Incidents of violence against doctors are being increasingly reported in India. A recent nationwide strike saw doctors boycotting outpatient services for a day, but without affecting emergency care. This was a clear indication of the frustration felt by the healthcare community. Although the incident occurred in West Bengal, the fact that doctors in all states of the country stood together in unity is noteworthy.
While discussing the topic of healthcare violence, it must first be realised that delivery of healthcare in India is subject to severe limitations. Several of these limitations are beyond the control of the individual doctor. In most instances, doctors work in overcrowded settings, with limited supply of essential equipment and personnel. This is particularly true in most of the government-run and a few private healthcare settings. Inexperienced young doctors who have just completed training are often thrown into the deep end of the pool, with inadequate supervision and backup. Lack of sleep, irregular meals, suboptimal training in communication skills, limited time with family and relentless pressure to advance one’s professional career by appearing for numerous competitive examinations add to the stress of these young doctors.
That being said, a patient does not visit the doctor with an intention to create violence. Violence is often the end result of a series of unfortunate events. Spontaneous violence can be compared to a wildfire: it occurs only when certain conditions are simultaneously met. A natural wildfire occurs only when lightning strikes the right kind of dried vegetation in a forest in summer, during a time when there are no rains, the air is warm and there is a breeze that helps the fire spread.
Likewise, violence can occasionally break out when several of the following conditions are met:
An unexpected bad outcome occurs for a patient when there is a lot of emotion and guilt in the air
Prejudiced or dissatisfied bystanders who are already unhappy about the quality of care given in the past
Loose talk and allegations of a cover-up, often made worse by crowds and alcohol
Perceived or real rude behaviour of healthcare providers or staff
Failure of doctors to effectively communicate with the family
Non-existent local grievance redressal systems
Mounting medical expenses
Absence of adequate security measures in the hospital.
This article is written to critically analyse the topic of healthcare-related violence on a broad canvas, discuss the limitations of our healthcare system and put forward workable solutions.
Violence cannot be justified, and requires specific legislation
In a democratic country like India, healthcare-related violence cannot be justified under any circumstance, regardless of the nature of the complaint.
In this context, it should be noted that most people are peace-loving and will not resort to violence even under duress. However, there is a section of society that believes in violence as a means of expressing discontent. The only deterrent for such people is the fear of severe punishment. Specific legislation is required to achieve this. While in Kerala there is a Hospital Protection Act with a non bailable clause since 2012, what is required is a nationwide law that protects healthcare establishments and personnel from acts of violence.
The need for communication skills training in Medical colleges:
The ability of a doctor to listen empathetically, and speak with clarity and compassion to the anxious patient is both an art and a skill. The same subject matter can be presented abruptly or empathetically to the patient by two different doctors, depending on their skill sets. The choice of words, the tone, the style of speech, facial expression, body language and professional etiquette are important. These factors are sometimes overlooked by inexperienced doctors during communication of matters of serious nature.
At this time, medical students in India do not learn communication skills as part of their curriculum. Although knowledge of science subjects is necessary, it is the communication and soft skills that enable them to become a complete doctor. This subject must therefore be given equal importance in the curriculum. It is learned that a welcome change will occur from 2019 onwards.
In fact, all healthcare personnel who interact with patients and bystanders must be trained in soft skills, and adept at communication. This includes not only doctors, nurses and paramedical staff, but also those who work in administrative, billing, clerical and security sections. Unsympathetic, indifferent or rude behaviour from any team member could be the first step in a chain reaction that eventually results in violence.
Security measures in the workplace
Violence in healthcare settings is more prone to occur in the casualty (E.R.), and the waiting areas of ICU, labour room and paediatrics. Diseases that are treated in these areas tend to be of more serious nature. Unpredictable outcomes could sometimes occur, triggering emotional reactions. Unsurprisingly, healthcare-related violence is a problem in several countries including the UK, US, Australia and China.
According to mob psychology, a crowd of four or more people behaves differently from a group of less than three. The actions of a large group are frequently determined by the person of lowest moral and social standing. In fact, the person who initiates the physical assault is often someone who is not closely related to the patient.
Security measures including CCTV cameras must be installed in high-risk areas. The number of bystanders must be restricted by employing professional security officers, who also actively monitor the premises. As part of crowd control strategy, it must be made clear that a hospital is not a place for social visits. Hospitals that implement an upper limit of two bystanders per patient have reported lower incidence of violence. The tendency for large groups of people to enter the casualty with a patient must be curbed. The emergency department must always be manned by experienced staff who can politely but assertively communicate with bystanders.
