Rise in violence leaves doctors afraid, vulnerable

The provisions of the law protecting healthcare workers from attacks are scarcely being implemented

At a crowded casualty department in a government medical college in April this year, a PG resident doctor is trying to stabilise a critical patient. With her is a junior doctor. It has been a busy night.

At around 3 am, a walk-in patient's attender starts verbally abusing her and her junior. He takes videos, then grabs her hand. She is completely shaken. “He was a politician's driver and wanted to be treated immediately and all this because of a five-minute delay,” the doctor, who requested anonymity, said.

It happened again, later that month. A patient, who had consumed a powerful poison, had been admitted to the ICU; he was critical. His condition subsequently worsened and he passed away. “Despite repeatedly explaining the grave prognosis and daily counselling, a group of 10 men broke the ICU barricade, entered the ICU, hurled abuses on our educational qualifications and accused us of murder,” the doctor recollected. Things were getting out of hand.

The men could physically hurt them, she sensed. Fearing for their lives, she and another PG resident who was on night duty, hid in a duty room and called for help. “Sometimes, I wonder whether it’s worth it,” she said.

Each day, healthcare professionals across the country face threats, intimidation and assaults. While some cases are reported, several go unheard.

The Karnataka Association of Resident Doctors (KARD) said there are more than 12 documented incidents of assault on healthcare workers in the past eight to 10 months, but this is just the tip of the iceberg.

A 2018 report by the Karnataka Law Commission showed that between 2010 and 2017, a total of 173 cases were registered under the Karnataka Prohibition of Violence against Medicare Service Personnel and damage to property in the Medicare Service Institutions Act, 2009.

Of this, 20 cases were acquitted, while 101 cases were pending trial. There were just three convictions and not a single case in which compensation was awarded to the victim.

“A significant number of verbal abuses, intimidation and humiliation, happening almost on a daily basis, are underreported," Dr Ganesh Prasad Mudraje, Chairman, Harassment Committee, Indian Medical Association, Karnataka said, "because of the busy schedule of the doctors, apprehension of negative publicity, lack of support from colleagues, lack of cooperation from police officers and fear of further attacks from the culprits."

When attacks on the medical fraternity happen, their morale takes a beating. They experience dejection as well as helplessness.

A lot of them are dissatisfied and want to continue their medical career abroad. There is brain drain and further depletion of resources.

The violence also leads to an increase in defensive medicine and ordering more investigations, as one healthcare professional pointed out.

The attacks spare nobody, not even the senior doctors.

Last Saturday, Dr Padmakumar A V, a critical care specialist at the Fortis Hospital on Bannerghatta Road in Bengaluru, and a nurse, were assaulted by the son of a Covid-19 patient who was admitted at the hospital.

The patient, who was in his 50s, passed away due to complications arising from Covid-19.

More than what happened with him, Dr Padmakumar said he is worried about the effect the incident will have on those around him.

He said that he has been training young medical students sent by the National Board of Examinations for several years, and many of them now head the critical care departments in hospitals in Bengaluru.

“If something like this can happen to me in broad daylight, I am worried about the people working in ICUs all over India, especially at night,” he added, referring to the increased security risk when hospital wards are sparsely staffed during nighttime.

On June 18, more than three lakh doctors of The Indian Medical Association (IMA) participated in a nation-wide protest for a Central law to deal with violence against healthcare professionals. They also demanded enhancing security features in all medical facilities across the country and declare them as protected zones.

“The Karnataka Epidemic Disease Act, 2020 doesn't have much teeth to keep these people from carrying out violent acts. We are working to bring an amendment to the law that will increase the duration of the punishment to 10 years," Dr Venkatachalapathy, President, IMA Karnataka, said.

"For any law with a punishment above 10 years, the bail will be difficult."

The IMA has written to the Central government for a stringent law in the past as well, and a draft bill was even proposed by the Ministry of Health in 2019, which was not passed.

