ondering on the issue that I
wish to explore through this article, I was instantly reminded of the
title of Crouching Tiger, Hidden Dragon, which is a famous film directed
by Ang Lee, the same filmmaker who also gave us Life of Pi. In the
original movie, the title refers to a Chinese aphorism about hiding
strength from the world. But here I use it in the negative context – to
highlight the untold dangers lurking in the shadows that we doctors have
to face every day. The recent case reported from Max Hospital in Delhi
is a grim reminder of the fate that could await any of us on any given
day. At this hospital, a preterm baby was declared as dead and later
found to be alive; though scientifically these instances can occur,
there was a terrible backlash. Luckily there was no violence in this
episode but the credibility of the medical profession took a sound
beating. The hospital license was also suspended.
In another incident which occurred at Fortis
Hospital, Gurgaon, a 7-year-old girl died after her treatment for dengue
failed, despite the best efforts of doctors. The hospital bill, which
included prolonged intensive care unit (ICU) care, was over Rs. 16 lacs.
As a result of public outrage, the intensivist concerned was held
responsible and a police case was slapped on him. This doctor happens to
be a renowned expert and a pioneer in this field. From the information
available, it appears that nearly 95% of the amount involved went to the
hospital expenses and government kitty. The doctor’s fee was nominal,
his efforts highest, and the blame total. Thus it is clear that he has
been made a scapegoat because it is very convenient. We often hear of
similar instances elsewhere in country, and they are rising at an
alarming rate. Physical assault, verbal abuse, vandalizing of premises
and harassment are only some of the other ways in which doctors are
victimized for alleged acts of professional negligence or failure.
This is not a new, India-specific or
specialty-specific phenomenon. Writing as long as two decades back on
the topic, Morrison, et al. [1] observed: "One of the most
difficult situations that physicians face is being threatened, abused,
or physically harmed by one of their patients. This is not an uncommon
problem: Bureau of Labor Statistics (BLS) data for 1995 indicate that
more workplace assaults and violent acts occur in health care and social
services industries than in any other. Health care patients, the most
common perpetrators of nonfatal workplace violence, were responsible for
45% of all nonfatal assaults in 1992. Although the majority of such
incidents involve nursing staff, all health care workers are at risk,
and physicians are no exception. From 1980 to 1989, 22 physicians were
killed while at work. This represents almost one-fourth of all
workplace-related homicides among health care workers during this time
period" [1].
Writing earlier this year on volence against the
medical profession, Mukul Chandra Kapoor noted: "Violence is
increasingly being used against doctors and other medical personnel.
More than 75% of doctors face violence during their practice. Almost
half of the violent incidents occur in critical care units…There are
regular reports of doctors being abused, threatened, bullied,
manhandled, and even killed. The issue is not restricted to our country
but is a worldwide phenomenon. Multiple reviews and studies have been
published in contemporary literature, with the largest number
originating in China. The World Health Organization has drawn out a
global action plan to prevent this violence" [2].
Hence we can see that there has been a steady trend
of doctors being exposed to increasing risk of unwarranted behavior from
patients, and if the patient has died, from their relatives. It is true
that occasionally patient grievances are genuine. It is also true that
in most cases the doctor’s decisions are based on perfectly valid
medically accepted norms. For every child that dies, hundreds more are
saved from the jaws of death by the pediatricians. Many times, it is the
host response to the pathogen that determines what happens. Of course
when everything is tried to save the patient, very costly drugs are used
and every expensive technology is employed to diagnose hidden problems.
Use of disposable equipment to prevent infection is also bound to
increase the cost of treatment.
I do not wish to get into a detailed analysis of all
this here except to state that this subject has not got a well reasoned
and properly formulated response from the medical profession as a whole.
A lot of hows, whats and whys as already being hotly discussed on social
media platforms and also in the mass media. Hence rather than delving
into the details, I wish to only present a few of my broad observations
on how I feel this menace should be tackled with the hope that it will
contribute to an evolving consensus on the future course of action,
especially under the auspices of Indian Academy of Pediatrics (IAP).
It’s an ever-changing world out there
Historically, doctors have been hailed as members of
the ‘noble’ profession and their knowledge and wisdom were never
challenged. With the advent of universal education and the general
advancement of society, this position has undergone a paradigm shift.
Today’s generation only sees us as service providers of our respective
domains of expertise and their relationship with us is more like that
between seller/vendor and buyer/consumer. The proliferation of
information technology and social media platforms has further flattened
the world. The birth of superspeciality hospitals and corporate
hospitals has blurred the role of doctors as individual experts in the
eyes of the public. High-end technology, while improving the health
prospects of patients, has also made treatment exorbitantly costly. The
glut in mass media has led to a hypercompetitive environment in which
everyone has become vulnerable to the glare of the camera and its
intensely cynical scrutiny. And lastly, the political sensitivity of
issues relating to healthcare give them a dimension far more
catastrophic than all of the above.