Grievance redressal systems must be locally available
Every healthcare establishment must have an efficient grievance redressal unit that swiftly identifies discontent, gives an empathetic hearing to the aggrieved, and is proactive with remedial measures. A stitch in time literally saves nine; it is easier to put out a small spark than fight a large wildfire. Many wars have their origins in seemingly trivial incidents that were not dealt with early enough.
Therefore, it is helpful to have professional in-house grievance redressal systems that are manned by experienced and committed staff. Most of the common complaints can be dealt with by such a forum. The advantage of a local forum is that remedial measures can be immediately undertaken as required; this will in turn help other patients in the future. If it still can’t be solved, patients have the option of approaching local regulatory bodies.
A common reason for aggravation is when patients feel that their grievance is being ignored by their healthcare providers. This prompts a few of them to resort to unorthodox and destructive methods of retaliation, which unfortunately do not generate positive outcomes for anyone.
Crowd control and triage
In India, there is a mismatch between the volume of patients and the availability of doctors. The availability of doctors varies widely according to region. Some states like Kerala, Karnataka, Punjab and Delhi have more doctors per 1000 population, when compared to other states. In India, 74% doctors reside in urban areas, catering to only 28% of the population. Thus, rural areas suffer the most from shortage of doctors. Overcrowded and understaffed clinics are common. It is not unusual for a doctor to be asked to see over a hundred patients in two hours. In such settings where a doctor only gets to spend a few seconds with each patient, communication and counselling are impossible to achieve.
Even the most skilled doctors in the world will not be able to contribute anything worthwhile if they were posted in some of these establishments. Without attempting to improve infrastructure and manpower at government-run clinics and hospitals, it is unfair and counterproductive to blame the doctors who happen to work in these areas.
In developed nations, all elective, non-urgent cases are seen by appointment, in contrast with the chaotic walk-in system that is the norm in most parts of India. Although the appointment system can involve a few days’ wait, this ensures that all patients receive quality care during their visit with the doctor. Bringing in the system of appointments is a good first step that will allow doctors to prioritise their work according to the merit of the situation.
Triage is the system by which patients who arrive at a hospital are streamlined according to their level of discomfort and priority, so that delivery of healthcare is efficient. Triage system at a busy outpatient clinic can be likened to the presence of an expert traffic police officer at a crowded intersection. Without traffic regulation, there is chaos and all traffic grinds to a standstill. Likewise, without triage, patients can be seen wandering aimlessly in the hospital corridors - often crowding around the doctor’s table, with several people demanding to be seen first.
The doctor needs a peaceful work environment
Doctors are intellectual people who make important clinical decisions based on multiple complicated parameters and data, after correlating with their own knowledge and past experience. The quality of these decisions depends considerably on the workplace environment. No doctor will be able to perform competently when rushed or threatened. Ensuring a peaceful workplace is an important part of any medical establishment.
For example, a child health clinic will be visited by many babies who are crying, all of whom are not really sick. To the lay person however, they would all seem equally ill. Besides, babies can’t explain how they are feeling through spoken words. But a paediatrician has the extraordinary ability to tell a sick baby from a healthy one simply by listening to the history provided by the parents and by keenly observing the child. This decision could sometimes mean the difference between life and death for the child. However, to achieve this, the doctor needs time to focus, listen, observe and think calmly.
Not all doctors can work effectively in all settings. To the extent possible, for their own safety and peace of mind, doctors must try to find a work setting that they feel comfortable in. However, this can be impossible during training, and relatively difficult during the early days of a doctor’s career.
Doctors need to realise that they are vulnerable to the same physical and mental ailments as anyone else. A doctor who is stressed out might come across as rude and incompetent to patients and bystanders. Identifying and treating work-related stress early is important to prevent physician burnout.
Hospitals must become patient-friendly.
Most of the hospitals in India are not patient-friendly. The construction and functioning are often conceived from the perspective of the hospital administration, rather than the patient. As a result, patients lose considerable time and energy by wandering through various sections and payment counters of the hospital, fulfilling the requirements of the hospital’s administration. Inefficient systems and service delays at various counters aggravate the dissatisfaction.