Categorising the nature of violence as physical attacks and verbal abuse, Dr Mudraje, said, “doctors are perceived as soft targets.”

Dr Mudraje said when unexpected deaths or complications happen, the patients end up assaulting the doctors either physically or verbally.

The high cost of medical treatment in private hospitals is another reason for this kind of behaviour, he added. “Doctors become scapegoats in such cases as high cost is not due to doctors’ fee but because of various domains of hospital treatment.”

Sometimes, even small incidents snowball into assaults.

A few months ago, a young man came to the crowded Emergency Department of a hospital with an injury to his hand, where Dr Murtuza Ghiya was an assistant professor. The patient was advised to get a hand X-ray done. Since he had not billed it, the X-ray department did not go ahead with it. In a fit of anger, the patient threw the papers in his hand at the nurses and started mouthing abuses.

When Dr Ghiya told the patient that such behaviour is not right, he started threatening the doctor, creating a scene while critical patients were waiting patiently for the process to take its course, Dr Ghiya recollected.

“When I pointed out that threatening a doctor is a non-bailable offence, he started shooting a video of me saying that ‘this doctor has destroyed my hand’ and called me money-minded,”

He said when he tried to take away the phone, the patient twisted his arm and broke his watch.

That evening Dr Ghiya went to the police station and filed an FIR. “But I was told by many people that the FIR won’t be followed up. I never got a call from the police. There was no closure." Ultimately, feeling that the more he got into the matter, the more it would eat into his work, he let the incident slide.

“You take it as work because there are 30, 40 patients waiting for you,” he said.

“While laws exist in various states with regard to violence against healthcare fraternity, what has been found lacking at times is effective implementation of it by the local law enforcement agencies,” said Dr Nitin Yashas, a medical oncology resident.

“It is important for doctors to document all the counselling that they have done regarding the condition of critical patients and also take signatures from those they have counselled.”

Dr Mudraje emphasised the need for internal grievances’ committees in hospitals which should offer services of counselling for a patient’s attenders, as a source of venting out their disappointment.

This, he believes, may significantly avert the violence in hospitals.

Clearly, the attacks on healthcare professionals mirrors a poor public healthcare system with all its frailties.

“There are around 1.26 lakh modern medicine doctors in Karnataka,” informed Dr S M Prasad, Honorary State Secretary of IMA.

Dr Prasad said that despite most doctors being present in urban areas like Bengaluru, the doctor to patient ratio in the city is nearly 1:1511, above the 1:1000 limit prescribed by the World Health Organisation.

Poor healthcare system

Coupled with this shortage is the fact that accessing quality healthcare remains a challenge in many parts of the country. Lack of awareness about preventive medicine and early detection has led to patients being presented to hospitals in an advanced or critical state, which increases fatalities.

“Inadequate doctor-to-patient ratio leads to burnout among doctors due to prolonged working hours and attending to a large number of patients, at times with limited resources,” Dr Yashas said.

He added that most of these factors can be addressed if the public healthcare system can be improved, with an increased allocation in the state budget.

Dr Padmakumar looks at the assault on him as part of a bigger social problem.

“In the last 10 - 15 years, I can see that doctors are not respected. People don’t trust doctors or the hospital,” he said.

The other problem is the difficulty people have in acknowledging death.

“Everybody talks about somebody else's death, not their own. If you tell the family of a critically ill or cancer patient that they are going to die, they get upset. Then their anger is not directed towards the disease or god, it is towards the treating doctor,” Dr Padmakumar said.

The constant fear of being attacked hangs overhead like a sword of Damocles affecting the confidence of healthcare workers.

Meanwhile, the PG resident doctor who faced attacks twice said despite doing their best to save the patients and working in PPE for hours together that often leaves them dehydrated with scars on their skin, they have to encounter such attacks.

As doctors, a stethoscope should be our tool, she said, not pepper spray or helmet.

(With inputs from Prajwal Suvarna)