In no way, it is intended to defend any criminal or other unlawful activities of any person or profession which, unfortunately, also are on the rise in recent times.

Several of medical practices can be interpreted as malpractices, "negligence" or "dereliction of duty" when these are scrutinised by rigid legal standards. This may not necessarily be so on scrutiny by well-meaning medical personnel.

The law decides about negligence on the basis of the evidence presented to it and does not appreciate the background factors into account which are less objective but guide the doctor to take a particular decision. The evidence taken from the files is usually incomplete since personal experiences and reasons are not essentially documented in each case file. Moreover, doctors are not good record-keepers. They spend most of their time in practical work — attending to patients. Some of the medical decisions are very sudden and spontaneous based upon a mixture of knowledge, intuition and wishful thinking. In case of a misjudgement, the law always asks for the record, which is often inadequate.

It is rather easy to criticise or condemn a treatment choice proved wrong afterwards, although it is always a challenging exercise for a doctor in the beginning. The hindsight of a treatment through a retrospectroscope is totally different from the initial medical approach to the problem. A lawyer bases his opinion on precedence and logic while the doctor's decision, even though based upon known concepts, is invariably and heavily biased by his personal experiences. Moreover, present-day medicine is heavily inflicted by controversies. A therapy which is claimed to be useful by one group of scientists may be condemned by another. Similarly, what is right today may well prove to be wrong, or even dangerous, tomorrow. A non-medical person can hardly appreciate these difficulties.

The situation is even more complex regarding the trial of a new medical or surgical therapy or a procedure where no previous experience is available. Any such therapy may prove useful, or worthless, or even dangerous. What would be the legal opinion in such cases? If the doctor has to work under the constant fear of prosecution, no progress can be made in medicine and society has to remain content with what is available.

It is the accepted practice for the doctor to weigh the pros and cons of any procedure and he proceeds only if the medical book-keeping shows the odds in favour of the expected gains. The physician has an obligation to discuss the risks involved, but is it a must for him always to discuss the horrendous-sounding list of all the side-effects of drugs? The reported rare effects, for example of routinely used and relatively innocuous drugs (such as analgesics and antihistaminics), include depression of blood-forming marrow, severe dermatitis, shock and even death. Would it be justifiable to frighten the suffering patient by telling all these "probabilities" and increase his miseries? Every routine injection or operation carries the risk of death, but would the patient and/or his/her relatives, already scared, really appreciate the given list of all the awful things that "might" happen?

The doctor faces the most distressing problem presented by the patient with incurable disease when death is inevitable. Patients may find it easier to share their feelings about death with physicians who are likely to be more objective and less emotional than their own family members. Must the patient be told "everything"? Legally, yes. But physicians are often circumspect.

Sir William Osler, the father of modern medicine, had aptly stated:"One thing is certain, it is not for you to don the black cap and assuming the judicial function, take hope away from any patient.... Hope that comes to us all".

Doctors are often asked to suggest solutions to personal problems by friends and others at private meetings and gatherings. But is it wise for them to give off-hand advice? Every word uttered by a doctor on a medical topic to a layman can make him liable in negligence. Unfortunately, many pieces of medical advice are generally misconstrued and misinterpreted by people with reference to their own knowledge and belief.

Medical negligence is more of an anticipated finding. It is not a wilful act and is sometimes practised even knowingly when the doctor has to deal with the risks of a therapy for the benefit of the patient. Similarly, to "hide" certain facts and give "false hopes" to sick and/or dying patients are inherent in the nobility of the profession even though they may be wrong in legal terms.

Dr S.K. Jindal is the Professor and Head of the Department of Pulmonary Medicine at the PGI, Chandigarh

Advanced laparoscopic surgery at PGI

A 20-year-old boy was suffering from progressive difficulty in swallowing food for the past four years owing to a disease called "Achalasia Cardia". This disease is characterised by the extreme narrowing of the lower end of the food pipe (oesophagus). Lately, he had developed heaviness and discomfort in the chest along with regurgitation of the foul smelling food matter. Prior to his admission at the PGI, Chandigarh, he was unable even to take liquids. A barium contrast study revealed that his oesophagus was markedly dilated and tortuous and there was complete obstruction at its lower end. Repeated attempts to dilate the oesophagus failed. The only option left for this patient was conventional open surgery with a long incision, more pain and higher complications resulting into prolonged hospitalisation.

Thanks to the progress made in laparoscopic surgery, besides the gallbladder stones for which this surgery is almost standardised, even the surgery for the oesophagus, the intestine, the liver, the spleen, the kidney and the adrenals has come within its fold. Dr G.R. Verma, a pioneering laparoscopic surgeon and a member of the Endoscopic and Laparoscopic Surgeons' Association of Asia, started laparoscopic surgery at the institute and he is credited with the performing of the first laparoscopic cholecystectomy here.

The patient under reference was admitted under his care. After a thorough evaluation, advanced laparoscopic operation"Laparoscopic cardiomyotomy", the first of its kind of operation at the PGI, was successfully performed. The patient made excellent post-operative recovery. A barium contrasts study after the operations showed that the food pipe had opened and the contrast was flowing freely into the stomach.

The operation was performed with the help of five laparoscopic ports — three each of 1 cm. and two 0.5 cm ports in the upper abdomen. The surgery had to be performed meticulously to avoid injury to important organs like the liver, the heart and the lungs. Any mishap during the operation might lead to disastrous consequences.

Advanced laparoscopic surgery like this requires a mastery of knot-tying and suturing from outside the body without actually touching the organs, which is a rather difficult process and very different from those used in open operations as well as in basic laparoscopic surgery.

To perform advanced laparoscopic surgery, it requires competence and dexterity in basic laparoscopic techniques and experience in comparable conventional open surgery. Additional hands on training in advanced laparoscopic surgery are also a prerequisite.

Dr Verma, a Fellow of the Royal College of Surgeons (Glasgow), has undergone training and hands-on experience in laparoscopic surgery in Germany and Japan. Beside that he has also participated in a number of workshops and conferences on such surgery. He believes that in the near future, all types of advanced laparoscopic operations will be performed at the PGI, which has top-ranking seniors, an excellent atmosphere and administrative and staff support of high quality.

Laparoscopic surgery, which has made rapid strides in every specialty of surgery, is going to be the most popular method of its kind in the coming millennium. And rightly so, because laparoscopic surgery has significant merits and is a major advance in the treatment of patients.

In the beginning, such surgery may be costly but with the passage of time its benefits like less pain, quick recovery and shorter hospitalisation, will tilt the balance significantly from merely the cost factor.

No new surgical technique can be popularised by gimmicks. It has to prove as patient-friendly and safe — and should be within the reach of the common man. Today, virtually every patient of gallbladder stones wants laparoscopic cholecystectomy. This trend is likely to cascade down to various types of abdominal surgery. However, cautious enthusiasm is needed on the part of the surgeon. Without proper training, advanced laparoscopic surgery may prove to be the doom of the surgeon as well as the patient.

— KPS