Oh Kolkata !

The increasing spate of violence against doctors in the country and elsewhere, epitomized by the horrifying incidents in Kolkata compels me to write the following.

Most attacks on doctors occur in the accident and emergency (A & E) services of a hospital or a clinic for following obvious reasons:

In the hospital wards, for patients suffering from subacute or chronic diseases or awaiting an elective procedure, there is enough time for the doctors to explain and for the patient and the relatives to understand, accept and ask questions. Decisions can be made jointly, and responsibility shared after discussion. An example in heart diseases is what is known as a “heart team” approach for decision making in a case with stable but complex coronary artery disease.

On the other hand, the ‘scene’ that happens in the A &E units is due to a combination of factors that the 3 ‘actors’ in the ‘drama’ suffer from, like lack of time, agitated mental states and seriousness/acuteness of illness or injury. 

Firstly, actor number one: The patient- mostly is one who has serious and acute illness or injury which has high mortality despite best treatment. This is what the relatives HAVE to understand and accept. For example, a patient in cardiogenic shock after a heart attack. Even the best of treatments like urgent opening of a blocked coronary artery by angioplasty and stent implantation leaves a mortality rate of 50 % (and not doing anything a mortality rate of almost 100%). Would you beat up a doctor who in the middle of night endeavors to save someone but is not successful for reasons beyond him?

Then the actor number 2: The agitated, ignorant, aggressive relative. Gone are the days when relatives were compliant and more accepting of the results of treatment. Now we have a combination of lack of understanding along with aggression and muscle- a particularly lethal combination.  Of course, some of it comes from the lack of time and expertise in communication skills of the doctor on duty-the 3rd actor in the drama.

Generally, the doctor on duty is from the lower or middle rung-not a senior person, is already harrowed with the continuous flow of serious patients and his or her inadequacies of facilities, time and communication skills. The requirement of urgent action leaves little time to explain the relatives the seriousness of the illness and possible outcomes with or without treatment. Even if a doctor is accused of being inefficient, having poor knowledge or judgment, he or she can never be accused of poor intent. His or her first and last effort is to treat in ways best known to him or her-which hardly deserves the ‘treatment’ he or she is meted out. Although Although God judges by intent, the world judges by results, unfortunately.

Since the A and E units are hardly the place to discuss these issues, the best way to prevent violence is probably by doing the following:

1.       Have training and workshops for A & E doctors in communication skills and behaviour changes-it is how you say that makes all the difference; also, by skits and role playing. Justifiably or not, people expect the same courtesy from doctors as they get now-a-days from other service people. May be the IMA and MCI can take a lead on this.

2.       Make violence against doctors a non bailable offence-and put up sign boards prominently to that effect outside all A and E departments and as news item in the media.

3.       Have at least 2 bouncers in every A & E department, (to be paid by a surcharge on every patient).

4.       Explore the feasibility, effectiveness and safety of use of crowd dispellers like tear gas guns etc.

5.       Put up sign boards such as “Your patient may have illness or injury that has a high chance of death despite treatment and certain chance of death without it. Please decide whether you want treatment or not”.

6.       Have a short consent form in relation to the above for the relatives to sign (in presence of a bouncer or security staff).

7.       Have meetings and seminars with the police force to initiate rapid response systems.

8.       Have public seminars and write ups on this topic-especially to political groups.

Finally, last night one of the TV channels was showing how patients are suffering due to the medicos' strike in Kolkata which only implies how much needed they are and how much difference they can make.

Would you hit a person you badly need?

 No wonder Socrates was compelled to say: “Why do you hate me, I have not helped you!”