Incidents of violence against doctors in India: Can these be prevented?

Background and Current Scenario

India is not the only country facing violence against its medical practitioners; today this is a global phenomenon. In the USA, between 1980 and 1990, over 100 healthcare workers died as a result of violence.^[1] Another survey conducted in 170 university hospitals revealed that 57% of all emergency room employees had been threatened with a weapon over a 5-year period before the survey.^[2] A survey of 600 doctors in 2008 by the British Medical Association revealed that though one-third respondents had been a victim of verbal or physical attack in the past year, over half of them (52%) did not report the incident.^[3] Chinese doctors are often victims of violence. In June 2010, a doctor and a nurse were fatally stabbed in Shandong province by the son of a patient who died of liver cancer 13 years ago. A paediatrician in Fujian province was injured after leaping out of a fifth-floor window to escape angry relatives of a newborn baby under his care who had died.^[4] According to an editorial published in The Lancet, ‘Doctors in China are not unique in facing violence. However, for a third of doctors to have experienced conflict and thousands to have been injured, the scale, frequency and viciousness of attacks have shocked the world.’^[5] Seventy per cent of physicians and 90% of support staff working in a hospital emergency room in Israel reported violent acts, mostly verbal abuse.^[6] Violence in Bangladesh has been reported to occur mostly in the hospital setting, but in the private healthcare setting as well.^[7] In a study of 675 physicians in training in nine tertiary institutes across Pakistan, 76% reported verbal or physical violence during the previous 2 months.^[8] Another study from Pakistan by Imran et al. reported that 74% of respondents in a public sector healthcare facility in Lahore were victims of violence during the preceding 12 months.^[9]

According to a study by the Indian Medical Association, over 75% of doctors have faced violence at work.^[10] A lady doctor in Tuticorin was killed by the husband of a pregnant woman who was admitted in a serious condition. She was referred to another hospital but died before she could be shifted. The husband entered the consultation chamber of the lady doctor with three accomplices and attacked her with a sword.^[11] In 2014, in Mansa district of Punjab a doctor's clinic was burnt following death of a boy who was referred to a tertiary hospital but died.^[12]

Innumerable incidents of violence against doctors are reported nearly on a daily basis across India, some resulting in grievous injuries. Even institutions such as the All India Institute of Medical Sciences, New Delhi, the premier medical institute of the country is not spared.^[13] Nineteen states of India have some kind of Medicare Service Persons and Medicare Service Institutions (Prevention of violence or damage or loss of property) Acts passed and notified in the past 10 years. Under the Right to Information (RTI) Act, the Medicos Legal Action Group Trust (MLAG) asked all senior superintendents of police in Punjab and Haryana, the two states where the Prevention of Violence against Doctors Act is in place for over 8 years, for the following information.

1. How many complaints by doctors or hospitals were registered under these Acts against patients or attendants?
2. How many of those accused of assault were punished under these Acts from 2010 to 2015.

According to the replies, most complaints were not registered as a first information report (FIR), a mandatory procedure to be followed by all police officials as per the judgment delivered by the Supreme Court of India in the case of Lalita Kumari versus the Government of Uttar Pradesh.^[14] In a few cases where the FIR was lodged based on the complaint, it was cancelled after a compromise was reached between the aggrieved parties and a cancellation report was filed with the local magistrate. Very few cases have reached courts after filling of a challan but no person accused of assault on a medicare establishment has yet been penalized under the Medicare Service Persons and Medicare Service Institutions (Prevention of violence or damage or loss of property) Acts of Punjab and Haryana from 2010 to 2015.

Causes Of Violence

There are many causes for the increase in violence against medical personnel, but not restricted to a general increase in aggression in society as evidenced by incidents of road rage^[15] and other acts of violence witnessed in schools and colleges across India.

Poor image of doctors and the role of the media

In India, doctors have traditionally been regarded highly by society. The present impression of private business-mindedness of some in the profession has led to a poor image of doctors. One of the factors that contribute to this poor image of doctors is the sensationalization of every news item, often ignoring information that would gloss over mundane details, exonerating a doctor in an incident of alleged medical negligence. As a hypothetical example, a television reporter shouting at the medical superintendent of a Delhi hospital reeling under a load of dengue patients as to why antimalarials were not given to a patient who died of dengue. This is done with an air of ‘knowledge’ that viewers would be convinced that not giving antimalarials to a patient of dengue in shock was medical negligence of the highest order.

