Where We Stand and How to Avoid
Dr. Krishna Prasad Kudlu
Dcirector, Prasad Nethralaya,
Udipi, Karnataka
Dr. Gopal Pillai S
Head of Ophthalmology Department,
Kochi Medical College and Amrita,
Institute of Medical Sciences and Research
Dr. Neeraj Nagpal
Convener, Medico-Legal Action Group
Violence on doctors has been on the rise. The doctor-patient relationship is slowly changing from a perceived goddevotee bond to a provider-consumer association. In a country like India where qualified healthcare services were far and few a few decades ago and where majority of healthcare was undertaken in the public setup around 50 years ago, doctors were almost like unapproachable idols whose words were final and who had no perceivable flaws. Over the past few decades, healthcare has shifted from a public to private domain and with increasing corporatisation, hospitals have shifted from being perceived as temples to flourishing business units which are out there to make money. Unfortunately, the reality is far from this and even today most of the large and deemed successful hospitals are just about keeping afloat.
The primary level clinics fall short in both infrastructure and human resources and while contributing significantly to healthcare, they are unable to provide adequate quality of healthcare. With the growing population and increasing burden on cities, the limited secondary and tertiary level public healthcare is strained. Doctor’s are seeing 5-10 times as many patents as they should and there is shortage of paramedical staff too. This results in what are sometimes shortcuts and delays which every once in a rare while result in a not so good outcome. Add to this, poor infrastructure and upkeep and we have a potentially dangerous cocktail. This is even more so in a private setup where the added commercial angle makes patients and their attendants believe that everything revolves around the doctor making money even though this could not be further from the truth.
With this background, it is not difficult to imagine what would happen if an unfortunate event were to happen to a patient. The attendants would immediately blame the doctors and often go on to assault them (as they are easy targets, in most cases actually apologising for the untoward event). There is often a mob mentality with regard to these issues and with one attendant showing aggression, many others join in. While it may be assumed that ophthalmologists are to an extent immune from this since they are generally not dealing with life threatening conditions, there have been enough incidents of violence on them for this to be a burning issue for AIOS Times. A recent study conducted by IMA has shown that upto 75% doctors have faced some form of violence.
Dr Krishna Prasad Kudlu, director Prasad Netralaya, Udupi, Karnataka recounts an incident where a senior surgeon had to stop doing surgery from the fear of public backlash after a few cases of endophthalmitis in Shimoga district of Karnataka. “A senior surgeon in government practice, who was regularly operating cataracts, had some endophthalmitis cases a few years ago and has stopped operating since. He fears a backlash from people in that region and has been running a medical ophthalmology practice since.” said Dr Kudlu. He feels that the growing epiodes of violence against doctors needs to be tackled by a collective effort from the medical fraternity to bring awareness and put in place stringent legal systems.
Dr Gopal Pillai, head of ophthalmology department at Kochi medical college and Amrita Institute of Medical Sciences and Research, knows the potential threat that violent attendants pose. He says “In Kerala, I have heard of cases of aggressive patients and attendants who have threatened doctors and verbally abused staff, when dissatisfied with outcomes”. He goes on to state that “while none of my colleagues have been physically assaulted, the day when that may happen is not too far considering the way things are going.”
The harsh reality of violence on doctors is not unique to India alone. It has been reported in countries such as the USA too. In fact, long before India started to see such untoward incidents, the developed countries “where doctors were not Gods” had faced this issue. Stringent laws and an effective judicial system has led to improvement in the situation in the developed countries. Laws protecting doctors exist in India is the form of “The Prevention of Violence Against Medicare Persons and Institutions Acts”, which have been notified in 19 states. However these have
failed to address this problem due to an overloaded judicial system and inadequate penalties.
