Crouching Tiger, Hidden Dragon

Pondering on the issue that I wish to explore through this article, I was instantly reminded of the title of Crouching Tiger, Hidden Dragon, which is a famous film directed by Ang Lee, the same filmmaker who also gave us Life of Pi. In the original movie, the title refers to a Chinese aphorism about hiding strength from the world. But here I use it in the negative context – to highlight the untold dangers lurking in the shadows that we doctors have to face every day. The recent case reported from Max Hospital in Delhi is a grim reminder of the fate that could await any of us on any given day. At this hospital, a preterm baby was declared as dead and later found to be alive; though scientifically these instances can occur, there was a terrible backlash. Luckily there was no violence in this episode but the credibility of the medical profession took a sound beating. The hospital license was also suspended.

In another incident which occurred at Fortis Hospital, Gurgaon, a 7-year-old girl died after her treatment for dengue failed, despite the best efforts of doctors. The hospital bill, which included prolonged intensive care unit (ICU) care, was over Rs. 16 lacs. As a result of public outrage, the intensivist concerned was held responsible and a police case was slapped on him. This doctor happens to be a renowned expert and a pioneer in this field. From the information available, it appears that nearly 95% of the amount involved went to the hospital expenses and government kitty. The doctor’s fee was nominal, his efforts highest, and the blame total. Thus it is clear that he has been made a scapegoat because it is very convenient. We often hear of similar instances elsewhere in country, and they are rising at an alarming rate. Physical assault, verbal abuse, vandalizing of premises and harassment are only some of the other ways in which doctors are victimized for alleged acts of professional negligence or failure.

This is not a new, India-specific or specialty-specific phenomenon. Writing as long as two decades back on the topic, Morrison, et al. [1] observed: "One of the most difficult situations that physicians face is being threatened, abused, or physically harmed by one of their patients. This is not an uncommon problem: Bureau of Labor Statistics (BLS) data for 1995 indicate that more workplace assaults and violent acts occur in health care and social services industries than in any other. Health care patients, the most common perpetrators of nonfatal workplace violence, were responsible for 45% of all nonfatal assaults in 1992. Although the majority of such incidents involve nursing staff, all health care workers are at risk, and physicians are no exception. From 1980 to 1989, 22 physicians were killed while at work. This represents almost one-fourth of all workplace-related homicides among health care workers during this time period" [1].

Writing earlier this year on volence against the medical profession, Mukul Chandra Kapoor noted: "Violence is increasingly being used against doctors and other medical personnel. More than 75% of doctors face violence during their practice. Almost half of the violent incidents occur in critical care units…There are regular reports of doctors being abused, threatened, bullied, manhandled, and even killed. The issue is not restricted to our country but is a worldwide phenomenon. Multiple reviews and studies have been published in contemporary literature, with the largest number originating in China. The World Health Organization has drawn out a global action plan to prevent this violence" [2].

Hence we can see that there has been a steady trend of doctors being exposed to increasing risk of unwarranted behavior from patients, and if the patient has died, from their relatives. It is true that occasionally patient grievances are genuine. It is also true that in most cases the doctor’s decisions are based on perfectly valid medically accepted norms. For every child that dies, hundreds more are saved from the jaws of death by the pediatricians. Many times, it is the host response to the pathogen that determines what happens. Of course when everything is tried to save the patient, very costly drugs are used and every expensive technology is employed to diagnose hidden problems. Use of disposable equipment to prevent infection is also bound to increase the cost of treatment.

I do not wish to get into a detailed analysis of all this here except to state that this subject has not got a well reasoned and properly formulated response from the medical profession as a whole. A lot of hows, whats and whys as already being hotly discussed on social media platforms and also in the mass media. Hence rather than delving into the details, I wish to only present a few of my broad observations on how I feel this menace should be tackled with the hope that it will contribute to an evolving consensus on the future course of action, especially under the auspices of Indian Academy of Pediatrics (IAP).

It’s an ever-changing world out there

Historically, doctors have been hailed as members of the ‘noble’ profession and their knowledge and wisdom were never challenged. With the advent of universal education and the general advancement of society, this position has undergone a paradigm shift. Today’s generation only sees us as service providers of our respective domains of expertise and their relationship with us is more like that between seller/vendor and buyer/consumer. The proliferation of information technology and social media platforms has further flattened the world. The birth of superspeciality hospitals and corporate hospitals has blurred the role of doctors as individual experts in the eyes of the public. High-end technology, while improving the health prospects of patients, has also made treatment exorbitantly costly. The glut in mass media has led to a hypercompetitive environment in which everyone has become vulnerable to the glare of the camera and its intensely cynical scrutiny. And lastly, the political sensitivity of issues relating to healthcare give them a dimension far more catastrophic than all of the above.

