Doctors in Distress: Why is the Healthcare Sector in India Under Assault?

For as long as I can remember, I wanted to be a doctor. And whenever people pondered over various career options for their children in my presence, the medical profession has always been one of my top recommendations.

 

It continues to be the most satisfying and inspiring of paths - full of challenges, trials and tribulations, with more than its share of defeats and victories.

 

However lately I am more guarded. The recent events which transpired in Kolkata, but quickly took attention over the national stage, has only further strengthened my circumspect stand.

 

No Country for Doctors: Why is the Healthcare Sector in India Under Assault?

 

 

The Calcutta Medical College set up in 1835 was probably the first medical college in Asia. Recently, it witnessed a strike of OPD and routine clinical services, along with a large majority of government hospitals, private hospitals and nursing homes throughout India.

 

The Issue

 

A fight that broke out between the relatives of a patient who died in NRS Medical College, Kolkata with the medical professionals taking care of him. Evidently, a mob of about 200 broke into the hospital hours after the event, and went about thrashing medical residents, seriously injuring two. Both have suffered depressed fractures of their skulls, and only time will tell what sort of long-term consequences these young doctors will face.

 

The state government was quick to respond. The residents were threatened with harsh action unless they return to work immediately. There was initial escalation - hostel rooms were burnt and female residents were threatened. The assailants claim to have been carried away in the flow of emotions.

 

In retaliation, the doctors in West Bengal (except emergency services) went on strike demanding action against these hooligans and better security in hospitals, apart from an apology from the Chief Minister (which appears a bit uncalled for, but doctors claim that the goons were TMC-backed, which is why police did nothing to stop them). Fortunately, there has been a settlement between the state government and the striking doctors, leading to resumption of usual medical services.

 

But Why Are We Discussing This

 

Such attacks have been reported several times earlier, both in government and private hospitals, over the last decade or so. However, what is worrisome is the impunity with which these aggressors have managed to beat up doctors, inflicting grievous injuries, damaging hospital equipment, and generally holding healthcare to ransom.

 

 What is the Problem, Then?

  

It is difficult to determine what are the causes for this mounting public hostility towards doctors and healthcare. It is unlikely to be lack of service, few other professions have to indulge in such excruciating ordeals. It should not be one of results, for over 95% of patients admitted in hospitals are discharged healthy. It could possibly not be one of corruption, India ranked 78 on a list of least corrupt countries when it comes to transparency of administration. The unimpressive rank is perhaps suggestive of a greater preference for getting work done for a commission.

 

Could it be that we expect 100% results once we have paid the cost? But we don’t beat up teachers and vandalise educational institutions when children fail exams. Is it that we beat up those who break promises? But we don’t hit our elected representatives if and when they forget their election manifestos once elected. Or do we feel infuriated when justice is denied? Apparently not, for nobody indulges in violence in courts for an unfavourable verdict. So wherein lies the problem?

 

It also doesn’t appear to be one of law. There are adequate provisions to penalise hooliganism and vandalism such as this, with special provisions for protection of hospital staff and equipment. Notably, there are laws protecting hospitals and healthcare providers in at least 13 Indian states (an example is the Punjab Protection of Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage to Property) Act, 2008). In spite of this, we have rarely seen a conviction under any of the Acts providing for the security of healthcare providers even though dozens of such cases have been reported from all parts of the country.

 

Apparently, our society expects a doctor to be bright, efficient, committed, honest, self-sacrificing, delivering top class services, often forgetting that running hospitals involves investing huge amounts of money on land, construction, equipment, maintenance, electricity, clearances and manpower, which are unavoidably factored into the bills of patients undergoing treatment. Moreover, one needs to examine as to why medical professionals are time and again scrutinised under a harsher lens, often quoting the huge amounts of money the government spends on their education. Why is it that the same society does not look for a handsome return on investment in cases of IIT/IIM/Law graduates on whom the government spends as much as the amount, if not more, whereas doctors have to compulsorily work in hospitals for their degrees.

 

A predictable pattern is seen in hospitals around the country. In government hospitals, people complain about the lack of facilities, while in private hospitals they complain about the exorbitant bills. Which could only mean that they expect the services of an international-level private hospital at the price of a government hospital. When this doesn’t happen - or when a patient unfortunately dies despite running up a big bill - there is trouble.

