VIOLENCE AGAINST DOCTORS

VIOLENCE AGAINST DOCTORS
CAUSES ,PREVENTION AND MANAGEMENT 

Voltaire once said that - the physician amuses the patient while nature cures the disease. But today’s scenario is not so amusing  in Indian subcontinent as also in others  .Doctors are frequently assaulted  ,shot and  even stabbed. (1)

Of all work settings, medical sites carry the greatest risk to staff of verbal abuse and threats, with 73% of staff on medical premises suffering abuse, compared to 65% on recreational premises and 63% for transport and public administration .(2 )

WHAT CONSTITUTES VIOLENCE ?

-      TELEPHONE THREATS

-      INTIMIDATION

-      ORAL ABUSES

-      PHYSICAL MANHANDLING

VIOLENCE can be defined as  “ Incidence where people are abused , threatened or assaulted in circumstances relating to their work ,involving an explicit or implicit challenge to their safety ,well being and health .”

WHAT IS THE EXTENT OF PROBLEM ?

A GLOBAL PROBLEM –

US -According to 2005 data from Bureau of Labor Statistics, health care workers are twice as likely as those in other fields to experience an injury from a violent act at work, with nurses being the most common victims. Nobody in this country keeps consistent track of how much of that violence is directed at doctors. ( The last report from the Department of Justice put the number of doctors assaulted at about 71,000 from 1993 to 1999.)

75 percent reported at least one verbal threat in the previous 12 months; 30 percent indicated that they had been the victims of a physical assault; 12 percent had been confronted outside of the ER; and 3.5 percent had experienced a stalking event.( 3)

)

CHINA - According to figures from the China Hospital Association, there were, on average, 27.3 serious assaults on doctors and nurses per hospital in 2012, up 35 per cent from 2006.(5)

UK – Overall attacks on NHS staff in England reached almost 60,000last year ,an increase of more than three percent on the previous year . 

Australia -"It is a startling reality that more than 24,500 health care employees reported being a victim of a violent incident at work in the past five financial years. More than 4,400 health workers in the last financial year alone were victims of violence in their workplace

Health Minister Lawrence Springborg said thousands of health workers were punched, stabbed, bitten and spat on every year in Queensland while serving the public in their daily duties.

PEOPLE who assault nurses, doctors and paramedics will face up to 14 years in prison under tough new laws introduced as part of the Queensland Government's Safe Night Out Strategy. (6)

Same is the story in Kuwait ,Syria and round the world .

INDIA –

February 27, 2015Around 15,000 resident doctors from Ram Manohar Lohia Hospital, GTB, Safdarjung, Lady Hardinge, Hindu Rao, Ambedkar, DDU, Mahrishi Balmiki, ESI and others boycotted work. They were protesting the assault on a doctor at Guru Tegh Bahadur Hospital by relatives of a patient late on Monday night.(7)

March 20^th 2015  -physical assault on doctors of the Regional Hospital in Kullu (8)

Apr 6, 2015 - Dr Sandeep Amle in PANVEL MUMBAI was attacked by the family of a patient of a 65 year-old woman suffering from Stevens-Johnson syndrome when she died died in the hospital (9)

12^th April 2015 Dr.Rohit Gupta is a well practiced Gastroenterologist associated with multiple hospitals, Maa Sharda Hospital and Shakuntala hospital, Allahabad. As he was visiting the ICU to see a patient who had just passed away, he was brutally beaten up by the relatives. His fault- he tried to save an 80yr old patient with kidney and liver failure rèfused from SGPGI (10)

Moradabad – We all know about attack on Dr Vinita Agarwal ,Dr vibha mullick And attacks in Sai Hospital .

My own hospital KILKARI witnessed an attack recently causing damage to hospital furniture not long back .

WHY SHOULD WE DISCUSS ?

To understand conditions leading to such occurrences .

To device and take precautionary corrective measures .

