How doctors protect themselves from patient violence

75% doctors have at one time or the other faced verbal or physical abuse, according to a study

It’s 6 pm on Monday. Ten resident doctors of the All India Institute of Medical Sciences in New Delhi gather at a park to learn self-defence from two taekwondo experts, a man and a woman. Over the next hour or so, the duo takes them through the paces: how to deflect an unexpected attack and neutralise an armed combatant. 

After the training, at least four of the doctors confess that they have faced violence at work and have been abused. A huge crowd of patients turns up at the hospital everyday, which makes it impossible for them to give enough time to all — way short of what the anxious attendants of the patients want. Tempers run short. Abuses get hurled at them. Fisticuffs break out. 

Security is poor. The private guards on duty fear losing their jobs and police harassment if they take on the miscreants. Plus, there aren’t enough CCTVs in the sprawling complex. 

Jawahar Singh, tall and soft-spoken, recounts how a group of men with guns charged at the medical staff recently. “Shots were fired but no one was injured. Second-time lucky is a chance we are unwilling to take.” This is what brings him to the taekwondo class.

Recent months have seen doctors attacked in Maharashtra, Tamil Nadu, and West Bengal. Doctors in government hospitals in Maharashtra went on a flash strike in March after a series of assaults across the state, triggering a health crisis: over 500 surgeries had to be postponed or cancelled. The same month, more than 1,000 doctors took to the streets in Chennai to protest the assault on a doctor in a government hospital.

A study conducted by the Indian Medical Association shows that 75 per cent doctors have at one time or the other faced verbal or physical abuse.

The attacks have happened inside overworked government hospitals and inside plush private hospitals. Some private hospitals are known to have hired bouncers to protect their star doctors.

The government hospitals are visited by violence because of the capacity constraints. Doctors at AIIMS disclose that 3 million people turn up at the hospital every month for treatment but the 600-odd doctors are able to treat only about 10 per cent of them. 

Much of the violence takes place inside the emergency section. In the emergency ward at AIIMS, of the 20 positions for doctors, as many as 11 lie vacant. “A doctor barely has time to properly examine a patient. Only one technician is on duty and when ventilators or other machines malfunction, it frustrates people whose loved ones are hanging between life and death,” says Vijay Kumar, the president of AIIMS’s Resident Doctors’ Association.

The result is grief on the streets outside the hospital — a breeding ground for violence.

Rakesh, a carpenter from Etah in Uttar Pradesh, brought his child, Bina, to AIIMS two months ago. Bina is ill. Her bulging eyes stand out because of her unusually thin limbs. She lies on a pink towel spread on a luggage bag, her makeshift bed on a pavement, in the scorching heat. “The doctor said she needs a heart surgery but she has polio too and that needs to be treated first. We completed the medication in March and are waiting for a second appointment ever since,” says Rakesh.

Thanks to the capacity constraint, the heart surgery of Bebi Devi, a middle-aged woman from Patna, has been slotted for November 2018 — a full year and a half away. “She can’t breathe properly. I don’t know if we can wait that long,” says her husband, Brijlal. He says he will plead his legislator in Bihar to expedite the process.

Neither Rakesh nor Brijlal has violence on his mind yet, but for many the inadequacy of public health care has become deeply upsetting, something that brings out the demon in them. 

It is not uncommon for a specialist in a government hospital to see up to 90 patients in a day. In this short time, it is unreasonable to expect him to do justice with each of his patients.

In March, a doctor in Dhule, Maharashtra, was assaulted by a mob because he had referred a patient with a skull injury from an accident to another hospital because there was no neurosurgeon on call. Rohan Mhamunkar, an orthopaedic surgeon, instead of celebrating Holi with his family, had been working non-stop for over 24 hours. Mhamunkar, who risks losing vision in one eye from the injuries, wonders if he made a mistake by becoming a doctor.
 

Resident doctors at a self-defence class in the hospital premises. Photo: Dalip Kumar

In most hospitals, such is the shortage of nurses and technical staff that attendants are required to chip in. Doctors are aware that this is not right but turn a blind eye because otherwise there will be a total breakdown. As a result, hospitals at any given time are swarming with attendants — anything goes wrong and there is nothing to stop them from falling on the doctors.

In private hospitals, there is a perception that doctors write extra medication and investigation just to drive profits. These hospitals may provide affordable health care for the whole world, but for a large section of Indians they have come to represent unscrupulous greed. 

This received official endorsement when the government came up with price controls on stents and Prime Minister Narendra Modi announced that doctors will soon be allowed to prescribe only generic medicine — not brands. 

In February, a mob attacked a private hospital in Kolkata after a girl, who had been admitted with stomach pain, died. Another hospital came under fire for reportedly asking the relatives of a deceased patient for fixed-deposit as security before releasing the body. The Hooghly Police booked a private nursing home after the relatives of a deceased patient alleged that it did not have the wherewithal to treat cardiac complications and yet had admitted the patient who had suffered a heart attack.

