On the night of March 16, motorists on Poonamallee High Road were stranded as a long queue of vehicles brought traffic to a standstill. Just outside Rajiv Gandhi Government General Hospital — the State’s largest health care facility — hundreds of postgraduate medical students and interns were staging a protest in the wake of an assault on a few trainee doctors and PG students by a patient’s relatives.
This was hardly a one-off incident, either in the State or across the country.
Over the last five years, there have been a number of attacks on doctors in Tamil Nadu, predominantly in, but not limited to, government hospitals. In the space of a few weeks in 2012, there were two violent incidents at a government hospital. The following year saw doctors at two other hospitals roughed up. Private hospitals are no exception. In January 2012, T. Sethulakshmi, an anaesthetist, was murdered at her private clinic in Tuticorin by the husband of a pregnant patient who died days after she received treatment from her.
The incident galvanised doctors across the State to take to the streets, demanding better protection for medical practitioners. Despite several such protests and even the existence of a law specifically meant to protect them — the Tamil Nadu Medicare Services Personnel and Service Institutions (Prevention of violence and damage or loss of people) Act, 2008 — such attacks have not abated.
Scope of the problem
According to media reports, a study undertaken by the Indian Medical Association (IMA) in 2015 found nearly 75 per cent of the doctors surveyed to have reported facing some form of violence. The relatives and attendants of patients were said to have been responsible for 68.8 per cent of such violent incidents.
According to IMA national president K.K. Aggarwal, the dissatisfaction with medical practitioners is either due to unreasonable expectations or miscommunication, and should be settled through available redressal mechanisms and not through violence. “Every hospital is required to have a redressal mechanism. Doctors are professional, and are governed by a code of conduct which makes them accountable,” he says.
K. Senthil, state president, Tamil Nadu Government Doctors Association (TNGDA), says the attacks on hospital staff occur, on an average, once a month in Tamil Nadu. “In rural areas, isolated institutions are particularly easy, soft targets as they don’t have much protection. Such attacks occur usually in tense situations such as deaths or accidents — people do not understand what is going on in the doctor’s mind. They simply assume the doctor is lethargic or negligent,” he says.
P. Balakrishnan, state secretary, TNGDA, says, “The problem is that patients now view doctors with suspicion, and this is combined with high expectations. In cases of serious illnesses or accidents, when patients are brought in late, doctors and nurses do their best but the patient may still die. The doctor is then immediately blamed.”
The rising incidence of such attacks carries serious consequences — besides the physical and mental trauma inflicted on the doctors, it also dissuades them from attending to patients who are seriously ill. Also, more of such attacks would only result in doctors not wanting to practice in rural areas, says S. Gurushankar, chairman, Meenakshi Mission Hospital, Madurai.
Legal provisions
The Tamil Nadu Medicare Services Personnel and Service Institutions (Prevention of violence and damage or loss of people) Act, 2008, more commonly known as the Hospitals Protection Act, contains provisions of jail terms for violence. But, according to Captain Nedunchezian, also from TNGDA, the legislation has barely been implemented.
“In the last few years, there have been over 30 arrests, but no convictions,” he says.
The Association wants better implementation of the law and has been consistently calling for this. “No doctor should have to work while fearing for his or her life,” he adds.
Even today, police personnel are not adequately aware of the Act. In smaller towns in particular, the doctors are having to explain it to them, Dr. Senthil says.
The ‘attendants’
A major demand of the protesting interns and students at the government hospital last week was that the number of patient ‘attendants’— relatives and friends who accompany a patient to the hospital — be limited. They also called for passes to be issued to them and for visiting hours to be enforced. But this is easier said than done.
Take the case of the government hospital in Chennai, for instance. Over 10,000 patients visit the hospital every day, with 3,000 patients, on an average, admitted there at any given time.
With the growing popularity of the Chief Minister’s Comprehensive Health Insurance Scheme, the number of patients has risen, but the increase in the number of personnel — doctors, nurses and other staff — has not kept pace, says Dr. Balakrishnan.
For many patients hailing from disadvantaged backgrounds, who may have travelled long distances to get treatment at the government hospital, being accompanied by several members of their family is the norm.
And while doctors point out that they tend to crowd wards and that there is no single point of communication that they can benefit from, the attendants are also expected by the hospital to buy medicines, take patients from one section of the hospital to another, accompany them to the washroom and do a number of other things they may not necessarily be expected to do in a corporate hospital. The attendants also have to provide food and water to patients.
Pointing out that hospitals are extremely labour-intensive set-ups, J. Amalorpavanathan, a retired government doctor, says, “Government hospitals simply do not have the mechanisms to handle this, and so, attendants are expected to do everything. The hospital cannot function without them. While crowd control is necessary, it needs to be undertaken with proper provisions.”