Reengineering is required to make hospitals less tedious for patients and their bystanders to visit. Paying close attention to patient satisfaction surveys and feedback during peaceful times will be helpful to nip potentially serious problems in the bud. Softening the ambience with some artwork and calming music will help reduce the overall anxiety level while patients wait to see the doctor.
Quality of support staff
No doctor is able to work alone: healthcare is almost always a matter of teamwork. The team typically includes doctors, nurses and other hospital staff, some of whom are clerical. Even if the chief doctor’s knowledge and skills are first-rate, the effective work output from the team will depend largely on the quality and diligence of the other members. Shoddy work from any team member could lead to a bad outcome.
Examples of such shortcomings include a technician who inadvertently enters the wrong name on a biopsy specimen bottle, a house surgeon who fails to double-check the blood type before a transfusion, a clerk who copies and pastes the wrong paragraph on a scan report, or a nurse who does not promptly recognise an anaphylactic reaction. Each one of these instances could potentially lead to a complication, including death -- for which unfortunately the chief doctor takes the blame.
In India, although there are several good people who keep the healthcare system afloat in spite of limitations, the overall quality of available support staff is significantly lower than the norm in developed nations. Unauthorised paramedical and nursing training establishments contribute to this irregularity of standards.
Attrition rates are high in the private sector, which means that many newly inducted staff members leave the unit as soon as they become competent. The doctor therefore needs to constantly educate, supervise and motivate the team so that errors can be prevented and quality be maintained.
Steps for error prevention and audit.
Any system is prone to errors, and to err is human. However, unlike most other fields, an error in healthcare can occasionally lead to a tragic and irreversible outcome, even death. Therefore, healthcare systems must have systematic error-detection mechanisms in place. Maintaining custom checklists, conducting periodic audits and holding quality improvement meetings with the whole team are practical methods of minimising error rates.
All errors do not lead to complications, and not all complications are due to errors. For example, a patient with no past history of allergies can suddenly develop a life-threatening anaphylactic reaction after taking a medication. During labour, a pregnant woman can suddenly collapse from amniotic fluid embolism. These are inherent risks--none of which are preventable. In other words, they are not due to a mistake committed by an individual.
However, when a complication occurs, every effort must be taken to save the patient and ensure the best possible outcome. In addition, a systematic investigation must be conducted to find out the root cause of the problem. The root cause could be completely different from what is immediately apparent. Emotional outbursts, knee-jerk reactions and finding someone to blame are definitely not the right way to approach a problem.
For example, when film actor Sreedevi’s mother was operated for a brain tumour in Memorial Sloan Kettering Cancer Centre in the US in 1995, she was expected to receive the world’s best treatment. Unfortunately, the neurosurgeon operated on the wrong side of her brain. The hospital did a systematic investigation, and found that the surgeon had looked at the wrong patient’s X-rays just before operating.
In addition to doing everything to take care of the patient and initiating disciplinary action against the neurosurgeon, they also introduced a ‘time-out’ system for all future operations. This meant that before any surgical procedure, the team would assemble around the patient, go through a last-minute checklist and reconfirm the nature of the operation and the side to be operated upon – almost as a ritual. Even today, this protocol is followed all over the world.
The moral of the story is that they were able to find the root cause of the problem and solve it with a simple measure. The root cause was that in a busy hospital where there are several operations occurring simultaneously, the details of one patient could inadvertently get mixed up with another. What is remarkable here is that their systematic approach to problem-solving helped reduce the number of wrong-side operations in other centres too.
Medicine is an imperfect science.
It is important to acknowledge that medicine, as we know it, is an imperfect science.
Unlike a bicycle, mobile phone or a car, the human body is not a man-made object. It does not come with an instruction manual. Over thousands of years, physicians and healers have tried to understand the mechanisms of health and disease, and numerous contrasting theories and treatments have been proposed, none of which are perfect. As we examine the forward timeline of science, it is evident that a good number of accepted treatments of the past are being proven false as more research emerges.
Although modern medicine has made significant strides in the past two centuries owing to scientific research from all over the world, the ability of science to understand and treat disease still remains grossly inadequate. It would not be wrong to state that the efficacy of modern medicine at this point in time is no more than 10% of what would be deemed optimal.
