When life-savers are afraid for their own lives

On June 11, 2019, a furious mob of 200 assaulted and seriously wounded Dr. Paribaha Mukhopadhyay and Dr. Yash Tekwani at NRS Medical College Hospital. The result of the gruesome attack by an angry mob on the young Dr. Mukhopadhyay — a skull fracture — are there for all to see on the internet. The precipitating event was reportedly the death of a 75-year-old gentleman, Mohammed Sayyed, who allegedly died because of medical negligence. Further details of the nature of his medical condition or antecedents could not be gleaned from the available news reports.

This assault galvanised the medical community as never before, leading to a call for a nationwide strike by the Indian Medical Association on June 17 and a reiteration of the demand for better security and zero tolerance for violence against doctors. The assailants continue to be at large at the time of writing this article.

Violence against doctors is not a new phenomenon. In March 2017, over 2,000 residents and junior doctors from seventeen government-run Mumbai hospitals went on strike for four days. This was to protest a similar violent streak against doctors. A month before that, in February 2017, the Calcutta Medical Research Institute, a private hospital in Kolkata, was vandalised by an irate mob. Here too the precipitating event was the death of 16-year-old patient Saika Parvin due to alleged medical negligence. Similar events continue to happen in countless smaller hospitals which are not reported in the news or deemed newsworthy.

In each event, an “untimely “death or adverse event happens, a mob gathers due to their perception (mistaken or otherwise) of medical negligence and, in a display of destructive emotion, violence is wreaked upon the doctor and medical personnel on duty, not to mention the loss of property caused. A study carried out by the NGO CEHAT on 193 resident doctors in collaboration with KEM hospital and MARD, as reported in the Times of India on June 18, revealed that a startling 60% of doctors in Maharashtra hospitals have faced violence by families of patients. The brunt of these events is borne by junior doctors and residents in government and public hospitals, but private hospitals have had their fair share of such events as well.

 

Violence in the healthcare environment is not restricted to India alone. The website of the United States–based Occupational Safety and Health Administration states that healthcare workers in the U.S. are at an increased risk for workplace violence. For the years 2002 to 2013, incidents of serious workplace violence were on average four times more common in the healthcare sector than in any private industry. In 2013, the broad “healthcare and social assistance” sector had 7.8 cases of serious workplace violence per 10,000 full-time employees. Other large sectors including construction, manufacturing, and retail had less than 2 cases per 10,000 full-time employees.

So, are we condemned to a perpetual cycle of violence against doctors and medical personnel?

As a letter in the medical journal Lancet in 2017 observed, these attacks are a sign of a deeper malaise in our healthcare system.

Management expert Peter Drucker says, “A crisis that recurs a second time is a crisis that must not ever occur again.” But if it keeps recurring — in the same pattern, over and over — then the flaw is not in that mistake itself. The flaw is in the management of issue and the fact that we’re letting it happen over and over again and we’re not learning.

So, what can we learn from these recurrent crises and can we prevent them in the future? Here are my thoughts:

1. Anticipate, intervene early and decisively

It is often possible to identify, early on, patients who are at risk of suffering a bad outcome such as death. Relatives of these patients should be counselled and appropriately informed of the prognosis ahead of time by senior doctors and, if necessary, by trained counselors and management.

Certain diseases like acute cardiac or neurological events sometimes deteriorate rapidly, leaving a very small window of opportunity to communicate with guardians of the patient. Algorithmic approaches with preplanned responses such as ‘code blue’ for cardiac arrest and ‘code violet’ for violence would speed up the process of reacting to an acute event. Healthcare institutions must develop and review their protocols for an appropriate response to these events.

A fog of misunderstanding and misinterpretation in the heat of the moment can lead to violence. In May 2018, a large mob, in a fit of emotion, vandalised the Wockhardt Hospital on Mira Road, Mumbai, after the death of a Shia cleric who had complained of chest pain and collapsed. He could not be revived despite cardiac resuscitation. One of the triggering factors was that the process of resuscitation was being performed by people who the mob thought were not doctors. The violence abated after it was explained to them by the Emergency room doctors that the process of resuscitation requires a large team of doctors, nurses and paramedical personnel and that the resuscitative process was being performed under the doctors’ supervision. In certain circumstances, second opinions should be obtained to project a consistent and unambiguous message.

