Medical practice is currently at crossroads due to several ills that have crept into the profession. The malaise may have its genesis traced down right from the time of entrance into medical school due at least in part to inadequacy and lack of contemporariness in current medical curricula. There could be several limitations of the medical course at present. The first problem is that rapid technological advances in the practice of medicine have led to an exponential increase in the amount of information and skills that needs to be acquired by the student. Broadly it is a question of dropping vestigial knowledge and re-prioritization of education according to the requirement of the day. The second problem is the alienation of the prospective physician from the society. However, perhaps the most alarming problem is lack of inculcation of empathy, rather a steady decline in its level over the course of medical school. We discuss how these issues can be appropriately addressed in a new curriculum.
In a predominantly capitalistic society health-care is probably the only remaining profession in India which still works on welfare model (at least in the government institutions). This ensures a prioritized, cost-effective health-care delivery to practically entire population. However, violence against doctors (among other problems) is seriously threatening the status quo. While violence on road (road rage), public places, even schools is common (though not condone-able), it can under no circumstance be acceptable in hospitals. Although violence is just a symptom of dysfunction of overall health-care system, the hospitals cannot be allowed to become battlegrounds for the simple reason that sick people need a peaceful environment where they can get sympathy, empathy, support etc on one hand and the health-care professionals also need a stable and peaceful environment if they are ever able to give self-less care (rather than worry about their personal safety). Thus, if the hospital environment is exposed to violence its practitioners might start practicing defensive medicine, and focusing on saving their own skin rather than treating a patient.
Workplace violence is an act of aggression, physical assault, or threatening behavior that occurs in a work setting and causes physical or emotional harm to an employee.1
3. Myths about violence against doctors
- Violence is only restricted to doctors
- It is an Indian specific phenomenon
- Media and other associations convey both side of picture – It is the doctors and hospitals which remain on defensive (because it is newsworthy to be anti-establishment)
4.The doctor’s respect has declined over the years
4. Violence against doctors is an Indian phenomenon
USA Today in its op-ed piece quoted 2010 survey from the Emergency Nurses Association that more than half of emergency room personnel were victims of physical violence, including being spit on, shoved, or kicked, and one in four reported being assaulted more than 20 times over the past three years. The survey went on further to state that this violence was actually increasing over the period of time.2Closer home an Editorial published in Lancet reported that doctor–patient relationships in China were in crisis. Doctors had been injured or even killed by patients at work.3
5. Violence is restricted only to doctors
US Department of Justice reveals that Medical Profession constitutes around 10% of all work-place violence whereas professions like law enforcement (police, regulators etc), security guards, retail professionals and even cab and bus drivers carry a higher risk of workplace violence than health-care providers.4 The situation in India may not be much different.
6. Genesis of the problem
While there certainly has been some erosion in the esteem of physicians the matter-of-fact is that medical profession still remains the most prestigious of all. At the same time there is no doubt that over the years there has been a significant erosion in stature of medical professionals. The etiology of this whole issue can be really traced to a rising intellectual class. While in 19th century the members in this class (intellectuals) were miniscule (constituted exclusively by landed gentry), by early 21st century around 45% of the population belongs to this class overall. However, in context of health-care profession the exposure to intellectual class is much higher because this is an affording class unlike the labor class).5 That this class cannot be ignored now can be aptly shown by numerous examples; Leninists did that with disastrous consequences (they considered only proletariat and the bourgeoisie) and they were relegated to confines of history.6 The Arab spring was a direct consequence of this class and even problem of terrorism to a large extent represents inability by the ruling class to accommodate the intellectual class.
7. Characteristics of intellectual class
The essential characteristic of this class is that they crave freedom and may go to any extent to supposedly preserve it.
- They hate trappings of power or control
– many of the intellectuals harbor anti-pathy and poor image of medical profession because doctors are perceived as having control/power over them/their loved ones which they are 4 unable to accept
-intellectuals have less fear/faith of law (which again is perceived as power or control)All this manifests as more demanding, more aggressive behavior.
- They are more knowledgeable; access information easily as a result of information revolution
- May resort to issue based organization (even if they don’t understand the issue) – mobocracy or anarchy
- Desire to achieve leadership position on any issue
- Dislike their own ego bashing
8. How does this impact on medical profession
The one value that an intellectual cherishes most is freedom: whether it is freedom from oppression or freedom to make choices. For making choices information is required; to understand and know what choices are and thus the need for communication to convey this information. It is not thus surprising that emergence and consolidation of this class has led to information revolution and manifold increased the importance of media be it classical or social media.
9. Factors predisposing to violence
Since vast majority of patients (because of paying capacity) are now intellectual class, the etiology in majority of these incidents can be traced down to improper patient doctor communication. In brief since the basic instinct of an intellectual is to have freedom, i.e. freedom of choice, which comes only through information. While in e-age a lot of information is available online, the patients/attendants still depend on the treating physician to give them accurate and honest information about the cause of disease, the disease process, the options for investigation and treatment, the course and prognosis and finally the costs involved in the therapy. However, when this information is not adequately communicated to them it leads to trouble. Thus the crux of whole problem in majority of cases is a lack of proper communication. In this context several issues can predispose to violence by attendants/relatives:
- Misunderstandings – miscommunication at any level from explanation of etiology, disease explanation, need for investigations and treatment options.
- Mishappenings – when the disease course and prognosis is not properly communicated to the patient if a mishap occurs the treating doctor and staff may be perceived as callous or inconsiderate.