Sensing the public angst, Mamata Banerjee, the astute chief minister of West Bengal, called all the private hospitals and gave them a mouthful — she went to the extent of comparing them with slaughter houses. 

She also pushed through the state assembly a Bill that sought to make it criminal for hospitals to engage in over-billing, decline an accident victim and hold on to a dead body till the bills are cleared. Hospitals in the state will have to offer patients fixed rates for procedures covering the entire gamut of treatment with scope for the final bill exceeding the initial estimate by only a percentage. The bill also envisages a regulator for private health care. 

On Thursday, at the inauguration of the Indian Institute of Liver and Digestive Sciences at Kolkata, President Pranab Mukherjee said doctors should provide a “human touch” while serving patients, though he condemned the recent attacks on doctors and hospitals.

Doctors say much of the friction is because of their inability to communicate properly with the patients. 
 

Anoop Misra, director and head (department of diabetes and metabolic disorders), Fortis, says: “Soft skills are singularly lacking in physicians, Most of the doctors (and many surgeons) do not effectively communicate with patients.” 

K K Aggarwal, the president of the Indian Medical Association, says the patient has moved on from the Bhakti Yuga, marked by complete faith in the doctor, to Jnan Yuga, when the patient is well-informed about his illness and medication, while the doctor is still stuck in the time when raising questions was considered insolence, a challenge to his authority.

An online survey started by the Indian Medical Association recently showed that a vast majority of people want the doctor to introduce himself upfront and mention his qualifications, listen to them in greater detail, explain everything about the illness, treatment and medication, and check with them if they have understood the treatment. 

Clearly, there is a communication gap that the doctors need to work upon. Till then, there will be serious heartburn amongst patients.

Also, the first point of contact for any patient — and his attendants — is invariably a junior doctor who is often unable to communicate properly, which leaves the patient deeply dissatisfied.

Some corrective action can be seen after the recent incidents, At Mumbai’s Sion Hospital, new CCTVs have been installed two months after a resident doctor was beaten up by relatives of a patient who had died.

In the days after the attack, protection was provided by police commandoes. Now, Maharashtra Security Guard Board personnel strictly enforce the policy of not allowing more than two attendants with a patient. The doctors have taken some comfort from the state government’s promise that the police will take prompt action against the attackers and expenses for treatment of injuries and for legal aid will be covered.

“We knew we’ll have to work in 24- to 36-hour shifts when we entered the profession. We are only asking for better facilities,” says Gagan Singh, secretary of the Maharashtra Association of Regional Doctors.

At Kolkata’s government-run Seth Sukhlal Karnani Memorial Hospital, where junior doctors were assaulted in March over their alleged delay in admitting a patient, more guards have been hired but the security remains insufficient. 60-odd guards are deployed during the day, which reduces to 40 at night.

Meanwhile, around 130 MBBS students in the government-run Nil Ratan Sircar Medical College have completed a two-day introductory class in taekwondo.

‘Soft skills are singularly lacking in physicians, Most of the doctors (and many surgeons) do not effectively communicate with patients’

Anoop Misra

Director and head (department of diabetes and metabolic disorders), Fortis

Aggarwal of IMA says the association is battling to bring in a stringent law, akin to the ones against rape and child abuse, to deter people from harming a medical practitioner. Till that happens, hospitals are taking no chances. 

“Violence is the weapon of the weak… support our doctors who continuously strive to enrich lives,” reads a standee at the Fortis Hospital in south Delhi. In the backdrop of recent incidents, the hospital has intensified security and trained doctors and staff to identify an aggressive person.

“It’s a patient’s body, his illness and his money,” says Sameek Bhattacharya, professor and unit head (department of burns, plastic, maxillofacial and microvascular surgery), at New Delhi’s government-owned Ram Manohar Lohia Hospital, who tells his students that a clear communication right from the beginning can thwart the violence.

For now, most hospitals have beefed up their first line of defence but are reluctant to part with details fearing a bad public image. Buff men hide in plain clothes in security control rooms and respond to any alarm within seconds. Even security agencies are reluctant to talk about the extent of services extended to the hospitals.

At Ram Manohar Lohia Hospital, a lanky guard in his 20s, posted near the VIP parking, says that he’s constantly abused by people for lack of doctors or other facilities, but does not retaliate. However, if a situation escalates, bouncers are called in. 

“People who come with an entourage demand preferential treatment and sometimes threaten doctors for not examining them first,” he says. “When it’s beyond our control, security control sends bouncers.”

Security at Gurugram’s Medanta Hospital is tight with guards posted every 50 metres. The lifts block access to certain floors and the staircase from the main lobby is out of limits. Muscular men in black safari suits can be spotted in the vicinity and guards ask the nature of your business at every checkpoint.

The care giver needs protection like never before.
 

Ranjita Ganesan in Mumbai and Avishek Rakshit in Kolkata contributed to this report