Physical as well as verbal violence against healthcare institutes is regularly reported from some State or the other in India. On a few occasions, it becomes so violent that the crowd may indulge in arson of the hospital and destroy the costly equipment as well. Though the exact figures are not readily available, such skirmishes may be nearly thousand or so in a year. According to an expert, an ongoing study of the Indian Medical Association (IMA) revealed that over 75% of doctors have faced violence at the work place. In the recent past, in Sassoon Hospital at Pune, one local Member of the Corporation allegedly assaulted the resident doctor when she noticed that the latter did not attend a patient on priority. As a reaction, the resident doctors association threatened to proceed on strike unless the person who assaulted, was arrested and case was registered under the provisions of Prevention of Violence against doctors Act. Similar incidents keep on being reported regularly either from public hospitals as well as private clinics. In few incidents the violence has even taken the toll of the doctor or usually results in huge property damage. During the Corona pandemic situation, several incidents of assault was reported against the health care workers tin various parts of the country. Following these, Union Health Minister had immediately announced that Central Act to prevent such violence would be promulgated soon, which would have stringent provisions to prevent recurrence of such incidents.
Violence against doctors is not restricted only to India. Recently in US, Dr. Michael Davidson, forty-four year old Director of endovascular cardiac surgery at Brigham and Women’s Hospital and father of three young children (Aged 9, 7 and 2) was killed in cold blood by gunman Stephen Pasceri. Dr. Davidson had treated Pasceri’s seventy-nine-year-old mother and apparently there had been some complication and she had died. Pasceri, blaming her physician walked into the hospital, sought Dr. Davidson out and shot him in cold blood in the very clinic where he used to treat patients. His friends and colleagues rushed him to the operating room, but unfortunately he succumbed to his injuries. Similarly, violence against nurses in US is also commonplace. According to a study, nearly million attacks against healthcare institutes are reported in China per year. Many of these are so violent that the crowd has lynched the doctors as well as nurses.
In order to prevent such violence, many states in India including Maharashtra, Andhra Pradesh, Kerala, Punjab, and Delhi have enacted legal provisions in the last few years. As per this Act, violence means activities causing any harm, injury or endangering the life or intimidation, obstruction or hindrance to any healthcare service person in discharge of duty in the healthcare service institution or damage or loss to property in healthcare service institution. The healthcare service persons includes registered medical practitioners working in healthcare institutions (including those having provisional registration), registered nurses, medical students, nursing students, para-medical workers employed and working in medical service institutions. The Act provides stringent punishment including imprisonment and fine as well as double the amount of damage as compensation to the institute. These stringent legal provisions do not permit bail to the accused. The Act also provides forum for the patients to lodge criminal complaint against the doctors if the patients feel aggrieved. Available details do not indicate that the Act has deterred the attackers so far. Hardly any person appears to have been convicted under these provisions. According to Dr Neeraj Nagpal, Medico Legal Action group, “only a central Act on lines similar to state Act will not give the desired results unless changes are also made in Indian Penal Code.” In his opinion, the issue of arrest of doctors under section 304 A of IPC is a part of the problem of violence against doctors because invariably cross FIRs are registered by patient party as well as doctor which results in inevitable compromise.
In public general hospitals, violence is usually targeted against the young resident doctors, who are on the starting point of their medical career. Analysis of these incidents indicates; a) violent incidents happen at places where there is emergency situation, b) senior doctors were not available and as such these emergencies were left to be attended by young and inexperienced resident doctors, c) resident doctors failed to appreciate gravity of the medical emergency and as such valuable time in saving the patient was lost, d) medical equipment either are not available or if available not functioning since long and no efforts were made to keep these in functional and up to date position. In few incidents resident doctors were reported to be under influence of alcohol and allegedly misbehaved with the relatives. In view of these violent incidents taking place repeatedly, and consequently resulting in strikes by resident doctors, I was given the task of devising a scheme for about twenty five medical colleges-cum- hospitals run by The State Government of Maharashtra and Mumbai Corporation. With the help of Medical Superintendents of these hospitals, we identified places where the trouble starts. It was noticed, at places where, emergency patients are treated, and when in few occasions, the patient dies, the trouble starts. Hence, provision was made to deploy small armed contingent, equipped with dedicated communication equipment so that they can call for additional assistance at short notice. These places were brought under CCTV cameras, and access control was monitored and restricted to patient and not more than two relatives. As a result of these measures, which were reviewed from time to time, the situation improved and the resident doctors expressed their satisfaction, saying that they were able to focus on treatment better.