Meagre health budget and poor quality healthcare

Among other causes of violence against doctors in India are the pathetic conditions in which patients are treated in government hospitals. There is overcrowding, long waiting time to meet doctors, absence of a congenial environment, multiple visits to get investigations done as well as consult doctors, sharing a bed by two and sometimes three patients and poor hygiene and sanitation. There is frustration with systemic problems of government hospitals, from dysfunctional equipment to shortage of staff. Given the poor budgetary allocation for health in India, these problems are unlikely to change. Only 106 415 doctors are employed by the government in India, of the 938 861 doctors registered to provide healthcare to a population over 120 crore (1.2 billion).^[16] Of these, only 27 355 are posted at primary health centres (PHCs), which serve the rural population. With poor infrastructure and no increase in the number of posts for government doctors over the past many decades, despite an increasing population, the public healthcare system is on the verge of collapse. Violence against the health service provider is only a symptom of this crippling underlying malady.

Vulnerability of small and medium healthcare establishments

According to International Trade Administration, the US Department of Commerce, the Indian government's share in the healthcare delivery market is only 20%. The remaining healthcare providers are in the private sector. The private healthcare providers consist of private practitioners, for-profit hospitals and nursing homes, and charitable hospitals. They are diverse and fragmented. Various population surveys have shown that private small and medium healthcare establishments (SMHCEs) have a dominant role in providing healthcare to the population, and it is reported that 84% of private hospitals have less than 30 beds.^[17] According to the WHO, just 33% of Indian healthcare expenditure is from government sources and the remaining is from out-of-pocket expenditure.^[18] This out-of-pocket expense for healthcare in SMHCEs pushes many households into poverty all over India even though these are more affordable than the corporate hospitals. Insurance penetration is low and the government does not provide enough resources for free healthcare, leaving people to fend for themselves as best as they can. Many incidents of violence have occurred at the time of billing and with any decrease in the already pitiable budget for health the situation is likely to deteriorate further.^[19]

Lack of faith in the judicial process

Another cause of violence against doctors in India is the lack of faith in the law and order machinery and the judiciary.^[20] A person with a grievance does not trust the mechanisms of redressal provided by law. There is sometimes a perception that doctors being well connected will get away and hence there is a tendency to take the law into their own hands by resorting to violence. There is also a belief that the patient's attendants who assault doctors will go unpunished.

Mob mentality

Mob mentality frequently snowballs into a violent crisis in hospitals. In China mobs, called ‘yinao’, regularly protest at hospitals or harass hospital administrators in exchange for money.^[21] In India, emotional turmoil due to death of a loved one is sometimes used by local politicians as an opportunity to demonstrate their political relevance by orchestrating violence at the clinical establishment. The 2-minute of fame and news coverage drives these antisocial elements to often damage the social fabric during a medical accident. Unique to India, the unfortunate death of a patient is sometimes given religious and caste colour by some miscreants, especially if the doctor belongs to a different caste or religion than the patient.

Low health literacy

This is often used to propagate myths and false accusations are made even in cases of death due to a previous illness. During emotional breakdown following death of near and dear ones, it becomes impossible to present or understand a rational view. In India, where 30%–40% of cases of acute coronary syndromes present to emergency with complaints of dyspepsia/gas,^[22] it is difficult, if not impossible, to explain death during primary angioplasty due to ventricular arrhythmia. Unrealistic expectations are also part of the low health literacy. There is an increasing expectation from patients that with modern medicine and technology a doctor should be able to guarantee a good outcome.

Cost of healthcare

The rising cost of healthcare is the key reason for the breakdown of the bond between doctors and their patients.^[23] Even in the USA, catastrophic medical expenses account for half of all personal bankruptcies.^[24] Physicians receive only 20% of all money spent on personal healthcare in the USA, but their decisions determine most of the remaining expenses.^[25] Even though the costs of all medical procedures in India are many times lower than those in western countries, they are sufficiently high to cause many families to go into debt and slip below the poverty line. In a family where a regular meal takes primacy over health, anger and grief at losing someone despite spending beyond their means is understandable, but unfortunately it often culminates in violence. Whatever the provocation, justifying any violence especially against a doctor who tries to help in times of need has to be strongly condemned.

