Flaws in our medical system and uncertainty surrounding the security of medical professionals call for concrete measures to bring back trust among doctors and patients
Recently, Maharashtra witnessed one of the worst healthcare crisis when 60 per cent of resident doctors across the state went on a strike. The strike was led by Maharashtra Association of Resident Doctors (MARD) in order to raise their voices against the rising incidences of violence against doctors and medical establishment. The strike lasted for five days affecting around 40 hospitals in Mumbai alone, resulting in a serious resource crunch that caused severe disruption to healthcare services. The most affected units in the state were the emergency health services, surgeries, post-operative care departments, ICUs and OPD services. As per Brihanmumbai Municipal Corporation’s (BMC) report on March 24 , 2017, 135 patients died due to lack of availability of emergency services in three BMC hospitals in Mumbai. The worst hit were patients coming from the lower socioeconomic strata who lined up outside government hospitals across the state waiting to be treated. Owing to the crisis situation, the Maharashtra government and the Bombay High Court had come down heavily on the doctors and had threatened them to be suspended or terminated from their services.
In a press conference, Maharashtra CM, Devendra Fadnavis, gave a legislative warning to the doctors and asked them to resume work immediatel., He also said that he failed to understand the insensitive attitude of doctors of leaving patients to die. However, doctors were too perturbed to understand the damage that was caused due to the strike. Legal threat escalated the issue giving it a pan-India colour. Doctors from around 40 government hospitals, including RML, Lady Hardinge Medical College, Safdarjung Hospital stayed away from work, while those at AIIMS continued with their protest against assaults on doctors by wearing helmets at work. Even the Indian Medical Association (IMA) extended its support to the strike. They claimed that attacks on doctors have often resulted in serious injuries, half of which go unreported. According to the IMA, last year alone there have been over 50 cases of attacks on doctors reported while the government did nothing to resolve this issue and provide security to doctors. In a survey, the IMA found that over 75 per cent of doctors faced mental or physical violence at least once.
Doctors’ demand were as follows:
- Increase jail term of attackers from existing three years to seven years, under Doctors Protection Act, 2010
- No bail for accused for at least three months
- Form a medical committee to decide how serious a violation is
- Enact a strict law to prevent trespassing in hospital
- Consider it violation of law if a patient is accompanied by more than two relatives
- Suspend security personnel if they fail to prevent an assault on doctors
- Release funds to implement the law and appoint a brand ambassador to spread awareness for the safety and security of doctors
A number of private hospitals, including Sir Ganga Ram hospital also joined the strike in Delhi. Apart from the National Capital Region (NCR), junior doctors from the Guwahati Medical College Hospital, also extended support to their colleagues in Maharashtra by wearing helmets in the hospital.
Ironically, this issue divided industry opinion into two viewpoints- one in support of the strike and the others refuting the strike.
Some thoughts shared…
Dr Prateek Rathi, Fellow Member Post Graduate Program In Public Policy Management IIM, Bangalore and Special officer, ESIC Maharashtra, opines, “Though the government acted swiftly and condemned the attacks on doctors as well as assured all possible measures to curb such incidents, the assurance could not satisfy the agitating doctors. There is a huge trust deficit. The argument made by the striking resident doctors was that they have received such assurance in the past from the government and there has been a High Court order to that effect but there has been no change in ground realities. On the contrary, such incidents of attacks on doctors, vandalism in hospitals, assault, verbal abuse etc., showed a substantial increase in recent months. The striking doctors were also of the view that the conviction rate of these assault cases is almost negligible and the law made in this regard is toothless”.
Presenting a counter argument on the same, Dr Kunal Saha, President, People for Better Treatment (PBT), Consultant & Adjunct Professor, Columbus, Ohio, USA says, “We never condone physical attacks on doctors or hospital vandalism on any ground, even in the event of a genuine case of medical negligence. The medical community will have to try harder to realise why an otherwise peace-loving and law-abiding citizen suddenly lose control after seeing his loved one dying from real or perceived “medical negligence” and take law into his own hands. It is because ordinary people in India find no reasonable path to get justice against the powerful doctor/ hospital. Doctor-only members in the medical council function primarily to shield their errant medical colleagues without caring for the pain and suffering of the ordinary patients. Finding medical justice in the court of law is also a seemingly impossible task for an ordinary man in India in the absence of any supporting opinions from another doctor. Until the medical fraternity can restore public trust on doctors and medical councils are transformed to provide equitable justice to the victims of genuine medical negligence, doctor bashing and hospital vandalism are not likely to end in India.”
