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K Anil Roy Speaks, … Increasing violence against doctors in India …. a frightening phenomenon.

MAHARASHTRA 14 NEWS, (DATE 10 SEP.) : One the most common news in Indian the print or digital media today is about violence against doctors and of hospitals being vandalized. A doctor beaten up, a hospital ransacked, another doctor shot at and yet another lynched by the mob, for reasons best known to the assailants. This is now a common phenomenon across all states in India.

The violence is seen both against the medical professionals both in the government sector as well as private sector, neither has been spared. This violence ranges from verbal abuse at workplace or even over the phone, manhandling of doctors, physical dangerous assault, use of weapons and fire arms and vandalizing of the clinic or hospitals.

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There was a time when doctors in India were worshiped and revered. Not long ago they were gods or demi gods. What has gone wrong??? Why this sudden and sustained events of attacks. Here I am making an attempt to analyze some of the probable causes as observed by me in my 34 years of the medical profession. The blame game is perpetual, is the doctor or hospital wrong or is it the citizens/ patient and his relatives at fault for this violence. Let me make it very clear in most of the cases the attacks are unwarranted and the doctor is rarely at fault. I am not denying that in a few cases, very minuscule number of cases the fault has been with the medical professionals.
Did the doctors and medical profession bring this upon themselves or is it that patient attitudes and expectations have changed with time. Has there been a loss of trust in the medical profession, are half baked knowledge of patients regarding medicine responsible, is poor communicating skills of doctors responsible, is it the arrogant behavior of the medical profession with the patients and relatives or vice versa, is it the financial angle, huge bills, is it political interference or is it lack of adequate facilities that has led to this state of affairs or is it plain misunderstanding.


Unrealistic expectations coupled with poor medical awareness……

One the major causes for this unprecedented violence is poor medical knowledge amongst patients and relatives. They fail to understand the situation, the need for the treatment, they do not realize that the doctors can only diagnose and treat patients with the best of their judgment with available facilities and medicines. The doctors are not magicians, each illness will follow a course, and there is no shortcut to treatment and recovery. A magic cure or an immediate recovery is their usual expectation. They are bewildered if B-complex is given for oral thrush when last time it was given for plain debility, they are not satisfied if paracetmol is prescribed for pain when on another occasion it was given for fever, one doctor prescribed tab stemetil for emesis and another for migraine and so on.

Take this case where a person hanged himself, his relatives get to know of it after half an hour, they break open the door, take him down and a mob now collects and carries the body to the hospital. First thing on reaching the hospital is the mob barges into the doctor’s room and pleads for him to attend immediately as it is an emergency case, though knowing very well that person was dead even as they had brought down the hanging body. Yet the expectation is the doctor should do something to revive him. The doctor feels for the pulse…none felt…blood pressure not record-able…he auscultates…. No respiration …no heart beats…pupils are dilated , rigor mortis is setting in… the person is dead for sure, the doctor knows it, the mob knows it,

but the moment the doctors declares the person dead, the verbal abuses begin…. Doctor you******* you did nothing to save our patient, you rotten***** we shall ***** your happiness.

What could the doctor have done when a person who is dead by hanging is brought to him after an hour?   This is one classical case of unrealistic expectations.   Many a times these verbal abuses turn into physical assault and later to vandalizing the whole place.. Who was wrong, was it the doctor, definitely not. There had been violence.

The lady was wheeled in, she was full term, the young resident attended to her, and she examined her carefully. Oh! She had a transverse lie, there was meconium stained liquor, the fetal heart sounds were erratic and low, the lady would need an emergency caesarean. The resident explained to the relatives. No they wouldn’t hear of it, the husband retorted that his wife had a normal delivery last time, so why a caesarean now, the young resident explained, all in vain, they wouldn’t hear her out, they accused her of making a fool of them to increase the bills, they were adamant a caesarean was not warranted and the choicest abuses began. A tear trickled down the young lady doctors eye, how could they not understand, why didn’t they trust her, after all she was trying to save two lives. She had put in innumerable hours of hard work and study, burnt her energy to get to this position today, she wanted to serve the people coming to her, she was meticulous in her work , then why this,She cursed the day she had decided to become a doctor. There was mayhem until the security stood round her and the senior doctor arrived and ultimately convinced them that the surgery was necessary. There had been violence.
A middle aged known diabetic and ischemic heart disease patient who is on irregular treatment is brought to a primary health centre. The doctor sees him records his history and complaints, gets his ECG done. It is showing changes indicative of massive infarct, the doctors gives the primary treatment and refers him to the higher centre or cardiac centre.   Again the abuses begin…. Why can’t you treat him here, are you a real doctor, we shall leave with our patient now but we shall be back to see you. Similarly in this case had the patient passed away during primary examination all hell would have broken loose. Is it the doctor’s fault that the patient does not follow up regularly or not take his treatment, if the patient is non-compliant, does not follow the doctor’s instructions and ends up with a massive infarct, how one can blame the doctor? There had been violence.

Large number of patients in government hospitals, lack of adequate manpower, facilities and medicines.