 

Over time, people have realised that everybody is with them in this fight against healthcare providers - the public, the administration and the media. It doesn’t matter if the victim is someone who had a high-speed crash under the influence of liquor or a heart attack, or if there are many sick patients in a ward and only a single doctor to attend to them. Violence breaks out due to the turbulence in the attendants’ minds (owing to the unexpected developments); but exemplary behaviour is still expected from a doctor. Police officials often advise doctors to withdraw any complaints registered by them, as the attendants just got carried away in the flow of emotions: after all, they just lost someone close to them. And in cases where there is a big hospital bill but the patient doesn't survive, the bereaved family often resorts to harassment and violence, forcing the hapless doctor to negotiate a settlement.

 

Realizing he is up against a wall, what does the doctor do to make up for such losses? He/she ends up passing such costs to other patients. All big private hospitals hire private security agencies to provide round-the-clock guards, while smaller nursing home owners often hire bouncers; the payment for all these non-medical services must be necessarily factored in the patients’ bills. But, the cost inflicted on their souls is high, and a mental breakdown is often waiting to happen.

 

Is There a Solution in Sight?

 

Doctors have to understand that patients who come to them in pain, need relief and a kind word. Meanwhile, the society needs to recognise and duly appreciate the care-givers who work for their benefit.

 

MBBS curricula continue to focus chiefly on diseases and their management. Students are never taught how to inform relatives that their dear one is terminally ill and may not recover, nor how to comfort grieving relatives when a life is lost. Regular counselling of relatives does go a long way in preparing them for the loss, if and when it occurs. Furthermore, money cannot and should not buy lives, but without it, high-quality hospitals will be unsustainable. The exorbitant hospital bills of our country are still one-tenth or lower than those in the West, and less than one-fourth of those in Asian countries like Singapore. No wonder, then, that so many hospital chains have been sold due to extensive losses in the last few years.

 

Violence in hospitals should be totally unacceptable. If society expects doctors to be sympathetic and empathetic, it should empathise with their problems as well. We as a society need to understand and accept that humans are mortal beings. While treatments and procedures save lives, and provide relief, they cannot be uniformly successful. Just as nothing can be said to be certain (except death and taxes, as per Benjamin Franklin), medical procedures have certain defined failure and complication rates. Hence, picking up cudgels each time a life is lost in a hospital will not improve healthcare; rather, it alienates the very people working to save our lives.

 

Senior doctors, especially surgeons and interventional physicians like cardiologists and gastroenterologists, should display their competence and results on websites. The law should be particularly strict for those who are practising outside their specialities or levels of competence. A big part of the problem stems from there being no regulation (or rather poor implementation of regulation) over who can practice what. Outcomes of procedures will improve, as will the level of care. This may also result in some increase in the cost incurred, so the penetration of effective insurance must increase, enabling sick patients to get much-needed care.

 

All medical colleges mention in their prospectus that resident doctors are not expected to do over 12 hours of straight duty except under exceptional circumstances, the only problem being that these occur on a daily basis. The government needs to recognize this and correct the anomaly wherein a doctor under training has to look after dozens of patients without rest or food, often getting little or no sleep for 24-36 hours. Courts recommend that a doctor should optimally work for 48-54 hours per week; it is well known that residents and busy consultants work in excess of 100 hours per week. One needs to spend a day or two with a resident on duty to really understand their plight. Consultants also need to support their residents more: they must play a bigger role in providing emergency care, and not delegate it entirely to senior and junior residents. India also needs more hospitals with good secondary and tertiary care facilities, ideally in the public sector, as a large majority cannot afford private healthcare.

 

Regardless of the circumstances, no medical professional who has been caring for dozens of sick patients deserves to be beaten up by an angry mob. In case of alleged negligence, people have the right to go to hospital authorities, the government or the courts for an inquiry, but not bash them up this way. The inevitable consequence of this incident, and the recurrent acts of violence against medical professionals is that doctors have just stopped or limited admitting very sick patients or performing complex life-saving procedures. It’s not worthwhile risking one’s neck for another person day-after-day.

 

Brain drain will also continue to increase and brighter kids will stop choosing medicine as a profession, as it is no longer paying in terms of respect or quality of life. The bottom line is, until we as a society can promise basic security to our care-givers, how can we demand it of them to give us their all?

 

If not, the ultimate loser in this whole affair would be We, the people of India. 

 

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