State of the Doctor-Patient Relationship in TN
India has a population of over 134 crore and a little less than ten lakh doctors. Of these, about one lakh doctors work at government hospitals.
In the next few minutes, I’d like to present a collection of stories and some facts from government hospitals and small private hospitals across Tamil Nadu. You’ll hear my voice and that of another senior doctor, and we will tell you about the sudden severing of trust between doctors and patients, possible reasons for escalating violence, and the way forward.
Listen to the story here:
Mapping the Rise of Violence Against Doctors
“Way back in the year 2009, a mob of relatives of one patient who died of septicaemia, you know, lots of bacteria in the bloodstream is called septicaemia. There is every chance of imminent death in that case. Relatives of the patient gheraoed, asked for post mortem... WhatsApp, Facebook, videos, media, everyone gathered and shared...General Surgeon, Rajaji Hospital, Madurai
According to a study in International Journal of Contemporary Medical Research, the Indian Medical Association suggests that up to 75% of doctors have faced some kind of violence at work, including telephonic threats, intimidation, verbal abuse, physical assault, murder, vandalism, and arson.
Medical professionals who have faced violence have higher susceptibility to psychological issues. Many have lost their clinics, sustained injuries, lost their lives, and also had their professional reputation tarnished due to these incidents.
It's pretty easy to find videos, photos, media reports of doctors being beaten up by the friends or relatives of patients. But as yet, there is no ready reckoner for the number of people booked under the Tamil Nadu Hospital Protection Act of 2008. Is this why the incidents of violence against doctors are on the rise?
Also Read : Why Violence Against Doctors Must Stop
The Catalyst for Violence
“Probably the patient’s attenders, relatives... might have gone through Google search. Didn’t understand fully about the diagnosis and treatment plan. Thinking that’s fine, they expect the doctor to toe their line. This is not possible in many of the cases. For example, a small wound may be there in the head, but inside, there could be a lot of problems. Even a small contusion in the brain stem might lead to the death of a patient. But it will not be visible outside. There would be a small aberration/wound in the scalp. But there will be intense injury to the brain stem and it would be lethal prognosis. So, for people expecting treatment for a small injury in the scalp, how can they accept that death is possible?”General Surgeon, Rajaji Hospital, Madurai
The 2008 Tamil Nadu Hospital Protection (TNHP) Act says that any person who commits, abets or incites any act of violence against the hospital or the staff is liable to serve 3-10 years in prison and may also be slapped with a fine for damage of property. But this in no way has ebbed the tide of violence, or mitigated the general feeling of distrust among people when it comes to doctors.
In 2012, in Chennai alone, there were four widely publicised incidents of violence against doctors at the government hospital. Last year in June, at the Stanley Hospital in Chennai, a duty doctor was slapped and manhandled because a patient screamed while being administered an injection. In August the same year, three people assaulted a duty doctor and a group of PGs who came to his rescue. A Primary Health Centre in Alanganallur, near Madurai, famous for the Jallikattu sport, was vandalised because the patient involved in a road accident had died.
In none of these cases were the arrests made under the TNHP Act.
Pop Culture and Doctors as Villains
But there has to be more to the growing violence and distrust. Doctors have been portrayed in a bad light in Tamil cinema for almost two decades now. Doctors who cover up medical negligence, apathetic doctors, greedy doctors, doctors who are all of the above... Right from 2002’s ‘Ramanaa’, to Shankar's ‘Indian’, to most recently, the actor Vijay’s ‘Mersal’, the medical community has been squarely targeted. Mostly, the premise is all about unnecessary diagnostic tests at exorbitant prices.
“Regarding investigation and all, of late, I could see extra investigations are written in the fear of anticipating legal problems. If you want to do a surgery, simple X-Ray (chest) and ECG are sufficient to assess the heart and the lungs of the patient. It’s enough. Now the doctors think, ‘The patient may go to court, and they might ask me why echo cardiogram and all have not been done to assess the heart condition.’ So the doctor will think, so, extra-investigation has to necessarily be written to avoid medico-legal problems. That is not written with the intention of making money out of it, but for fear of medico-legal problems. This was not at all done in the past.”General Surgeon, Rajaji Hospital, Madurai.
And by the past, he means before 1995, when the Supreme Court decreed that medical practitioners, like other service providers, were liable under the Consumer Protection Act of 1986. The Supreme Court’s intention was to speed up the resolution of cases of medical negligence, which would otherwise have taken much longer had they had to go the civil court way.
From Doctor-Patient to Customer-Service Provider
However, the ruling changed the doctor-patient relationship to a service provider-customer relationship. And suddenly, more money translated to better outcomes.
This had two long term effects; a breakdown of the doctor-patient trust. And the second,
“Every small clinic and small hospital will try to avoid taking or treating a complicated case. So every time a patient comes, if there’s even a 0.1% chance of needing higher treatment, definitely, they will refer the patient to a higher centre. They would be reluctant to treat the patient there. Immediately, they will refer the cases to the corporate setup where there is every facility for higher equipment and all, but which may not be required for the patient if he’s getting treated in a rural area. These problems mean they will refer each and everything to the small clinic setup. Naturally, the practice in the small clinics, the small hospitals in the peripheral areas, will become obsolete. In a small clinic, they will ask a hundred questions. Why are you doing this? Why are you running that test? But there (in corporate hospital), they cannot ask any question. They will be charged more, they can’t do anything.”General Surgeon, Rajaji Hospital, Madurai
Stricter Laws or Trust, What Is the Basic Need?
After the assault on doctors in West Bengal and the ensuing strike, Union Health Minister Harsh Vardhan wrote to state governments, highlighting the need for stringent action to be taken against anyone who assaults doctors. West Bengal has such a law. So does Tamil Nadu and almost all states of India. And in most of them, this law makes violence against doctors a non-bailable offence. Obviously, it does nothing to detract or curb violence against the medical fraternity. Yes, medical negligence is among the top ten global killers according to the WHO. Yes, there are doctors who put money or themselves over their patients.
In the last two decades, the Supreme Court has been fine tuning and fixing liability of negligence on corporate health centres, general physicians and doctors in government hospitals. Put simply, laws that protect the patient, the customer, if you will, are not lacking. What is lacking is trust.
“Doctors should reveal the prognosis, the treatment protocol, everything should be explained in detail to the patient. That will avoid 50% of the incidents. People should trust the doctor as they did in early 80s and 90s. That attitude should come back. They should avoid Googling or going to the media to find out diseases, which is incomplete. Third, if at all they have a problem with the treatment protocol, they should go to court. Not indulge in violence. There is a medical council in each state where one can register any complaints. Or he can go to court, which will appoint an expert committee to find out where the negligence has occurred. Direct violence will worsen the current situation, the relation between the doctor and the patient. I request the doctors working in the government hospitals again, to spend extra time with the patient. And you must also trust the patient. Don’t look at every patient as your enemy.”General Surgeon, Rajaji Hospital, Madurai.