Lack of adequate finances are the reason for the large number of patients turning to government centers for treatment. Inadequate manpower puts a huge strain on the available medical and paramedical staff. Many a time equipment is not available or not functioning, medicines too are in short supply leading to clashes and arguments and later to violence at these centers.
The man had brought his father all of 80 years to the hospital for his monthly checkup and medicines. The old man was a hypertensive. As the queue was big it took him an hour before he got into the doctors cabin. He had been coming here for the last 7 years and was happy with the hospital and doctor. The doctor saw him and recorded his blood pressure and was happy to note that his blood pressure was well controlled, he prescribed the medicines and went on to see his next patient. It was then that he heard the commotion, abuses were being hurled, a window was smashed, and there was a banging of the doors. He rushed out of his cabin, nearly another 50 to 60 patients were coolly waiting for their turn, he walked towards the area where the sounds came, it was in front of the pharmacy, the pharmacist was being manhandled, he walked across and placed himself in front of the pharmacist, other employees too had gathered around.  Reason….. The stock of anti hypertensive medicines was over and the old man was requested to come two days later as the stocks would come by then. The man lunged at the doctor, you rotten fellow, why you run the hospital if you have no medicines, the doctor tried to explain, he wouldn’t listen, the old frail security guard just stood there watching, the younger staff managed to pull away the person and take him out of the building.  Whose fault was it, definitely not the doctors, but suffer, he did. No gratitude in treating a person for 7years.  There had been violence.
Similarly at times there would be a staff nurse in the injection room on leave and none to replace her, dressing of wounds could take time, a doctor not well and hence not on duty would lead to more waiting time at the other doctors consulting rooms, an ECG machine would suddenly malfunction, at times patient demand medicines which the doctors feels is not necessary and hence refuses, patients demand injections where there is no need for one. Any refusal will lead to abuses. If an emergency case is taken out turn there will be a big hue and cry as to, is that a patient a VIP. Then again influential people want immediate attendance, if refused again verbal abuses. The doctor and his staff are always at the receiving end.

Political interference and pressure

Another major reason for violence stems from political interference in the medical and health system.
The man walked in with a case paper for a medical fitness certificate. The doctor looked up and asked who was the person mentioned on the case paper. He said he is at home but needs a medical fitness certificate. The doctor refused, he couldn’t possibly issue such a certificate in absentia, the man pulled out his cell phone and connected to the local politician and informed him that the doctor was unwilling, he passed on the phone to the doctor who explained that he could issue the certificate without examining the patient and the expletives started, abuses were hurled at him, the doctor sat grim faced, he couldn’t possibly hurl back abuses at him. What was the doctor supposed to do, he stood his ground, and he refused. In half an hour the Politician and his cronies came and started a ruckus, the police had to be called in There had been violence..

She had been admitted 8 hours ago, she was a primi gravida, she was in labor. She was being monitored regularly, she would deliver normally. The senior consultant too had seen her. No problems. Just then the phone rang, the on duty nurse picked up the phone, and he asked to speak to the doctor. The doctor took the phone, the politician demanded as to why the lady hadn’t delivered yet, the doctor explained how long it would take as she was a primi gravida, the politician was in no mood to listen, he demanded that she be delivered immediately, the doctor explained it is a natural process and it would take its own time, the politician demanded that she be injected to fasten the process, the doctor refused and the abuses began. There had been violence.

It was a 100 bedded private corporate hospital. They had a 20 bedded ICU. The beds were full, so was the ICU. A road traffic accident patient was brought into the casualty. The on duty doctor examined him, he was given initial treatment, the specialist saw him, and he would need an ICU bed with a ventilator. The doctors explained that as no ICU beds were available they would have to shift the patient to another hospital, nothing doing said the relatives and friends, and you have to provide us an ICU bed. They wouldn’t see reason, the patient was sinking, and he would be needed to put on a ventilator in the ICU, the mob refused. They called for their local politician who rushed in. He demanded that a patient be removed from the ICU so that this patients could get in. No explanation was enough to convince them, they wouldn’t shift the patient, precious time was lost, the patient breathed his last and the violence began, they thrashed the doctors and staff on duty, broke windows smashed computers and printers, broke the chairs, this continued till the police came in , as usual they were too late, the damage had been done. There had been violence.

Similarly these politicians demand medical unfit certificates for their cronies when they are hale and hearty, they want false medical certificates to get their henchmen in jail out on parole, they demand their patients be seen on priority, they demand hospitals give huge concessions arbitrarily, they demand that certificates in medico legal cases be issued as per their directions and what not. Any refusal by the hospital administrations invites verbal abuses and at times violence. Will this ever change, if it does not very soon lesser and lesser intelligent people in India will opt for medicine as a career or they will look for greener pastures abroad. This violence has to stop.
A newly married lady was rushed to a small nursing home; she had apparently consumed some organophosphororus compound due to some domestic violence. Luckily she hadn’t taken much, the doctor and nurse immediately gave her a gastric lavage and started the treatment, soon she was out of danger. The doctor got down to preparing his case sheets and informing the police. He was legally bound to inform every medico legal case to the police. The husband, the in-laws of the lady objected, they knew she was out of danger, they didn’t want to mess up with the police. The doctor coolly explained the law, they wouldn’t budge, the doctor a law abiding one went ahead, and the husband snatched the papers, slapped the doctor and shook him by the collar. The staff called in the police, the doctor filed his complaint, the cross complaint by the husband stated that the doctor had molested his wife, luckily the lady refused to support the husbands statement.       There had been violence.

