Doctors are most unsafe in ICU and emergency

Civil Society News, New Delhi

THE rape and murder of a young woman doctor in the seminar room of R.G. Kar Hospital in Kolkata shocked the nation. But for those who work in hospitals, they have been becoming increasingly unsafe.

The R.G. Kar tragedy brought doctors and other health professionals onto the streets to seek justice for the young physician who was brutalized. But they were also demanding better working conditions and greater accountability from governments.

In an atmosphere full of acrimony and mistrust, the doctors first kept Chief Minister Mamata Banerjee waiting at a venue for the talks. And then she kept them waiting outside her house. Finally, when they met, some demands were conceded.  

But matters might never have reached such a flashpoint if governments like hers had been engaging with doctors and understanding their challenges.

Several suggestions have been made by the organizations representing health professionals but they haven’t been picked up by governments.

One such effort to bridge the gap has been a well-researched book titled: “Perils in Practice: The Prevention of Violence Against Healthcare Workers”. The book, which has been around for some time, is authored by Dr Alexander Thomas, Sahajanand Prasad Singh and Divya Alexander.

The book digs deep into the causes of such violence and has a useful list of preventive and post-incident measures to be followed if a doctor or healthcare worker is attacked while going about their duties. 

Data reveals that such violence in India is worse than what happens globally. About 75 percent of doctors admit they have had to deal with violence in some form or the other. It could be verbal, emotional, sexual, psychological, threats, abuse or serious bodily harm. Seventy percent of such violence is perpetuated by the family or relatives of a patient in a hospital.

As many as 62.8 percent of doctors say they are unable to see their patients without fear of violence, 13.7 percent fear criminal prosecution and 57.7 percent have thought of hiring security guards in their clinics or hospitals. These are alarming statistics.

India needs to act quickly to prevent such violence. Trends reveal the healthcare system is attracting more women, and 60 percent are becoming doctors. Nurses are overwhelmingly women. Violence isn’t limited to government hospitals but extends to private sector ones, the dominant player in the health sector. Government hospitals provide only 30 percent of healthcare today. 

The book looks at the reasons why violence against doctors and nurses is rising. The trust deficit between doctors and patients
has widened over the years. The earlier reverence for doctors has been replaced with an impression that doctors merely want to make money and are business-minded professionals.

In government hospitals, doctors are forced to work with crumbling infrastructure, lack of adequate staff, poor hygiene and sanitation, shoestring budgets, short supply of life-saving drugs  and more. In rural areas especially, there are very few doctors and staff to attend to a large number of patients.

There is also low literacy on health matters among people. They assume that the patient, if not overly dependent, will come home. This could be due to poor communication between the harried, overworked doctor and the patient’s optimistic family, about the sick person’s condition. Delayed treatment, inadequate supply of life-saving drugs or diagnostic equipment can also lead to anger. 

The perception that the patient is being overcharged,  delayed discharge of patients, not handing over the bodies of patients are also reasons. Although there are government health schemes to pay for procedures, the money is not enough. The schemes don’t pay for aftercare or if further surgical intervention is required.

According to the book, the areas in the hospital most prone to violence are the emergency rooms, the ICU, the delivery room, and even the wards. Research shows, 50 percent of violence takes place in the ICU, 45 percent in the emergency room, mostly by the patient’s emotionally upset family and relatives. Another study in 2018 revealed that 50 percent of attacks are reported during the night shift.

The authors recommend that an ICU with over six beds should have a medical counsellor to communicate with the patient’s relatives and such interactions should be recorded. 

There are laws to protect healthcare workers. During the COVID-19 pandemic, when several incidents of violence occurred, the Central government brought in an ordinance and 23 state governments too have promulgated laws. These are cognizable and non-bailable but implementation is poor. Filing an FIR and following up on a case is tedious so less than 10 percent of such cases have been registered under these Acts. Special courts can be tried out along with creating awareness among the public, prompt action by state agencies and sensitization of the police and judiciary.

Bringing doctors into the ambit of the Consumer Protection Act has worsened the doctor-patient relationship, according to the authors. It has led to an increase in cases of medical negligence and made doctors defensive and wary.

“The unique nature of medical and healthcare services must be properly appreciated before dealing with legal issues relating to these services. Medicine is truly a science of uncertainty. Each drug could have a different degree of effect on different individuals. Some may develop side effects, which others do not,” write the authors.

More women are becoming doctors and health workers

Consumer courts are not experts to decide medical negligence. The authors recommend that regulatory bodies under the National Medical Commission Act, 2019, handle such cases with appropriate safeguards rather than consumer courts.

The authors have several recommendations to prevent violence in hospitals.

Most important is better communication between doctors, patients and their family members/attendants. Healthcare workers must know how to convey bad news to the patient and family members. An entire chapter has been devoted to communication, including verbal, non-verbal communication and active listening. Since 2019, a module on attitude ethics and communication has been introduced in medical colleges.

Information about waiting time, proper signage, a grievance redressal cell, CCTVs and a trained security team are other suggestions put forth. The media too could play a positive role by being impartial, scientific and by also reporting successes in healthcare. 

Finally, the authors emphasize that it is the patient’s well-being that must be the focus of attention. It falls on the shoulders of the overworked, harried doctor working in a crumbling government hospital to ensure that the patient is better taken care of.