"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
Physician
Hyderabad, India
All
views in the above write up are the personal views of the author (and not that
of this blog site)
©M HEMADRI
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