Sunday, 3 December 2017

Doctors in India: Villains or Victims?

"We have not lost faith, but we have transferred it from God to medical profession"
- George Bernard Shaw

The doctors community in India, both in public and private sectors, is in a state of unrest. Every few days there is news about brutal attacks on doctors and these are justified by patients’ family and friends as attributable to alleged medical negligence. Thanks to social media, copycat attacks are becoming frequent. The members of the medical fraternity very actively exchange news/ideas, devise strategies to overcome the problem, go on transient strikes, get assurances from the powers that be that concrete steps would be taken to contain such attacks; only for the cycle to restart after a short period. In a study that was conducted by IMA a few years ago three fourths of the doctors surveyed said that they were physically attacked at least once. In a study published in the national medical journal of India last year, not only significant number of doctors are getting attacked but it is also grossly under reported. The trend is getting worse.

Doctors were considered Gods at one time, when did the doctors become demons? From being the rakshak why did they become raakhshas in the public perception.
"Vaidhyaraja namasthubhyam, Yamaraja sahodara!! Yamasthu harathi praanaan, vaidhyah praanaan dhanaanicha!!"
(Meaning: Salute you doctor, brother of Yama, for Yama takes away only our lives, you take away our lives and wealth too) Sanskrit subhashitha.

The problem started when the health care started shifting from public sphere to private. Up to early 1980s patients were get treated in the private sector but when they had major ailments depended on government and teaching hospitals for their treatment. With the advent of corporate hospitals who were capable of providing care for an extended range major ailments, health care cost escalated and high end health care became inaccessible to a majority of people in India. In the absence of national health insurance scheme many citizens make out of pocket payment (OOP) which pushes 32 to 39 million people every year into Catastrophic Health Expenditure (CHE), which is defined as health expenditure which threatens a family's basic standard of living. The situation is only getting worse by the fact that the government's expenditure on health is just at 1% of GDP. (MOHFW2009).

Doctors who work in private hospitals in India know very well that one of the important triggers for irrational behaviour by patient and families is financial issues, especially when the patient outcome is not favourable. The potential for catastrophic health expenditure could cause psychological havoc.

"The huge gap between the rich and the poor, globally and within nations is not only morally wrong, it is also a source of practical problems"
Dalai Lama.

A patient who is at the risk of eliminating his/her financial resources to obtain healthcare, does not realise medical science has its limitations, every illness cannot be cured and there will be an outcome which is unacceptable in some cases. Good counselling of the exact nature of the problem and probable or definite poor outcome including mortality can mitigate this misunderstanding to some extent. Most of the doctors in India have realised the importance of this only in the recent years. As we are battling out issues like large volumes of patients, limited resources and poor infrastructure in almost all public sector providers and most of the private hospitals; effective communication and empathy could be one of the ways to keep situation under control at least partially and temporarily.

"To effectively communicate, we must realise that we are all different in the way we perceive the world and use this understanding as a guide to our communication with others"
Tony Robbins

Even as we doctors condemn unacceptable behaviour by patients and their relatives, can we absolve ourselves of wrong doings? Doctors say that there are some irregularities by a few individuals and a few hospitals and that should not be reason enough to portray the entire community adversely. True, that should not be the case but is it only a few individuals or hospitals? If we believe so, then we may need a reality check. Have we not heard of hospitals expecting their consultants to work to a target? Are we not aware of conversion rates, referral fees, unnecessary laboratory investigations by doctors and cross referrals, indicated or not?

"I am dying from treatment of too many physicians"
- Alexander the great.

This commercialisation and greed has become worse by the entry of unscrupulous businessmen, liquor barons and politicians into the ‘business’ of medical colleges and hospital ownership. Some/many, with their clout seem to flout every rule, manage accreditation yet unable to provide infrastructure or sufficient human resources.

"I have always tried to avoid politics because most politicians I know are quite dirty in terms of human dignity, ethics and morals"
- Steven Seagal

The reality is, when an idealistic young doctor comes to practice with noble intentions he/she is caught in this web of helplessness because of the lack of the right conditions needed practice his/her profession. This is highlighted by Dr Arun Garde, from Pune, in his book in Marathi "Voices of conscience from the medical profession".

"Every truth has two sides; it is as well to look at both before we commit ourselves to either"
- Aesop

So who are the one who get attacked and is physical attack of doctors justified?

The ones who are attacked are residents, doctors who are on duty in high risk areas, especially in government  hospitals, charitable trust hospitals, small nursing homes and occasionally resident doctors on duty in bigger corporate hospitals though the vicarious responsibility of treating these patients rest with the consultants. The corporate hospital owners or senior consultants who are in many ways responsible for the impression (or truth) that hospitals are primarily profit seeking places, never get attacked. Like every battle, it is only the foot soldiers who get attacked. By doing this the patients further alienate the residents who are already overworked, under suboptimal working conditions which results in worsening of already acrimonious situations.

