Portal de Periódicos da CAPES

Why Violence Against Doctors? What to Do?

2023; Medknow; Volume: 27; Issue: 2 Linguagem: Inglês

10.4103/ijoem.ijoem_159_23

1998-3670

Bobby Joseph, Merlyn Joseph,

Stalking, Cyberstalking, and Harassment

The recent untoward incident involving the death of a junior doctor at the hands of a felon brought for routine examination in Kerala, India, had made the entire medical fraternity rise in arms. There were nationwide protests held by junior doctors for a while, debates on popular television channels regarding the vulnerability of the medical staff at the hands of patients and their relatives, condolence messages, and support posts on social media with hashtags galore—#doctormurdered, #savelives, #justicefordoctors, and so forth. Now once all the hue and cry has died down, what has really changed? How are we protecting our doctors and nurses from such attacks in the future? Who is responsible for the safety of those who have vowed to dedicate their lives to saving fellow human beings? This incident is certainly not an isolated case in India. While there have been sporadic cases of violence across the country, the trend has steadily been rising.[1,2] What constitutes workplace violence? According to the World Health Organization (WHO) Framework Guideline set in 2002—"Workplace violence is defined as the situations where staffs are ill-treated, intimidated or attacked in conditions linked to their workplace, including commuting to and from the workplace, involving an explicit or implicit challenge to their safety, well-being or health."[3] While this definition captures the physical and verbal abuse meted out to healthcare staff at the workplace, it does not talk about the newer forms of psychological attacks that one can unleash by just the click of a button. A bad rating or an unsavory comment about the services of a doctor on social media can tarnish the image and question the competence of any established doctor, even affecting his sanity. In the present times, workplace violence should therefore be simply defined as "A situation where staff are attacked, abused or ill-treated either physically, virtually, verbally, psychologically or financially resulting in an immediate threat to their safety, well-being or health." WHY IS THE CULTURE OF VIOLENCE INCREASING TOWARD DOCTORS? Gone are the days when doctors were revered next to God and held in high regard in society. In present times, a doctor is just like any other service provider. Workplace violence has now become an inevitable part of health care globally.[4,5] The annual incidence of violence is four times higher for healthcare worker when compared to any other profession![6] In a recent study published by the Indian Journal of Medical Ethics, an alarming 75% of doctors reported having faced some form of violence either physical or verbal at the workplace.[7] The healthcare system in India is inching toward unregulated commercialization and privatization and with it come the perils of rising healthcare costs and therefore an ever-rising expectation from the paying public that all illnesses must be cured. Slowly but surely respect has dwindled and has been replaced with disdain and distrust from the public. While the reasons for this mindset shift are aplenty, here are a notable few: Rising cost of health care. A single visit to the hospital ends up costing more than the daily wage earned by many people. Added to the registration and consultation fees is the cost of investigations and medications. A patient surely returns home lighter in the purse and not completely disease-free. In this scenario, there is a high expectation from the patients and their relatives to get back their "money's worth." When this expectation is not met, the situation can quickly escalate into violence. Overwhelmed staff. Outpatient departments of any reputed hospital or medical college during peak hours are bustling like the marketplace with heavy footfall. There is just not enough staff to cater to the ever-increasing crowd of patients. India has just about achieved the WHO-recommended doctor–patient ratio of 1:1000 if we include both allopathic and ayurvedic doctors.[8] In this context, it becomes impossible to please every patient who walks in through the door. The doctor–patient interaction is now limited to a few high-impact questions about the history, a slew of investigations, and a prompt prescription hoping for quick patient disposal. The gentle art of rapport building and history taking that the erstwhile general practitioner (GP) employed is now long forgotten in the buzz of early morning OPDs extending well into the evenings. Gaps in communication. Treatment outcomes are greatly influenced by effective doctor–patient communication; however, several studies conducted across India have shown that this skill is slowly declining.[9,10] Many patients complain about the attitude of unfriendly and rude staff, lack of transparency in the treatment process, difficulty in understanding complex medical terms, and lack of empathy from staff who are ill-equipped to allay the fears and anxiety of patients. This could be a fallout of the excessive patient load and severe time crunch as mentioned above or the poor soft skills of the hospital staff. Whatever the case be, these lacunae in communication are one of the prime reasons why an unsatisfied patient is increasingly resorting to violence toward the healthcare staff. Lack of infrastructure and inconsistent referral systems. Many of our government hospitals function with inadequate infrastructure and staff. Unavailability of basic life-saving medications, congested ward rooms, oxygen shortage, and absent healthcare staff are something of daily occurrence in the public healthcare sector. The confusion regarding where to refer an emergency case leads to critical wastage of time. This is why we often hear about irate patients' relatives complaining of gross negligence and complacency and sudden mob violence erupting in emergency situations. Misinformation via social media. In current times, social media has replaced the doctor as the primary source of health-related information. Patients are now resorting to solutions from Google and other search engines instead of visiting their healthcare provider. Often, information available on social media platforms turns out to be exaggerated and unrealistic. This misinformation