Safe-guarding the medicos

Steps that hospitals must adopt to prevent violence against their medical staff

Violence against doctors, Fast track courts, Protests, NRS Medical College and Hospital, Kolkata

There has been country-wide protests by doctors demanding their safety and security,  after a junior doctor at Kolkata’s NRS Medical College and Hospital was brutally assaulted on June 10th by the family members of a patient over allegations of negligence. A clash had erupted between junior doctors and relatives of the 75-year-old deceased patient patient at the state-run hospital, turning the hospital premises into a battleground.  A large team of police personnel from the local police station had intervened and had to restore to lathicharge to bring the situation under control. The doctor who sustained a skull fracture and admitted to the Institute of Neurosciences in a critical condition has been recovering well,  but the incident has once again underlined the increased incidence of violence against doctors over alleged medical negligence.

Dr Harsh Vardhan, Union Minister for Health and Family Welfare, expressed concern on the recently reported incidents of violence against doctors. Strongly condemning the violence, he said it was necessary for the doctors to get a safe work environment. “Doctors are an integral pillar of the society and often work under stressful and difficult conditions. I urge the patients and their caregivers to observe restraint,” said he.

According to Dr Sudarshan Ballal, president, NATHEALTH, “Doctors and healthcare providers comprise the backbone of modern healthcare delivery and require a safe environment to deliver care and save lives.  We need to understand that medical professionals and establishments are doing their job and trying to save lives..”

According to a survey on violence against doctors that was published in June this year in the Indian Journal of Public Health, seven in 10 resident doctors at Government medical colleges in three Uttar Pradesh towns have experienced violence from patients or their relatives or friends. The survey, which sampled 305 resident doctors at medical colleges in Agra, Aligarh and Jhansi, found that 264 (86.6%) had witnessed and 212 (69.5%) experienced workplace violence. About 70% of the resident doctors surveyed had experienced verbal abuse and 47% faced physical assaults. The resident doctors attributed the violence to factors such as the non-availability of medicines, staff shortages, and ineffective communication between the doctors and the patients or their friends and relatives. (For more on the survey, see box on page 17)

The World Health Organisation estimates that the proportion of healthcare workers who face physical violence at some point in their careers ranges from 8 to 38% worldwide. A German study published in the 2015 found that almost 50% of surveyed doctors had confronted aggressive behaviour, with 10% of them experiencing violent attacks. Another survey conducted in China found that incidents of physical violence causing harm had increased from 48% in 2008 to 64% in 2012.  Instances of violence have considerably increased in recent years not just in overburdened public hospitals but also against private hospitals. 

According to Dr Dharminder Nagar, managing director, Paras Healthcare, “At the root of this problem in India is the paucity of healthcare resources. Shortage of human resource, medical infrastructure and number of beds are real problems that must be addressed on the policy level." However, this disturbing trend is also symptomatic of the changing relationship between doctors and patients in India. Till a few decades back, doctors in India were looked upon with much trust and faith by people. "Unfortunately today most common people look at medical practitioners with an element of suspicion and distrust, “ he rues.
The trust deficit between doctors and patients has reached an all time low in the last decade. With the proliferation of private clinics and the emergence of corporate hospitals, there is a growing perception that doctors are operating with the intention of fleecing. “The mistrust phenomenon has also been fuelled by constant media scrutiny that highlights malpractices and corruption by medical practitioners.  In a country where the doctor patient ratio is far from satisfactory, doctors are always overwhelmed with patients,” says Dr Nagar.

There has been a dramatic change in the cost of therapy because of the ability to take care of very sick people, who in the past would not have survived at all. “Advances in technology, infrastructure, consumables and drugs costs have made the costs go through the roof. Obviously, the patients bear the brunt of this as, most of the times, medical insurance is not available to the vast majority,” says Dr Ballal, who is also chairman of Manipal Health Enterprises.

Verbal and physical threats, abuse, vandalisation of hospitals and work places is a day-to-day day affair now and this has long-term effect on the noble profession. “The situation has become so bad that many doctors fear practicing medicine and are seeking early retirement or alternate professions. None of the youngsters or even their parents want them to get into the medical profession,” laments Dr Ballal.
Below are a few steps that hospitals and the Government need to take towards ensuring safety and security of doctors:

Communication at regular intervals
Often, doctors do not adequately communicate with patient attendants, who later complain about being kept in the dark.  Says Dr Sanjeev Singh, medical superintendent, Amrita Institute of Medical Sciences, Kochi, “It is extremely important that relatives of patients be informed about the condition of the patient and the treatment at a regular interval. Often, the patient attendant keeps changing and the new attendant complains of not being informed about the prognosis adequately. So, regular flow of information about the treatment is essential, especially for critically-ill patients.” Having a regular and honest communication also ensures that patients are under no false expectations.