Steps to Avoid Violence
A recent article in the National Medical journal of India by Neeraj Nagpal have recommended certain steps that Doctors can take to help reduce violent incidents and their repercussions. These include:
1. Sticking to your limits: Doctor’s should not attempt procedures beyond their training, experience and facilities. For example, if one has not received formal training in retinal surgeries, it is best trefrain from performing them and seek the help of a specialist. Likewise, if one is not satisfied with the facilities at a certain centre (eg. Improper operating theatre design or inadequate sterile practices) where one may be visiting, it is best to avoid performing surgeries there. An important point that holds valid for all medical specialties is cases where a life threatening medical emergency presents.
All doctors are supposed to have knowledge of basic life support and should not refuse a patient in a emergency requiring it. However, it is best to arrange to send the patient to a nearby hospital/centre which is equipped to deal with such conditions as soon as possible. It would help to have emergency numbers of nearby hospitals at hand and proper guidance or help to the attendants to shift the patient there is imperative.
2. Consent: Valid and informed consent is the second most important step in preventing violence. Despite the rush and low health literacy, consents should be given due time. Explain things to the patient and take an attendant in confidence. The purpose and outcomes of procedures should be explained as well as possible complications. When a patient and attendant is part of the decision process, chances of anger and violence reduce.
3. Documentation: Proper documentation of the patient’s course in hospital may not prevent violence but is important once violence occurs and the police are called. The records are often seized by the police and only they can actually help in the litigation which may follow.
4. Communication: Spend time with the patient and attendants. Studies have shown that even a few additional minutes spent with the family and patient have reduced litigation rates considerably. Improving communication skills will certainly help prevent doctors from facing violence in the long run. Use newer techniques such as videos and online media to explain to the patients what is going on. They should be part of the decision making on themselves.
5 Be alert: Be alert and evaluate each situation for potential violence when you are going to meet a family or explain an unfavourable outcome to the attendants. It is advisable to always try to keep an open path for exiting. Do not let the potentially violent person stand between you and the door. Friends, staff members, colleagues should collect at the site of incident without being provocative. It is advisable to look for indicators of violent behaviour such as staring and eye contact, tone and volume of voice, anxiety, mumbling and pacing (STAMP) as described in a 2007 publication.
6. Restrict entry: The most important step in preventing mob violence in a hospital is restricting entry of the public. A large number of relatives should not be allowed at the patient’s bedside. Entry should be strictly by passes and this must be implemented through good security. It helps to have CCTV cameras (even dummy ones at some places) to keep violence at bay. Security guards should be alert and trained to notice aggressive behaviour.
Standard operating procedure (SOP): Develop an SOP for violence. Mock drills need to be conducted and each member of the staff should be clear about his role if the situation of impending or actual violence does arise.
Insurance: Insure the establishment against mob violence, damage to property and injury to workers to at least mitigate the financial losses that are incurred in the aftermath of violence.
An advice from a legal expert for violence, if it occurs is as follows:
If violence occurs:
1. Do not meet anger with anger. Remain calm in the face of provocation and let things blow over.
2. Depute someone (preferably beforehand) to take photographs and, even, audio/video records of the violence. This can sometimes be a deterrent and helpful in case of legal proceedings.
3. Depute someone to immediately (preferably as part of the SOP) get the medical record of the patient photocopied. If the mob carries away the original record, the photocopies will be useful.
4. Inform your lawyer.
5. Inform the police immediately by phone, etc. and keep a record of such phone call, etc.
6. Identify the troublemakers/leaders in the mob.
7. Get written, signed statements from the persons present (doctors, staff, patients, relatives, others) regarding the occurrence of violence.
8. Lodge an FIR with the police. When making a police complaint the doctor/hospital should make sure that a request is made to register an FIR under the relevant Act for protection of medical personnel.
9. Do not try to ‘settle’ the issue by paying hush money (more often than not it is taken as admission of guilt).
The need of the hour is stringent laws and good communication practice. There is a need to train doctors in soft skills particularly with regard to conversing and managing such stressful situations.