Reports of 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. Ghastly rape and
murder of resident doctor in State-run R.G. Kar hospital in Kolkata is the most
gruesome of these. Few years ago, 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
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Prevention of Violence against doctors Act. Similar incidents keep on being
reported regularly 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 in various parts of the
country. Following these, Union Health Minister had promised that Central Act to
prevent such violence would be promulgated soon, which would have stringent
provisions to prevent recurrence of such incidents. The same has however has not
seen the light of the day.
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,
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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, almost twenty-nine 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
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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-cum5
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 from Maharashtra Security
Force (MSF), equipped with proper training, 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. These MSF personnel were used for
surveillance, running control room activities and as a quick response team. If
necessary, they would seek help from local police at short notice. 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. This system is working effectively in all Medical
Colleges in Maharashtra. In addition, following measures were also initiated:
Tele-medicine facility for prisoners & hospitals
Medical professionals and health workers in public hospitals and
medical colleges remained under constant threat from dangerous prisoners who
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are frequently referred to these hospitals. These prisoners threaten the medicos
to permit their long stay in hospitals under some pretext or the other. They
sometimes stab them or abuse them profusely, causing them great mental and
physical stress.
While working as Advisor in Medical Education Department in 2016-
17, I implemented following scheme. MHA has provided video link in prisons for
connecting with district courts. Ministry of Health has provided video link in
medical colleges and district hospitals for tele-medicine facility. There is a
provision of a doctor in every prison. I asked this doctor to list out the grievances
of prisoners who desired to be referred to specialist doctors. These details were
communicated to specialists by email in advance. After going through the same,
on a scheduled day and time the prisoner was provided video counselling by the
specialist and the prison doctor was given the list of medicines and advice which
was implemented in prison. A weekly time table was announced in advance to
facilitate all concerned.
This system worked very effectively from 2017 till 2020 in all prisons
in Maharashtra. More than three thousand prisoners took advantage of the same
and expressed their complete satisfaction. There is a need to implement the same
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in all hospitals and prisons and save the doctors from the threats of prisoners. The
scheme was implemented without any additional cost to the government.
Another major cause of trouble in public hospitals is the demand
from relatives not to conduct post-mortem of dead person. The same can be
avoided through digital/virtual post -mortem facility which is implemented by
AIIMS, New Delhi. Many advanced countries also implement this facility. This
ensures there are no complaints of fraud or interference in findings. Moreover,
findings can be used at any time with accuracy even though, the body might have
been disposed of.
Private hospitals
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
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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
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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/casestudies/.
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
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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
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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 cojourney
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)
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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
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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
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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.
