Doctors are at the receiving end of this growing menace. Nobody comes to their rescue during such inhuman experiences. The society in general and the government, the courts and the media, for reasons best known to them, are indifferent and at times coercive. Safety and security of doctors does not appear to be their concern or responsibility.
The assaults on doctors in India are becoming so frequent that now it does not arouse any feelings of outrage or resentment in the society. While an assault by an MP on the Air India staff set the whole country boil with rage, assault, abuse and misbehaviour with doctors and nurses while on duty is, surprisingly, taken lightly. It is primarily because of this looming problem that a majority of doctors have started feeling frustrated and insecure, leaving them no other choice but to protest against such abuse and seek protection from the law. Unfortunately, the law and the legal system, owing to its own limitations, has time and again disappointed the medical practitioners and has failed to stand by and protect them. What are the factors contributing to a rise in violence against medical practitioners? What does a doctor do or not do when faced with threats and abuse at the hands of attendants? Also, what should a doctor do or not do to manage such violence?
The insensitivity of the society in general and indifference of the courts and governments in particular, towards this serious issue is worrisome! We have seen the vicious cycle of assault – strike – ESMA – court directions – assurances – strike called off – assault again in the same or another hospital, so many times. The assurances are vague and their execution amounts only to a shameless lip service. The society needs to be sensitised and made aware of the fact that doctors and patients are not adversaries. Why should they be pitted against each other? They both have the common goal – fighting the disease. It is the duty of the government as well as the social organizations and professional bodies of doctors to bring the doctors and public on the same side rather than allow them standing opposite to each other.
Hospital violence is the worst form of workplace violence. It is a violence between the two parties who have been fighting disease ‘together’. It is a violence where one party has its hands tied as doctors are not expected to retaliate, and rightly so. It is a multi factorial problem. Some of the factors are internal (within the fraternity) and some are external (society, government and media). We may or may not have much control on the external factors but we certainly ought to have full control on the internal factors. The main causative factors include:
1. Overall erosion of social bonding. Every one is tending to cling to his rights without bothering about his responsibilities. This is true for all sections of the society.
2. The relationship between doctors and patients has shifted from one of trust to a contractual relationship and both sides do not hesitate in exploiting the other, whenever an opportunity arises.
3. Poor law and order in the society. With lax administration and soft governmental controls, goons tend to dominate over the law-abiding citizens. Moreover, the police force is not adequately trained in handling mobs in sensitive situations.
4. Commercialization and competitiveness in medical practice. There is nothing wrong with this, as these factors ensure better quality of service and care. Over the past about two decades, the gap between the corporate hospitals on the one hand and the smaller hospitals and the public hospitals on the other hand, have grown many folds. The common patient is aware of the quality of care in these different sets of hospitals. His expectations become very high even when he chooses to be treated in the smaller hospital or the government hospital. This mis-match between the expectations and the reality triggers discontent and its consequences.
5. Inadequate control on visitors or patients’ relatives visiting the hospital, especially in the emergency room, ICU and in the OT area. Though some measures are indeed taken in most hospitals yet it cannot be enforced very strictly. We have to be tactfully strict and yet not be rude.
6. Show of might by the ‘powerful’ people in the society is a difficult problem to handle. We need to learn appropriate communication skills to convince them of their contribution in the welfare of their patient.
7. Doctors and hospitals, generally, have poor marketing sense. Statements like “All major and minor operations are done here” or “24 X 7 services” or “Gold Medallist doctors” or “Facilities for all major surgeries available” make an impact on the psyche of a prospective client. Such statements may be fine to attract some clients but if these statements do not correspond to the ground reality and prove to be nothing but tall & false claims, they may trigger litigation or violence.
8. Doctors are generally not very good with communication skills. They usually present a rosy picture in the beginning (perhaps to keep the patient in a positive state of mind) but in the event of an adversity, many doctors are found wanting in their communication skills. They are either in denial or are evasive and sometimes even expect their junior assistant to handle the situation rather than leading the situation when needed the most. The other common mistake is that doctors tend to communicate with the whole group of attendants and often in the corridor or in the waiting area. One wrong word here or one wrong expression in such a scenario may trigger an adverse response.
9. The security staff in most hospitals is poor – both in quantity and in quality. They are usually not well trained to handle sensitive situations or crowd management.
10. The CCTV cameras are either inadequate in number or not strategically placed or are not functioning.
11. Many hospitals, especially the government hospitals, are understaffed. They have to attend to a huge number of patients, go through prolonged and strenuous periods of duties and sometimes under poor working environments.
In a complicated problem like this, obviously, the solution would require a multi pronged approach. Different sections of the society have a responsibility to solve this problem, as everybody is a stakeholder in good and safe healthcare. Some of these probable solutions are briefly discussed below.