Dr Suleman Merchant, Dean, Lokmanya Tilak Municipal Medical College and Hospital informed that the matter could have been handled in better way. He said, “Resident doctors are the backbone of public health delivery and their security is vital. However, disruption of healthcare services is an immoral act. The government needs to create a conducive learning environment for these doctors as they are the future of our healthcare sector. We talk about retaining talent in healthcare, how can we do so if our medical colleges do not have an encouraging learning environment?” he questioned.
Further, he updated that the court has been observant of this issue and has recommended the government to set up a committee to inspect the security services at government hospitals across the state.
What happens after the strike?
Nevertheless, the strike came to its end when the Bombay High Court took cognizance of this issue and directed the government as well as hospital administrations to provide at least 500 security guards in these state hospitals, including four hospitals in Mumbai, by April 5 and the remaining 600 by April 15. The court also mentioned that the court would be monitoring the physical security and other issues within these hospitals every 15 days.
This is one part of this story. What happens after the strike is over?
Dr Vijay Satbir Singh, Additional Chief Secretary, Health, Government of Maharashtra, informs, “The state government has taken the issue of attacks on doctors very seriously. Already, Chief Minister Devendra Fadnavis has made it clear that security for doctors would be beefed up. We are strengthening the security system in the government hospitals by recruiting more security officials. We are also planning to form a team under IPS officer who can work over the security arrangements of the government hospitals and medical colleges. I don’t know how far it will be of help, but we are putting in our sincere efforts. Moreover, we are installing CCTV cameras, so that violence against doctors can be curbed.”
Until April 15, 2017 the inspection had not began and only 330 security guards were deputed at these four hospitals, informed a trusted source from a government hospital in Mumbai who did not wish to be quoted. He also informed about a growing unionism among resident doctors, which has been supported by politicians in order to fulfil their political agendas.
When Express Healthcare approached the Public Health Department and the Directorate of Medical Education and Research, we were confirmed that the inspection process has begun recently and has picked momentum. Dr Pravin Shingare, Director Medical Education and Research, Government of Maharashtra informed that until 26, April, 2017 around 16 hospital across Maharashtra were examined and the security strength was increased to about 1100 guards. “We have begun our inspection process and feedback on the same is that the security still needs to be heightened at government hospitals,” disclosed Dr Shingare.
If we carefully analyse the vulnerability of this issue, it will be clear that the issue continues to remain unaddressed. Violence against doctors, nurses and medical establishments continue to exist and more so trust among patients and relatives for doctor continues to decline.
Why are medical professionals being attacked so often? Why is doctor striking a frequent phenomenon these days? Why are private hospitals being lashed out for commercialisation of services? Why is the number of medical negligence cases increasing in India? And most importantly, why are patients loosing trust in the most trusted profession called – medicine?
Several questions still remain unanswered as the entire focus is shifted on taking sides. Whether the doctor fraternity is right to go on strikes in order to demand protection or whether the agitation from patients and relatives is justified? Also, has this entire issued been handled in the right manner?
Both sides have their arguement and counter arguments to validate their point of view. What’s more important is to understand the ways and means to build trust between the medical fraternity and patients.
Measures suggested
Explains Dr Rathi, “There is a broad consensus that the cases of assault against doctors is on rise and has to be tackled with a firm hand. The question remains in regards to the instrumentality for such action. The issue could be handled by having some short-term solutions and a long term vision to improve the health system. Short-term solutions can be by having a more stringent law for such assaults, making in non-bailable, punishing the guilty by a fast track justice system, which acts as a deterrent for future such action and other measures like having adequate security measures; security guards, CCTV camera, entry of limited relatives with the patients and alarm system. But all of the above are short term and myopic measures. If we want to solve this problem, substantial and significant measures need to be taken on the policy front which will get to the root of the problem and minimise such attacks. The philosophy of the measures should be to fulfill the patient’s aspirations, his expectations, minimising his out of pocket expenditure and avoiding any delays in quality treatment.”
He further lists down some of the measures to resolve this issue in the long run:
- Increasing the healthcare budgets ( Government spending on healthcare in India is hardly 1.2 per cent of GDP)
- Improving the healthcare infrastructure.
- Increasing the human resources in the health sector.
