On violence against doctors

The recent incident of violence against Dr. Paribaha Mukhopadhyay, an intern from NRSMCH, Kolkata, was a saddening incident. Though such news is commonplace for medical students by now, we saw major protests by doctors nationwide because of the insensitive and heavy handed treatment of the issue by the West Bengal government.

Doctors protested for better workplace safety demanding legal action against offenders, proper security, bouncers and restricting the entry of multiple attendants amongst other things. These are important safety measures necessary for a place running high on tensions and emotions like the emergency room. But these demands are just a band-aid solution. Violence against doctors is not a disease in itself, but a mere symptom of a systemic disease. Both the issues of the violence against doctors and the poor management of the recent encephalitis outbreak are manifestations of the same deeply rooted systemic disease, i.e., the failure of our public health system. For which we require much more than just band-aids to solve. Unless we look deeper, we shall be attempting to treat only the symptoms and ignore the disease.

Violence can be both physical and verbal. Doctors even face verbal threats and expletives on a regular basis. Either form of violence can be considered just the tip of an iceberg. The massive submerged part of the iceberg that is left unnoticed, is the anger that relatives of patients leave the hospital with. Anger translates to violence in only in a tiny fraction of cases – those that infuriate the medical community in return and might as well catch the media eye. The normalization of violence in recent times has also helped bring this threshold delineating anger and violence a tad bit lower. The demands put out by doctors during the protest not only help deal with an act of violence but can also be expected to prevent such events by raising the anger-violence threshold.

Let us for the sake of argument assume, that the doctors’ demands are not just fulfilled in heed but also in deed. We successfully prevent people from transitioning into violence from anger and violence against doctors becomes a phenomenon of the past. Still, would we be comfortable with a significant proportion of patients and relatives leaving the hospital angry? The natural response to the success of treatments is of relief, and of failure or the death of a loved one is of grief. Although anger seems like a misfit here, it could be a natural response during the grieving process. Anger stems from dissatisfaction and that arises when expectations don’t meet reality. Hence anger needs to be dealt with empathetic and relevant communication and information exchange by the doctor.

Most incidents of violence occur in emergency rooms and ICU settings where patients are critical and require intensive monitoring and attention. It is in such anxious situations that vulnerable and overwhelmed relatives need to be transparently updated at regular intervals. Formal training in communication skills for Indian medical students is abysmal. Courses on communication are not only compulsory in medical schools of the West, but also form an important part of their residency applications. It is a common perception amongst medical students in India that ‘communication skills’ are just seasoning to actual medical care but not an inherent part of it. But wouldn’t that mean ripping the ‘care’ off ‘healthcare’? Moreover, with immense patient load and poor working conditions, Indian students are much more in need of training in communicating efficiently than their western counterparts. It is refreshing to see the newer MCI curriculum filling up this lacuna.

Communication also involves non-verbal cues and body language. A burnt-out doctor despite delivering state of the art medical care can come across as negligent or shoddy if she does not carry herself professionally or dehumanizes the patient. This perceived negligence is different from actual medical negligence which is a much rarer phenomenon and needs to be dealt with legally. In any case, violence is never the answer.

Doctors might feel that calling out poor communication skills of the caregiver as the cause for mob violence is akin to victim-blaming. The persons inflicting violence are not being absolved of their crime. They are definitely the ultimate cause and need to be punished by the law of the land. But we shouldn’t limit ourselves to such a myopic view. Doctors too along with patients and the system are a part of the web of causation leading to the unfortunate event.

Patients need to realize that expectations in a hospital should not be unrealistic. It needs to be acknowledged that treatment failures and death are inevitable in healthcare. It is ironical that many patients consulting quacks and spurious healers, have immense trust in them despite having poor or negative treatment outcomes. Conversely, they get infuriated at the failure of evidence-based practices in hospitals. This reflects an unrealistic standard of expected return from modern healthcare.

Now assume that we have a doctor with flawless communication skills, but is the sole senior resident on his 48hr shift in a 20 bedded emergency room with 60 patients. Add to this a shortage of drugs and supplies. In such a situation, is it humanly possible to meet even realistic expectations of a patient? Certainly, the quality of care is compromised. Who then is to blame here? With a per capita healthcare expenditure of just three rupees, there is acute shortage of beds and doctors across the country and the ratios are actually worse due to distribution skewed towards the urban areas.

Doctors at Primary Healthcare Centers (PHC) usually play the role of a glorified referral clerk. Even a well trained doctor in lack of facilities would necessitate referral. A robust public health system with rigid referral mechanisms eases the load on tertiary care (higher) centers. Primary healthcare not only directly reduces the burden of higher centers but also prevents complications of disease. For example, an elderly gentleman on BP meds from a PHC could be saved from a fatal paralytic stroke. One patient prevented from complication is one patient lesser in the tertiary center – hence reducing the burden of the duty doctor. In a country like India, this could even mean preventing one family from drowning below the poverty line for the healthcare expenditure the stroke would have incurred. Out of pocket expenditure is being normalized and public health systems are thought of as only for the poor. People have forgotten that the state is responsible to provide for the citizen’s healthcare. Only when health becomes an electoral issue shall the politicians listen.

With never-ending wait times, incessant running around for tests and appointments, back and forth referrals, insufficiency of wheelchairs or medicines, doubling of beds, exorbitant fees in corporate hospitals, filthy corridors of government hospitals, patients and relatives are bound to be frustrated. Although not directly responsible for any of the above, overworked and underpaid doctors being the face of this underfunded healthcare system, naturally turn the victims of the attendants’ displacement of frustration. If this frustration is directed towards the government, it shall bear more fruit instead. It is important to realize doctors aren’t Gods but mere humans who tirelessly try to maximize the efficiency of a broken system that they are a part and also a product of. That very system exploits and takes for granted the empathy towards patients for whom doctors skip meals, sleep and sacrifice much of personal life. Doctors have treated humans for eternity. It is time for patients to now treat doctors as fellow humans. Only then can the sacrosanct human relationship between doctor and patient evolve to greater heights.

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