If there is a perception of continued threats, consider proactively involving the concerned community’s mature elders and religious leaders so that the grief may be expressed in a safe way.

2. Bad medical care differs from a bad medical outcome

A bad medical outcome such as death happens due to circumstances not in our control. This does not mean that bad medical care was delivered, just that the patient was too ill to recover.

For example, in my specialty of oncology or cancer medicine, patients unfortunately do die but that is usually not a reflection of the quality of care rendered. Indeed, in dealing with the terminally ill, a focus on palliative care — that is, controlling the patient’s symptoms and not their disease — may be the right choice.

Educating the family and its mature elders on the difference between bad medical care and bad outcomes is crucial as part of the ongoing engagement mentioned above. These elders and the family are sometimes key to calming down a simmering mob.

Resident doctors face multiple competing demands on their time. Families need time to process complex information regarding the health of their loved ones. This is once again an avenue where trained counsellors can be brought in to articulate a clear message to the families on behalf of the hospital.

3. Build a robust doctor-patient relationship

The relationship between a patient and his or her doctor is a sacred bond of trust. This trust forms the bedrock of the process of caring for a patient and communication with the family. In many instances of uproar and violence, the ailing individual has usually been a first-time patient with no prior meaningful relationship or trust with any of the hospital’s doctors.

Reversing this absence of engagement requires a long-term commitment on the part of the governments — State and Central — to invest in healthcare so that all patients receive regular and ongoing care and are not seen for the first time when they are seriously ill.

Conveying empathy during the interaction with families is often key to avoiding violence. In December 2016, relatives brought in a middle-aged gentleman to the NMMC hospital in Vashi, Navi Mumbai, who had been injured in a car accident. During the process of care, his relatives had an altercation with a ward boy. As family members grew agitated, a calm and reasoned discussion by the on-call resident doctor, Dr. Sachin G., persuaded the relatives against resorting to violence.

4. Enforcing laws

An impartial and timely enforcement of existing laws is necessary to build confidence among members of the medical community and a reassurance that they will be protected in case of dangerous remonstrances.

As we wait for lawmakers to decide on a more stringent law, the need of the hour is to enforce action within the current legal framework and effectively prosecute criminal behaviour. A speedy resolution of pending cases should clarify the legal and financial consequences of such behaviour, and act as a deterrent.

5. Hospital security

In the end, it may be judicious for hospitals, both public and private, to do more than simply bank on the goodwill of society and to actually invest independently and adequately for their own security.

Common-sense policies of crowd control — restricting authorised visitors to immediate relatives alone, allowing only two or three at a time — reduces the risk of a mob mentality taking over an unhappy situation.

Adequate precautions should be maintained to protect the institution and healthcare personnel when an adverse event is expected. A skewed ratio between the number of agitated persons and security personnel increases the possibility of violence.

A long-term and proactive engagement with law enforcement agencies and local communities would help to anticipate and tide over acute events. Investment in better living conditions for their medical residents as well as medical personnel would lead to a happier and more secure workforce.

Conclusion

We, as a society, do need to incrementally learn from and prevent these recurrent attacks on doctors and medical personnel. Well begun is half done and it is encouraging to see willingness on the part of the Union Health Minister as well as the Chief Minister of West Bengal to engage with the problem and focus on dealing with it.

Anticipating risky encounters and finding ways to communicate effectively with families are the key to defusing a volatile situation. No one in society benefits when doctors and medical personnel are distracted from focussing on taking care of you and your loved ones by the threat of potential reprisals.

From a cultural perspective, there needs to be a universal acceptance that assaulting those who care for you and your family is bad behaviour and not an acceptable way to grieve. As a society, we need to work out constructive ways to enable families and communities to grieve effectively. We must explore ways to help people channel the powerful emotion of grief.

We must invest in developing an effective healthcare infrastructure so that every patient is cared for regularly by a primary physician and that they can rely on their doctor to see them through their acute illness.

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