To be well versed with medico-legal implications and accordingly be ready to take the Legal steps

WHY DOES IT OCCUR ?

Not all adverse outcomes end up in violence and not all violence is related to adverse outcomes .

Society has changed over years and violence is 
seen in all walks of life

     -    More demanding society .

-      More availability of knowledge

-      More aggression in Society

-      More violence on roads ,public places and even schools

    

CAUSES OF VIOLENCE IN MEDICAL FIELD 

NOT  JUST  A  RESULT  OF  HEIGHTENED  PATIENT  EXPECTATIONS AND  ENTREPRENEURIAL  LAWYERS   BUT  CERTAIN  OTHER TRIVIAL  CAUSES  TOO

   Causes Outside India of which some are seen in Indian scenario too  

       -  Delay in attending to patient (perceived as immediate unavailability )

       -  Not paying proper attention to patient’s and family’s concerns

       - Poor delivery of information

       - Asking patient to do something,

       -  Restraining patient

       -  Administering medications

       -  Patient physician altercation

  -  Physically guiding or leading patient,

       -  Alcohol or drug intoxication

       - Patient with a psychiatric history.

A study in Israel showed that the most common causes of violence were

- long waiting time (46.2%)

-  dissatisfaction with treatment (15.4%), and

- disagreement with the physician (10.3%). (11) (12)

IN INDIAN SCENARIO

INCREASED EXPECTATIONS

-      Unrealistic expectations at times of miracles and at times of not understanding

      the expenditure involved in specialised care

-      Formerly when region was strong and medicine weak ,men mistook magic for medicine ;in today’s era when science is strong and religion weak men mistake medicine for magic

COMMON SITUATIONS ARE –

1. Casualty Department : Bleeding patient delay in attention, status asthmaticus unrelieved, death on arrival, delay in admission.

2. ICU: Death of patient, unreasonable demands of relatives not acceded to by doctors, unsuccessful request for entry passes.

3. Operation Theatre: Table death, delay or postponement of operation more than once. Wrong operation.

4. Wards : Unreasonable demands of relatives, suspected molesting of female attendants, denial of access to case papers and records, complications of drip leading to operations and amputations.

Causes of Violence

1. Lack of Communication between doctor and patient : Doctor must tell the truth to his patients and the relatives as to how serious the condition is. Evasive answer is interpreted as shirking responsibility.

2. Poor image of medical profession : Newspapers carry reports about doctors involved in financial frauds, torture, molesting, house breaking and scams like kidney transplant. The doctors do not wear halos anymore. The medical profession once considered noble, has taken a severe beating. Some patients even see them as chistlers and extortionists.

3. Lack of faith in judicial system and the police : There is an impression that the police will take no action and can easily be bribed. Trials take long and judgements cannot be predicted.

4. Mobocracy : Tempers rise and verbal spats become physical. Patients know

   they can get away with it. There is a strong desire to achieve 2 min of fame and notoriety by small time leaders .

5. Insufficient security for doctors : In public hospitals, police and guards can only be

found in the casualty department. Hospitals need stronger security by professional men.

6. People are not aware of the laws to protect doctors : People dare not attack a policeman when they are on duty. The reason is hitting a uniformed person on duty they know since long  is a non bailable offence. That is the reason for the law on violence against doctors to be displayed prominently .(13)

7. Caste based and other such politics has a strong role at times .

8. Frustration with systemic problems of dysfunctional equipment to lack of staff

    

We should learn to cope with this problem by keeping in mind  what  CHARLES DARWIN SAID “It is not the strongest of the species that survives ,nor the most Inelligent but the one most responsive to change “

WHAT CAN BE DONE ?

