Attack on doctors: Will Delhi govt’s new order against violence in hospitals change things?

Astha Saxena
At Lok Nayak, one of the Delhi government's biggest hospitals. It has around 1,500 doctors to provide treatment to 7,000 patients on a daily basis; (below) at a protest by AIIMS doctors last year, following an assault on a colleague (Praveen Khanna)

At Pitampura's Bhagwan Mahavir Hospital, a patient was rushed to the emergency ward four years ago. As doctors turned their attention to him, his relatives demanded that they be allowed into the ward. An argument ensued, and ended with the relatives raining blows on the doctor. Within 16 hours, another case was reported from Babu Jagjivan Ram Memorial Hospital in Jahangirpuri.

The two incidents had pushed 20,000 resident doctors at government hospitals to launch a strike, demanding improved security inside hospitals.

The protest continued for over two days, forcing authorities to invoke the Essential Services Maintenance Act (ESMA) in Delhi. For the first time then, an institutional FIR was lodged by a Delhi government hospital under the Medicare Service Personnel and Medicare Service Institutions (Prevention of Violence and Damage to Property) Act, 2008, effectively giving the backing of the institution and the government to doctors assaulted on the job.

Since 2017, at least 10 such cases have been reported in the capital, but no arrest has been made so far. Frustrated, doctors have gone on strike 11 times in the last two years. But even as doctors pushed for registration of institutional FIRs in cases of assault, it was not mandatory until last week, when the Delhi government came out with a directive stating that a hospital must file an FIR in such cases, instead of expecting a doctor to pursue the case alone.

"Institutional FIRs are registered in many cases but it was never mandatory for hospitals to do so. Private hospitals might have been doing it but many government hospitals were not aware of it," said Sanjeev Khirwar, health secretary, Delhi government. The recent order means doctors need not make rounds of police stations or courts; the medical institute will take responsibility of pursuing the case.

"It will be incumbent on the medical superintendent/director of the institution to ensure an FIR is lodged in such cases promptly by the hospital or institution concerned, rather than insisting on the hospital staff concerned to lodge an FIR," states the order.

The trigger

In January, a resident doctor at Safdarjung Hospital was manhandled, allegedly by a Delhi Police head constable's son who had come for treatment. The accused is out on bail.

Earlier this month, a paediatric surgeon at Chacha Nehru Bal Chikitsalaya was roughed up, allegedly by a relative, when he asked the family to get a diaper for the baby. "The baby had urinated on the doctor during the examination, and he asked the family to get a diaper. The family refused and a fight broke out," said a colleague.

A recent meta-analysis study on violence against doctors, published on April 9 in the Indian Journal of Psychiatry, found that women and younger doctors face more physical violence as compared to others in the profession. (Representational)

Lack of infrastructure, shortage of doctors, long waiting times, dissatisfaction with nursing care and denial of hospital admission due to limited availability of beds are among the reasons that lead to altercations, doctors and hospital officials said.

Taking suo motu cognizance of increasing incidents of violence against doctors in government hospitals, the Delhi High Court had in 2017 called for a status report from the Centre, the Delhi government, the Indian Medical Association (IMA) and the AIIMS Resident Doctors' Association on security provisions for doctors, nurses and staff.

A bench of Acting Chief Justice Gita Mittal and Justice Anu Malhotra had also directed the Centre and Delhi government to furnish details of operationalisation of all public hospitals and increase in their patient load.

"A doctor is harassed and assaulted by relatives of patients coming to the hospital for treatment… He/she is slapped, kicked and abused for providing treatment… Is this what we get after spending years in medical education? There should be a counsellor posted in the emergency ward of the hospital," said Sumedh Sandanshiv, president of the Federation of Resident Doctors' Association (FORDA), an umbrella body of resident doctors across the country.

Delhi Police PRO, DCP (New Delhi) Madhur Verma, however insisted that "at hospitals, the cases that come up aren't very violent in nature". "Also, most big hospitals have their own security personnel in place. The cases are usually compoundable, and get settled between the two parties," he said.

Soft targets

A recent meta-analysis study on violence against doctors, published on April 9 in the Indian Journal of Psychiatry, found that women and younger doctors face more physical violence as compared to others in the profession. The analysis further claimed that the department of obstetrics and gynaecology reported the highest rates of violence, followed by the medicine department with allied specialties, and surgery with allied specialties.

Last week, a female resident doctor at Ram Manohar Lohia (RML) Hospital's department of medicine was beaten up by a family of a patient when she asked them to "lower their voice".

"Initially, they used foul language with my male colleague, but one of them got physical with me when I asked them to lower their voice. There were other patients in the ward and they were sleeping. A woman came forward and pushed me," alleged Dr Aayushi Singhal.
Dr Singhal recalls another incident where one of her seniors was slapped by attendants of a patient who had died at the hospital. "They hold doctors responsible for even a natural death. Attendants feel we will not speak about it and continue to harass us," she said.

The analysis found that in the emergency department, almost 100% doctors reported some kind of verbal violence. "Female doctors are considered soft targets. During our research, we found that the department of obstetrics and gynaecology is most vulnerable. It is evident that doctors face a higher risk of workplace violence as compared to other professions. Almost 100% doctors have faced violence once in their lives," said Dr Jateen Ukrani, consultant psychiatrist at PsyCare Neuropsychiatry Centre and a researcher of the study.

According to the IMA, 75% doctors have faced some kind of violence at work, which ranges from telephonic threats, intimidation, verbal abuse, physical but non-injurious assault to physical assault causing simple or grievous injury, murder, vandalism and arson.