Adds Jasdeep Singh, COO, Columbia Asia Hospitals, “There has to be more effective communication between the hospital and the patient party, so that there is less room for ambiguity. It’s even better to record such interactions  with the knowledge of both the parties for reference later on.” 
According to Dr Ballal, “A well-informed patient who after discussions with the medical team  understands the condition, course, complications, outcome  and more importantly actively participates in the care plan and is aware of the all the nuances involved. A good financial counselor is needed to interact with the patient and family to explain costs and the reasons for the escalating costs.”

Selection of patients
Experts say it‘s important on the hospital’s part to carry out the right selection of patients and send them to the corresponding departments without delay.  Says Dr Alok Roy, chairman, Medical Group of Hospitals, “Often, patients are unwilling to believe that they are critically ill and need hospitalisation or urgent treatment. In some cases, the patient is in critical shape and hardly has any hope. So, counseling patients and family about the critical cases is extremely crucial."
Informed consent
Informed consent is another significant step in preventing violence. While attendants are always made to sign documents before a medical procedure, doctors or hospital managements hardly explain the contents of the documents to medically illiterate families. “Not to forget the need to have proper documentation of patients’ course of treatment so as to be secure in case a matter goes to police or court. The Golden Rule of consent taking is “The person (doctor) who holds the knife holds the pen”, in short the consent should be taken only by the doctors after a detailed explaining in the language understood by the patient / patient family,” says Dr Nagar.

Counseling and compassion
It is essential for hospital managers to inculcate the spirit of compassion and care among all staff members. For doctors and medical staff witnessing serious illnesses and mortality, it is an everyday affair. However, for families who lose a member, it is nothing less than an earth shaking event. It is important therefore to be considerate to them, make processes smooth and quick and eliminate unnecessary hassle. “Care must be taken that attendants of critically ill patients are not pestered too frequently to pay bills. Doctors and staff members must try to console grief stricken families. Compassionate treatment can go a long way in pre-empting any kind of unrest,” says Dr Nagar.

Training of doctors
To expect doctors to explain to patients or the relatives in a language that they understand and regularly update them about the treatment, training doctors in soft skills is important. Says Dr Col NK Parmar, CEO, BR Life, “Most doctors are poor in handling of terminal cases, grief or certain death cases. They need to be trained for that. We need to focus on improvement in communication skills of doctors and make them show empathy.”

Identifying potential trouble makers
Experts say it’s important to identify potential trouble makers to avoid incidents of violence.  “The medical community should be trained adequately to identify the potential trouble makers from their aggressive body language and rowdy behaviour. Often, it’s not the immediate relatives but distant relatives or people with political agenda who create trouble. So before the trouble makers take an upper hand, the hospital should intervene and take corrective steps,” says Dr Roy.
He suggests that before the trouble makers could swell in numbers, the hospital should increase its manpower in the troubled area. “Crowd can beat crowd and the crowd of relatives trying to create a pandemonium would step back, seeing adequate manpower from the hospital side,” says he.

Enhanced security
There should be deployment of police patrol vehicle at hospitals which receive high traffic especially trauma. Security guards must be placed at  sensitive areas such as ICUs and emergency units. Staff members at such locations must also be trained to stay alert to signs of any possible unrest. “A standard operating procedure must be developed and each staff member should be aware of the do’s and don’ts of such situations. If signs of aggression are noticed, senior management must immediately reach the spot, intervene and speak to attendants to prevent the incident from escalating,” says Dr Nagar.

Fast track courts for medico-legal cases
According to experts, there should be better and faster courts for medico legal cases. “Having such courts would ensure that the patients and their respective family members build more faith in the law of the land rather than taking issues in their own hands,” suggests Jasdeep.

Central law against violence on doctors
The Indian Medical Association has been pressing for a strong Central Act prohibiting violence against doctors. Though 17 states have brought out laws against violence on doctors and hospitals, there is a wide disparity and very little scope of implementation amongst the state legislations due to the absence of a Central law, IMA has pointed out.

Public awareness
It’s important to create public awareness about how such incidents affect the medical community and disrupts healthcare services. “We must make the larger population aware of the prevalent success rates of key surgeries and treatments, so that they are aware of the probability of success of the treatment,” says Jasdeep.