Poor communication

One of the prominent reasons for patient–doctor mistrust in China was the perception of injustice within the medical sphere, related to profit mongering, knowledge imbalance and physician's conflict of interest. Patient–doctor mistrust precipitated medical disputes leading to outcomes such as non-resolution with patient resentment towards physicians or violent resolution such as physical and verbal attacks against physicians. Policy responses to violence included increased hospital security forces, which inadvertently fuelled mistrust. Instead of encouraging communication that facilitated resolution, medical disputes sometimes ignited a vicious cycle leading to mob violence.^[26] Poor communication too is an important cause of rising incidents of violence in India. The relationship between a doctor and a patient is paternalistic where patients are still not considered equal partners by their caregivers. This at time leads to arrogant behaviour, condescending attitude and use of jargon by doctors, which confuses the patient. This is an area where much emphasis needs to be laid especially during medical training. Doctors are taught clinical behaviour but not empathy. Effective patient–doctor communication has been shown to correlate with patient satisfaction with healthcare services.^[27] Aspects of patient–doctor communication such as ‘receiving an explanation for the occurrence of the symptom/ sign, likely duration of treatment and the lack of unmet expectations’ were found to be key predictors of patient satisfaction.^[28] Caregivers must be trained in breaking bad news, empathizing and communicating with their patients. Given the patient load, lack of time, gross deficiency of staff and other resources, these issues receive only lip service in India, especially in the government sector.

Lack of security

Violence is easily orchestrated in Indian healthcare establishments partly because security staff in SMHCE in the government and private sectors is non-existent due to lack of funds. With meagre budgets, not sufficient to hire enough doctors and nurses, it would be unrealistic to expect adequate security in Indian hospitals except in a few corporate hospitals.

Types of violence

Violence against doctors in India comprises: (i) telephonic threats; (ii) intimidation; (iii) oral/verbal abuse; (iv) physical but non- injurious assault; (v) physical assault causing injury: simple and grievous; (vi) murder; and (vii) vandalism and arson. Doctors facing violence have been known to go into depression, develop insomnia, post-traumatic stress and even fear and anxiety causing absenteeism^[29] in the UK; a similar situation likely prevails in India.

Prevention of Violence Against Medical Practitioners in India

Possible steps

There is an urgent need to make healthcare facilities a safe environment. Only then can healthcare professionals be expected to work with devotion and dedication. Sensational media coverage of the death of a patient due to a doctor's alleged negligence has only served to work against the patient's own interest. Healthcare professionals are now reluctant to handle serious cases; hence many precious lives that could have been saved are being lost.^[30]

Legal steps needed to be taken by the government

Any complaint filed by a patient or the relatives in any court of law, fora or commission, should be automatically infructuous and cancelled ab initio if proof of violence by the patients or the relatives can be provided by the hospital/doctor. This single change will stop all violence by the patient's attendants. This should be in addition to the punishment for violence under the Prevention of Violence against Medicare Persons and Medicare Institutions Acts and relevant sections of the Indian Penal Code (IPC).

The problem with the present law is that after violence has occurred, the doctor files a police complaint and simultaneously the patient and relatives file a complaint for criminal negligence. Finally, after the hue and cry has died down and news is no longer worthy of front pages the medical association stalwarts who led the agitation against the violence suddenly realize there has been a compromise between the two parties. This results in no punishment to the perpetrators and hence no deterrence for next incidence of violence. If on providing proof of violence any complaint of alleged negligence by patient party could be declared void ab initio automatically this will act as a strong deterrent for future incidents of violence.

Having a Central law for prevention of violence against healthcare persons and institutions would also help but not as much as a change in the IPC to make such violence a cognizable offence with stringent punishment.

Steps that doctors should take

Do not overreach. Modern medicine is changing rapidly. Hence, it is inappropriate to attempt to treat and do procedures beyond the scope of one's training and facilities. This is fraught with allegations of negligence and consequently of violence. The cardinal principle to prevent violence against doctors in India would be: ‘Do not overreach’. Remaining within one's capability and experience is important in today's litiginous environment.

Consent. Valid and informed consent is the second most important step in preventing violence. Despite the rush and low health literacy, consent should not be considered a formality. Detailed consent in the patients' own dialect and language with witnesses (preferable) is mandatory before any invasive procedure. The purpose of treatment/surgery/procedure, its prognosis, the commonly occurring life-threatening and non-life-threatening complications must be explained. The available alternatives, advantages/ disadvantages and the consequences of refusal by the patient of treatment should be explained and mentioned in the consent form. It is also important to do only the procedure for which consent has been taken and not any additional procedure, even if it is in the ‘patient's interest’ unless it is a life-saving additional procedure.