TRY UNDERSTANDING A BASIC FACT -- When we think how do we get rid of this situation, we must remember that practice of medicine is really about providing service, not just science. It is basically a combination of art, science and professionalism. The fundamental of medicine is that it is principally a human activity aimed at helping the sick through healing, alleviating suffering and caring for people with respect and dignity. This role of physician must be guided by the codes of ethics governed behavior. The financial incentive is not negligible but the principle remains the same- serving humanity. The lucky doctors of the past were treated like God and people revered and respected

them.(14) (15)

PRINCIPLES OF DEALING  ( PREVENTION AND MANAGEMENT )

·        Not Meet Anger With Anger

·        Address the grievances ,but also call for help

·        Doctors must form Groups which can take over in such instances .

LAW  - WHAT DOES LAW SAY ?

The UP government has now taken its first step towards formulating a law to protect medical

 practitioners. The government on May 21 promulgated an ordinance -- 'Uttar Pradesh Chikitsa

 Paricharcha Seva Karmi Avam Chikitsa Paricharcha Seva Sanstha, 2013' (Hinsa Avam Sampatti Ki

Chati Ka Nivaran) -- for the protection of medical service providers and medical institutions.

.

The ordinance has been drafted by the department of health in collaboration with Provincial Medical

 Service Association ( UPPMSA), Uttar Pradesh Chapter of Indian Medical Association (UPIMA) and 

Uttar Pradesh Nursing Home Association ( UPNHA). Indian Medical Association-Kanpur played a

 major role in the formulation of the law by providing major documents to the government.

The ordinance offers benefit to all medical service persons, including registered medical practitioners, nurses, medical students, paramedical workers as well as any person employed in a medical institution. It says that an act of violence against medical professionals will be considered as a cognizable and non-bailable offence, to be punished under the law with a maximum imprisonment for three years and a fine extending up to Rs 50,000.

In addition to the violence against medical service persons, the ordinance also has provisions for realising double the cost of damage or loss of property caused to a medical institution in the act of violence.

"There are two aspects to the Act. The first being penal action against those who attack medical service providers, which will be extended to both private and government service providers. The second is the damage to property of the medical institution. The department is taking legal opinion whether the second provision should be extended to private service institutions or not," 

PREVENTION

TO  UNDERSTAND  PREVENTIVE  MEASURES  LET US TRY  TO  UNDERSTAND A  FEW  THINGS

PATIENT’S EXPECTATIONS –

·        Doctor doesn’t make them feel inferior

·        Doctor doesn’t implicate him by showing the disease to be his mistake

·        Doesn’t rush him

·        Is respectful and sensitive

·        Tries to compile and get to the crux of the whole medical history

·        Clear explanation of waiting time

·        Accept diversity of patient backgrounds

·        Accept the right of patients for respect and fair play

·        Accept responsibility ;to err is human to , admit superhuman

·        Don’t charge for managing complications .

·        Show humanity in financial dealing after death .

DOCTORS EXPECTATIONS :

A - FROM PATIENT

·        Understanding of the fact that doctors’ need to work peacefully

·        Doctor is not God and Patients should be willing to accept limitations

·        To understand that it is difficult for doctor to carry on the socialist tradition in a largely capitalist society

B – FROM ADMINSTRATION

·        To Implement law by letter and spirit .

C – FROM MEDIA

·        Publish both views ,avoid sensationalism .

·        Be more positive

·        Should not ascribe wrongful intentions

Strengthing Doctor Patient Relationship

·        Encourage patients to talk about psychosocial issues such as family and job

·        Phone call after surgery

·        Greetings on occasions

PREVENTIVE MEASURES TO BE TAKEN BY  INDIVIDUAL PRACTITIONERS

A. The Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002and amendments of 2009  should be strictly complied with.(17)

B. Keep liaison with the local police.

C. Keep proper records.

D. Do not commit negligence. Be knowledgeable in your subject. Do not venture out of your area of work/expertise.

PREVENTIVE MEASURES TO BE TAKEN BY HOSPITALS / NURSING HOMES

It needs to be appreciated that violence against hospitals occurs because of lack of information and misunderstanding. It also occurs because of negligence or crudeness or arrogance or greed on the part of nursing homes. The nursing homes should do

the following:

A.   They should take steps to minimize the possibility of such attacks. Examples of such steps are:

The Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002, should be strictly complied with by the doctors working in the nursing home.