A call to adapt
All these are important changes that have taken place
in the last few decades or so. I believe that our present problems have
more to do with not fully digesting these dramatic changes and coming up
with suitable adaptation strategies. Constant and continuous change is
the reality of life. We as doctors have absolutely no control over what
course life can or will take. It might console us to know that it is not
just medicine but also that almost every other field of human endeavor
has experienced similar upheavals during the same period, especially in
the wake of globalization and liberation that has swept the country for
the last two decades. The future will bring in more challenges of
unimaginable nature, and we cannot even flatter ourselves that we are
capable of comprehending them. We can only develop the flexibility of
mind and openness to accept change and try to use it to our advantage.
While I believe that we have been quick to absorb technology and modern
management practices, we have lagged behind in two aspects: (i)
understanding and safeguarding our role as individual experts in the
context of the large organizations that dominate the healthcare
landscape, and (ii) understanding and effectively addressing the
social dimension of our profession. The sooner we catch up with this,
the better it is for all.
Need for rational response
In the course of the recent outrageous occurrences in
different parts of the country, I have often participated in discussions
with other doctors, both in person and on social media. While many
attempt to come up with constructive observations and suggestions, I am
also struck with awe that an equal number express anger and resentment
against all sorts of targets like the aggressive patient parties, the
intrusive media and the opportunistic political classes. They demand
tough punishment for the wrongdoers, legal retaliation and other
punitive measures. Being a colleague, I find their anger understandable
as it does seem unfair that we should be rewarded so shabbily after a
hard day’s work. But the moot question is this: has anger ever solved
any problem? True, most of the states now have good laws in place to
specifically protect medical personnel. But just having these laws have
not resulted in any decline in the occurrence of unsavory incidences
[3]. Hence angry response – while giving us temporary satisfaction –
will only further aggravate the vitiated atmosphere. Hence the need of
the hour is to come up with a rational response to the problem. For this
to happen we first need to put our minds together and commit ourselves
to honest introspection and courageous reform.
Communicate to connect
For all issues involving human beings, there is a
thumb rule that 50% of the problem can be solved by just listening,
communicating and connecting. This is a trick that most managerial
experts are masters of. This involves going back to our roots and
establishing our lost human connect with the patient by exercising our
compassion, sympathy and all other qualities that make us human. Today
technology has overtaken us to such an extent that we are probably more
distant to the patient than we might imagine. We as a profession have
also failed to sufficiently communicate to the patient regarding matters
like the complexities involved in patient care and the reasons for high
cost of treatment. We also need to develop a strategy to communicate
with society at large. This invariably happens through a friendly –
rather than adversarial – mass media. For this to happen, we need to
establish a Media Cell that can develop rapport with the media people
and be available to respond to their queries. The Media Cell can also
identify good spokespersons from amongst us who can represent us in
television debates, press interviews etc. As there is obviously a trust
deficit between the public and the medical profession, we could engage a
Public Relations agency to conduct research and come up with solutions.
Yet another proactive initiative could be to arrange sensitization
workshops for journalists regarding medical issues by aligning with
press clubs, journalism schools and so on.
An integrated approach
Lastly, we need to recognize that not everything is
in our hands. The problem is much larger than ours alone. Hence we must
identify where the interventions are needed to be made, and push for the
correction. As Neeraj Nagpal writes: "Violence against doctors is on the
rise all over the world. However, India has a unique problem. Meagre
government spending on healthcare has resulted in poor infrastructure
and human resource crunch in government hospitals. Hence, people are
forced to seek private healthcare. Small and medium private healthcare
establishments, which provide the bulk of healthcare services, are
isolated, disorganized and vulnerable to violence. Violence against
health service providers is only a manifestation of this malady. The
Prevention of Violence Against Medicare Persons and Institutions Acts,
which have been notified in 19 states in the past 10 years, have failed
to address the issue. To prevent violence against doctors, government
spending on healthcare must be increased and the Indian Penal Code
should be changed to provide for a tougher penalty that could act as a
deterrent to violence against doctors" [3].
In conclusion, I would like to draw attention to an
integrated approach, which could provide a long lasting solution to this
vexing issue once and for all. This idea is best described by Morrison,
et al. [1]: "addressing violence and aggression requires an
integrated, multidisciplinary approach. A common link among the three
cases that we presented is the failure to recognize the systemic causes
of frustration and the resulting vulnerability of the physician who
seemed responsible, as an individual, to deal with the aggression.
Violence prevention and control is a systemic problem that requires the
input of administrators, educators, security personnel, and legal staff"
[1].
So ‘Crouching Tiger, Hidden Dragon’ are the hidden
ghosts lurking in our practice. We are still a long way from warding
them off. The least we can do is to acknowledge the real magnitude of
the problem and shape a sustained and effective response based on hard
facts and strong reason.
References