Why doctors are unable to find a cure for attack from patients

Scene 1: Fatima Hospital, Kozhikode

March 4

Dr PK Ashokan, a senior cardiologist of Fatima Hospital Kozhikode, was brutally attacked allegedly by some bystanders. The incident happened after a patient who was under the treatment of Dr Anitha Ashokan, his gynaecologist wife, working in the same hospital, developed some complication and lost her child during labour. The bystanders attacked the 60-year-old doctor and vandalised the hospital as the relatives accused the doctor and hospital staff of delaying treatment and other medical negligence.

According to witnesses, a 15-member crowd broke into the hospital and broke the window panes around, claiming that the woman’s CT scan results were being delayed. Dr Ashokan, who received heavy punches on his face, fell unconscious with nose bleed and was taken immediately to the ICU. Police registered a case and arrested the husband of the woman and another person who later secured bail from the court. The doctors’ organisations observed a day’s protest on March 17 demanding stern action against the attacks against the health workers which has become the norm, as per their leaders.

Scene 2: Kerala Legislative Assembly

March 13

KB Ganesh Kumar, former minister and LDF MLA from Pathanapuram, during a discussion on supplementary grants, referred to a case of alleged medical negligence meted out to a woman in his constituency and went on to say that some doctors deserve to be beaten. “Seventy per cent doctors perform their duties very well. The remaining 30 per cent are the ones who bring the health department’s reputation into disrepute,” the MLA said.

Ganesh Kumar explained the ordeal of some patients, including a case from his constituency in which a 48-year-old woman, who had been subjected to seven back-to-back surgical procedures including the removal of her uterus and had been left with an open surgical wound, which is yet to heal after several months.

The woman has now been admitted to a private multi-speciality hospital in Kochi where she has been getting free treatment since the MLA’s outburst in the assembly. Ganesh Kumar’s statement, however, did not go down well with the doctor’s association and added fuel to the strike call. The medical community felt that the MLA justified violence against a section of medical professionals and the Indian Medical Association (IMA) filed a complaint before Kerala Assembly Speaker AN Shamseer and the Chief Minister Pinarayi Vijayan.

According to the Kerala Government Medical College Teachers’ Association, the MLA is not aware of the scientific facts of the case. The association claims that the woman’s infection was caused by the multi-drug resistant pathogen Klebsiella pneumoniae, which complicated the healing process. The doctors delayed suturing her wound because it was the tried-and-true way to treat wounds that don’t heal well, read the association’s press release.

Increasing attack on health workers

According to data collected by the Kerala chapter of IMA, 189 cases of attacks on health workers have been reported in the past three years in Kerala. As many as 140 such incidents had been reported between June 2020 and June 2021 during the Covid pandemic, but none of the culprits have been convicted.

“According to the data we have, at least one attack on healthcare workers happens every week in our state. There are multiple reasons for this, with the main one being the fragility of existing rules. In any other country such attacks will be dealt with strictly and the culprits will definitely be punished. Here we have a hospital negligence complaint authority but rules for prevention of violence against health care staff are not properly framed. Till date not a single person has been convicted, under the act which had been in place from 2012,” said Dr Sulphi M Nuhu, secretary IMA, Kerala chapter.

Lacking teeth

According to doctors, the Kerala Healthcare Service Persons and Healthcare Service Institutions (Prevention of Violence and Damage to Property) Act, 2012, clearly lacks teeth and is inadequate in preventing violence against healthcare service persons and damage or loss to property in healthcare service institutions. The IMA has already submitted a memorandum suggesting amendments in the Act.

“The government is well aware that the existing Act is not adequate and we are mulling over enactment of a new law. As the existing act is too small, it won’t be practical to amend the same. We have intimated the assembly and the high court of Kerala,” Veena George, health minister of Kerala, told The Federal.

The doctors, however, remain apprehensive of the government’s move. “We are demanding an amendment to the existing law, because we know that enactment of an entirely new bill will take a long time. It won’t materialise in the near future for sure,” said Dr Sulphi.

