First he skipped breakfast, and then found there was no time for lunch. As afternoon stretched into evening, the famished young doctor considered slipping away for a bite, but there were too many patients turning up at the emergency ward. At 7.30pm, he thought he might take a breather after just one more case. It seemed easy enough. No question of life or death — just one 10-year-old boy, sobbing loudly over a fractured leg. The child was riding an autorickshaw when it hit a divider and the leg got caught.
Suresh Sana, the 28-year-old postgraduate doctor on duty at MS Ramaiah teaching hospital in Bangalore, explained to the parents that a clear X-ray could be obtained only if the boy calmed down and stopped crying and shaking. But the child proved difficult to soothe. Eventually, Sana dispatched the family to the X-ray unit. When he met them there to get the results, however, Sana suddenly found himself a target of the relatives’ wrath. It was a bewildering turn in the course of his life – until then, a clear upward arc. He had been the first in his father’s village to win a medical seat, and was newly engaged to be married. And here was this patient’s aunt, giving him a sharp slap that carried the sting of public ingratitude. “Why don’t you behave like a doctor?” she snapped, seemingly furious over the delayed X-ray. Then a male relative grabbed Sana by the collar and punched him in the face. His head hit the chipped cream paint of the corridor wall, and he fell unconscious. Down the hall, framed images of goddess Saraswati and the god Venkateswara hung silently above the fracas.
Fallen from grace
Ten or fifteen years ago, doctors in India were still treated as demi-gods. They commanded vast respect and could not, would not, be questioned. A punch in the face over an X-ray? Unthinkable.
But those were the days before healthcare emerged as a hardcore business. Technology has advanced, yet trust has faltered. “Patients have a perception that doctors and hospitals are out to fleece them,” observes GD Ravindran, a professor of medicine and medical ethics at St John’s Medical College in Bangalore. Second-guessing has also become routine, with Internet search habits eroding the previous doctor-knows-best mindset. Those are big bumps in the road toward a shared desire for a positive outcome.
Compared to road rage, however, hospital rage appears far more complex. From all accounts, it stems from frustrating shortfalls in the public health system, crucial gaps in communication between doctor/patient/relatives, low-level political bullying and high expectations for recovery. And don’t discount the brain-wiring. “When a relative suddenly and unexpectedly dies…it is far easier for the brain to blame the doctor and the institution he represents, who are quickly demonized as outsiders with their arcane and mysterious ways,” says Sai Gaddam, a neuroscientist and Bangalore-based author who recently completed a book titled Keepers of the Flame: What Outrage, Snark and Trolling Reveals About Our Social Brain.
Consider the annals of Indian doctor-bashing in recent times. In Tuticorin, a female anesthesiologist was hacked to death in January 2012, allegedly by the husband of a pregnant woman who did not survive an emergency surgery. In Imphal, a professor of medicine was shot in the head in March 2014 while working in her private clinic. In Kanpur, a medical college turned into a virtual war zone in February 2014 after a local politician allegedly exhorted police to mount a raid there, in a hail of rubber bullets. In New Delhi, a female doctor was assaulted in September 2013 by a mob in a public hospital’s casualty ward and threatened with rape. In Hassan, drunken buddies of road accident victims periodically disrupt the emergency ward at the district hospital, manhandling medical staff and breaking furniture – the latest incident was in early March 2014. In Raichur, someone splashed petrol on a nursing home in February 2014 and set it ablaze.
Trouble comes to both government hospitals and private clinics. Sometimes a lucky doctor can run away and hide in a locked toilet. But not always. The weapons vary: a knife, a stick, an iron pole normally used to suspend an IV drip. In the wrong hands, it can be wrenched from a hospital bed and smashed against the side of a doctor’s head, perforating an eardrum. “The sense of fear stays with you,” says 33-year-old Kailash Bagale, who in June 2012 made the mistake of trying to appease an angry mob in a recovery room at the Sri Jayadeva Institute of Cardiovascular Sciences and Research in Bangalore. The pain in his ear subsided after three months.
The hazards of being a junior doctor
In the Ramaiah hospital case, the punch in the face led to a brief strike by Sana’s colleagues. This is how such incidents tend to surface – if only sporadically and locally – with short media bulletins detailing a fresh strike, usually by the younger doctors. They carry the lion’s share of responsibility in emergency wards on late nights and weekends, when the atmosphere is most likely to get edgy. If beds are scarce, tempers flare. “Ninety-nine percent of the time, it is the junior doctors who are thrashed,” says Anirudh Lochan, Secretary General of the Young Doctors’ Association of India.