The government needs to work objectively in this direction. Some of the tasks include:
1. Public sensitisation on related matters must be imparted in a careful and systematic manner. In a civilised society, nobody should be allowed to take law in its own hands. As a matter of fact, in the healthcare industry, violence should never be an option. In contrast to judiciary (where the aggrieved person is required to approach a particular court depending upon the jurisdiction), the patient has the freedom to approach any hospital and any doctor he likes. He has the option to go to a government hospital or a trust hospital or a private hospital. He can switch over in the middle of treatment. In our country, the patient has the freedom to seek treatment at any level of the hospital, including tertiary care hospitals, even if the ailment is trivial. He has the choice to opt for allopathy or ayurveda or homeopathy or naturopathy or even quacks. Having made a choice and getting treatment from the care givers whom he thought were the most appropriate, there is no reason for show of aggression, if something goes wrong or the treatment does not bring the desired results. This is especially important because the patient, if aggrieved, has several options of seeking redressal for the perceived negligence/deficiency of service etc through consumer courts, criminal courts or medical councils and so on. The governments as well as the MPs & MLAs of different constituencies must discharge their responsibility of sensitising the public on civilised behaviour. It is agreed that for doing this, they themselves will also need to observe a civilised conduct in their day-to-day lives.
2. We often hear about the Essential Services Maintenance Act (ESMA) but that is heard only when the government / district administration wants to coerce the doctors and other healthcare professionals, because they are not able to handle their protest. Do they really believe that healthcare is an ‘essential service’? Probably not! Little do they see that the ESMA entails a huge responsibility on the government and local administration to see to it that the essential services are run smoothly since they are ‘essential’. They must see to it that their infrastructure is appropriate, their equipment is adequate in quantity and quality, the maintenance services are perfect, the people who man these services are well motivated and enjoy a safe and comfortable work environment, because these are ‘essential’ services. It is an utter failure of ESMA if the hospital building is leaking, the taps are blocked, toilets are stinking, the imaging machines are out of order, the wheel chairs in the emergency room are either not there or broken, the ambulance has not been serviced for several years or there is acute shortage of doctors and support staff, they are over worked or medicines and devices are not available at reasonable cost and so on.
3. There is a law for protection of doctors and medical care establishments in several states but unfortunately, the police and local administration is not proactive about its implementation on the ground. The doctors generally have to work hard to convince the police that it should act under the provisions of this law.
4. There must be some serious deterrence against such violence. For example, a person who himself or through his representatives indulges in hospital violence should be debarred from filing a complaint of medical negligence against that doctor or hospital, in that case, in any forum. This will deter them from indulging in violence more than even the Medicare protection Act.
5. The police must be provided adequate training in handling mobs in sensitive circumstances. The police should act as an impartial and neutral party in this scenario. It is demeaning under such circumstances to ‘arrest’ the doctor and take him away in the police jeep, so as to diffuse the situation. This, in fact, amounts to punishing the victim in the hope that the accused will oblige by stopping the violence. This emboldens the violators and empowers the perpetrator of violence and weakens the victim’s faith in the legal redressal system.
The medical professional bodies like IMA and other speciality associations have a huge responsibility in this direction. Most of the time, these associations are engrossed in their internal political wars or running after the ministers for building a personal rapport with them for personal gains. Some of the tasks for them include:
a. A diligent campaign to improve the sagging image of the profession. This would require exposing and shaming the black sheep of the profession, who fleece the patients or resort to cut practice or knowingly do unnecessary investigations or surgeries and so on. The network of IMA (with HQ, state branches and district branches) is so huge that such wrong doers are known to them and if they gather courage and act on collective will, this task can be achieved easily and this will have far reaching results.
b. Prepare proper guidelines for the management of common clinical situations and update them on a periodic basis. These should be circulated to the members so that they observe those guidelines while managing their patients. If such authenticated guidelines are available, the decisions of grievance redressal fora will also become objective rather than subjective.
c. IMA must have an objective mechanism for grievance redressal at district and state levels, with medical and non-medical people of repute on the committee. Such fora should be active and fair, largely to infuse confidence in the minds of the aggrieved patients that there is a forum where they can immediately put their complaint and get redressal, rather than take law in their own hands.
d. IMA would do well to leave academic updating for the speciality organizations. They should utilize all their might and resources to improve the image of the profession and ensure the above mechanisms for a healthier doctor-patient relationship.
e. Develop clinical and administrative guidelines for appropriate work environment, as per international standards. Publicize them and work diligently to implement them across the country. This is true not only for the public hospitals but also for the private hospitals. This has to be done in the name of quality of care, if nothing else. This will enable the doctors to see limited number of patients per day, spend more time with the patients, have proper interaction with their attendants, spend adequate time in writing notes in the patient files, perform surgeries with a peaceful mind. However, the running cost of the establishment has to come from the beneficiaries of the service. The charges should be raised appropriately. Yes, it does irk the society but any good quality work means a higher charge. IMA can provide some guidelines with respect to charges and that may be followed by the members so that there is no allegation of arbitrariness. However, it goes without saying that the charges should be well displayed and the estimates should be discussed (and documented) with all patients ‘before’ a particular service is provided.