In private hospitals, the healthcare workers feel the problem gets aggravated as invariably, the relatives and friends of the patient who might have died, approach locally elected politicians, who in turn demands action against the healthcare workers.
Relatives and friends allege that the healthcare workers including doctors and nurses show total neglect towards attending the patient in emergency. They accuse doctors of fleecing the patients by forcing them to undergo several tests, which may or may not be relevant. On certain occasions, according to the relatives, the hospital authorities do not permit removal of the dead body until the charges are paid in totality. To counter the situation, many doctors demand that they should be provided with license to possess a weapon.
Analysis of the problem and gravity of the situation indicates that the issue of violence against healthcare institutes is not simple to be tackled simply by possessing arms or legal enactment. It calls for determined efforts by everyone including hospital authorities and healthcare workers. Absence of these measures results in severe damage including gutting of the costly infrastructure, injuries to healthcare workers, depression among healthcare workers and severe impact on reputation of the hospital.
The reasons for violence in healthcare institutes may be sporadic as well as due to absence of adequate training, lack of infrastructure as well as absence of any policy to tackle such incidents and inadequate policy to prevent these. The emphasis should be to take all measures to ensure that such violent incidents should not take place at all. The foremost thing in this regard is to arrange for initial as well as mid-term training by experts on regular basis. The training modules should be addressing each level separately right from the billing clerk, receptionist, nurses, ward boys, technicians to resident doctors or senior most subject experts. The modules should address specific requirements and be provided by persons two ranks higher in the same hierarchy and not by someone who is not related to the field. The focus should be on Dos and Don’ts and tips which can be practically implemented. It is advisable to have case studies and participants are encouraged to discuss these in the presence of experts to reach proper conclusions. Fortunately now experts in the field have prepared ‘case studies bank’ and it can be easily accessed from www.http://ciilm.com/case-studies/.Training modules can be made more effective if these are delivered through audio visuals, having actual videos on the subject.
Secondly it is imperative that all those who run healthcare institutes need to consider all aspects about security right from the time of establishing the institute and upgrade it from time to time as newer technology becomes available. Domain experts in security need to be consulted as things which might appear to be simple may not have been noticed by others. A few things which may be mentioned include separate entry and exit gates, separate gates for the technicians and staff as well as for the doctors. Access control is an important aspect to avoid stampede as well as to prevent intruders. Installation of CCTV cameras with recording facility for a week and night vision facility is critical. Along with the same, there should be adequate trained staff to monitor these and they need to be equipped with instant communication facility to inform law enforcing authorities about the developing situation and directions to prevent further catastrophe. Adequate facility and restricting the number of visitors and persons accompanying the patients is critical to provide tension free atmosphere for the doctors, staff as well as for the recovery of the patients.
Documentation of every aberration as well as various incidents is an important requirement which is generally neglected. If there is a record of the past incidents, one can see the pattern likely to emerge and prevent or cure distorted behavior in time. These recordings need to be shown to the staff from time to time to make them aware what went wrong and how it was possible to avoid the same. Moreover there is a tendency not to report the incidents to law enforcing agencies to avoid approaching the police or to remain present in court to narrate the course of events before the magistrate. Very few are aware that evidence can be given through video conferencing even if the witness or complainant is away at a distant place. In fact the single most important reason for non-conviction in criminal cases involving violence against healthcare institutes is apathy of the complainants and refusal to appear before the magistrates when called to deposit. The complainant can even demand protection for him as well as witnesses by requesting the court.
