Year : 2019 | Volume
: 8 | Issue : 11 | Page : 3457--3460
Violent-acts against doctors and healthcare professionals in India: Call for action
Raman Kumar1, Pritam Roy2,
1 President, Academy of Family Physicians of India; Chief Editor, Journal of Family Medicine and Primary Care, India
2 Chairperson, Primary Care and Public Health Policy Forum, Academy of Family Physicians of India, India
Dr. Raman Kumar
049, Crema Tower, Mahagun Mascot, Crossing Republic, Ghaziabad, UP - 201 016
Doctors in India are facing violent-acts against them, and there is an increasing trend in recent years, leading to a Public Health Riot-like scenario in India. There are reports of a doctor being murdered, thrashed, beaten, injured, handicapped, harassed, threatened, and socially maligned with news of demeaning messages spreading such as wild-fire through social media and news channels. More alarming is that common people are justifying the acts of killing, beating, and provoking others to do more such acts, thereby triggering a vicious cycle. Most of them get away without any legal proceedings being instituted against them. A recent incidence of grievous injury to the junior doctor at NRS Medical College, Kolkata, drew National and International attention. More recently, a retired senior doctor volunteering part-time at a tea estate of Assam was killed by a mob. The authors call for action and earliest resolution of this issue with active involvement of all stakeholders.
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Kumar R, Roy P. Violent-acts against doctors and healthcare professionals in India: Call for action.J Family Med Prim Care 2019;8:3457-3460
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Kumar R, Roy P. Violent-acts against doctors and healthcare professionals in India: Call for action. J Family Med Prim Care [serial online] 2019 [cited 2019 Dec 5 ];8:3457-3460
Available from: http://www.jfmpc.com/text.asp?2019/8/11/3457/270969
Violent-Acts Against Doctors
Violent-acts against doctors (VAD) may be defined as “any event committed or incited by a person/group of persons/leader of a group or organization, where the doctor is threatened or attacked physically (not only the actual but even attempted use of physical force that causes death or injury, but also threatening statements or behaviors that cause a doctor to believe they are at risk of injury), undergoes mental trauma or social harassment due to his/her professional position or related with the professional services rendered.”
Doctors in India are facing violent-acts against them, and there is an increasing trend in recent years, leading to a Public Health Riot-like scenario in India. There are reports of doctor being murdered, thrashed, beaten, injured, handicapped, harassed, threatened, and socially maligned with news of demeaning messages spreading such as wild-fire through social media and news channels. More alarming is that common people are justifying the acts of killing, beating, and provoking others to do more such acts, thereby triggering a vicious cycle. Most of them get away without any legal proceedings being instituted against them. To add is the recent incident of grievous injury to the junior doctor in NRS Medical College, Kolkata, drew National and International attention. More recently, a retired senior doctor volunteering part-time at a tea estate of Assam was killed by a mob. The overall scenario is disturbing, to say the least. It is almost like an outrageous riot being directed against the doctor community as a whole. Yes, it is now a state of Public Health Riot in India. The people and society are hostile toward doctors now. Accept it!!!
The reasons for such violence are manifold; however, one of the core underlying factors is the deteriorating doctor–patient relationship over the years. Like William Osler said, “The good physician treats the disease; the great physician treats the patient who has the disease.” Similarly, we need to treat system rather than just plugin the issues. Following are the pertinent dimensions of this systemic issue.
Longstanding Apathy of Policy Makers on Healthcare
Since Independence, the country's policymakers have always been silent either over health issues or recognizing health in true sense as the basic fundamental right. In this vacuum-driven situation, common people failed to understand if health is a “service” or “product.” Common people suitably interchange them as per needHealth may not be a fundamental right in the constitution of India; however, if a citizen of India dies due to public health insufficiency (three patients on one bed), it is a violation of right to life under Article 21 of The Constitution of India. The right to life, it has wider meaning which includes the right to live with human dignity. Doctors and health workers also have right to live with dignity under the same ArticleAccording to the welfare state model, a budget has been allocated in the health sector, by which the government-run public health programs, medical education, and curative services are provided, but it is far less than being adequate. As a result, government healthcare system faced challenges with a huge shortage of health centers, beds, doctors and paramedical workers, medicines, and diagnosticsTo add up, there is overcrowding leading to inhuman situations. Doubling and tripling is a norm. Three patients on one bed is common. 500 emergencies at one night is an accepted workload. While staffing is done as per the number of beds. 200 patients in 2 h of outpatient basis is every day businessThe facilities from Government did not increase in pace with the explosive rate of population growth. Hence, Government hospitals offering subsidized medical care are forever swamped with patients and their attendants. It is logical to assume that quality of care may sometimes get compromised while attending to such a huge number of patients in a limited window of time.
