Violence Against Doctors

12 October, 2017

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Medico-Legal Newsletter
October 2017, New Delhi
VIOLENCE AGAINST DOCTORS

“No doctor on earth can ever think of hurting or causing any damage to his/her patient to the best of his ability and expertise”. However, no doctor can guarantee and ensure complete safety of his/her patients.
In the past few years, more instances of violence against medical practitioners have come to light than probably in the entire last decade. With the rapid spread of information and growing awareness of instances both among the public and medical fraternity, this has created dissatisfaction on both sides, creating an atmosphere of suspicion and distrust on both the sides. However, what the patients fail to understand is that Medical Practitioners aren't "Healing Angels", they impart medical treatment and recuperation of the patient depends upon a number of physical and organic factors. Victimizing the Medical Practitioner if a patient doesn't respond to treatment, is not justified. Such attacks have occurred both in urban and rural areas, in both government and private hospitals.

As per the research/reports:
  • Over 80% of doctors across country are reported to have faced at least some form of violence as estimated by the Indian Medical Association.
  • A nationwide study conducted by IMA showed doctors face maximum violence when providing emergency services, with as many as 48.8% of such incidents reported from intensive care units (ICUs) or after a patient had undergone surgery. The main reason behind such violence is unnecessary investigations or delay in attending to a patient. Violence against hospital authorities are often triggered from request of advance payments or withholding a deceased body until settlement of final billing.
  • Attacks on healthcare providers generally peak during hospital visiting hours or at the time of emergency medical interventions, or post-surgery.
  • The World Health Organization states, between 8% and 38% of health workers suffer physical violence at some point in their careers. Many more are threatened or exposed to verbal aggression.
  • Kin and attendants of patients behind 68% of such cases
  • Experts say figures would be higher as most doctors don’t report such incidents
  • Data shows escorts of patients committed 68.33% of the violence.
Health-care staff are the most exposed professionals to workplace violence worldwide:
  • A survey of violence against general practitioners (GPs) in Birmingham found that 63% had suffered abuse or violence, with 0.5% suffering a serious injury. Another survey of GPs found that over 60% of GPs experienced abuse or violence by patients or their relatives over a 1-year period and nearly 20% reported some sort of abuse at least once a month.
  • A German survey reported that almost 50% of GPs were confronted with aggressive behaviour, with 10% of them experiencing critical to violent attacks, such as criminal damage to property and/or physical assault.
  • About 87% of respondents, in a survey in China, reported an increasing trend of violence against doctors. Patients are becoming more aggressive in their demands and are much more likely to resort to aggression if not satisfied with health care. Numerous cases of violence against healthcare professionals leading to death of some doctors as well as nurses by patient’s relatives. The reasons for this violence according to the authors are poor quality of services. They have further reported that more than one million cases of violence against healthcare professionals are reported every year in China.
  • According to a survey in Pakistan, almost 77% of physicians have faced either verbal or physical abuse in Pakistan. Emergency Departments were the most common place where violence was witnessed and the sources of violence were patient’s relatives along with negative media reports besides irritating staff attitude.
  • A report from Bangladesh also throws light on the fact that violence in healthcare sector has been increasing at an alarming level throughout the country. Doctors become an easy target for the blame game by sensational media reports. Since a wide gap exists between the patient’s expectations and the reality, patients who feel they have not been looked after properly then take the matters in their own hands. These incidents have certainly decreased the self-esteem of the doctors. Another report suggests that almost 70% of doctors won’t want their own children to go into the medical profession.
  • As per the survey in Saudi Arabia, more than two third (67.4%) respondents reported that they were victims of violence. Nurses were more likely to be exposed to violent incidents as compared to physicians. The reasons for this violent behaviour were reported to be excessive waiting time, shortage of staff and unmet patients demands. Verbal abuse was the most common and the assailants were mostly the patients relatives or friends followed by the patients themselves.
  • A survey conducted among Physicians in Kuwait showed that 86% of doctors had experienced verbal insults or imminent threat of violence while 28% had experienced physical attacks of which 7% reported serious or fatal injury. Out of 781 violent incidents reported by the doctors, 73 involved physical attacks, eight involved physical assaults likely to have caused serious or fatal injury.
  • A national survey in Australia revealed that 58% of General Practitioners had experienced verbal abuse and 18% experienced property damage. GPs with fewer years of practice were more likely to experience verbal abuse as compared to those more experienced who becomes better equipped to deal with verbal abuse in such situations.
Shockingly, a large proportion of doctors don’t report such incidents, believing them to be a part of the job so the true figures are likely to be higher. Laws to prevent violence against doctors in India do exist, but they need to be made stricter and implemented properly. It is important to reflect on how the medical profession-always held in respect in our society-has come to such a sorry pass where health-care workers need protection from the very people they are meant to take care of.