A notice should be prominently displaced providing information to the public about the actions that an aggrieved patient may take. Such information may include:

Name and mobile telephone number of the person/doctor who is officially assigned the duty of attending patient complaints/ emergencies on 24-hour basis.

Name of the person in charge and the members of the “Patients Grievance Redressal

Committee” of the hospital or nursing home concerned and the time limit (say, 48 hours)

for the necessary action.

The mechanism for supplying a copy of patients’ medical records on request, including

the fees and time limit for the same.

The following information should also be prominently displayed:

Schedule of  hospital charges

Names, qualifications and medical council registration numbers of all doctors.

B. They should buy a hospital professional indemnity policy through a legal risk cover company. While choosing the legal risk cover company, they should choose that company whose terms and conditions include a written clause that the company will provide legal services in connection with criminal/police complaints related to violence against the

hospital.

C. They should organize a collective nursing home defence mechanism through the local IMA. If this is not possible, a few nursing homes should come together on their own to form such a joint mechanism. Such joint defense mechanism,  would do the following:

It would collect fees from members and keep proper accounts of the funds collected and spent.

It would provide the following services to the members:

Liaising with the police.

Organizing joint seminars on the issues related to nursing home protection. The local police

officers; CMO; DM; media and some persons from the legal field, if possible the magistrate

or sessions judge, should be invited on these occasions and they should be requested to

express their views.

Engaging the services of an advocate on the criminal side to act as a standing counsel for the member nursing homes for any legal help at times of violence.

Engaging the services of a security agency to provide security cover in normal times as well,

additionally, in emergencies, to the member nursing homes.

D. The cost of the JDM incurred by the member nursing homes should be recovered, in part or full, as appropriate, from the patients by adding an item in the bill, such as, “Protection against violence charges”. Such charges should be levied in a transparent manner and should be supported by proper accounting procedures. The consent  form signed by the patient at the time of admission should clearly state that the signatory consents to pay the “hospital patients protection charges”.

E .A written undertaking should be taken from the patient and two relatives that they would not indulge in violence and that any loss to hospital property as a result of violence caused by them would be recoverable from them by various means, including but not restricted to adjustment against the advance deposit and any bank guarantee or any other guarantee provided on behalf of the patient at the time of admission.

Hospital records in respect of patients (case sheets) should be properly kept.

Treating doctors should spend sufficient time with the patients and relatives to answer their doubts and queries. The consent form should not be got signed in a cursory manner. It should be an informed consent in the true sense.

No false assurances, even verbal, should be given to patients.

Patients should be clearly and documentedly told that they are free to shift their patient to any other hospital at any time.

Prompt police complaints should be made against those who commit violence. Video cameras should be installed at a few places to record the photographs and voice of any bad elements who commit violence. This would greatly help in making a police complaint and pursuing it. Patient records should be properly maintained. They should be kept in proper custody of the hospital and should not be loosely displayed.

However, proper and detailed referral letters and discharge summaries, containing necessary details, should be given to patients under signature when they leave the hospital.

Note: Some nursing homes may be small nursing homes with only a few beds. However, all the above measures need to be taken for every nursing home, big or small. The smaller the hospital, the more the chances of violence against it.

TO SUM UP THE PREVENTIVE MEASURES  TO BE TAKEN

1. RESTRICT ENTRY -The most important step is to restrict entry of public. At no stage hordes of relatives should be allowed at the patient's bedside. Entry should be strictly by passes and this must be implemented through good security, preferably by ex-army personnel.

2. SECURITY -Security guards must be placed inside the hospital at sensitive areas like ICU, Operation theatre and casualty.