Interviews with three dozen medical professionals and analysts across India indicate that violence against medical personnel has increased over the past three years, despite a wave of state laws passed in 2008/2009 that explicitly prohibit such attacks on doctors, nurses, paramedics and hospital property. The legal remedies were first prescribed in Andhra Pradesh, moving up to Haryana and across to Rajasthan, Punjab, Karnataka, Tamil Nadu, Maharashtra and elsewhere, categorizing such attacks as non-bailable offenses and mandating prison terms of one to 10 years, depending on the state. (Health is considered a state subject in India.) As a deterrent, such laws have clearly failed.
The consequences appear grave. Interviews suggest that doctors are now less likely to take risks, since the death of a patient might provoke mayhem. “If a patient comes in a serious condition and I spend all night in the ICU, if he dies, they will be after my blood,” says Rajan Sharma, an orthopedic surgeon in Haryana. A defensive strategy involves shunting complicated cases to other clinics and hospitals, with the delay actually magnifying the health risks in some cases. And referrals just add to the frustration. At the Bangalore-based Institute of Public Health, director N Devadasan argues that India’s stubbornly high maternal mortality rates can be linked to this practice of referring pregnant mothers to institutions that lie further away from their homes.
The violence has also led to growing fissures within health systems, with younger doctors resentful of becoming punching bags without adequate protection from their supervisors and institutions. Strikes may provide an outlet for outrage, but they also lead to neglect of countless other patients.
Meanwhile, boundaries are blurring between India’s violent political culture and the blue-curtained hospital space. According to medical superintendents and social workers, numerous politicians like to throw their weight around crowded emergency rooms in a bid to pump up the vote bank in their constituencies. Their designated patient must get immediate attention, or else. “Don’t you know who I AM?” seems a common prelude to bullying and shattered windows, courtesy of his or her entourage. At St John’s, security chief MB Aparna also points a finger at groups he considers troublemakers, including the Karnataka Rakshana Vedike and autorickshaw unions.
It can be difficult to grasp the severity of the problem, though, because data is simply not available – unlike in China, where a well-documented spike in attacks on medical staff was highlighted by The Lancet, a prestigious medical journal, spurring coverage in foreign media. In India, doctors are frequently reluctant to file an FIR, wary of getting tangled in a time-consuming process or creating more enemies in their locale. Some give way to the urge to hush up the incident, and simply carry on, albeit demoralized. Moreover, police often seem unaware of the recently enacted laws and favor private exchanges of cash, or apologies, over registering an FIR.
“The ignorance of police personnel should be penalized,” insists Narendra Saini, Honorary Secretary-General of the Indian Medical Association. “Even if they do know the law, they give importance and sympathy to the patients’ relatives, which in my opinion, should be curbed.” Saini reports that he is getting “five to eight times more complaints than I used to,” from doctors who are harassed or attacked.
Tamil Nadu, for one, has promised to post more police on hospital grounds. Elsewhere, some hospitals have taken the initiative to install more CCTV cameras and post signboards in red and black letters spelling out the penalties for anyone who creates trouble. Some are getting slightly more creative: at Victoria Hospital in Bangalore, for example, medical superintendent Devadass PK is excited about commissioning pictorials that will portray the dire consequences of assaulting a doctor or destroying medical property. He describes an image of someone punching a man wearing a white coat, with a big ‘X’ over it. The next frame will show a glum man behind bars. That’s a bit more dramatic than a ‘No Smoking’ sign.
But the law-and-order prescription can only go so far. Consider the clash at Ramaiah hospital, which happened last November. After Sana collapsed, he was revived by another doctor and admitted to the hospital for two days. Physically, there wasn’t much wrong with him – some bruises on his face, and a bit of hypoglycemia due to his empty stomach – but the depression was worrisome. The hospital had encouraged him to file an FIR but he doubted much good would come from that. He rose from his hospital bed and went home to his village in Kadapa district, Andhra Pradesh, where his family grows sunflowers. His parents persuaded him to withdraw the FIR, fearing some further retaliation from a family wealthier than theirs. Sana brooded over the incident, asking himself if he had made any mistakes. He realized that there had been some language barrier, as he couldn’t catch everything the relatives were shouting in English and Hindi. But that could not justify what happened, he reasoned.
When he returned to Bangalore, the police handed over a letter of apology from the boy’s relatives. He tossed out the letter and refused any meetings. “I didn’t want their apologies,” Sana says curtly. “They did the wrong thing.” He still feels an aversion to that particular corridor in the hospital. But he has not given up his specialization in orthopedics. He sits waiting for the next patient, his scuffed sandals hidden by sanitary blue hospital netting.
Reached by telephone, the boy’s uncle declines comment on the case. “Please, Madame, it’s over,” he says.
