There has been a sudden spurt in graphic pictures of serious body injuries on my social media accounts. There are several things in common between these pictures. All these incidents occur in India. The injuries are quite grievous and brutal, some leading to death. And in a stunning saga of modern day savagery, all the victims are doctors. The occurrence of these crimes has become so common in current times that a fear seems to have gripped the medical community in India. It is unlike any other phenomenon in healthcare worldwide. There is a constant stream of news coverage that describes doctors being verbally abused, badly beaten, manhandled, intimidated, and even killed on a daily basis all over the country.

The World Health Organization describes healthcare professionals to be at the highest risk for workplace violence and four times more likely to be a victim as compared to other professions [1]. A study done in New Delhi, India in a tertiary care hospital concluded that almost half the doctors experience violence of some sort – verbal, emotional, or physical [2]. Almost all participants considered workplace violence as the daily norm. Women face more violence than men and younger doctors more than older. The most vulnerable specialty was OB/GYN. Most violence occurred in the afternoon and night. The most common reasons for violence against doctors were described to be long waiting times, delay in patient care, stringent visiting hour rules, and conflict with nursing staff. There are some reports that the Indian Medical Association puts the prevalence of violence against doctors higher – 75% of doctors in India have faced some form of workplace violence. Many cases go unreported and therefore the prevalence may unfortunately be even higher. Most of the violence occurs in the intensive care unit and after a surgery or procedure.

Sporadic incidents of violence against doctors by patients happen everywhere. However, it has never been a worrisome attribute of practicing medicine until now. The two countries that have experienced the most violence against healthcare workers are China and India. The deterioration of the patient-physician relationship in China has been well documented in a recent article in The Lancet as being the most important reason for violence against healthcare providers[3]. This deterioration is claimed to have stemmed from a distrust in physicians and consequential patient dissatisfaction. This distrust, in turn, is said to have originated in alleged unscrupulous practices by doctors that has bestowed a corrupt and devious reputation on them. However, the author goes on to say that patient dissatisfaction should be viewed not as the cause of violence against doctors but as a “symptom of a flawed system that victimizes both patients and doctors alike.” Doctors have many negative experiences during their career in China that impacts the way they practice. This includes questionable traits of medical students who are a poor fit for medicine, low reimbursements, faulty pay-for-performance models that encourages defensive practices, astronomical patient load, and general discontent with a career in medicine.

In response to this article, a letter from an Indian doctor describes the four common reasons why families of patients in India get violent – advance payment requests, delay in patient care, perceived unnecessary tests, and full payment clause prior to the release of the body of a deceased patient [4]. The relationship between the pharmaceutical industry and doctors is also looked at with suspicion. Doctors are accused of availing many luxuries at the cost of the patients including expensive international vacations and conferences. There is no legal provision to put a halt to kickbacks within the industry. Payments disguised as professional fees are commonly exchanged among specialists for referring patients to each other [5]. Those who want to stay honest get isolated for not adapting or fitting in with such malicious practices. These corrupt activities are allegedly rampant across the country and seem to be an open secret in the medical community. Anecdotal reports describe a sense of entitlement among physicians to earn as much as possible after spending many years and a hefty amount of money in training.

The Medical Council of India (MCI) has been rather lackluster in taking any steps to curb these unethical practices despite steps from honest doctors to furnish irrefutable evidence. Although there is a robust code of ethics, the implementation is weak. There is a small group of doctors policing individuals and institutions that indulge in immoral practices, but they are few and far between. The rise of large corporate hospitals focused on the bottom-line has led to a culture of business and profits, an unacceptable trend in the minds of Indian citizens who see the practice of medicine purely as charitable and compassionate. The perception that medicine has increasingly become too commercialized has created a smoldering resentment among the working class. Poor bedside manners and lack of communication skills portrays a lack of compassion on the part of the doctor.

This state of affairs is rather chilling and dangerous for the medical community in India. Studies show that any experience of violence affects the steady mental state of doctors which may negatively impact decision making and patient outcomes. Violence prevention policies are non-existent in most healthcare practices and institutions, and training in dealing with violence is minimal. In medieval times there are plenty of stories about physicians being blamed for every adverse outcome suffered by patients. The doctor was buried alive with the dead patient in some cases. This mindset has not changed in the Indian society.

