Saturday, 25 March 2017

Assaults on doctors: what can be done to prevent them?


Sharire jarjaribhute vyadhigraste tathapare|
Aushadham Jahnavi toyam vaidyo Narayano Harih||

(When the body has lived its duration of time, and has been caught up in the diseases therein, 
The medicine is Ganga water, and the doctor is Narayana who takes away suffering.)

The above Ayur-vedantic injunction which accords a godlike status to doctors is both at once uplifting and troublesome in our country.  

It is uplifting because it can draw aspirants to the field, motivate a medical practitioner to always perform at his or her best, and ascribe a sacred quality to the patient-doctor interaction, which is unlike any other professional interaction.  

It is troublesome because it implies that the doctor can do no wrong.  From a patient and his family's point of view, a doctor is an infallible and magical creature who can provide panacea to all maladies.  

In actual fact, there is probably no other profession that is as underrated, taken for granted, vilified, victimised, targeted and condemned as the medical profession.  

Let us, for the time being, leave aside the mess that is medical education today, the incompetence of the chief medical governing body of the country, non-availability of postgraduate seats, and non-recognition of foreign postgraduate degrees, and look at the immediate problem that is facing the medical fraternity today: assaults on doctors.    

It is the second troublesome aspect of the injunction above that is largely the reason behind the spate of attacks on doctors in the recent times.  Of course, attacks on medical personnel is neither a new phenomenon, nor is it unique to India.  But why do these attacks occur?  And how is it that other countries seem to be very successful in managing this problem?

For this we need to understand the problem at a deeper level.  Let's consider some of the issues at play. 

As a disclaimer, let me also add I am not justifying malpractice of any kind.  The medical professional is not above law, and not for a moment am I suggesting that there are no cases of medical negligence at all.  If anything, the medical field is one of the most error-prone professions and is definitely not an exact science.  There have been horrific cases of medical negligence, and unethical practices that need to be addressed through proper channels.  Even then, taking the law into one's own hands and resorting to violence are definitely unacceptable.

There are, no doubt, several measures that doctors and hospitals can take to help the victims of wanton attacks.  Representative bodies are already looking into these, and considering legislative and legal alternatives as well.

The purpose of this article is not to 'firefight', but to look at how to mitigate the risk of attacks altogether.  In keeping with the oft repeated medical truism, 'prevention is better than cure', the purpose is to look at preventing these attacks from occurring in the first place.  

So, who are likely to be assaulted?
Statistics suggest that junior doctors; on-call doctors; those working in high risk areas such as casualty, ICU, CCU, PICU and NICU; doctors working in lonely setups and remote areas; and those in government setups are most prone to being assaulted by patient's attenders.

Who are likely to assault?
Those with a short-temper; proneness to violence; those in nexus with powerful people; people from lower socioeconomic strata; and those under the influence of alcohol and other substances.  

What might be the possible risk factors for assault?  
Sudden and unexpected bad news, such as disease and death; loss of a child; deaths from road-traffic accidents; failed resuscitation attempts; and death on the operating table.  

When two or more of the above situations coincide, the imminent risk of violence is very high.  Analysis of the individual cases of assaults that have occurred thus far will confirm this.

What can be done to prevent these attacks?  
This is by no means an exhaustive list, but here are a few suggestions:

1. Communication:

Medical profession is concerned with the human condition, and involves daily interaction with patients and their families who have varying levels of awareness about medical matters.  

The Medical Council of India includes the topic of communication skills in the two-month foundation course that precedes the medical undergraduate course, in addition to making it a part of the core competencies expected of Indian Medical Graduates.  

However, to what extent this implemented across various medical colleges, in addition to the core subjects that comprise the medical course is not known.  From what I have seen, junior doctors are not very competent communicators, and what they say in certain situations may easily be misinterpreted, or worse, may sound derogatory and patronising to a patient or his relative. 

Take for example the phenomenon of grief reaction.  Elisabeth Kubler-Ross has described its five stages: denial, anger, bargaining, depression and acceptance.  While the entire process of grief and bereavement may last up to six months, the first two stages, denial and anger, which frequently occur together, can lead to an immediate flare up when the news of death is broken to the patient's attenders.  The need to ventilate the sudden outburst of shock and angst takes over, and the nearest 'punching bag' - the doctor who gave the bad news - has to bear the brunt.

It is also worthwhile remembering that grief does not have to progress according to these stages.  Each one of us is unique, and so are our reactions to adverse situations.  Therefore the initial emotional shock may manifest in any manner, depending upon the presence or absence of the risk factors listed above.

Therefore there is a very real need for training in communication skills to be inculcated at an early stage in the medical career.  Trainees should practise these skills again and again to get them right in real life situations.  

Breaking bad news is an art in itself, which not many doctors are good at.  It involves several steps that are frequently not followed: setting the scene, assessing the patient's/attender's knowledge about the illness, breaking the news gently, taking an empathetic approach (for example, generous doses of 'I am sorry', and offering water/tissues), and providing further help/assistance as necessary.

2. Hospital policies:

Issues such as working conditions, infrastructure, working hours per day/week should be looked into.  High risk areas of hospitals should be equipped with counselling rooms with CCTV monitoring and presence of security personnel, especially at the time of breaking bad news.  

There should be a zero-tolerance approach to violence towards medical personnel.  In all cases of assault, as a standard practice, legal route should be pursued by the hospital administration.  Statistics from western countries suggest that successful prosecutions go a long way in reducing the risk of violence towards medical personnel.  

3. Legislation:  

According to a recent report, 53 cases of assault on doctors have occurred in India over the last two years, but there hasn't been a single conviction.  Contrast this with Australia, where a prison sentence of up to 14 years is meted out to the offenders.  

But then again, why would there be any convictions, if the representatives of the highly honourable judiciary of the land issue statements such as:

'if doctors do not want to work without security, they are not fit for the profession',

and

'you are not factory workers who resort to such protests...shame on you!'

This is rich coming from a system that is known to be corrupt to the core, sits for decades on hundreds of thousands of pending cases, and finally delivers judgments which can only be described as gross injustice, or in some cases, ludicrous.  It has been rightly said that there is a lot of law in the courts, but not enough justice.  

Many judicial office bearers are high on ego, and are a cantankerous lot who make loose-cannon statements such as those listed above.  They frequently take a highhanded, judgmental and condescending attitude towards all that they look down upon from their lofty perches.


It is time that the legal eagles and their bosses are asked to account for their shortcomings.  

I hope the government of the day will bring about some amendments to reform the legal system, and will also strive to improve the lot of the doctors.  

I am forwarding this write-up to the Prime Minister's Office as a mark of protest, and as a request for his affirmative intervention in the matter.  

















References:

1. Ayurveda-vedanta: The Vedanta of Life Science, Atmatattva Dasa, Tattva Prakasha, Volume One, Issue Nine - November 9, 2001 (http://veda.krishna.com/encyclopedia/ayurvedanta.htm)

2. Vision 2015 document, Medical Council of India (http://www.mciindia.org/tools/announcement/MCI_booklet.pdf)



3. 53 doctors attacked in two years, not a single conviction, Mumbai Mirror, 22 March 2017 (http://mumbaimirror.indiatimes.com/mumbai/cover-story/53-doctors-attacked-in-two-years-not-a-single-conviction/articleshow/57761708.cms)


4. The 5 Stages of Grief and Other Lies That Don't Help Anyone, Megan Devine, 12 November 2013 (http://www.huffingtonpost.com/megan-devine/stages-of-grief_b_4414077.html)