The attack against Dr. Mukhopadhyay on June 10, 2019, at the Nil Ratan Sarkar (NRS) Medical College & Hospital in Kolkata, created a wave of protest from the medical fraternity across India. The Indian Medical Association, the largest professional body of doctors in India, demanded stringent laws to ensure workplace safety. 

No doubt, the doctor-patient relationship is deteriorating to new lows, and as per IMA studies, more than 75% of doctors experience various forms of aggression from patients or their bystanders. 

 Traditionally, Indian culture gives a divine status to the healer. But how come the number of violence against doctors is increasing all over the country? Whether our doctors suddenly lost all their ethics and become looters? If so, why did doctors at the government institutions that offer free treatment also get attacked?

Escalating treatment costs and high Expectations

The health care facilities in villages, where the majority of the population live, are ill-equipped to provide advanced medical care such as surgeries or ICU care. Tertiary-level facilities are available only in cities, often hundreds of kilometers away. 

Even those facilities would be overcrowded, and there is no guarantee of availing a bed. Doctors work beyond their capacities. They may need to consult 100s of patients within a short span of 4-6 hours. It reduces the time he spends for a patient to a few seconds. Poor communication, inadequate facilities, and human resources shortage significantly reduce the treatment quality in a Government facility. 

If you need an invasive process like surgery, the waiting time could be years. The hapless man either has to succumb to his disease or move to a private hospital for his treatment. 

In India, the patient has to bear the treatment expenses from his pocket. Only a very minute population alone enjoys the liberties of medical insurance or medical reimbursement. So availing of treatment at a private hospital will be a taxing endeavor, even for the middle class. 

Even with the best efforts, sometimes things can go out of control. It creates a feeling of betrayal to the patient and his relatives. First place, they didn’t get proper treatment at the free facility. It required them a life’s saving to avail treatment in the private hospital, but everything is in vain now.

 For the agitated mob, everyone in the white coat belongs to the same clan, and they may vent out their frustration, irrespective of your involvement with the entire episode. 

Commercialization of healthcare

Private players provide more than 80% of health care in India. Affordable single doctor clinics or small to medium hospitals were the primary treatment options for the Indian middle class for decades. 

But the advancements in medical science, technological revolutions, and the induction of new treatment modalities require enormous investments, much beyond the capabilities of such small hospitals. Corporates with deep pockets smartly used this vacuum by starting chains of multi-specialty hospitals with advanced facilities. 

They attract competent health care professionals with better packages and facilities. Doctors would be happier to join such firms due to the availability of better facilities that boosts their productivity level. 

These corporate hospitals significantly contribute to the advertising revenue of new papers and channels. So they easily manipulate the news content to suit their business interests.

 Paid news about a procedure or giving too much visibility for a doctor or department through various shows etc. are some of the activities in building a cult image for the hospital or doctor.
The media purposely makes news elements to destroy the trust of the common man in public institutions or affordable facilities by planting news with malicious intentions. 

For instance, they may present a minor mistake, such as plastering of the left arm instead of the right, in a government hospital as grave negligence. Meanwhile, they will follow a tight-lipped approach about the news of a surgical instrument left behind during surgery in a private hospital. 

Such a well-orchestrated campaign about the demerits of affordable health care prompts people to seek treatment in such multi-specialty hospitals. The treatment expenses on such hospitals are mind-blowing. The investor has every right to get his money back. There is no harm in charging extra for treatments. 

But when the doctors act with a profit motive by performing unwanted investigations and unnecessary surgeries, they cheat the patient by forgoing the values of medical ethics. 

Unfortunately, doctors fail to understand that the people trust the doctors, not the hospital owner. 

People won’t mind if you charge double or are a bit unfriendly, as long as you deliver results. No management will be daring enough to compel a competent one to achieve the targets. 

But if the doctor fails to deliver results, even after charging exorbitant money, the patient will be devastated and may behave with a vengeance attitude. 

I know it irritates my doctor friends, but it is the reality. We all are human beings, and being in a particular professional alone won’t give us immunity against worldly temptations of wealth and fame. 

How can anybody justify an MRI scan and plastic surgery for a kitchen knife wound at a corporate hospital while the same is treated with three stitches at a local hospital that, too, at the OPD itself?

