‘Violence on doctors is rampant in India’

WHEN things go wrong, doctors face the brunt of public anger and angst. Dealing directly with patients, they are held to account and very often become targets of violence.

How much are doctors themselves to blame for the messy and dangerous situations they find themselves in and to what extent are hospital administrations responsible?

The rape and death of a young and committed doctor in Kolkata shows that there is much about the running of hospitals that needs to improve, especially in the state sector.

So, what can governments do to shape up? We spoke to Dr Alexander Thomas, a veteran of the healthcare system and founder of the Association of Healthcare Providers India.

Q: The terrible episode in Kolkata has made everyone aware of what doctors go through. But surely this is not the only episode. In your position, could you tell us how frequently doctors face this kind of insecurity, and the tragic consequences that result from it? 

I think this violence is not restricted to doctors alone. Nurses and healthcare workers, as well as doctors, have been subjected to violence for many, many years. In the past few years, the situation has actually become worse, especially after the Consumer Protection Act came into force.  Earlier, it was a different relationship. Doctors had a bond of trust with their patients. Unfortunately, that has changed. We are trying to remedy it.

But violence in hospitals is rampant in India. I also need to tell you this is a problem globally. In fact, the World Health Organization (WHO) has declared violence against healthcare professionals a global emergency. But, I think, compared to other countries, India has a much, much larger share of the incidence of such violence. During the COVID-19 pandemic, you must have read about many instances.

Q: Do you recall other cases of doctors elsewhere in the country who have met such a horrible death while just going about their duties?

In 2022 we lost Dr Archana Das, a young mother of two, in Rajasthan. She was harassed by the police and other people in the community. She died by suicide. The very next year in Kerala, Vandana Das, who was just 21, was stabbed to death by a convict patient.

And the list goes on and on. There are many other cases which we don’t even hear about. It has prompted us to start taking a very proactive stand.

Q: So, it’s a problem which should have been attended to a long time ago. Doctor associations have made suggestions about what could be done to make hospitals safer. And to make the work of doctors safer. Can you explain to us some of the suggestions that have been made as policy prescriptions?

Actually, we took it up at the national level, perhaps two years ago after Dr Archana Das died. Leaders in the healthcare sector who have experience on the ground went through the issues and, more importantly, the remedies. We wrote a book called Perils in Practice, which is available as a free download on Amazon.

We realized that doctors and nurses are soft targets. Usually, in a hospital, people come in full of emotion. There are anti-socials who take advantage of the situation. There’s a regular racket in many hospitals where anti-socials will say, “I’ll get the charges reduced, you give me 25 percent.”

They used to foment trouble and attack doctors. We came up with suggestions. We looked at various reasons why we have reached this stage in our country.

Just a decade or two ago, doctors had almost the same status as God. We don’t want that. We just want to be normal people whom people trust.

One of the things we realized was that from our side too there have been issues. We went about addressing them first.

One was the capitation fee. That’s hopefully gone out of the window. It commercialized medicine. I’m thankful to the government for having brought in legislation to stop that.

Secondly, a very important aspect was that we forgot how to communicate with our patients. We weren’t taught this. It’s a very strange situation because in developed countries, unless you pass an exam in communication, you don’t get your degree. In India, nothing like that exists.

We wrote the first book on patient communication in the country. The book became a movement for various reasons. One reason was that administrators found that better communication actually saves a lot of money. Our purpose was to try and improve communication with the patient and thereby alleviate the patient’s stress and go back to a good relationship with patients.

We were able to influence the Medical Council and the government to introduce it in the curriculum. I’m very happy to say that the first batch of those who have been trained will be passing out this year. That will definitely bring down some of the incidents of violence because medical students who become doctors will know how to communicate with patients. We have to realize that patients are very vulnerable. They are emotionally stressed. 

On the ground, we have realized that anti-socials and then patients get upset. They target one particular doctor whom they surround and intimidate. There’s a chapter in our book on how to pre-empt violence, along with signs of impending violence.

If something happens, the hospital staff comes down. If it’s a small hospital, people from other hospitals join in to physically protect the doctor.

We have told our doctors they have to practise ethical medicine. They have to be honest with the patient. We have been saying this to governments. Many governments have been very positive, especially in Karnataka. They have brought in strict laws against healthcare professionals being assaulted. It is a non-bailable offence.

