Violence against doctors in the Indian subcontinent: A rising bane.

Incidents of violence against doctors in the Indian subcontinent have increased in the last few years. Most doctors in India, China, Pakistan, Nepal and Sri Lanka are concerned about their safety at work. The problem is worse in government hospitals, which characteristically lack appropriate security protocols. In order to tackle the issue, doctors need to accept the problem, discuss the various causative factors, understand the public sentiment and collaborate with the government to find a solution. Formulation of legal provisions and standards to ensure the safety of health workers is the need of the hour.

Not too long ago, there was a time when doctors in Asia were bestowed upon a divine status. Rural and urban peoples alike, revered medical personnel and blindly trusted them with the lives of their loved ones. Alas… times have changed and how! The current situation is an alarming one. It speaks of rising incidents of violence1, 2 against doctors, with some ending in fatal outcomes. According to an ongoing study by the Indian Medical Association, more than 75% of doctors have seen violence at work. National newspapers constantly report doctors being abused, bullied, manhandled, and even killed by the patient's relatives.

Mahatma Gandhi devoted his life to ‘Ahimsa’ – The Practice of Non Violence. Through these principles, he inspired millions across a much divided nation to unite and break the shackles of British monarchy. However, over the years his legacy seems to have been permeated by an undercurrent of acrimony, and a sense of distrust toward the medical community.

Why is this happening?

According to the United States Department of Labor, Workplace Violence is defined as any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide. It can affect and involve employees, clients, customers and visitors.

The problem is multi-factorial in origin. Over the past two decades, the Indian subcontinent has witnessed an economic boom. So much so, that the Socialistic fabric of the region laid down by Gandhi has slowly changed to a Capitalistic one. With the rise of corporate hospitals, the mentality of physicians has changed from a charitable to a lucrative one. Though not necessarily deleterious, this change has drastically influenced people's perception of physicians. Earlier even when there used to be one medical officer for an entire village or a small district, people's trust in the doctor remained high. The doctor was regarded as part of the local community and was integral to the health and well being of the social unit. With commercialization of health, more and more physicians have migrated toward corporate settings in urban centers, where large number of patients feel like a fish out of water. The rift between the educated class and the labor class of India has never been wider. The burgeoning intellectual class of doctors has become alienated from the grass root society.

Trust in the doctor–patient relationship has taken a beating over the last few decades. In earlier times, people went into the medical profession for the predominant objective of serving ailing mankind, and thus were viewed as saints. Over time with medical care commercialization, some physicians were accused of being driven by greed and of adopting unethical practices. The ever hungry media rapidly jumped to conclusions and published sensational stories of organ theft, medical negligence and malpractice. Furthermore, reports of unnecessary tests and needless invasive procedures have caused patient distrust to grow.

Government hospitals in India follow the welfare model, as majority of people are poor and do not have health insurance. Such hospitals offering subsidized medical care are swamped with patients and their attendants. The average medical officer posted in the outpatient department, sees close to 350 patients a day. It is logical to assume that quality of care gets sometimes compromised while attending to such a huge number of patients in a small window of time. This may impart a perception of neglect to the patient and leave him/her only partially satisfied. After waiting in long lines for hours, some patient's attendants are already at the brink of an emotional cliff. Ineffective communication or delay in attending to a patient can easily drive them over the edge. Since most patients lack health insurance, sometimes the diagnosis comes as a financial disaster and shocks them into emotional turmoil. This results in displacement of anger toward the physician.

The highest number of violent incidents (close to 50%) occurs in the ICU and almost 70% are caused by relatives of patients. Miscommunication by physicians causes attendants to have unrealistic or too high expectations for patient recovery. Hence it is important to emphasize the patient's prognosis to the attendants in a lucid manner. As a doctor trained in India, I can say that Indian medical schools are excellent in imparting medical training to their students; however teaching to be empathetic toward the patient is seriously lacking. Young doctors fresh out of medical school are often not empathetic enough with the attendants, leading to a sense of perceived neglect. This is often the trigger of violent assaults.