According to Dr. Sancheti, leading orthopedist at Pune, mistrust between patients and doctors is the root cause of violence against the health care workers. In his long fifty years of practice, he never faced any violent incident, as he always used to explain each and every step being taken to patients and his relatives. According to Dr. Sanjay Gupte, the journey to recovery should be a co-journey of the patient and doctor. Dr. Shrikant Kelkar, Ophthalmic has done pioneering work in developing training modules for health workers and implements the same in several hospitals. Dr, Mohan Agashe, psychiatrist states, ‘when there is lack of understanding; it gives rise to legal enactments. Intelligence and money alone does not solve the problem. Healthcare workers must have intelligence as well as empathy for the patients.’ He has played a leading role in a drama prepared at his instance on this very subject.
US Department of Labor, Organizational Safety and Healthcare facilities’ Roadmap for healthcare facilities has published Guidelines for Prevention of Violence in Healthcare and is available at www.osha.gov/SLTC/ workplaceviolence. Briefly, these include: i) management commitment, ii) employee participation, iii) worksite analysis and hazard identification, iv) hazard prevention and control, v) safety and health training and vi) record keeping and program evaluation.
Realizing the gravity of the issue, training modules should be designed for healthcare workers including doctors, nurses as well as law enforcing agencies such as police, judicial officers and prosecutors highlighting case studies of such violence. The Indian Medical Association (IMA) and their local Chapters should come up with standard operating procedures for establishing any healthcare facility in public as well as private field. Constant review and rehearsals should be made at least once in six months to find out aberrations and take corrective actions. International best practices should be made available as case studies for continuous guidance.
At present, IMA has suggested formation of ‘crisis management committee at each Taluka or District level. The committee shall include doctors, social workers, legal personalities, politicians, press reporters etc. The committee members may meet the police officers and request them for complete investigation of the incident and to avoid prosecution of the healthcare worker including doctor till the guilt is proved. The committee can also request the press reporters not to give unnecessary publicity to such cases.’
The Supreme Court in “Martin D’Souza vs Mohammed Isfaq” case has issued stern warning to police officers against any harassment including arrest against doctors unless parameter laid down in Jacob Mathew’s case are followed. Recently, Ministry of Transport, Government of India, has introduced directives to health workers not to harass the Good Samaritans who come forward to inform about the injuries to anybody and made it mandatory that the patient be treated on priority and his life be saved. Police are also directed not to suspect the persons who inform of such incidents and provide priority to save the life of the injured.
Strict adherence of these directives and guidelines by all concerned as well as introspection by healthcare workers and improvement of their practices and monitoring of these periodically alone can create visible impact against such violence.
To tackle such incidents of violence, comprehensively, Core India Institute of Legal Medicine (CIILM) in association with retired police officers in Maharashtra has launched a unique program in the form of quick response teams. These well trained retired police officers who have necessary skill in crowd controlling, mob psychology and excellent rapport with local police stations have formed several such quick response teams and working as trainers to health workers as well as defusing critical situations through their timely interventions. It would be imperative that every private hospital should join in these efforts in promoting their welfare and acquiring peace of mind.
To conclude, I would say having enactment to prevent violence, per se, does not guarantee absence of violence. Involvement from all stake holders, preparedness to meet the contingencies, well laid out policy with standard operating procedures (SOP), frequent rehearsals of the drill, coordination with all stake holders including law enforcement agencies even when there is no crisis are some of the tips which may help healthcare institutes to avoid and overcome incidents of violence if any. If the Doctors adopt more sympathetic attitude towards the patients, and explain the circumstances properly, many adverse situations can be avoided.
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Author is IPS & Director General of Police (Retired), Maharashtra State.