leads to a culture of mistrust and suspicion where every investigation and prescription are considered unnecessary and viewed as one performed only to benefit the doctor financially. CONSEQUENCES OF INCREASING VIOLENCE TOWARD HEALTHCARE PROVIDERS Apart from disruption of routine medical services and physical injury or death being an obvious consequence, there is also the underlying psychosocial distress that the doctor must endure. In a study conducted across India,[11] feelings of shame, loss of self-esteem, stress, depression, and anxiety were among the top mental health concerns faced by doctors following an act of workplace violence. Such negative emotions can in turn affect the very psyche and moral of the treating physician forcing him or her to change their work location or even leave the country in search of a more stable and safe work environment. This will further compound the shortage of healthcare staff and propagate the vicious cycle of violence even more. Additionally, doctors will practice a more defensive mode of treatment necessitating more investigations further increasing the cost of care. MEASURES TO REDUCE THE MENACE OF VIOLENT ATTACKS AGAINST HEALTHCARE PROVIDERS The time has come when these reports of violence and abuse against healthcare providers can no longer be brushed under the carpet as isolated incidents. The trend is alarming, and concrete steps need to be taken to tackle this issue. A multifaceted approach is warranted, and the provision of a supportive workplace should be at its forefront. Investing in quality health care. The Indian investment in health care is still lower than 1.5% of the GDP and well below the National Health Policy, 2017, recommendation of 2.5%.[12] We cannot create wonders when the existing system is bursting at its seams. Strengthening the primary healthcare system, establishment and optimal functioning of primary health centers and subentries in the villages can help ease patient load in district- and tertiary-level hospitals. Recruitment of vacant posts at all remote hospitals with the provision of basic laboratory facilities and well-stocked medications can strengthen the roots of India's healthcare system. Legal safeguards. The Indian Medical Association has been advocating for a dedicated central law to protect the interests of healthcare personnel for several decades now. During the pandemic, in 2020, we had the "The Epidemic Diseases (Amendment) Ordinance." The amendment created a provision to levy those convicted of harassing or assaulting a healthcare worker a fine of Rs. 50,000 to Rs. 2 lakhs and be imprisoned for three months to five years. In case the injury (inflicted on the worker) was serious, the convicted person would have to pay a higher fine and/or spend more time in prison. After the massive outrage following the recent stabbing and subsequent demise of the young doctor, the state of Kerala has approved new legislation to provide stronger protection for doctors and healthcare workers. Under the ordinance, anyone found guilty of causing grievous bodily harm to any healthcare worker or professional would be punished with imprisonment ranging from one year to seven years and a fine between Rs. one lakh to Rs. 5 lakh would be imposed upon them. The ordinance also provides that anyone who commits or attempts to commit or incites or inspires an act of violence against healthcare workers or those working in healthcare institutions shall be punished with imprisonment for a term not less than 6 months and up to 5 years and with a fine between Rs. 50,000 and Rs. 2 lakhs. This provision extends not only to doctors and nurses but also to paramedical students, security guards, ambulance drivers, and managerial staff working in hospitals.[13] Patient education and awareness. Emphasis should be on educating patients regarding the pitfalls of blindly following online medical information and the limitations of any modern treatment or treating doctor. No surgery is 100% safe, no medication is without side effects, and no doctor can promise a complete cure. Keeping realistic expectations can help open channels of communication and benefit the patient in the long run. Soft skill training for healthcare professionals. Doctors, nurses, and other healthcare providers should be taught about the nuances of effective communication. There is a need to be trained, in addition to a variety of skills, about how to communicate with the patient at every stage of their treatment process, cultivate the art of active listening, learn how to break bad news, and show empathy toward their needs. The current undergraduate curriculum has taken a step in the right direction with the inclusion of Attitude, Ethics and Communication (AETCOM) classes in the CBME curriculum. Such soft skills training is also required for the senior staff who may propagate this cycle of abuse via their authoritarian leadership style. Strengthening surveillance and security measures at hospitals. Creating a database of violence experienced by healthcare staff can help us understand the magnitude of the problem. Stricter protocols when dealing with criminals, alcoholics, and drug abusers and increased security measures especially for doctors tending to emergencies or ICUs and those working night shifts will deter most miscreants. Greater focus on the mental health of healthcare providers. Counseling sessions, group therapies, and paid vacations are some of the measures adopted by our Western counterparts to address the issue of physician exhaustion and burnout. A mentally exhausted doctor with no sleep and constant stress is bound to make more mistakes. Better staffing patterns, fewer night duties, reasonable working hours, reduced administrative tasks, and computerization of documentation along with supportive management can work wonders. Automation of healthcare tasks. Technology and artificial intelligence can be used to ease the bottlenecks and delays faced at the hospital. Clever queue management systems, faster delivery of medications, investigation reports, and discharge summaries can make visiting the hospital a much more pleasant experience for the patient. In conclusion, the road ahead seems quite daunting, but the solutions are right here. The need of the hour is to provide a safe and welcoming environment for the healthcare provider to do what she or he is best suited to do—to heal and to comfort!