f. The doctors should join social organizations (e.g. Rotary club, Lions club, Gymkhana club) etc for socialization rather than have such activities in IMA or in their professional associations. This will help remove the social isolation of the doctors, whereby they are often perceived to be arrogant and high headed. Moreover, it will spare the resources of its own associations for more constructive remedial measures.
g. The medical associations must be proactive and expressive on all matters related to different social issues and particularly those related to health, healthcare and healthcare providers. They, as an organization (not as individuals), should develop a good rapport with the political and bureaucratic class as well as with the media.
h. The medical associations should develop a good network with all their members, through interactive website and/or through social media sites. These will provide a platform for conveying of vital health related information as well as exchange of ideas, opinions and concerns.
The solutions should also come from the doctors and hospitals themselves. Ours is a free country. ‘Self-regulation’ may or may not happen. However, as intellectuals who are at the receiving end of litigations and hospital violence for quite some time now, it is important that medical professionals arm themselves with certain skills and employ certain practices that make their practice professionally comfortable and as risk free as possible. In this connection, it is important to:
1. Learn from the past experiences of self and others.
2. Sincerely undertake the preventive measures.
3. Time has come when doctors should genuinely accept that they are not “Second Gods”. They are just skilled professionals, whose services can be hired. Similarly, each patient should be considered a potential litigant and each gathering a potential mob.
4. It is not a good idea nowadays to project very highly of skills and facilities available. Medical practitioners should be very realistic about it, if at all it has to be done. Ironically, it is more important to convey, if not project, and display your and your hospital’s limitations.
5. If during the period of hospitalization, you find an aggressive or abusive attendant, it is a good idea to put a bold code (say VIP or Caution or something else) on the file and with each repetition of such conduct add one plus against it. If it reaches say 3 plus, consider referring him to a higher centre. You have to develop some mechanisms to identify troublemakers ‘before’ they actually cause violence.
6. Availability of the treating physician when a complication or death occurs is very useful. In case he is not available and not accessible even on phone, generally, the attendants get angry. The behaviour of the staff as also their communication skills, especially while conveying bad news, are also matters of grave concern. Avoid direct communication with a large group and in the corridor or waiting area. All sensitive communication must be done with 2-3 sensible representatives of the patient, in a comfortable room, preferably under CCTV watch. Proper periodic training of the staff in this direction should be mandatory in all hospitals.
7. Feedback forms are a simple mechanism to allow patients or relatives to vent their feelings when they see something not to their liking. If you address the issues mentioned and convey to them the action taken, this will send a good message and give them an assurance that their grievance has been addressed and an escalation could be avoided.
8. When a hospital death occurs, clearance of the bill can be very tricky. If you present the bill this might be provocative. If you don’t, they might presume that you didn’t do it because you were guilty within. So, it is a good idea to raise the bill but do not press for it. Proper counselling should be given to the attendants or close family of the deceased in case of a hospital death.
9. Be ever vigilant and escalate the steps to be taken, in case there is anticipation of trouble.
10. In case violence does happen, there must be a swift mechanism in place so that the damage is reduced to the bare minimum.
11. The cases of violence should be taken to their logical conclusion because appropriate penal action in such cases will provide some deterrence against future violence.
12. The security at vulnerable points in the hospitals should not only be adequate in number but also it should comprise of people who are well trained to handle sensitive situations.
Doctors are at the receiving end of this growing menace. Nobody comes to their rescue during such inhuman experiences. The society in general and the government, the courts and the media, for reasons best known to them, are indifferent and at times coercive. Safety and security of doctors does not appear to be their concern or responsibility. The fact that they come under essential services, is considered relevant only to pressurize them to call off their strike but is never seen as their bounden duty to provide a congenial work environment to people who man these essential services. We should continue to sensitise all sections of the society to contribute in improving the situation. However, at the same time, we must undertake and employ measures which are under our control.
Dr P K Kohli is a medical graduate from Rohtak, MS & PhD in surgery from PGI Chandigarh, and LLB from Delhi University. After a brief stint in the faculty of Medical College, Rohtak, he started his nursing home at Sonepat. Here he was known for ethical surgical practice and pioneering laparoscopic surgery programme. His unique laparoscopic surgery training programmes approved by the IMA & IAGES, had attracted about 450 surgeons and gynaecologists from different parts of the country. In 2008, he shifted to Artemis Hospital, Gurgaon where besides heading the General Surgery & Trauma unit, he was Dean, Medical Education. After four years at Artemis, he has worked as Medical Director & Head of Legal services for different hospitals. His main interests are Medico-legal Services, Quality & Patient Safety and Medical Education.
Roohi Kohli is an accomplished advocate and accredited mediator, after having done her BA LLB (Hon) from NLUI Bhopal and LLM (with merit) from University of London. She is presently Editorial Manager, LexisNexis India, RELX Group.
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