Misunderstanding and distrust in doctors

The doctors of yesterday, the gods and demigods of society have seen the trust in them being slowly eroded. Unlike previously when there was blind faith in the doctor, today with advent of internet, they are being questioned, misunderstanding and distrust has crept into the system.
Every diagnostic test advised by doctors is questioned, the patient has a misconception that he is being fleeced; he feels all those tests were not necessary. He takes opinions of friends, paramedics, other doctors and even Google’s out knowledge and then concludes he is right and the doctor wrong. This develops in to gross distrust in the doctor and grave misunderstandings.
When advised any surgery the patient and his relatives will follow the same route of multiple opinions and then feel surgery is unwanted. This mistrust in the doctor leads to misgivings, apprehensions and later violence if something goes wrong.

Inflated bills and unwarranted tests.

Perhaps the only place where a doctor or hospital might be the reason for abuse and assault is the hospital bills or the battery of tests done. We must understand that with the bringing of the medical profession under the ambit of the consumer protection act, the doctor needs to be doubly careful. He will definitely advise all test which perhaps he would otherwise have not advised. Cases in consumer forums always finds fault with the doctor for not having a test done, hence the cautious doctor will do every test remotely related to the disease or diagnosis, he can’t take chances, he can’t afford to not do it. This is mist rued as the doctor or hospital trying to make a fast buck by fleecing the patients and is a major cause of arguments, abuses and violence.
The doctor or hospital needs to take extra care and time in explaining to the patient and the relatives regarding the need for the tests and the approximate costs. The daily room charges, consultation charges , administrative charges, oxygen, procedure charges and ICU charges all need to explained to the patients and relative in advance and on a daily basis if any violence later is to be avoided.

One grey area where most of the violence is seen is when a patient unfortunately passes away and the relatives refuse to pay the bills especially when it is a large sum. Legally they have to pay up, ethically and morally the hospital administration should take a lenient view and either give major discounts or waive off the bill on humanitarian grounds. This is not always possible considering the financial aspects. Patient relatives should settle for a reasonable discount and pay up. But they are prodded, by friends, politicians, anti social elements and so called social organizations not to pay up. Most of the activists do not care about the patient or relatives, they just want some cheap publicity, the politician feels it’s his birthright to demand waiver of the bill. The hospital administration too is at times unyielding and refuses to hand over the dead body unless the full amount is paid up. This invariably leads to violence at the hospital with large adverse media coverage for the medical profession. Immediate steps need to be taken to address this and find an amicable solution.

It is high time society learns to pay up services rendered. If you to travel by air, rail or road you always pay up first and then travel, the lawyer takes his fees first and only proceeds with his case; the passport office takes their fees and then gives you a passport. All fields and business the dictum is pay up first, but not at doctors and hospitals, no one wants to pay up, they haggle over fees and bills. Even the best criminal lawyer can lose a case but his fees are not waived off, then why the violence against doctors only. Simple …..The doctor fraternity is a peace loving community and are sitting ducks for everyone, patients, relatives, friends, social organizations and anti-social elements.

Can the violence be avoided

Attitude of patients towards doctors has to change, behavioral change is very necessary. Medical and doctors associations have to take the lead to bring about this.
The trust which has been eroded has to be reestablished. Doctors need to give adequate time to their patients good counseling and improved communication skills needs to be established. Unnecessary tests and inflated bills should be curtailed. The patient should not feel he is being fleeced. Many a times the patients relatives feel that the doctors are not discharging the patient on time and that the purposeful overstay is to increase bills, this misunderstanding can only be removed through proper counseling and detailed explanation of the situation to the relatives. In cases of deaths hospitals need to take a more humanitarian view regarding payment of bills and handing over of bodies.
Patients should go only to doctors they trust and place all their faith in them, they should not dictate how a patient is to be treated, the doctor has spent a life time learning the intricacies of diagnosing and treating patients. Politicians should desist from interfering in the treatment process and stop dictating terms to these highly qualified doctors. In fact no one should interfere with the way the health system functions, the doctors know best to handle it.
There are laws for violence against doctors in India; they need to be made more stringent, better is to have them actually implemented. Hospital should have CCTV systems and good security men. Hospitals have to invest into the aspect of security heavily. The government has to improve manpower and equipment and medicine availability at all their health centers. The doctors attending to patient should never be rude; they should be kind and empathize with their condition. They need to instill the confidence in the patient that they are in proper and good hands. When the doctor/hospital and the patient / relatives change their present attitudes we shall see an India where there shall no more be any violence against the medical fraternity.
Looking forwards with hope to that day when violence against doctors shall be unheard of in India.

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