Indian citizens also gradually started to adjust to this deficit-driven health system. Nobody ever raised demands of procuring more ambulance than bullet-proof cars for ministers. This acceptance of the citizens equates with their inabilities to demand for better health. Given the poor budgetary allocation for health in India, these problems are unlikely to change for the better. Violence against doctors is only a symptom of this underlying deep-seated chronic malady. There is frustration with logistic problems of government hospitals. These result in displacement of anger toward the doctor in front who represents the most visible face of this crippled medical system. This is not just a police and security issue. This is a complete failure of public health system. Often not acknowledged, but it is disaster situation all the time at large government hospitals.
What can be done
Doctors need to take a lead in raising demand for health as a right. Things will change if we create awareness among people to demand for better facilities and adequate workforce posting. Once there is demand, resource allocation can be changed. We need to communicate with people, participate in various talk shows, be a part of civil societies, and spread the reasons why health system is crippling and what should people demand from government.
Private Hospitals and Healthcare Facilities
India has witnessed an economic boom resulting in a shift from the socialistic outlook to a capitalistic one. Due to lack of adequate resources and long queues, the middle and upper economic class return for their health-care needs to private hospitals. People who do not wish to go to government setup due to inadequate services are ready to pay a bit extra. However, then, it is raising expectations (sometimes unrealistic) about the standard of care. When there is clash of expectation, dissatisfaction arises, ultimately ends up in violent actsNewer treatment, updated diagnostics, and medicine are available in corners of the country. However, in-between, medical expenditures increased manifold globally. Seeking quality care becomes costlier. To overcome the vacuum of quality care availability, the rise of corporate hospitals was inevitable. After spending all resources, if outcome is adverse, it raises discontent. High expectations of complete and quick improvement from the patient and their relatives are major contributing factors for increasing assaults thereHealth insurance is not popular or widely available. People do not save some money for medical emergencies or health insurance. Sudden spending (out of pocket expenditure) on health issues then multiplies the anger and dissatisfaction. They perceive that huge treatment cost is charged by doctor only and they are getting all profit. As doctors are the ones who dictate patient care, they are an easy target for patients' complaints and frustration.
It is perceived that doctors alone are earning huge amount of money at private hospitals where as the reality is that they are merely employed by the industry and earn only fraction. Also hospital industry is an high investment business with high cost of operations. Besides, when one brings patient to private setup, expectations of complete cure is very high.
What can be done
It is important to clear out that professional fees is only a small fraction of overall treatment charges which doctor get. Bed charges, diagnostics, and consumables are the major contributors of hospital bill in which the doctor has no role. It should be amply projected that doctors only provide the care part and do not run the whole system barring few exceptions. There should be complete transparency in financial transactions with the patients.
Patient /relative's Perception
Patient perceives that their complaints are not heard properly and medicines and tests are advised without listening to complaints in full. This may impart a perception of neglect to the patient and leave him/her only partially satisfiedTrust in the doctor–patient relationship started taking a beating on investigation charges. Reports of unnecessary tests and needless invasive procedures have caused patient distrust to growEven tests which are necessary are perceived as useless and advised only because doctor wants cut-money
Over time with medical care commercialization, some physicians were accused of being driven by greed and of adopting unethical practices. The perception of cut-money from investigation is so deeply rooted among public that every investigation goes under a lens.
What can be done
During advice of investigation, the usefulness of the test in diagnosing and also in ruling out certain conditions should be discussed as well as explained to the patients conducting the test.
Giving time to hear the patients and their relatives, their concerns are important. All frustrations' misunderstanding starts from there. Communication is the key.
Media and Social Media
Media has contributed to the patient's distrust to grow against the doctors and the hospitals. The occasional mis representation by media adds fuel to damaging this delicate relationship by rapidly jumping to conclusions and publishing incredible stories of malpractice and medical negligenceLately, it has been noticed that the media has been trying to demonize the health sector professionals and hospitals through their “revelations” and “breaking news”. Sting reports and are also done and televisedSocial networking sites are further escalating the problem. People celebrate posting a negative comment toward doctor even admitting the violent behavior toward the doctor. They get hundreds of likes, comments, and encourage other to be aggressive toward doctors. Social learning of violence is a matter of great concern.
Medical professionals are not trained to handle mass media. Few black sheep do no mean that the whole profession is drowned in corruption.
What can be done
Medical associations should make appropriate representations and formal press releases are required addressed to platforms of mass media.