A call to adapt

All these are important changes that have taken place in the last few decades or so. I believe that our present problems have more to do with not fully digesting these dramatic changes and coming up with suitable adaptation strategies. Constant and continuous change is the reality of life. We as doctors have absolutely no control over what course life can or will take. It might console us to know that it is not just medicine but also that almost every other field of human endeavor has experienced similar upheavals during the same period, especially in the wake of globalization and liberation that has swept the country for the last two decades. The future will bring in more challenges of unimaginable nature, and we cannot even flatter ourselves that we are capable of comprehending them. We can only develop the flexibility of mind and openness to accept change and try to use it to our advantage. While I believe that we have been quick to absorb technology and modern management practices, we have lagged behind in two aspects: (i) understanding and safeguarding our role as individual experts in the context of the large organizations that dominate the healthcare landscape, and (ii) understanding and effectively addressing the social dimension of our profession. The sooner we catch up with this, the better it is for all.

Need for rational response

In the course of the recent outrageous occurrences in different parts of the country, I have often participated in discussions with other doctors, both in person and on social media. While many attempt to come up with constructive observations and suggestions, I am also struck with awe that an equal number express anger and resentment against all sorts of targets like the aggressive patient parties, the intrusive media and the opportunistic political classes. They demand tough punishment for the wrongdoers, legal retaliation and other punitive measures. Being a colleague, I find their anger understandable as it does seem unfair that we should be rewarded so shabbily after a hard day’s work. But the moot question is this: has anger ever solved any problem? True, most of the states now have good laws in place to specifically protect medical personnel. But just having these laws have not resulted in any decline in the occurrence of unsavory incidences [3]. Hence angry response – while giving us temporary satisfaction – will only further aggravate the vitiated atmosphere. Hence the need of the hour is to come up with a rational response to the problem. For this to happen we first need to put our minds together and commit ourselves to honest introspection and courageous reform.

Communicate to connect

For all issues involving human beings, there is a thumb rule that 50% of the problem can be solved by just listening, communicating and connecting. This is a trick that most managerial experts are masters of. This involves going back to our roots and establishing our lost human connect with the patient by exercising our compassion, sympathy and all other qualities that make us human. Today technology has overtaken us to such an extent that we are probably more distant to the patient than we might imagine. We as a profession have also failed to sufficiently communicate to the patient regarding matters like the complexities involved in patient care and the reasons for high cost of treatment. We also need to develop a strategy to communicate with society at large. This invariably happens through a friendly – rather than adversarial – mass media. For this to happen, we need to establish a Media Cell that can develop rapport with the media people and be available to respond to their queries. The Media Cell can also identify good spokespersons from amongst us who can represent us in television debates, press interviews etc. As there is obviously a trust deficit between the public and the medical profession, we could engage a Public Relations agency to conduct research and come up with solutions. Yet another proactive initiative could be to arrange sensitization workshops for journalists regarding medical issues by aligning with press clubs, journalism schools and so on.

An integrated approach

Lastly, we need to recognize that not everything is in our hands. The problem is much larger than ours alone. Hence we must identify where the interventions are needed to be made, and push for the correction. As Neeraj Nagpal writes: "Violence against doctors is on the rise all over the world. However, India has a unique problem. Meagre government spending on healthcare has resulted in poor infrastructure and human resource crunch in government hospitals. Hence, people are forced to seek private healthcare. Small and medium private healthcare establishments, which provide the bulk of healthcare services, are isolated, disorganized and vulnerable to violence. Violence against health service providers is only a manifestation of this malady. The Prevention of Violence Against Medicare Persons and Institutions Acts, which have been notified in 19 states in the past 10 years, have failed to address the issue. To prevent violence against doctors, government spending on healthcare must be increased and the Indian Penal Code should be changed to provide for a tougher penalty that could act as a deterrent to violence against doctors" [3].

In conclusion, I would like to draw attention to an integrated approach, which could provide a long lasting solution to this vexing issue once and for all. This idea is best described by Morrison, et al. [1]: "addressing violence and aggression requires an integrated, multidisciplinary approach. A common link among the three cases that we presented is the failure to recognize the systemic causes of frustration and the resulting vulnerability of the physician who seemed responsible, as an individual, to deal with the aggression. Violence prevention and control is a systemic problem that requires the input of administrators, educators, security personnel, and legal staff" [1].

So ‘Crouching Tiger, Hidden Dragon’ are the hidden ghosts lurking in our practice. We are still a long way from warding them off. The least we can do is to acknowledge the real magnitude of the problem and shape a sustained and effective response based on hard facts and strong reason.

References

1. Morrison JL, Lantos JD, Levinson W. Aggression and violence directed toward physicians. J Gen Intern Med. 1998;13:556-61.

2. Kapoor MC. Violence against the medical profession. J Anaesthesiol Clin Pharmacol. 2017;33:145-7.

3. Nagpal N. Incidents of violence against doctors in India: Can these be prevented? Natl Med J India. 2017;30:97-100.