WHAT CONSTITUTES VIOLENCE?
Telephone threats, Intimidation,
Oral abuses and Physical manhandling.
Vandalism is another form of violence particularly common in India
For More Details and Tips on Handling Click Here
WHY DOES IT OCCUR?
  • Misperception and unreasonable expectations among patients and relatives regarding healthcare and adverse events
  • People attending private hospitals expect exceptional quality service from doctors, as they have paid for it
  • Long waiting times, short consultation times, and poor doctor–patient communication can easily trigger tension whenever doctors fail to meet patients' high expectations
  • Delay in providing care, absence of equipment and drugs during emergencies
  • Demand of advance payment
  • Dissatisfaction with the course of treatment
  • Disagreement with physician on modalities, option and course of treatment
  • The general public has started seeing diseases and death as an avoidable phenomenon so there is growing mistrust towards the intent of doctors
  • Costly surgeries and treatment
  • Adverse medical events evoke a violent response from the public
  • Increased awareness of patients about their rights and their willingness to knock the doors of courts to seek justice
  • Inadequate workforce and infrastructure to treat the huge patient load
TIPS FOR HANDLING:
  • Each patient should be adequately examined, investigated and treated.
  • Doctors should never assure 100% cure and avoid negligence.
  • Patients should be involved in decision making regarding their treatment giving them adequate information about the possible complications.
  • Try not to frequently change the treatment plan as well as the cost.
  • Calm and quiet approach is required while handling the issue. Staff should not in any circumstances respond in a like manner.
  • Effective management strategy should be put in place: a damage control plan, when violence against heath staff seems imminent (not to react tit for tat i.e. anger for anger) and address patient grievances.
  • Improve doctor-patient relationship, communicate tactfully with patients and show empathy while communicating news of death
  • The current atmosphere of fear and distrust must be addressed.
  • A realistic appraisal of the prevailing situation and communication to the patient and their attendants, relatives should be ensured.
  • Report all incidents of physical and verbal abuse (threatened or actual).
  • Security personnel will always be out-numbered by the mob and hence inadequate during such vandalism, however, such establishment should have CCTV cameras installed
  • In case of complications/death a senior doctor should talk to patients/relatives which gives them assurance that best treatment is being/was given to the patient. In desperate situations, the patient must be given the choice of calling another doctor for second opinion if they so desire.
  • Second opinion should be given very carefully, with careful choice of words.
  • Better patient flow management
  • Reduce the waiting times for everything and if they cannot be done at least explain why these times are there in the first place.
  • Training of employees/security to defuse crisis
  • Restrict entry of attendants to clinical workplace
  • Displaying information and also the laws governing the safety of doctors up-front, to satisfy the intellectual class and to make them aware of consequences of violence against doctors
  • Unconcealed closed circuit television with video recording may serve as a deterrent, as well as be used to record evidence.
  • Hospitals and clinics must have panic alarms and all threats/episodes of violence should be recorded in a critical incident book. There must be a zero tolerance policy for abuse.
According to the Doctors’ Protection Act, 2010:
  • Any damage or act of violence against Medicare professionals is an act punishable by law.
  • Any damage to the property or the Institution of Medicare service is prohibited. Destruction of hospital beds, burning of ambulances, smashing medical stores is punishable by law.
  • Imprisonment to lawbreakers for a minimum period of 3 years and amount of Rs. 50,000 to be imposed if found guilty.
    fine
  • Offenders of medical professionals/medical colleges can be cognizable or non-cognizable crime depending upon the offences committed.
  • Damage to any medical devices and equipment is a punishable offence and the offenders are liable to pay twice the amount of the damaged equipment’s cost.
ASSAULT OF A DOCTOR: A NON-BAILABLE OFFENCE
Recently a Public notice has been issued by the Delhi Police stating that “a doctor is a life saver. Owing to several reasons, your doctor may be under extreme pressure and thus have regard and faith in him. Assault upon a doctor is a non-bailable criminal offence and attracts imprisonment for a term which may extend to three years, or fine or both under the Medicare Service Personnel and Medicare Service Institutions (Prevention of Violence and Damage to Property) Act, 2008.”
A study of workplace violence experienced by Doctors and associated risk factors in a tertiary care hospital of South Delhi, India
Distribution of doctors experiencing violence during working hours according to gender
Distribution of different departments from which violence was reported