Healthcare is a complex and often byzantine assembly of multifactorial components. However, the doctor is considered the face of healthcare. This puts them at a distinct disadvantage of having to bear the brunt of anything that goes wrong within the intricate grid of systems and humans that comprise the lumbering world of medicine. Any system failure can lead to aggression against doctors – medications, billing, visitation, food, etc. The expectation that the doctor will cure all disorders is universal in the Indian society and any outcome that does not meet this high bar can make the patients and their families completely unhinged. The cost of medical care is often a contentious bone. Health insurance is sparse and out-of-pocket pay is often the norm. Families do not budget for illness. When it happens suddenly, they are left with few options and often become belligerent at the perceived overpayment for services. Seriously ill patients with high mortality rates causes the family to feel cheated – since they paid a certain amount of money they expected cure. This is a direct result of lack of health literacy, incomplete and unscientific information available easily on the Internet, and poor planning on the part of the patient. That such insight is lacking within a society that blames the doctors for everything, is an insurmountable problem. Healthcare providers have started to ramp up their personal security at their own expense. A handful of hospitals are committed to providing security for their medical staff. It is quite ridiculous. Doctors wore a helmet to work as a sign of protest recently.

The solution to this problem is not easy to define. A cohesive multidisciplinary approach is warranted that systematically addresses every causative element. The challenge will be in trying to figure out how to outline a comprehensive blueprint that is effective on multiple levels – doctor, patient, society, law, institutions, public health, policy matters, politics, and curriculum development. A few suggestions for the medical community are given below.

(a) Healthcare reform is the need of the day and has to start in medical colleges. Training must include teaching future doctors correct bedside manners and proper communication skills, a key concept in western medical training. This will help to build a trustful relationship with the patient, the most critical element of medical care. Compassion, kindness, and empathy are often lacking among new Indian doctors as has been documented multiple times in literature.

(b) Keeping the patient and family in the loop right from the outset with shared medical decision-making should be fundamental. “Cowboy medicine” must be avoided – the inclination to project a bright outcome with anticipated heroic effort on the part of the doctor. Patient centered delivery of medical care is less likely to compromise the integrity of the patient-physician relationship. Any anticipation of adverse outcomes must be clearly communicated to the family as early as possible to avoid any surprises.

(c) Pristine ethical practice and strong moral values are mandatory. Rules and bylaws about kickbacks and rewards must be set by peer institutions like MCI and followed relentlessly especially regarding interaction with the pharmaceutical industry with punitive actions for those who refuse to comply. Transparent relations and minimal or no conflict of interest are ideal goals. In my opinion, this is the most important step. Indian doctors need some soul searching to reflect within themselves and indulge in active social ethics to set a perfect example of the nobility this profession is associated with.

(d) Risk management initiatives within hospitals, like root cause analyses of adverse outcomes, should be a priority for the administration. Patient safety and quality of care benchmarks must be set and implemented as standard of care.

(e) Clinical practice guidelines based on scientific evidence to establish consistent practice of medicine in India would mitigate the random practice of medicine, often done with the intention of enhancement of reimbursement and achieving impractical goals set by hospitals for practitioners.

(f) A set of red flag signs for high risk patients and families must be taught to all healthcare providers. Once a red flag is raised the risk management team should be galvanized into action especially towards clear communication with the family to minimize any anticipated violence. If collaboration with the local police department is feasible then this should be done with a 24/7 hotline for outgoing calls. The doctor should not be left to fend for themselves alone is such cases, especially during the vulnerable hours of the evening and night.

(g) Advocacy with political groups should be strong, structured, and well-coordinated. Unity and solidarity among doctors is vital without which we will remain fragmented and weak. Politics should be kept out of hospitals and clinics. Reasonable patient load and professional goals are critical.

(h) It is also essential for the medical community to have a positive relationship with the media. This will need a tremendous proactive effort from the leadership to erase the current negativity projected by the media regarding doctors in India.

For patients, education, health literacy, and proper communication is necessary. Public health programs that teach these skills would be very helpful. How to save money for a medical emergency should be an integral part of community education, perhaps through programs in banks and other financial institutions. Strict enforcement of laws against perpetrators of violent crimes against doctors would be a deterrent for others. However, we have little control over these factors.

Violence is never the answer to any problem. In the modern world though, it has become a consistent presence in our lives. Something must change. As educated professionals, I am sure that doctors can be the change that they want to see, just like Mahatma Gandhi said.

References:

1. Bureau of Labor Statistics (BLS). Non-fatal occupational injuries and illnesses requiring days away from work; 2012. Available fromwww.bls.gov/news.release/ pdf/osh2.pdf. (last accessed March 25^th, 2017)
2. Kumar M, et al. A Study of Workplace Violence Experienced by Doctors and Associated Risk Factors in a Tertiary Care Hospital of South Delhi, India. J Clin Diagn Res. 2016 Nov;10(11):LC06-LC10.
3. Violence against doctors: why China? Why now? What next?. Lancet. 2014 Mar 22;383(9922):1013.
4. Bawaskar HS. Violence against doctors in India. Lancet. 2014; 384(9947): 955–956.
5. Sachan, D. Tackling corruption in Indian medicine. Lancet. 2013; 382: e23–e24