We do not have even have the ability to treat pain effectively, let alone restore damaged nerves, brain, lungs, pancreas or heart tissue. Although we claim to have discovered certain ‘risk factors’, we still do not know what actually causes diabetes, hypertension, heart disease or cancer. Our outdated stock of antibiotics has become severely limited against worsening drug resistance, and very few new drugs are in the pipeline. Apart from a few diseases like polio and Hepatitis C, we still do not have a cure for the vast majority of viral diseases—including the common cold. These limitations apart, a larger problem is the delivery of available resources to those in need.
Unfortunately, a large section of the public does not understand these limitations of medical science. Instead, they equate the human body to a bicycle or car that is taken to a repair shop -- and expect the doctor to make the problem go away. However, due to the complexity of the human body, not all medical decisions would lead to a good outcome, regardless of the best intentions – and any failure could be regarded as a fault of the doctor. It is critically important for doctors therefore to educate the general public about these limitations.
A common example is pregnancy, a condition that is taken lightly by many lay people. In fact, there is a small but significant risk of complications and mortality that accompanies pregnancy. Adverse outcomes for the mother and child are reported--even in developed nations. Unfortunately, when such outcomes occur in India, it is often perceived as a fault of the doctor or hospital. Derogatory remarks, violent outbursts and negative propaganda against the doctor are becoming common in India when such events occur. This topic had been discussed in detail in my earlier article.
The MBBS selection process is flawed, and needs to be changed.
In India, the criterion for MBBS selection is the ability to score high marks in an MCQ (multiple choice question) test. However, a person who scores high marks in a science test need not necessarily become a good doctor.
Besides, MCQ is not a reliable method of assessing the depth of someone’s knowledge. Two people with equal knowledge will score different grades when subjected to the same MCQ test. This is due to the effect of coaching, where students study from established question banks, and also learn to guess the correct choice—even if they do not know much about the topic addressed in the question.
In fact, the obsession with scoring high on MCQ’s continues through undergraduate, postgraduate and subspecialty medical education in India. Experts in medical education are increasingly concerned that in India, medical students and junior doctors show more interest in preparing for the next entrance examination, than to learn medicine the traditional way by spending time with patients.
In an ideal world, in addition to academic excellence, the admission criteria to medical college must also include non-academic parameters such as the personality of the student, civic sense, baseline communication skill, ethical and moral outlook, and aptitude to serve. In India, CMC Vellore is the only medical college that followed all of these criteria for selecting their medical students.
Attempts to improve the MBBS selection process in the country must start now, through discussions with experts. Due to logistical limitations, it will not be practical to immediately perform such multi-pronged assessments for all MBBS applicants in the country. Instead, assessment of these important non-academic parameters could start in middle school through a tamper-proof, objective, central reporting protocol that is common across all schools in the country.
In addition to their regular grades, all school students could be given an Aggregate Civic Score (ACS) similar in concept to the acclaimed GPA (Grade Point Average) score of the US. The ACS can incorporate all of the above non-academic parameters—slowly accumulated by the student over a period of 5-8 years. In contrast to the grossly diluted 12th grade marks system which is gradually losing its discriminatory power, such a unified ACS score will not only be helpful when they apply for college admission and employment, but also serve as a powerful incentive for students to become responsible citizens.
The need for good role models
Medical students need good role models to emulate in later professional life. In addition to acquiring scientific knowledge, medical students also learn mannerisms, behavioural traits and conversation style by passively observing their seniors. If an influential senior or faculty member happens to be arrogant, greedy or corrupt, at least a few students might turn out to be such a person later in life. Not only do medical students need to be selective about whom they wish to emulate, medical colleges must strive to employ faculty who have exemplary ethical and moral values in addition to their academic credentials.
Doctors need to accept feedback and critically look at themselves.
As a group, doctors tend to hang out mostly with their peers, and have a sceptical attitude towards any criticism that is directed at the profession. Many doctors feel angry, victimised and let down by society, which contributes to this mindset. Perhaps as a result, they tend to react negatively to any suggestion to improve their own services to society.
It is important for doctors to mingle with all walks of society, and patiently listen to criticisms. They must realise that not all criticisms are of malicious intent. As in any other field, criticisms must be seen as part of a continuous self-improvement process. An impassionate open-minded approach is the best way to solve a problem and find a workable solution.
The doctor-patient relationship and medical ethics
The patient’s perspective is often quite different from that of the doctor. Depending on the cultural, educational, social and economic background, the patient’s outlook and expectation can vary. Attempting to understand this is essential for a healthy doctor-patient relationship.