Documentation. Proper documentation of the patient's course in hospital may not prevent violence but is important once violence occurs and the police are called. The records are often seized by the police. The doctor(s) later find it difficult to defend themselves because during the emergency they focused on saving the patient and not on maintaining proper records. Even in single- doctor clinics and nursing homes it is imperative to inculcate the habit of documenting everything or ask the nurse to document while the doctor is busy resuscitating the patient.

Communication. Improving communication skills will prevent doctors from facing violence in the long run. Even though medical practitioners in their forties and fifties may have cultivated their own methods to communicate with patients, it is imperative that they keep up with the times and train in communication skills from experts as part of their continuing medical education. This should be mandatory for all doctors to practise medicine in India.

Be alert. Only by being aware that violence against doctors is a growing problem in India is it possible to be alert and vigilant. Doctors need to evaluate each situation for potential violence when they enter a room or begin to relate with a belligerent patient or relative. It is important to be vigilant throughout the encounter and not isolate oneself with a potentially violent person or group. It is advisable to always try to keep an open path for exiting. Do not let the potentially violent person stand between you and the door. Friends, staff members, colleagues should collect at the site of incident without being provocative.

It is advisable to look for indicators of violent behaviour such as staring and eye contact, tone and volume of voice, anxiety, mumbling and pacing (STAMP).^[31]

• Staring is an important early indicator of potential violence. Nurses have felt that staring was used to intimidate them into prompter action–when they responded to this cue violence tended to be avoided.
• Lack of eye contact has been found to be an issue and was associated with anger and passive resistance. However, there can be cultural reasons for avoiding eye contact and it is important to be aware of this.
• Tone and volume of voice has been associated with violent episodes. Most instances involve raised voices and yelling but also involved sarcastic and caustic replies.
• Many people who attend the emergency department are anxious and nurses are aware of how stressful such a visit can be. They should intervene before anxiety reaches dangerous levels, but sometimes patient's anxiety does escalate to violence.
• When anxiety levels are raised by the disorientation associated with conditions such as mental illness, substance misuse, dementia, epilepsy, diabetes and head injuries, this becomes an issue.
• A majority of patients who become violent have been observed to be mumbling, using slurred or incoherent speech or repeatedly asking the same question or making the same statements. Mumbling has been perceived to be a sign of mounting frustration and a cue for violence.
• Pacing was seen as an indication of mounting agitation and has been observed in instances that resulted in violence. Other physical indicators include staggering, waving arms or pulling away from healthcare personnel attempting to treat them.^[31]

Restrict entry. The most important step in preventing mob violence in a hospital is restricting entry of the public. A large number of relatives should not be allowed at the patient's bedside. Entry should be strictly by passes and this must be implemented through good security, preferably by deploying ex-army personnel. Security guards must be placed inside the hospital at sensitive areas such as intensive care units, operation theatres and casualty.

Standard operating procedure (SOP)

All clinical establishments should develop an SOP for violence. Mock drills need to be conducted and each member of the staff should be clear about his role if the situation of impending or actual violence does arise.

Insurance

Insure the establishment against mob violence, damage to property and injury to workers to at least mitigate the financial losses that are incurred in the aftermath of violence. If violence occurs

1. Do not meet anger with anger. Remain calm in the face of provocation and let things blow over.
2. Depute someone (preferably beforehand) to take photographs and, even, audio/video records of the violence.
3. Depute someone to immediately (preferably as part of the SOP) get the medical record of the patient photocopied. If the mob carries away the original record, the photocopies will be useful.
4. Inform your lawyer.
5. Inform the police immediately by phone, etc. and keep a record of such phone call, etc.
6. Identify the troublemakers/leaders in the mob.
7. Get written, signed statements from the persons present (doctors, staff, patients, relatives, others) regarding the occurrence of violence.
8. Lodge an FIR with the police.
9. When making a police complaint the doctor/hospital should make sure that a request is made to register an FIR under the relevant Act for protection of medical personnel.
10. Do not try to ‘settle’ the issue by paying hush money (more often than not it is taken as admission of guilt).

Violence against doctors behoves ill for society. It is important for all medical practitioners to be aware that this can occur and they need to take steps to prevent it. Doctors need to pressurize the government to equate assault on a doctor with assault on a public servant on duty. Necessary changes should be made urgently in the IPC and Criminal Procedure Code (CrPC) to have a deterrent effect and prevent future incidents of violence against doctors. However, for this to happen a coordinated effort is needed. We hope no more healthcare personnel lose their lives to violence before action is initiated by their associations and the government.