3. COMMUNICATION ,COMMUNICATION AND COMMUNICATION --Much needs to be done to improve doctor – patient relationship. This must begin by the doctor informing the relative of what is going on. As the patient is being investigated diagnosis need not be given out. There should be no hyper bole nor understatements. Under no circumstances must the previous hospital or referring doctor be criticized. Words such as ‘You have come too late’ must not be used. This puts the blame on the patient. Who then retaliates by criticizing doctors. In desperate situations patients must be given a choice of calling another doctor (second opinion) if they feel so. The suggestions of organ donation must only be made in brain death. Never before. When the prognosis is serious the senior doctors must talk to the relatives. Security must be provided to the doctors at all times and at all places when they are at work.To manage the time barrier to communication make use of paramedical staff and delegate the work of repeated explanations to paramedical staff and counsellors .

4. ORGANISE WORKSHOPS -In the short term it is important to organize workshops to train physicians to prevent and deal with violent incidents. In these training sessions physicians will be taught to be patient, to provide appropriate and relevant information, and to show respect towards patients and family members . In the light of recent events, private practitioners should also be prepared by ensuring the basic principle of practice-a chaperone should always be present while

attending a female patient.

.

5.MEDICAL PRESS - Since the press has taken a stance against members of medical profession, concept of medical press should be emphasized where we publish our own news; we tell people our version of the truth and evolvement of social media has been of great help here where it is easy to share your side of the story .

6. MARTIAL ARTS -Lastly, there is something to be said for young doctors to learn martial arts. The world

is increasingly progressing towards violence. So karate, tokendo and other martial arts

are worthwhile learning for self defence. It will boost the doctors confidence even if not used .(18)

THINGS SHOULD NOT REACH  THIS FAR :

On your part

·        Pay the bills before you take the dead body

·        Doctor Sahib busy hain ,wait karte raho

On Patient’s Part

·        You are paid to do so

·        Mantri ji ko phone lagao

·        Netaji ki chitthi padho

·        Bhai Sahab se phone par baat karo

STRESS ON PATIENT DRIVEN QUALITY

(19)

MANAGEMENT 

INSPITE OF ALL MEASURES VIOLENCE TAKES PLACE . NOW WHAT TO DO ?

A. Depute someone (preferably beforehand) to take photographs and, even, audio records of the violence.

B. Depute someone to immediately get the medical record of the patient photocopied, preparing at least three copies. These will be useful for giving to the patient’s relatives and the police and to the court. If the mob carries away the original record, the photocopies will be useful.

C. Inform your advocate.

D. Inform the police immediately by phone, etc. And keep a record of such phone call, etc.

E. Identify the troublemakers/leaders in the mob and talk to them and try to pacify them, even though you may have to go out of the way to a certain extent.

F. Get written, signed statements from the persons present (doctors, staff, patients, relatives, others) regarding the occurrence of violence. An advocate’s help in this would be specially useful. (Note: Such statements are crucial as regards the legal course of the incident and may not be easily available later).

G. Lodge an FIR with the police. It is better to let the advocate prepare the FIR.

H. Issue a press statement about the incident.

I. The aggrieved doctor should not be left alone. The local IMA should provide him all support in the interest of the profession. The support should be on the following lines:

It should immediately constitute a high powered committee including, amongst others, its counsel and also, preferably, a retired judge (and may be also a police officer), to probe into the incident and submit its report along with the plan of action. It should get published in the newspapers a balanced and correct version of the incident so that the public understands the facts of the situation. This may be by way of a press release or an advertisement.

It should take direct action within law against the culprits. It should circulate amongst the members the names of those involved in the incident with a request that members may, at their discretion, decline to provide services to them except in emergency unless they submit apology to the concerned doctor and to the state IMA in writing.(20)

CONCLUSION –

 ·        Medicine is not magic,do not expect miracles inspite of all type of hype  

 ·        Medical results are never 100% ,doctors never fail INTENTIONALLY but sometimes failure is inevitable

 ·        Do not blame doctors for all the problems of Govt or Corporate set-up

 ·        DOCTORS TREAT – HE CURES

 ·        Cure where possible ,care always and communicate maximum

·        We may have our own problems but most patients are more troubled than us .