Negativity of Media

Anybody with a smartphone is a journalist now. They may even create their fascinating stories about the organized killing of patients for organ trading. 

Since health is an expensive affair, any content related to it attracts visitors. So these social media influencers try to improve their reach by painting doctors as representatives of the medical mafia and vaccines as a tool for the depopulation agenda. 

No hospital or doctor can avoid fatalities. There might be valid medical reasons, or there could be negligence, too. But the media uses emotionally vulnerable relatives to spread their propaganda and place the doctor in the dock. 

Such a situation forces doctors to follow defensive practices. It means they will be obsessed with the documentation process for a smooth exit than treating the patient.  

 In an ideal society, no doctor should overreach beyond their capabilities or facilities, and a referral to a tertiary care facility would be the best approach. 

But India is a third-world country with a massive population of 1.3 billion. Our GDP spending on health care is just merely 2%. So even if you refer a patient, there is no guarantee that he will get admission to the referral hospital.

Unfortunately, this negative media approach desists a doctor from doing any procedures with a remote possibility of complications.

Imagine, a poisonous snake bites someone, and you take the patient to a nearby hospital with sufficient Anti Snake Venom, ASV, availability. But the doctor refuses to administer the drug as there are no facilities to treat a possible rare allergic reaction of ASV. 

The doctor very well knows that the possibilities for such a response might be less than 5%, but without the ASV, the fatality will be 100%. But to avoid future complications, he may push the patient to the verge of death by giving a referral to a remote facility. 

No faith in the Judicial Process 

For a victim of medical negligence, someone from the medical fraternity alone can cure him. If he moves with a legal battle, getting expert testimony against a doctor is very difficult. They protect each other. 

The regulatory bodies such as state medical councils are a mockery to the public. Even if a doctor is convicted, the medical board treats them with kid gloves by not invoking drastic steps such as cancellation of registration or disciplinary actions. 

A common man won’t have the resources or energy to fight a prolonged legal battle. In Indian parlance, demanding compensation for a relative’s death is considered a cheap or vulgar process. 

It creates a baffling situation. On one side, you see the suffering victim, and on the other end, the culprits enjoy life without any issues. The helplessness of the victim could be a flashing point for the masses and prompt them to cross the lines. 

Low health Literacy 

If you are realistic, you have all reasons to be a pessimist here. The self-declared naturopath or a high school dropout traditional healer will educate and prescribe treatments even for the people of esteem stature and with high-flying academic qualifications. They take the words of these quacks as gospel truth, even for terminal illnesses.

It is not unusual to spot a chemistry professor before a homeopathic clinic. If you ask her, she will give you a long lecture about the advantage of homeopathic medicines or the harmful side effects of modern medical drugs. Such people not only negates their hard-earned faculties but are becoming potential influences for the propagation of pseudoscience. 

How to improve the situation 

No one can deliver results at gunpoint. Doctors are here to treat people, not to combat. A favorable environment is essential for them to deliver results. 

Violence against doctors is the ugly manifestation of inadequate health care infrastructure. It denies quality treatment to the common man and risks the life of healthcare professionals. 

Cosmetic stitches, like stringent laws, will not cure these deep-rooted diseases.

I. Increase the spending on public health 

Poor hygiene, the unfriendly attitude of the staff, and lack of necessary facilities are the deterrents for the Indian middle class to use the public facilities. Since they don’t use the facility, they will not bother about the sad state of affairs. 

This approach gives policymakers confidence to cut the allocations to abysmal levels and pushes the entire system to the doldrums. 

The government can restrict free treatment for the poor alone and can start pay clinics for others. The government can offer treatments at affordable rates by making partnerships with private hospitals.

For instance, Setting up a Cath lab or robotic surgery unit might not be an easy endeavor in a typical government setup. A private investor in a tier2 city might have the resources, but he may not be confident in ensuring proficient doctors’ service. 

The government has no scarcity for proficient doctors or patients. If they can use the facilities here, on a rental basis, that would be beneficial to the patients. The patient will get clean and quality care, albeit at a lower cost than a fully privatized hospital. 

It reduces the waiting queue for financially backward patients and enables them for timely treatments in government facilities. 

If we can introduce private partnerships in defense and airport management, why can’t we adopt the same in healthcare?

