An industry which will not accept any kind of regulation by the government wants the same state to protect it from an angry public.

Why the threat of violence against doctors though unacceptable may be getting us better healthcare
Voices Opinion Friday, October 23, 2015 - 18:38

Violence can never be justified, least of all against someone who is ostensibly attempting to save a person’s life. The number of incidents of attacks on doctors and other healthcare workers across the country has risen sharply over the last few years. Few accurate statistics are available, but based on media reports this seems to be the case. A recent IMA study states that that upto 75% of doctors in India have faced some form of violence. Not just India, China which too has a health care system that is struggling to cope faces a similar crisis with over a third of the doctors having been subject to violence.

So why are patients and their relatives, so used to worshipping their doctors as Gods, beating them up? Are these pre-meditated attacks? Is there a deficiency of service that is provoking patients to attack medical professionals? Is there a failure in communication that is causing patients to misunderstand their loved ones condition or what can be done to save them?

There is a widespread feeling that doctors have simply lost the trust of their patients, the feeling patients should have is that the doctors will only by guided by the patient’s best interests and not their own. The rampant kickbacks in the healthcare industry on everything, from prescriptions and lab tests to radiology investigations and referrals, means that every time the doctor makes a treatment or investigation recommendation the patient is busy figuring out the motive for the same.  The same dishonesty that permeates other spheres of Indian society also prevails in healthcare and the industry is unwilling to address this issue.

Almost none of these attacks are pre-meditated. Often the patient has already spent a lot of money and is at the end of his financial tether. Relatives have been told to expect an improvement and when there is a sudden deterioration followed by loss of the patient there is an instant feeling of anger that manifests as violence.  In medicine there are no guarantees and patients can develop complications despite the best efforts of the doctors but someone who has been told to expect a good result can be angry if the outcome is unfavorable. In earlier days they would just accept it as fate or the will of God. That was when the belief in the doctor was absolute and there was no question of him having done anything but the best for the patient. But now with the constant question, “Did he do the surgery just for the money?” a patient’s relatives are easily provoked.  It is of course not the case that all incidents of violence follow the same pattern. There are many situations where patients have untreatable conditions and doctors communicate the same and still face violence. But these are not as common. A recent IMA study said that doctors faced maximum violence when providing emergency or critical services, with over 48% of such incidents reported from intensive care units (ICU’s) or post-surgery. Over 65% of such violent acts are performed by relatives of patients.

Failure in communication due to the doctor being busy is often the aggravating factor. Patients do not have a problem with the doctor not spending enough time or paying enough attention as long as the outcome is good. But when the patient dies or suffers a complication this lack of attention or communication becomes a cause for violence.

One major issue is the low healthcare literacy among the general public. This coupled with “the limited recourse for dissatisfaction” as the Lancet terms it, offers a potent combination for a violent ending. The slow judicial process in India often leads to patient relatives venting their frustrations and anger on the spot. It can take years to get a verdict in consumer or other courts and the appeal process can drag on for decades.  When you have lost a loved one due to what you see as a gross or criminal negligence (though it may not be the case) if it is an option between going to a consumer court versus settling scores instantly some, wrongly, opt for the latter.

The healthcare industry will do well to push for self-regulation. Studies speak of over 40% of all surgeries done in India being unnecessary (for the monetary benefit of doctors and hospitals), kickbacks in every area of healthcare run into thousands of crore rupees annually. There is an unwillingness to adhere to even basic quality indicators of care which mean that the healthcare industry is a sitting duck for a catastrophic and (unfortunately) violent change. Various industry organizations like IMA need to be pushing for change, asking for greater accountability from their kin and ensuring that the guilty are punished with cancellation of their medical council registrations making them ineligible to practice. Sadly they are doing very little and indeed are closing ranks to protect the guilty among their own.

Governments(Center and States) abdicating their responsibility means that in India we have surgical units continuing to operate with their mortality rates 50 times higher than the global average for specific conditions. In most cases the government (and private sector too)is not even measuring the mortality and morbidity rates. That means a surgeon can go on operating and killing (due to poor patient selection, a faulty technique or poor post-operative care or whatever) many patients he operates on and no authority will stop him. He can continue as long as he gets patients. Even if he has been consistently negligent no authority will stop him unless the court orders it based on someone’s appeal.  As we are not even measuring outcomes no one will even know how negligent a doctor has been. In most civilized countries the surgical unit itself would be shut down as they mandatorily need to measure and report their outcomes.

The threat of violence though condemnable and unacceptable, in today’s scenario, is enabling patients to get better healthcare. The logic that a scared doctor would think twice before pulling a fast one on a patient is now a thought that occurs in many. Patients feel that there may be a trend to over investigate (defensive or safety first medicine) but the tendency to do unnecessary invasive procedures, spend too little time on patients and not communicate effectively may come down. In short the feeling is emerging that the threat of violence will prevent doctors from taking patients for granted. Nothing can justify violence as a means to achieve this end but by its short sighted policies the healthcare industry is pushing the patients into a corner from where they are being forced to lash out. Ideally the government must be putting the fear of the law into the doctors. Since the Government has failed to deliver on this patients are increasingly taking matters into their own hands.

The medical fraternity asking the state for special protection is laughable. An industry which will not accept any kind of regulation by the government wants the same state to protect it from an angry public. If the industry was willing to accept even the most basic form of regulation then the demand for protection would be reasonable. But an industry that says the government cannot even demand that a clinic have potable water for basic hygiene purposes (one of the requirements mentioned in the Clinical Establishments Act which the industry opposes) now wants security guards and policemen to save their skin. Let the industry first adopt the Clinical Establishments Act and abide by the same. Let them put in place a means to measure outcomes. Let them end the kickbacks system. Let them take action against their own charged with negligence. Let them devise communication protocols for doctors and other staff. And then let them ask the government for protection.  If they did all this there would be no need for them to ask for such protection.

The healthcare industry still has thousands of sincere doctors and other professionals working with only their patient’s best interests in mind. But thanks to the rotten apples in their midst, their lives too are being put at risk and that is a tragedy. As long as the conditions that are leading to violence remain these attacks are unlikely to stop, if anything they are going to increase. If the healthcare industry thinks that security guards are the answer, God help it. 

The writer is a doctor and healthcare professional, and also a television anchor and commentator. 

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