Distribution of type of violence reported from different departments.
*There were multiple responses from single respondent present

Perceived Causes of Violence according to Doctors

CASELAW : SITARAM BHARTIA Institute of Science and Research v. VIDYA BHUSHAN JAIN & ORS. (NCDRC 2017)

CASE BRIEF:
In a recent case filed against Sitaram Bhartia Institute of Science and Research, New Delhi, the patient had alleged that the doctors had not taken consent of family members before inserting a catheter for central venous line procedure adding that due to their alleged negligence, the jugular artery was ruptured resulting in profuse bleeding and he had to be shifted to another hospital for treatment.

HOSPITAL CONTENTED:
The hospital ‘s
defense was that the procedure of insertion of CVL in the patient’s neck was a routine procedure like giving injection and consent was not required as it was not a surgical or invasive procedure. The court however, not finding any merit in the hospital’s justification stated that putting CVL in the body of a patient could not be equated with ordinary procedure.

COURT HELD:
The court specified that the provision of taking consent could be overlooked only if
urgent intervention was required to save the life of a patient. However, it added that there was not such urgency in the current case.
The Consumer Court holding the hospital guilty of negligence asked it to pay a compensation of Rs 7 lakh to the patient.
LATEST MEDICO NEWS

On a report published by Times of India, the Hon’ble High Court of Delhi took suo moto action and has directed hospitals to put information of availability of beds online.

A bench of acting Chief Justice Gita Mittal and Justice C Hari Shankar recommended putting all information on bed occupancy and other facilities online so that patients know where the nearest best medical assistance could be availed. HC acted after advocate Ashok Aggarwal brought to its notice the news report that a new born died as the family failed to get
a ventilator-fitted bed in four government hospitals.
LATEST UPDATES

DON’T MAKE WITNESSES, ESPECIALLY DOCTORS, WAIT: JUDGE TELLS SUBORDINATES
Great thinker Bentham had once said: “Witnesses are the eyes and ears of justice.”

Keeping this in mind, a circular has been issued by AS Jayachandra, District and Sessions Judge, Shahdara emphasising on summoning doctors as witnesses only after 2 p.m. and priority be given to the cases in which doctors from hospitals are appearing as witness so that their evidence is recorded at the earliest and they may leave to attend their respective duties.

MEDICAL TIP

  • In all cases where a surgery/procedure requires more than one stage, the patient must be informed of the said fact at the outset and a proper written acknowledgement of having received this information must be taken from the patient. This fact must also be duly recorded in the patient’s medical records.
  • Referring a patient to an unqualified doctor is considered to be negligence on the part of the doctor. Furthermore, the referring doctor acting upon the report of such an unqualified doctor would also constitute negligence.
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