2. Protect small clinics

In developed countries, consultation with a specialist is only possible with a referral from a General practitioner. But in India, one can walk into a Sub-specialists room without any reference. 

Easy accessibility to specialized care can be beneficial at some points. But on the flip side, it escalates treatment costs. A neurologist has to deal with tension headaches to advanced movement disorders. Such a high patient load could affect his competency in the specialty and reduces his output.

The elderly population with various health issues constitutes a significant portion of our community. For them getting regular checkups or medical assistance in a remote facility is practically very difficult. 

Single doctor clinics or small hospitals with inpatient facilities in the neighborhood will be a blessing for such people. It reduces treatment costs, ensures proper follow-ups, and significantly improves their quality of life. 

So the government has to encourage their existence through various tax reductions or relaxations in statutory operational necessities. 

3. Introduce certified caregivers

Specialties such as Palliative care, Geriatrics, and Hospice don’t require continuous availability of a doctor or advanced hospital facilities. Still, professional supervision is essential to avoid emergencies. 

Getting a doctor or taking the ill to the hospital means loss of working days and livelihood. It can develop a hostile approach towards the patient and may worsen their conditions. A registered nurse with proper training in these specialties can do wonders in rural health care management.

Sadly, any moves to introduce an additional stream of healthcare professionals get fierce opposition from doctor associations. They argue that it will severely affect the country’s health care quality. But these noble souls will file a case against compulsory rural service for doctors trained in Govt institutions.  

Midwives of the UK manage most of the home and institutional deliveries. Advanced Registered Nurse Practitioner (ARNP) of the US is entitled to prescribe medicines and treat patients. Most of the developed countries use the service of such non-doctor professionals in different capacities to make their healthcare more efficient and accessible to all. 

4. Stop Harassing Doctors 

Each individual, his health condition, and his response to different medications are different. A panel of experts can only prove medical negligence. So the current practice of arresting the doctor and slapping criminal charges of homicides needs modifications. 

Instead of harassing the doctor for every complaint, there should be a proper grievance addressable system so that a patient can complain about medical negligence.

If the experts found any merit in the issue, then they can take the legal course. It gives the doctor ample scope to prove his innocence beyond doubt and helps him maintain his reputation and goodwill. 

What doctors or hospitals can do?

Whatever be the reasons, doctors are at the receiving end. You can’t expect a timely intervention from the police or security guards. They all will hole up somewhere until the issue is over. 

1. Improve your communication

Various studies across India show that the number of attacks against Sr. doctors is quite low compared with junior doctors. It could be due to their ability to manage such stressful situations, primarily through words.  

People approach doctors with high expectations. It is the doctor’s responsibility to give them a clear picture of the disease, treatment options, limitations, risk factors, realistic outcome, and, most importantly, cost. 

 If you are unable to communicate effectively, get a counselor who can do this for you. 

2. Respect your limitations 

Medical science is evolving, and patients are well aware of the options. So never try to perform any treatment modalities beyond your capabilities. You can guide them in the right direction, but you should have the audacity to judge the outcomes. If there is an emergency that you can manage with a slight overreach, you can do it after getting the proper consent from the patient or bystander.

3. Get a professional liability insurance coverage

A patient can turn to be a litigant at any moment. The commercialization of healthcare makes the doctor-patient relationship a commodity. So brace up yourself with proper documents and, most importantly, insurance coverage that bears the litigation and compensation expenses. 

4. Make the professional bodies more responsible 

 IMA is often touted as the largest professional body of Indian doctors. But for an outsider like me, they are not visible unless there are any awareness activities with high media visibility. They always keep a safe distance from government policy formations and make eye washing efforts in the form of protests when something happens to a fellow doctor. 

Dr. Mukhopadhyay is not the first or last victim of attack against doctors in India. As long as the patient has to bear the health care expenses, the life of doctors will always be at risk. 

The only category that receives an NHS-like treatment in India is Soldiers. ECHS covers their medical expenses in empanelled hospitals; most of them are the country’s best tertiary care facilities. 

How many of them attacked doctors when somethings went wrong? There might be isolated incidents. But it would never be anywhere near what the government doctor receives in his emergency room.

So it is not just grief, but the frustration and helplessness of the people that trigger the violence. Only a massive pumping of resources alone can make quality healthcare accessible to all and ensure a safe and conducive environment for the doctors.