As per the amendment suggested by IMA, all hospital employees including security staff should be treated as healthcare service persons. Recording or/and circulating information about individuals and institutions and tarnishing the image and goodwill of the healthcare service institution should come under the definition of violence. Violence happening within a certain perimeter of the institution should also come under the purview of the Act. They also demand that the First Information Report should be filed within an hour of receiving the complaint from an individual health care service institution and special courts should be set up for a mandatory time-bound trial. Another significant demand from the doctors is that presumption of guilt should be the legal principle in such cases.

“We have received many suggestions in this regard, and we will be examining all of them carefully. The government has already issued an order to prefer ex-servicemen as security guards in hospitals and FIRs be expedited in cases of attacks against health workers,” Veena George said.

“Anyhow our preference will be to introduce a comprehensive new act in this regard as early as possible. This does not mean that the government has anything against the doctors. We are very much with them. You must have noticed that we did not act harshly on their strike by imposing dies non or anything,” added the minister.

Root cause: meagre spending

Several studies and researches conducted across the country have come to the conclusion that the problem exists due to a multiplicity of factors.

“The 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, disorganised 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,” suggests a study by Neeraj Nagpal published in the National Medical Journal of India.

Are doctors soft targets?

“I personally think there is no particular violence against the doctor community per se, people do get violent on many occasions. You look at a motor vehicle accident on a highway, there are many incidents where the drivers of the vehicles get manhandled for no reason. There might be stray incidents, the doctors are taking it out of proportion,” said a police officer in Kozhikode on the condition of anonymity. “If you make a statistical data of violence after road traffic accidents the number would be even higher than that of doctors being attacked,” he added.

The same sentiment was shared by one of the accused in the Kozhikode case, who termed the violence against Dr KP Ashokan as normal, given the circumstances of the case.
“Doctors are always soft targets. The threat from the relatives of the patients is the same in private and public sectors. Since we take care of human lives, they know we do not hit back. Do any of them dare to hit police personnel, or lawyers, if they let them down,” asked Dr Parvathy Deth, editor, Kerala Federation of Obstetrics and Gynecology.

“As far as we gynecologists are concerned, the threat is even higher as no one is ready to accept that maternal mortality is a reality even if it’s very low in Kerala,” she added.

“Commitment is part of the curriculum in medical colleges, but in practice, many doctors lack it. We have to do some corrections from our side also. In this era of social media and the internet, people are more informed, so doctors should also develop better communication skills. We (IMA) are planning to introduce an internal training mechanism. For this initially a series of training for trainers’ workshops will be conducted. Later, they will train junior doctors and medicos,” said Dr Sulphi.

“The notion that Kerala’s public health system is faultless should be done away with. By any standard, it is under a lot of stress. Public hospitals have an unacceptable doctor-to-patient ratio that puts both patients and doctors at risk. The policymakers should consider whether a one-minute doctor consultation is worthwhile, especially in the case of patients with multiple comorbidities. The only solution is to recruit and retain employees while reducing the workload. The working hours should be set, and leaves should always be granted. Conflicts will result from a doctor’s lack of work-life balance, which will affect their productivity,” said Bebeto Thimothy, a Northampton (England)-based Malayali doctor.

Communication and transparency hold the key

“Along with stringent rules, the mindset of people should also change. Even in war, hospitals are spared from bombing. Here those who beat doctors are getting a hero’s welcome. The media and politicians have a significant role in it. Of course, there are incidents in which healthcare workers including doctors are at fault, but those are comparatively fewer,” Dr Sulphi said.

In many cases that The Federal examined, money was not the primary reason that triggered violence from the common people. Anxiety, alleged negligence, a protracted waiting period, the lack of important investigations, an excessive delay in referral, unhygienic conditions in the emergency and other wards, extreme crowding and above all a lack of correct information about the condition of the patient set off the relatives.
Proper communication and transparency along with enforcement of effective rules could prove to be the key in containing attacks on healthcare workers.