How violence against doctors changed their prescription

When I returned from the US two decades back a friend told me, “You should learn to drive again in India. Use ‘defensive driving’ so as to protect yourself on Indian roads where people may damage your car, or even kill you.” I did not know that nearly 20 years later, the term ‘defensive medicine’ would be apt for Indian physicians, where physicians need to protect themselves from disrepute and physical harm. There are numerous instances of attacks on doctors, nurses and other healthcare workers, who are usually defenceless and remain soft targets. Some of the doctors have been labelled as “killer doctors”, “murderers” etc. Mostly, these doctors did their best to save the patient, working at odd times in stressful conditions and with poor infrastructure. Some work for 24-36 hours at a stretch diligently to serve sick patients. Overall all physicians stick to the basic oath, “First do no harm.” Diagnoses shaped by new threat perceptions But episodes of violence and hate continue to occur. In this vitiated atmosphere, many doctors have changed the way they practise medicine. Gone are the days when pulse was taken, chest and heart were listened to, a few tests were ordered and diagnosis was made. Now algorithms for diagnosis and management take threat perception from a patient’s relatives into account. Here are some examples to illustrate my point. Case 1: A patient visits a physician with severe pain over the left side of abdomen. Clinically, diagnosis of kidney stone is almost certain. Usually, plain abdomen x-ray and urine exam would suffice. But having previously experienced hostile reactions from patients and relatives, the doctor orders several blood tests, chest x-ray, electrocardiogram, echocardiogram, ultrasound abdomen and a CT scan. This physician confided in me that he was making sure nothing was missed, so that patient would not blame him later. Case 2: Patient with complicated malaria admitted in intensive care unit is seriously sick, with low blood pressure and decrease in urine output. This patient is being carefully and appropriately treated by a senior internal medicine doctor. However, as days go by, his condition shows minimal improvement. At this time, several anonymous threatening phone calls are received by the doctor’s wife at home. Right afterwards, the physician initiates daily consultation with five more consultants and orders multiple tests. According to him, if six consultants are managing this patient, it would be safer for him. Costs upped for patients and relatives The result is a very high cost of tests and consultations. Patients or relatives say that they have spent so much money on expensive tests. What they don’t realise is that general fear amongst doctors has created such an unfortunate situation. Plus, now there is a pervading feeling among parents that medicine is not an appropriate career choice for their children, and even established doctors are thinking of prematurely leaving their practice. Some remark that this situation is akin to the 1970s in the US when physicians there started practising defensive medicine in the face of an increasing number of lawsuits. But at least they could argue their side of the story in court, while in India the injustice served is instantaneous and brutal. Here’s how to rebuild mutual trustSolutions are few and not easy to come by. As legal diktats work best for Indian mindsets, they should be foremost. To penalise those who abuse and physically attack doctors, laws are in place. But these are applied loosely and heterogeneously. And due to variety of local pressures, sometimes the police act without following due process and book doctors – as happened recently in the case of a gynaecologist who committed suicide. In case of an alleged medical malpractice, a committee (from local medical associations) should inquire and submit a report, on which legal or police action should be taken if indicated. Strict and universal application of these laws is a must.Second, some actions from doctors could help minimise such incidents. Doctors must be very transparent with patients and relatives, discussing the relevance and cost of tests and medicines, and the progress of the patient. In case of sick patients, a twice-daily dialogue with relatives helps. Similarly, daily information of total expenditure must be provided to the relatives of admitted patients, and approval must be taken for any expensive tests. All important test reports should be duly communicated to the family.Finally, infrastructure improvement in hospitals in small cities and primary healthcare centres remains an urgent issue. Shortage of facilities and ventilators in these towns has often accelerated patients’ demise, resulting in violence directed towards doctors and damage to hospital properties. Doctors always try to save a patient based on knowledge, skill and experience. But they sometimes fail, often unexpectedly. Their hands should be strengthened, not broken. Their resolve to treat humanity should be bolstered, not fractured. Then only we can hope to have a crop of intelligent and efficient doctors for the next generation. The writer is Chairman, Fortis CDOC Hospital for Diabetes and Allied Sciences