Positive contributions and good work cone by professionals should be widely disseminated.
Social media is a new phenomenon medical professionals should develop formal response system for such communications.
Poor communication too is an important cause of rising incidents of violence in India. The relationship between a doctor and a patient is paternalistic where patients are still not considered equal partners by doctors. This at time leads to arrogant behavior, condescending attitude, and use of jargon by doctors, which confuses the patientGiven the patient load, lack of time, gross deficiency of staff, and other resources, these issues receive only lip service especially in the public sector.
This is an area where much emphasis needs to be laid, especially during medical training.
What can be done
Recent changes in medical curriculum have taken up the issues. Medical associations may take up special programs for their members to conduct effective patient–doctor communication as per the specialty is concerned. Aspects of patient–doctor communication such as “receiving an explanation for the occurrence of the symptom/sign, likely duration of treatment, and the lack of unmet expectations” were found to be key predictors of patient satisfaction.
Death: End of a Life and Start of Violent-Acts
After the death of a family member, the family may blame the doctor for failure to provide adequate careThere is an increasing expectation from patients that with modern medicine and technology a doctor should be able to guarantee a good outcome. Thus, they consider that every death is a result of failure on behalf of doctors or negligence. For this, the angry public is always ready to punish and humiliate the doctorSometimes, the families blame the doctor and hospital to avoid paying the bill. They show aggressive behavior and violence with the excuse of malpractices and get the attention of media and through social media from other fellows. Frequently, the hospitals try to retain the reputation and settle the issue giving some financial benefits such as relief from the hospital charges. This is then perceived that hospitals were at fault and that is why they compromised. This paves the vicious cycle on.
This is a single most important triggering factor causing violent-acts, most death, or grievous injuries.
What can be done
Adequate counseling and briefing can be helpful in some cases. All such cases should be dealt with empathy.
In cases of death proper clinical audit should be done. Postmortem and medico-legal evaluation should be conducted where the cause of deaths can not be determined clinically. Doctors should refrain from alleging other doctors act for the cause of death. These specially happen with referred cases, where some casual comments on previous wrong diagnosis or nature of treatment given during referral is inadequate or wrong or the referral was not timely, heavily pay back to the doctor who have referred. This incites violent acts by mob to referral center/doctor. As individuals or institution, we should refrain from such comments.
Way Forward: Call for Strengthening Primary Care and Referral System in India
Today's situation is an outcome of long-standing policy apathy; many times, priorities drifting haywire due to vested interests and complex sets of conflict of interests. Strengthening prehospital care is capable of addressing majority of the medical or health-related problems. Unfortunately, as a country, we have heavily invested in developing hospital and tertiary care both in private and public sectors and all, at the cost of good primary care, which has capacity to absorb ninety percent of the morbidity. Even today, the momentum and trajectory are in the favor of more and more hospitals and medical colleges. The solution is to implement public health policies in public interest. There is a need of strengthening primary care through an investment for a permanent and strong general health system. Unfortunately no one talks about a structured referral system. Due to overtly private environment many times it appears that the threefold for referral has been quite low leading to default feeding of private tertiary care hospitals as well as over crowding at public hospitals. Primary care is funded but often remains low capacity, under performer and debilitated. Super specialist tertiary care, fragmented diseased based vertical public health program and quackery have become the hallmarks of the health system of India. This is not only a budget issue but also a design fault.
VAD perpetrated by patient relatives is a superficial sign of a deeper systemic failure. Reactionary measures, such as enhanced security at government hospitals or harsh laws, all alone, are unlikely to boost the flagging morale of the doctors or represent sustainable solutions. Given population and mobility profile, no government will be able to provide airport like security. Demand of new laws for stringent punishment (12 years) for any citizen for attack on doctors is not in the interest of Indian society on a long term. A new act cannot suspend fundamental rights guaranteed under the Constitution of India. There are sufficient sections in existing Indian Penal Code to address it.
Primary care can meet the majority of an individual's health needs over the course of their life. A health system with a strong primary care as its core delivers better health outcomes, efficiency, and improved quality of care compared to other models. Primary care development has been unequal across the country. This is often due to a combination of under-investment, lack of political will, and misconceptions about the role and benefits of primary care. Strong general health system can reduce patient dissatisfaction, the leading cause of violent acts. Investment in primary care is the key for the strong general health system. Focus on primary care and their benefits on individual health, health systems, and doctor–patient relation will be evident. And lastly with more then 1.3 billion population Indian needs to start thinking about a structured referral system; a true referral system which has capacity to absorb morbidity and not an apparatus precipitating movement of ill persons from community to tertiary hospitals located within cities.