·        Never ever comment adversely on another health worker’s efforts .
       
     There are studies showing that each participant (i.e. patient and doctor) can explicitly provide emotional support for the other, despite the evident asymmetry in the roles of doctor and patient. Patients can substantially contribute to the personalisation of their relationship with the doctor, which is often facilitated by the repetition and regularity of the interaction. Patients not only declare their empathy for doctors, but they can also avoid displaying a self-centred attitude, which further opens up perspectives for their effective participation in the treatment process.(21)

Archana Tandon

BIBLIOGRAPHY

1 . Violence Against Doctors P Madhok Bombay Hospital Journal, Vol. 51, No. 2, 2009

2. . Health Services Advisory Committee. Violence to Staff In the Health Services. Health and Safety Commission, London:

HMSO, 1987

3 http://www.slate.com/articles/health_and_science/medical_examiner/2010/03/when_patients_attack.html

4 . http://www.telegraph.co.uk/news/health/news/9713725/Assaults-on-NHS-staff-increase-to-163-attacks-per-day.html

5. http://www.theweek.co.uk/china/57772/why-chinese-are-beating-and-even-killing-their-doctors#ixzz3YfoYc4eJ

6 . http://www.sunshinecoastdaily.com.au/news/attacks-doctors-and-nurses-could-lead-14-years-jai/2430448/

7 . http://zeenews.india.com/news/delhi/doctors-go-off-duty-protesting-against-attack-on-colleague_1553850.html

8 . http://www.tribuneindia.com/news/himachal/community/ima-condemns-attack-on-doctors-in-kullu-hospital/56381.html

9. https://www.saddahaq.com/human-interest/doctorattacked/people-should-understand-doctors-are-also-human-beings-says-doctor-who-was-attacked-in-mumbai

10. https://youtu.be/6jXA-gJ-PpQ

11 . Iluz T C, Peleg R, Freud T, Shvartzman P. Verbal and physical violence towards hospital- and community based physicians in the Negev. An observational study Tal Carmi-Iluz et al ; BMC Health Services Research 2005, 5:54

12 . Violence against Physicians Frederick et al. J GEN INTERN MED 1994;9: 503- 506.

13 . Bombay Hospital Journal, Vol. 51, No. 2, 2009

14 . Rosenblatt RA, Wright GE, Baldwin LM, et al. The effect of the doctor-patient relationship on emergency department use among the elderly. Am J Public Health 2000; 90: 97-102

15 . Medical Professionalism, Faiz M A. J MEDICINE 2009; 10 : 1-2

16 . http://timesofindia.indiatimes.com/city/kanpur/UP-offers 
-protection-to-medical-staff hospitals/articleshow/20341657.cms

17 . http://www.mciindia.org/RulesandRegulations/CodeofMedicalEthicsRegulations2002.aspx

http://www.mciindia.org/Rules-and-Regulation/Gazette%20Notifications%20-20Amendments/Ethics%20-%2010.12.2009.pdf

18 . Bombay Hospital Journal, Vol. 51, No. 2, 2009
!9 .(21) . http://www.slideshare.net/sureshpandey/violence-aggresion-against-doctors-dr-vidushi-sharma-dr-suresh-k-pandey-kota-india

20 . Indian Journal of Clinical Practice, Vol. 22, No. 9, February 2012
21 New Insight into the Role of Patients During Medical Appointments: A Synthesis of Three Qualitative Studies
Ludmila Marcinowicz, Teresa Pawlikowska, Jerzy Konstantynowicz, and Slawomir Chlabicz.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4141969/