Most government hospitals in India lack adequate security personnel. During night hours, it is often the medical officer who plays the role of the doctor, as well as that of the security guard. There is no established protocol for tackling violence or a shooting incident. Most of the police force is plagued by corruption and is prone to bribery. Hence relying on the police for safety is more often than not, useless. The common public has complete lack of faith in the judicial system and feels it is only the rich who obtain justice. Thus in instances of patient death, people believe in exacting immediate revenge, seeking their ‘pound of flesh’ using physical means rather than filing a case in court.

There exist no laws for the protection and safety of the medical community. While it is a non-bailable offense to assault a uniformed public servant like a bus driver or a policeman, there is no distinct penalty for hitting an on-duty physician in a white coat. The public is cognizant of this phenomenon and feels no apprehension in manhandling a doctor. Since such acts of violence go unpunished regularly, it emboldens the mob and encourages the occurrence of the next incident.

Indian media has played a major role in demonizing doctors with the objective of selling news. Journalism has become increasingly competitive and blaming doctors sans proof has become commonplace. In addition to selling papers, this brand of yellow journalism sells a negative image of the medical community. Since it might be callous to pin the blame on the patient or the attendants, Indian media outlets find it sensational to scapegoat the physician, thereby causing the public to embark on a frenzied witch hunt. Such scandal mongering has sowed seeds of distrust and skepticism deep in the minds of the people.

Politics in India is dominated by sectarian groups with religious or quasi religious agendas. Some separatist party leaders feel no shame in publicly castigating physicians. In fact, a common method of gaining political mileage and securing the vote of the local community, is marching in a government hospital with the patient, and publicly manhandling the doctor. Such brazen acts are emboldened by a corrupt judiciary and a systemic failure of the law.

The problem of violence against doctors is not specific to India. In China, physicians are struggling with the same issue.10, 11, 12, 13 Reports of physician assault cases are rising in Pakistan14, 15 and in Nepal. Palestine conducted a cross sectional study to assess its own problem. Physicians in Turkey are no strangers to violence as well.18, 19

What can be done?

Though the current scenario seems gloomy, tackling the problem requires physician participation. Doctors should work with the government in creating an effective strategy to prevent hospital violence. Security personnel should be posted at the entrance of every hospital and should not let anyone through without checking for appropriate identification. Weapons should be confiscated before allowing passage to anyone. All attendants must register at the front desk and be given a visitor badge to be worn at all times. No more than two attendants should be allowed with the patient. Laws against doctor assault should be displayed on the walls. To ensure doctor safety, every hospital should create an emergency protocol and an evacuation plan in case of a major act of violence.

The importance of teaching empathy to budding doctors cannot be stressed enough. Proper and effective communication with the patient and the attendants is an art, and should be taught to all young doctors. William Osler famously said, “The good physician treats the disease; the great physician treats the patient who has the disease”.

In emergency and ICU settings, doctors should take time to clearly explain patient prognosis to attendants who may harbor unreasonable expectations. Counselors for emotional support should be available. Language translators can help in reducing chances of miscommunication. Since India is a Republic, The Rule of Law should prevail. Mobocracy cannot be allowed to raise its ugly head. Law should be enacted to safeguard the safety of doctors and nurses. Assaulting medical personnel on duty should be made a cognizable offense, with serious consequences. The media is the window of society. Demonizing physicians should be avoided and convicting doctors should be left for the courts.

Violence in any form and in any setting is reprehensible. However, acts of violence in a hospital are the most extreme and should be dealt with an iron hand. Hospitals are sanctums of healing and recuperation. In addition to jeopardizing the safety of medical personnel, violence threatens patient safety and hampers their recovery to health. For the good of the Indian society, doctors rather than turning a cold shoulder, should work in tandem with the government as well as the public, to tide over this crucial problem.

Conflicts of interest

The authors have none to declare.