- Use of technology to improve satisfaction and convenience of patients and also bringing efficiency in the system.
- Involving patients in the decision making process through various platforms (As proposed in the National Health Policy 2017) , making the Health Systems patient centric, with the moto No decision about me without involving me.
And how will these suggestions be helpful?
Increased health spending will ensure better services if the money invested is utilised in strengthening public health, which means increased access to healthcare services, added infrastructure, additional manpower to serve patients, less waiting time for patients and better outcomes. However, these need to be monitored on a regular basis. But will this build trust among patients and the medical professionals? Can building a healthy communication line between doctors-patients-relatives be fruitful?
In a recent survey conducted by IMA on patient satisfaction and their response, the organisation found that of the 1,246 patients they interviewed, 70.4 per cent of them expect their doctors to tell their patients about themselves, 90.1 per cent want doctors to listen to them in great detail during the first consultation, 80.4 per cent want the doctor to explain in detail about the drugs, investigations and the treatment, and 39.4 per cent expect the doctor to say ‘thank you’ to them.
This indicates that communication between doctors-patients-relatives is key to effective healthcare delivery. Indeed, it is the most important element that has been ignored to a large extend.
Dr Merchant also emphasises on the importance of building a healthy communication line. He informs that at Lokmanya Tilak Municipal Medical College and Hospital they have been constantly training junior doctors on effective doctor-patient communication. They also follow a strict rule that in an event of death of a pateint only senior doctors would break the news to the realatives. This is done with the understanding that senior doctors would be able to answer the questions raised by patient relatives in an appropriate manner. Morever, under the guidance of senior doctors, the resident doctors can also get trained in patient communication.
He also speaks on the need to provide good hostel facilities, appropriate training centres and good working conditions for resident doctors. Additionally, he says that about the need to make the resident doctors work in shifts, this will give them enough time to rest as well as for training purpose.
Time to change
Another aspect to solve this issue is positive reinforcement of the good work done by medical professionals. Dr Aniruddha Malpani, an Angel Investor of Malpani Ventures and a Funder funding frugal innovation in India and strong advocate of information therapy has come with Good Doctors website. This is a website where patients can share stories of their positive interactions with doctors. Dr Malpani in his post writes that the idea behind developing this website is to inject positivity within the healthcare industry, especially the doctor fraternity. This exercise will hopefully inspire other doctors as well, who can emulate these best practices.
Similarly, social media blogs such as Think Change India and Being Indian posts stories of extraordinary examples of selfless service by doctors working in rural India. One such example is the story of Dr Ravindra Kolhe and Dr Smita Kolhe. The couple has been working in a tribal village of Melghat district in Maharashtra for several years. They have improved health outcomes in the area and helped the villagers gain access to electricity, roads and primary health centres. What’s more interesting of their journey is that they have transformed the Poorest Regions of Mahrashtra into a ‘Farmer
Suicide-Free Zone’ which even the government with all its efforts could not subdue.
This unknown story was brought to light with the help of social media. Moreover, the good news is that now the government has taken special interest in the district and has committed to convert this region into a digitally connected village. Microsoft has partnered with the government to help achieve this dream.
Initiative like these need to be taken up on a large scale to bring back the trust among patients.
At the end, Dr Saha demands for a complete overhaul of the medical system in India. In his article in the British Journal he writes, “Unlike in the West, it is a common knowledge today that there are virtually no checks and balances for doctors in India. The Medical Council of India (MCI), highest medical regulatory authority in the country, has become a “den of corruption” as held by the Delhi High Court. The number of disciplinary action against doctors taken by the medical councils/ boards for medical and/ or ethical violation is virtually non-existent in India when compared to developed countries like UK or USA. Unlike in the Western countries, doctors in India are always reluctant to testify against errant medical colleagues making cases involving medical negligence almost impossible to win in the court of law. A complete overhaul of the entire medical regulatory system is necessary to restore public trust on the medical system and bring an end to the unfortunate incidence of doctor bashing in India”.
A complete overhaul at this point of time is certainly not possible in India, especially in times when the country is still struggling to provide equitable access to healthcare for all. However, a change is necessary. We still do not have concrete solutions on the government’s front to resolve this issue. Nevertheless, every step taken in this direction will be fruitful if executed with the right intent. Moreover as per government sources, the issue will be further discussed in court and a concrete solution can be expected in the near future.
(With inputs from Prathiba Raju)
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