"Soldiers win battles, generals get credit for them."
Napoleon Bonaparte.
(In this case they get attacked!!)

Are patients justified in attacking the doctors, whatever the grievance? If money is an issue, why do such attacks take place in government hospitals where treatment is free? While there may be many reasons, here is mine. We are living in a society which is becoming increasingly uncivil and aggressive. There are many people who throw shoes and slippers at politicians; vandalise houses of cricketers when there is something as trivial as defeat in cricket match. So when a major tragedy like a loss of life of a dear one happens they indulge in violence. Further, many of them come to a government hospital after exhausting their financial resources they have, this results in their desperate but bad behaviour.

The health benefit schemes introduced by some of the state governments have benefited the private hospitals and insurance companies; that government money could have been better used to improve the infrastructure in major hospitals. In a recent survey by the citizen engagement platform more than 40% of the participants said that they don't trust the private hospitals but 80% visited private hospitals when there was an illness in the family.

"There are far too many silent sufferers.
Not because they don't yearn to reach out but because they have tried and found no one who cares"
- Richelle E Goodrich

The media do not play a constructive role. The police choose to stay away because they believe it is natural for the patients to be distressed and use that as a justification. In some cases the hospitals and doctors don't help their own cause by criticising the treatment given at another facility either because they are not thoughtful enough or they think it will help in their own defence, thereby indulging in medical jousting. The already vitiated atmosphere is made worse by this, making an irate mob, violent.

"We are all connected, when one arm or foot is poisoned the whole body is infected"
Suzy Kassem.

We doctors often become defensive or even play the victim and say we sacrifice everything to continue as a doctor. Every profession in this competitive world has its own difficulties. Because we deal with human lives we seem to run the additional risk of getting attacked immediately by a crowd which gets provoked when things happen contrary to their expectations. However, we can demand stringent laws and better security in the work place. This is more easily said than done.

"Doctors are only doing KRIYA, that is earning their livelihood through this profession, not doing KARMA, that is doing charity for betterment of mankind"
Dr Pankaj Chaturvedi, quoting Bhagavath Gita

The educated people rarely resort to this kind of physical violence against doctors. I know of instances where frank negligence on the part of  doctors resulted  in mortality and morbidity. I know how a middle aged executive became disabled because of inordinate delay and inappropriate treatment; an elderly surgeon who succumbed to negligent care following a surgery and another elderly gentleman never recovered from an easily treatable problem because it was identified late. All these hospitals are well equipped, high end hospitals and what happened there was definite provable negligence. The families of these patients because of their education and politeness did not indulge in unruly behaviour despite spending huge amounts of money for treatment.

"Human behavior flows from three main sources, desire, emotion and knowledge"
- Plato.

Is it not an option to go to the consumer forum? According to a study, cases in the consumer forum has gone up by 400% in the last decade, the inordinate delay to get justice in Indian legal system adds to the frustration. Recently there was consumer forum ruling which was pronounced in 2017 for a case filed in 1998. More over the economically underprivileged ones are left with very little to fight a legal battle after they have spent their money in treatment, so they resort to their version of instant justice.

"Do not expect justice where might is right"
- Plato.

We are not Gods and cannot save all patients, we live at a time and age where practice of defensive medicine is almost a norm. We have not been able to address our issues of poor patient doctor ratio, infrastructure, abysmal working condition and inappropriate financial compensations.

Too many questions. Too few answers. The way forward.

We need a mechanism where we can make the patients our partners and communicate our difficulties to them. We have to spread awareness among public the factual and realistic capabilities and limitations of today's medical science.  We ought to stop advertising treatment modalities which may not be of benefit. We have to stop advertising treatment which could be inaccessible to many.

The doctor - patient trust and relationship is at its lowest point. Is the only way ‘up’?

While we demand a civil behaviour from our patients, it is important for us to do some soul searching and take that extra step and walk that extra mile to restore the trust and confidence of patients in doctors, medical profession and hospitals.
This in no way is a justification of violence against doctors. Every challenge is an opportunity and this is an opportunity for doctors for course correction where appropriate. The argument is advocatus diaboli.

"As doctors we generally don't tell outright lies. We don't speak the truth fully."
Dr.Allan Hamilton.

Are the patients ready for it? More importantly are we doctors ready for it?

Dr Usha
Hyderabad, India

All views in the above write up are the personal views of the author (and not that of this blog site)


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