In clinical practice, no two patients are the same. Medical decision making can involve the simultaneous processing of multiple clinical and non-clinical parameters including empathy, culture, compassion, ethics and perception – a process that is beyond the ability of the world’s finest artificial intelligence systems.
A few examples requiring complex decision-making are given below:
A teenager who is a Jehowah’s witness gets admitted to the ICU with severe bleeding and refuses a life-saving blood transfusion on religious grounds.
A demented widowed man with advanced cancer refuses to be fed through artificial means, and there is difference of opinion among the sons and daughters.
A patient who is on immunosuppressive medication for severe colitis does not follow instructions, leading to a serious complication.
A patient with pneumonia comes to casualty with severe breathing difficulty, but a ventilator is not available in the ICU at that time.
The doctor will have to make ethical treatment decisions after carefully considering the parameters in each case. Medical ethics is a complex subject that is part of the MBBS curriculum, but needs more attention in continuing medical education programs.
Poverty is the biggest comorbidity -- and is made worse by sickness
About 360 million people in India live in poverty: that number is equivalent to roughly ten times the population of Kerala. This means that they have limited food, shelter, education and healthcare. Countless families end up in debt and bankruptcy after spending their meagre savings on healthcare; their feeble voices are not heard over mainstream media.
Proneness to fall prey to scam treatments and unscrupulous money lenders only compounds the problem in this segment of the population that is already plagued by poor literacy and increasing alcoholism.
Due to insufficient staffing and infrastructure of the government-run health clinics in the country, people seek better care in private establishments, where costs are higher. However, without financial support from the government, the private sector is not able to significantly subsidise care. The net result is that numerous families who are not yet below the poverty line, get pushed underneath it as a result of sudden unexpected healthcare expense.
Poverty must be therefore acknowledged as a comorbidity by doctors, just like diabetes or heart failure, as it affects all medical decision making.
Unfortunately, in India, many contemporary medical conferences focus more on copying expensive treatment guidelines from developed nations, which suit only the wealthiest patients. It is equally important for doctors to develop customised treatment protocols that will not break the back of the average family that has limited life savings.
On the other hand, doctors also need legal protection from being harassed for not following the so-called ‘western standard of care’.
For example, it is not feasible to do blood tests and X-ray for all those who come to the clinic with a fever and cough. In good faith, to deliver the most economical care for the patient, a conscientious doctor might rely solely on his or her clinical judgment and not order any tests for a patient. (It should be noted here that clinical diagnosis is never 100% accurate, and doctors sometimes order investigations to improve the accuracy of their assessment.)
The downside of this cost-cutting approach is that occasionally, a diagnosis such as dengue, tuberculosis or cancer might get delayed or even missed. However, when such an outcome occurs, the doctor should not be harassed ‘for not ordering blood tests and scans as they would have in the west’.
Increasing numbers of frivolous litigations for such cases are already driving doctors to practice ‘defensive medicine’; that includes ordering more tests and treatments than are reasonably required. For example, when a patient comes with a headache, instead of suggesting a simple remedy and follow-up, the defensive doctor might decide to ‘play safe’ and order a scan, just in case a tumour gets missed.
As has already happened in the west, this practice of defensive medicine is driving up the cost of healthcare in India, worsening the existing economic situation for patients. One of the triggers of hospital attacks is the deadly combination of escalating healthcare costs, unrealistic expectation of cure and unexpected bad outcome.
If doctors start seeing their patients as potential enemies, they will not be able to act in the best interest of the patient any more. Healthcare works best when both the doctor and the patient are on the same side: when there is mutual trust. Far-sighted legislation is required to discourage needless litigation and harassment of doctors. This will empower doctors to rely more on their clinical skills, customise the care and keep costs down to the extent possible.
In summary, it is obvious that violence is one of the external symptoms of an ailing healthcare system that is imperfect at many levels. There is no one-stop solution, as each one of the imperfections are complex, and interrelated in several ways. Blaming society, patients or doctors for the problem is not the way forward. Thoughtful, well-meant and far-sighted interventions are required at multiple levels, including the government, legislature, law enforcement, school grading systems, medical education, healthcare infrastructure and public awareness-building.
(The author is the Kerala state IMA convener for communication skills for doctors, and has conducted numerous seminars for doctors, medical students and hospital staff on that topic over the past five years)