Yet another chapter in the sickening saga of violence against doctors in India is coming to an end. It mostly ran a predictable course: junior doctors in a state-run hospital in Kolkata were attacked by the angry relatives of a patient who died there, junior doctors across West Bengal went on strike, outraged senior doctors paid lip service to their cause, medical associations went on a token strike, and there were calls for stricter laws and for increasing security for doctors. It was the usual narrative involving lumpen mobs, allegations of political instigation, unrealistic expectations from patients, overworked doctors, and calls for increased security, which included bizarre demands for bodyguards and even bouncers. Perhaps the only novelty was the rather knee-jerk and insensitive response by a Chief Minister suffering from a poll hangover, which seems to have acted as further provocation.
Will punitive action, new laws or increased security change this scenario? Will we never see an incident like this if such measures are taken? As someone who participated in a strike by junior doctors as long back as 1985 in response to an assault by a corporator in Mumbai and continues to witness such events in the public hospital where I work, I can only dismiss these as rhetorical questions. But is there something beyond this customary discourse that springs from the debris of such a fracas that we should recognise? In medical parlance, is there a disease that is producing these symptoms in recurring fashion? These are questions worth examining.
Examining the setting
The setting in which a majority of such incidents have taken place offer some clues. The most common scenario is that of a patient being brought to the casualty ward of a public hospital in a critical condition by family members or neighbours. If the patient does not survive, there is the reality or perception that treatment was not administered to him or her in time. The tipping point is when the staff in hospitals display insensitivity when they are questioned about delays. It is true that the emergency wards of India’s public hospitals are chaotic, disorganised and resemble conflict zones. While there are several factors that contribute to this, the complete absence of the globally recognised protocol of ‘triage’ is a big reason. Triage involves a rapid examination of a patient to determine whether he or she needs instant care, early care, or care that can wait. The absence of this protocol means that emergency wards are often occupied by patients with all sorts of minor injuries. Data from a study at our hospital showed that more than 90% of patients frequenting the casualty ward over a two-year period had minor injuries which could have been easily treated in a smaller setting. In India, when people go to the police with a complaint of an assault, they are advised to go to a government hospital even if they have very minor injuries, to record them to strengthen their legal case. All these patients come to the casualty ward adding to the crowd and the burden of the hospital staff. If the staff have to treat only 10% of the load of critical patients, they would do a much better job and perhaps even save lives.
The huge workload in large teaching hospitals in cities, such as in Kolkata’s Nil Ratan Sarkar Medical College and Hospital, is also the result of the poor capacity of suburban and rural hospitals to handle sick patients. This uneven scenario is due to excessive centralisation of funds, staff and equipment.
A growing chasm
A dangerous argument that is put forth in the aftermath of such attacks is that people’s expectations have increased. I am not sure what this means in a system where the bar has been set very low. Are people who see huge delays, rickety ambulances and lack of equipment or malfunctioning equipment not supposed to respond? Isn’t it possible that common citizens who see swanky private hospitals delivering quick, organised care wonder why they get such a raw deal? That they now realise that just putting an oxygen mask on an individual who is gasping for breath is not enough, a ventilator is needed? In other words, is the realisation that there is a more effective way of care, which the common man is being denied because of his or her inability to pay for it, the cause for anger which periodically explodes in a perverse manner?
One reason why laws are unlikely to work is that patients and their families or friends do not come to a hospital with a plan to attack. Attacks are impulsive responses in an emotional moment. What may work instead is softening the blow on families by examining how, where and who delivered the bad news to them. If family members in moments of intense grief are now regularly donating organs to their near and dear ones, there must be something that we are doing right. This is happening probably because the news is broken to them in a planned and organised manner by a trained transplant coordinator, usually in the sanitised setting of an intensive care unit of a large private hospital.
As members of a profession who have been trained in the method of science, we can do better than imitate the impulsive, inappropriate responses of those who attack the first doctor in sight, as well as the political class. We can certainly do better than come up with ludicrous demands such as appointing bouncers or bodyguards in hospitals. Several structural and policy changes in the way India’s hospital systems work can reduce, if not eliminate, the perception that there is negligence in caring for patients. Medical associations who swing between fawning over politicians when they need favours to faux militancy after an incident, such as the one that took place in Kolkata, need to take the lead in demanding policy change.
In the heat of this debate it is worth remembering that in spite of being caught in the pincer of a tottering public health sector and an unaffordable private sector, a large majority of our patients show tremendous tolerance, resilience and trust in their interaction with us. We all deserve better.
Sanjay Nagral is a Mumbai-based surgeon