The Talking cure
In Tuticorin, Tamil Nadu, the January 2012 murder case of 55-year-old anesthesiologist Sethulakshmi has yet to be adjudicated, after being shifted to an understaffed court slated to handle crimes against women. The accused was held in prison for six months then mysteriously released, despite a tough state law aimed at protecting medical personnel. “The legal system in India is so corrupt. Whatever you do, it is totally useless,” says TS Gopinath, the son of the deceased and himself a government-employed doctor in Chennai. But he says that prosecution won’t bring peace of mind either. “We have lost a life. We have nothing to lose anymore,” says Gopinath. The family opted to shut down the private, seven-bed hospital.
Up north, a 29-year-old female doctor who was mauled by a mob last September at Lok Nayak Hospital in New Delhi needed three months off before she could resume work at a different hospital in a different state. (She requested that her name be withheld.) She recounts that she was the lone doctor posted one night in a casualty ward when two patients came in. One woman showed serious signs of ectopic pregnancy, so the doctor gave her priority. The other pregnant patient did not appear to have any complications. But after turning her attention to the more pressing case, she was challenged by another woman who identified herself as a politician. “How dare you deny my patient?” bellowed the woman, clawing the doctors’ clothes and pulling up her shirt. A bunch of male followers surrounded the doctor and called out threats of rape. Meanwhile, a frightened security guard and a nurse had vanished. After about 15 minutes, other doctors arrived and rescued her from the mob of 30-odd people. “When the police came, they should have taken strong action. They just let them go away,” she recalls. The doctor resigned that night. “I was scared they would attack me again,” she says. Her father promptly arrived by train and escorted her out of Delhi.
Siddarth Ramji, who took over as medical superintendent of Lok Nayak shortly after this event, says that the hospital has beefed up security since then. Hospital representatives have also held meetings with community leaders to explain problems of understaffing and request some patience. (For example, Lok Nayak employs 600 nurses, compared to the 1300 that are supposed to be on the roster.) Rules were changed to allow only one attending relative at a time. Having seen previous violent outbursts punished with fines of a few thousand rupees, Ramji, too, is skeptical of legal remedies. “Preventive action is going to be far more important,” he predicts.
In his view, one crucial task is to train doctors to communicate more effectively with patients and their family members. Medical colleges should stop waiting for the stodgy Medical Council of India to introduce changes in the medical curriculum and instead take the initiative to train doctors to become more accommodating in answering questions and more empathetic in their manner.
In Bangalore, St John’s Medical College is held up as a rare example of an institution that fosters communication. There, clinical psychology professor Tanya Machado introduces students to some basic skills through role play, such as breaking the news of sudden death to relatives. “It’s very important to teach doctors that there will be anger in the normal process of grieving. They are going to accuse you of incompetence. Let them cry, let them get angry,” she advises. Other tips: “Try to give the message very clearly. It may have to be repeated a number of times. Maintain eye contact. Don’t stand with your arms crossed.”
Such sensitivity training should also be extended to nurses and office staff, according to VL Sateesh, medical superintendent of the National Institute for Mental Health and Neuro Sciences in Bangalore. New batches of staff are trained to develop listening skills, despite the hectic pace of emergency settings. “If the relatives have the feeling of being neglected, the anger and frustration increases,” he says. Information-sharing is very important, he continues. If a patient arrives in a very serious condition, his relatives should be advised accordingly, not reassured that everything will turn out well.
Based in Mumbai, Shalini Ratan is starting to offer communications workshops for doctors in Maharashtra and elsewhere. Getting beyond their disease-centric training is a challenge. “I know that overnight they can never change,” she observes.
Will the talking cure have any significant impact? Krishnamurthy Balasundaram, the dean and director of Mysore Medical College and Research Institute, reports that violent incidents abated in the last six months after junior doctors were instructed to spend more time responding to concerns of the relatives. “Ours is an overburdened hospital. When doctors are overwhelmed, they get impatient and sometimes become rude. Now they have learned their lesson. Even if you talk to [patients’ relatives] for only a few minutes, ultimately it will take less time,” he says.
Other suggestions include introducing 24-hour inquiry desks at hospitals, a call center for registering grievances, and better mechanisms to file claims of medical negligence in a peaceful manner. (For various reasons, the Consumer Protection Act has not lived up to its promise in channeling healthcare disputes.) Given the multi-lingual mix in urban centers, both medical personnel and security guards must also bone up on their language skills to interact with a broad cross-section of society.
And this election season, politicians must be told to stay out of emergency rooms. A vote soaked in the blood of a doctor is hardly a sign of a healthy democracy.
Margot Cohen is a writer from New York. Her interest in India follows previous reporting stints in Indonesia, Vietnam and the Philippines.
Grist Media 25/03/2014