When we wrote our book, we found that doctors don’t follow up on cases. Supposing there is a case of assault in my hospital. I just go once to the police station, file a case, and then forget about it. So, hardly two to three percent of cases end up in convictions. We have put up some guidelines on this. They have been circulated widely and people have been using them.

Q: There is talk of increasing security in hospitals. Is that a solution? Are we really addressing a serious flaw in overall hospital management? You know, you could have security people, but if hospitals aren’t able to deliver certain end results, you will not get an atmosphere in which doctors can work safely.

I absolutely agree. Announcements that FIRs have to be filed within six hours won’t act as a deterrent. I think hospital managements should ensure that women doctors and healthcare workers are taken care of, their duty rooms are not open to everybody coming in or going out. There should be a system that creates a network in the hospital. So that, if there is trouble, we support one another.

After any incident of violence, we must counsel and support the victim. Many people, because of violence, have actually moved away from medicine.

And that brings me to another very important point. We are losing our best minds because of violence. They are turning away from medicine and opting for other professions. 

Q: State-run hospitals are the worst managed because of lack of oversight. Have you any suggestions on how oversight can be improved? Should we have citizen committees which oversee hospitals?

It’s not rocket science. This is easily doable. I can give you examples of great hospitals. The Jayadeva Hospital in Karnataka, for instance. It is a fantastic organization which makes sure that affordable treatment is available for everyone. And they take care of their staff.

There are umpteen problems due to lack of oversight and lack of accountability. Two steps can be taken. We have always advocated that patients have to be part of the process. We’ve recently started an organization called Patients for Patient Safety, an organization I’m part of. Our goal is to establish a committee in every hospital focused on patient safety.

We are aware that some clinicians are concerned that these committees might question their practices. No, we suggest that the patient be involved in the treatment. The patient can give suggestions. Ultimately, we tend to forget that all of us, from the director to the security guard, are all there for one person, and that is the patient. We need to remind ourselves of that.

So, it is imperative that the patient and his relatives are involved in his treatment or any other matters of the hospital.

Q: How serious a problem is corruption in the private sector and in the public sector?

In the private sector, it may not be so much, because the private sector has to sustain and show results. They drive hard bargains and so there’s not enough left for permissions.

In the government sector, I’m not so sure. I have heard that there is corruption, but I don’t have any proof. I think it is an issue. With technology and more transparency, I think that can be addressed. If it is a problem, there are mechanisms to address it.

Q: Very successful models of hospitals are available in the voluntary sector. What is it that works in a voluntary sector hospital that doesn’t work in the state sector hospital?

I spent my entire career in a mission hospital, the Baptist Hospital in Bengaluru. In all voluntary mission hospitals — you have Muslim mission hospitals, you have Hindu mission hospitals — the doctor doesn’t look at the money. He treats the patient as a patient. What is necessary is done. There is no pressure on him.

I think the small hospitals on the periphery are doing a great service to the community. They work very hard and basic healthcare is available. But I think the main thing we need to get back to is that we need to keep the patient’s interest first.

If you look after the patient, especially the poor patient, God will ensure that you get enough money. Mission hospitals are living examples of a patient-first approach, where treatment is affordable. Their patients are given free treatment and the hospitals are doing well.

But, at the same time, the government needs to invest more in tertiary hospitals like Tamil Nadu and Kerala have done where the ordinary citizen or the poor can go.

Why should that not be so in all the other states? They invest enormous amounts of money. The cost of the government hospital is actually more than the private hospital if you factor in the cost of procedures.

Q: You would say that, first, it is important to bring back the spirit of healthcare by placing the patient at the centre of it. Second is to manage the hospitals in a more transparent way along with oversight and a sense of mission and purpose.

Yes, and accountability.

Q: In West Bengal, this young doctor was obviously a public-spirited doctor, so she was also probably managing her patients really well. But there was no one managing the environment in which she was working. What would you give greater importance to: the doctor’s attitude or managing the administration?

I think it will be difficult to choose one over the other. Everything has to be worked on. Attitude, as well as better management are both needed.  There were a lot of things I learnt during my studies and in the course of my work. When I was put in a position of authority, I tried to implement certain measures which would be good for doctors.

Another important aspect that I think we need to look at is that resident doctors are sometimes really overworked.

They work for about 36 to 48 hours. That’s not right, both for the resident doctor and for the patient because you need to be in a good frame of mind when you look after your patients.

We are sending out an advisory to all our hospitals asking what their standards are on personal safety, especially for women doctors.