This is not to say that there are no problems with attendants. In a recent Facebook post, a government doctor narrated the case of an elderly woman who was ill and was abandoned by her attendants. The hospital staff took care of her, fed her and gave her emotional support throughout her treatment. One patient’s wife also said attendants were necessary, but should be limited in order to ensure cleanliness at the hospital. In a recent violent incident at the government hospital, around 20 relatives and friends of a patient had barged into the ward — a scenario that would have never been allowed to occur at a corporate hospital.
Crowding concerns
A doctor, who completed his postgraduation at the Madras Medical College in 2015, describes what it is like to work in the night.
“Since the GH is a tertiary care centre, we usually see patients who are critically ill or referred from other hospitals. We have faced a lot of rude and abusive behaviour. In case of an accident, 10 or more relatives and friends may accompany the patient and crowd around the doctor. This makes the doctor uneasy,” he says.
Another issue is that anxious relatives often want immediate attention for the patient. “But we have a number of medical procedures to follow, and this makes them impatient. When attendants are drunk, the situation escalates quickly,” he adds.
He, however, also points out that the shortage of paramedical staff has made attendants necessary. Multiple entrances to wards and buildings is another issue that needs to be tackled, he says.
In 2013, government medical colleges were asked to implement internship guidelines, following complaints from interns that they were made to do a lot of routine work that should be done by paramedical and nursing staff, such as administering injections and drawing blood. While at GH a doctor said this had now been implemented, a final-year student at another city college said interns still had do some of the routine work.
According to doctors, the long shifts left the interns fatigued, and sometimes even less empathetic. In some postings, a medical student said the shift could extend up to 24 hours at a stretch.
The demands of the protesting doctors and students at the GH included the setting up of CCTV cameras, a permanent police bandobast, strengthening the Hospitals Protection Act and dealing strictly with outsiders who were abusive and threatening.
Serious penalties for attackers are necessary, says Thomas George, former editor of the Indian Journal of Medical Ethics , but adds that increased security is not a lasting solution. “The issue here is the general breakdown of law and order in society, and the increasingly common mindset that violence can be used to redress a grievance,” he adds.
However, Dr. George also points to underlying structural problems. “Doctors are never seen as friends of patients, because working conditions make it impossible for us to be. One measure that would help is to have work plans, with doctors only attending to a certain number of patients in a limited amount of time,” he suggests.
Dr. George notes that with huge crowds at government hospitals, doctors are invariably overworked and stressed. This, he says, is partly due to poor urban health infrastructure. If neighbourhood clinics functioned better, crowds would lessen at bigger hospitals.
Patient experience
While condemning attacks against doctors, Dr. Amalorpavanathan also points out that hospitals could do more to improve patient experience.
Navigating the set-up of a large hospital can often be difficult. At the GH for instance, there are no signboards in corridors directing people and no help desks on every floor. and little computerisation, making it hard for patients and their attendants to find their way around the hospital and complete tasks
At the launch of the Citizens Doctors Forum for Ethical Healthcare in the city earlier this year, Arun Malhotra, former head of nuclear medicine at AIIMS, Delhi, spoke about simple steps that government hospitals could take. These included smart cards for payments, pictorial signage, coloured lines leading from counters to various areas, paperless technology for all tests, inter- and intra-departmental Wi-Fi and help desks with volunteers.
Also, relatives of patients say doctors, nurses and other staff are often brusque, insensitive and, often times, simply do not explain to them what is going on. Take for instance the case of Saroja (name changed), whose husband was admitted with a chronic condition at a government hospital in the city. For months on end, she says, hospital personnel have constantly failed to provide them information or explain things. “At one point, they would not even show us test reports. At every step, we had to fight for information,” she said.
Dr. Amalorpavanathan speaks of a case last year, wherein a 70-year-old tailor was repeatedly called a ‘fool’ when he did not understand what the doctor was saying to him. “Doctors sometimes forget that patients have self-respect. Better, more sensitive communication between doctors and patients is very necessary, as it is for social workers in wards to convey information to patients and attendants on a daily basis,” he says. However, he points out that doctors often have to deal with patients’ long-held beliefs, superstitions as well as suspicions. which is partly due to the increasing commercialisation of healthcare.
“At no point during the entire MBBS curriculum are we taught how to communicate with patients, especially patients who are anxious and angry,” said Dr. Gurshankar. “This sometimes leads to a lack of sensitivity and communication break-downs,You never hear of quacks being attacked — they always manage to talk to and convince patients,” he says.
“Overwork, frustration and a general ethos that the patient is a supplicant are some of the factors that make most doctors rude, says Dr. George, adding, “but doctors must remember that the poor have nowhere else to go”.
State's response
State Health Secretary J. Radhakrishnan said that the government had a zero-tolerance policy towards attacks, adding that enhanced security measures such as CCTV cameras and security audit committees at government hospitals would be implemented. “But we are also looking at grief counselling for patients at hospitals. The government is also looking at playing a more active role in placing doctors from the regular State health pool in Corporation areas to serve in neighbourhood clinics in order to reduce the burden on tertiary institutions,” he said.