Lack of infrastructure, shortage of doctors, long waiting times, dissatisfaction with nursing care and denial of hospital admission due to limited availability of beds are among the reasons that lead to altercations, doctors and hospital officials said. (Representational)

"In another study, more than 70% of doctors said that while treating patients, their mind is distracted towards their own safety. This is where we have failed. Such cases not only physically harm but also leave a mark on the mental state of the person," said Dr
K K Aggarwal, former IMA national president.

A study carried out on violence against doctors in tertiary-care hospitals in the Indian Journal of Surgery stated that medical professionals who faced violence have been known to develop psychological issues such as depression, insomnia, post-traumatic stress, fear and anxiety, leading to absenteeism.

Demand-supply gap

A recent study conducted by the Centre for Disease Dynamics, Economics & Policy (CDDEP) in the US stated that in India, there is one government doctor for every 10,189 people (the World Health Organisation recommends a ratio of 1:1,000), or there is a deficit of 6,00,000 doctors. The nurse:patient ratio is 1:483, implying a shortage of two million nurses.

One of Delhi government's biggest hospitals, Lok Nayak, has around 1,500 doctors to provide treatment to 7,000 patients who flock to the hospital on a daily basis. The hospital has around 300 security guards posted to maintain order. Guards are deployed by a private agency, hired by government hospitals on a contractual basis. As of now, no hospital has reported a shortage of guards.

"Confrontation is never a solution, we believe in prevention. We need more doctors and nurses to treat around 7,000 patients on a daily basis. The hiring process is always on, but it takes time. We are somehow managing the patient load at the out-patient department (OPD), but the problem is now with drug distribution. Shortage of drugs in other hospitals puts the pressure on us," said Dr Kishore Singh, medical director of Lok Nayak Hospital.

The RML Hospital administration has been organising training for new recruits to educate them about behavioural patterns and how one should deal with patients in distress. "Ours is a tertiary hospital and it doesn't have a defined area. From fever to cancer care, patients visit us for all diseases. This is where the problem is. People should understand the importance of a tertiary-care hospital," said Dr VK Tiwari, medical superintendent of RML Hospital.

A health system is pided into three parts - primary, secondary and tertiary care. Primary healthcare is provided through a network of sub-centres and primary health centres in rural areas, and through health posts and family welfare centres in urban areas. Patients from primary healthcare units are referred to specialists in higher hospitals for treatment - which is the secondary unit.
Under tertiary healthcare comes hospitals in which specialised consultative care is provided, usually on referral from primary and secondary units.

The five Delhi government hospitals that report a high incidence of violence are Lok Nayak, Guru Tegh Bahadur, Baba Saheb Ambedkar, Deen Dayal Upadhyay and Sanjay Gandhi Memorial hospitals.

"Most of these hospitals are tertiary care but patients do not understand that. It is important to pide patients between primary, secondary and tertiary care hospitals. Authorities have to take steps to manage patients. Doctors are overworked, and many times they get frustrated too. Most of the load is on these referral hospitals. If every hospital is strengthened at its own level and offers basic treatment and medicine, most of the problem will be solved," said Dr Pankaj Solanki, former president of FORDA.

Patients visiting government hospitals, however, complain that doctors are rude at times. Sunita Rani, who was waiting at Maharishi Valmiki Hospital, said: "We feel scared to ask about our illness or medication… they are always in a bad mood and hardly give any extra time. As we cannot afford a private hospital, we have become used to this behaviour."

Ram Kumar, who was waiting at Lok Nayak Hospital's casualty ward on Saturday, said: "Doctors are giving enough time today as it is a weekend. Most of the time, however, they are in a hurry. We just get a minute to explain our problem and are forced to leave the room."
On the issues raised by doctors and patients, Khirwar said: "We are continuously trying to fill the gaps by building more hospitals, increasing the number of beds and improving facilities. Hiring of doctors is done by UPSC and DSSSB, which is a tedious process."

Frustrated by assaults, doctors in Delhi have gone on strike 11 times in the last two years. (Representational)

Way forward

Experts feel training resident doctors in effective communication and alternative methods of resolving conflicts could also help address the issue, but only if accompanied by organisational and environmental safety measures.

"Filing an institutional FIR is one element, but we need to address the larger issue. While providing better safety and security is important, we should also address the underlying factors such as overcrowding, lack of resources, behaviour of frontline service providers and how they should handle cases sympathetically. Violence is not acceptable," said Dr Anant Bhan, researcher, Bioethics, Global Health and Health Policy.

He also stressed on the need to have a policy in place for such cases. "The government must ask institutions to have a standard operating procedure explaining do's and don'ts in cases of violence. A nodal officer can be appointed and regular training should be conducted for staff," he added.

With an aim to bring down stress levels, a three-day workshop was organised in March for resident doctors and nursing staff at AIIMS. The workshop included meditation classes. "We want to make it part of the weekly schedule by allocating a special meditation room. These activities are extremely important for medical staff to de-stress," said Dr Amrinder Singh Malhi, RDA president, AIIMS.

What hospitals can do

If violence occurs despite taking all precautions, it is important for institutions to protect the doctors involved, but at the same time not meet anger with anger. A standard operating procedure may be developed for such situations like Code Purple, used worldwide to alert medical staff to potential violence. It includes the following measures:

* An announcement on the hospital's public address system, giving the exact location of violence to disseminate information. A distinct siren may also be installed to alert everyone

* Security staff to respond immediately and assist, if needed. All staff, except that of ICU and OTs, to come to aid and form a human chain around professional under threat. Personnel in the chain need to remain calm, avoid any altercation that may escalate the situation

* A senior member of staff not involved in treatment may try to communicate with the patient's relatives and try de-escalating the situation

* Staff to practice restraint and not lose their control

* Announcement on PA system should be made once situation is under control

* Drill should be done every month in all medical establishments

This article first appeared in print on April 22, 2019 under the headline: 'Diagnosis: Critical'