- Dissatisfaction with the course of treatment
- Disagreement with physician on modalities, option and course of treatment
- Perceived lack of communication (collaboration) or inability to share information between doctor and patient
- Casual opinion – criticism by other/2nd opinion doctor
The second problem is that the patient and their attendants are in a most vulnerable phase of their existence, i.e. faced with temporary or permanent disability even death. In this state they are fearful, anxious and in doubt. Here what they require is empathy and humane behavior and not challenge by the doctor or staff.
- Prolonged waiting times: delay in attention or admission of sick patient or perceived delay in investigation and treatment.
- Perceived lack of availability of doctor (senior doctor)
- Perceived lack of caring by physician or staff
- Altered states of attendants: intoxication, mental illness, severe anxiety or stress
- Problems of public hospitals: dysfunctional equipment, poor quantity and quality of paramedical and supportive staff (and doctors being at apex have to take blame for it).
The third problem could be small time community leaders/troublemakers – This is more of a problem in government hospitals or employee insurance hospitals who cater to a significant population of working class (unlike corporate hospitals which deal nearly exclusively with intellectual or elite class). Classically, working class always grudges intellectual class (to which most doctors really belong) because they believe in quantity and not quality of work. In other words they believe in hard work to attain success and believe that intellectuals (just because of education) get undue rewards including fat incomes while their own hard work is not appropriately recognized. In this context there are certain individuals at the apex of working class who (because of an illusion prevailing in this category) wrongly identify themselves with the ruling class and thus have inflated egos to accompany. These individuals may grudge the perceived power enjoyed by the physicians (at that point of time) and feel that their own power is in jeopardy and may feel slighted. They may react by organizing others in this social class and inciting violence against so called usurpers of their just power. Likewise what an intellectual class (to which most doctors belong) dislikes most is ego basing and thus the doctors also respond even more vehemently to the perceived slight starting a vicious cycle.
10. What needs to be done?
10.1. By the physicians
- Better communication: This is the most workable strategy with the intellectual class:
-medical philosophy needs to be reoriented towards changed structure and accompanying perceptions of society. Classic parental doctor–patient relationship no longer works, now it has to be a participatory approach. It has to be effectively communicated that doctors can’t perform miracles, indeed they can modify disease process but they cannot prevent eventual mortality. At best they can help patients to adjust with disease its morbidity and mortality.
-The physicians have to understand that patients and relatives are going through extra-ordinary fear, anxiety and doubt and may not thus behave rationally. Further the doctors have to understand that patients come from a variety of background, class, educational and economic status.
-Don’t make the patient feel that the doctor is in a big hurry and that patient is wasting his time, rather devise a strategy to over-come the problems of time constraints suffered (by physicians) probably by having more supportive staff specializing in counseling.
-Avoid inculcating fear in patient or make them feel that they are somehow responsible for their state (to which patients respond by putting the blame on doctors).
-Patient satisfaction comes from being heard and being understood.
-in case of complications/death a senior doctor should talk to patients/relatives which gives them assurance that best treatment is being/was given to the patient.
Doctor–patient communication is a two-way street. While it is the patient’s right to get accurate medical information, it is their responsibility as well. The way doctors can facilitate this process is by prescribing information: i.e. by providing patients with educational handouts, putting up their own websites, or referring them to health libraries. This way the patients will know more about their conditions and available options and also obtain realistic expectations of what their doctor can do for them. At the same time it is the patients / attendants responsibility to give an accurate information to the health-care providers and not hide inconvenient facts from them.
- Second opinion should be given very carefully, with careful choice of words.
- Effective management strategy should be put in place: a damage control plan, when violence against heath staff seems imminent (not to react tit for tat – anger for anger) and address patient grievances.
- Give a sense of security to the patient and relatives: a sense that everything is going as per plan. In other words they should try not to frequently change the treatment plan as well as the cost. The cost of managing complications should as far as possible be incorporated in the initial costing.
- Show empathy for suffering and sympathy in financial dealings. The patient should be treated as a fellow human and not some abstract problem or worse made fun of or treated with ridicule.
10.2. By the hospital administrators
- Restrict entry of attendants to clinical workplace
- Strengthening of security
- Have a hospital committee (PRO) specializing in effective communication which can satisfy the patients/attendants.
- Reduce the waiting times for everything and if they cannot be done at least explain why these times are there in the first place.
- Displaying information and also the laws governing the safety of doctors up-front
-to satisfy the intellectual class
-to make them aware of consequences of violence against doctors
- Involving media in their activities
10.3. By society in general
- Strengthening of law – making it non-boilable offence. This approach is especially effective with working class because for them discipline is the most cherished value. However, the situation is more complex with the intellectuals. Since this class values the freedom most, intuitively it dislikes any kind of rules or laws. On the other hand it also realizes that freedom of one when stretched beyond a certain point becomes subjugation for others. Thus even this class favors rules and law if it can be shown that they are for common good.
- Implementation of laws: Often the problem is not the law, which does exist but implementation of law. Thus law enforcing authorities should realize that their mandate is to maintain law and order and not to takes sides (which is the work of a judge) in any dispute and deliver instant justice like some “fast food”.
- Media has a very important role to play: they should also write positive things about the profession or at least both sides of the issue in situations like this; they should avoid journalism of sensationalism and avoid provocative head-lines. While in short term these kinds of reports get a few eye-balls but in long run might prove counter-productive for the society.
Courtesy – Science Direct
Link – http://www.sciencedirect.com/science/article/pii/S0019483215002357
nd their attendants are in a most vulnerable phase of their existence, i.e. faced with temporary or permanent disability even death. In this state they are fearful, anxious and in doubt. Here what they require is empathy and humane behavior and not challenge by the docto s