At a recently held national seminar on “Violence against doctors”, hosted by the Indian Medical Association (IMA), a demand was to bringing in a strong and effective Central Medicare Act. A strong legal action against those who indulge in this kind of violence will hopefully deter people. Is it the lack of effective legislature, the only reason why people indulge in violence at places they primarily come to seek help? Or it is more than that. And are these sporadic incidences or there lies an underlying pattern.
Those of us who have associations with teaching hospitals can see a definite pattern in Most of these. These events are mostly reported from those departments which have high inflow of critical patients presenting as emergency. Trauma centers, neurosurgery, medicine, pediatrics are most at risk. There are hardly any of these cases from department not dealing with life threatening conditions in emergency. ENT, eye, skin psychiatry are the examples. Secondly the episodes almost always take place after the prime working hours have passed, it is usually after five pm. In these hours most of the regular strength of doctors and support staff has left and only the emergency team and support staff is there.
It’s no secret what is the state of mind of the relative of a critical patients rushing to the hospital in odd hours. Often a single patient is accompanied by more relatives the waiting room can accommodate. There are blood relative, distant relatives, just relatives, neighbors, coworkers, and friends. If the patients patient happens to some association with any religious or political organization, then of course their office bearers.
Now every hospital has a crowd management policy. And mostly it is to delegate the responsibility to some private security agency. Which in turn post few underpaid and untrained but well dressed guards at critical point. This critical point is often the door between waiting room for relatives and the examination room/ward for patients. The guard will stop a educated female relative, argue with a male, plead with someone with authority in the air and step aside if some is in khaki or khadi.
So very soon, whole of the examination room/ward is flooded with all the variety of relatives of this last patient presenting in emergency. Now you do not need to be doctor to figure out, the first thing they all want. They want immediate attention and answers to their questions. There are sisters and support staff there, but those are too busy with their routine work of other patients on the beds. So they point the finger to the doctor.
Now it is emergency hours, so do not expect the routine faculty to be in the ward. All you have are the resident doctors. Since we have a strict hierarchy system in residency, only the juniors are in the wards. The house officer who is getting oriented and the jr 2 who has just got oriented.
First struggle is to arrange the bed for the newcomer. Since we have a universal policy that no patient has to be refused the treatment, so the beds are already full, and the corridor is filling fast. Same is for the availability of other necessary equipment, staff, and nursing support. The resident doctor is desperately trying to provide the thing to patients, however he can.
Now in this scenario, the relative of the newcomer patient want a bed, the attention and the answers and they want it urgently. This valid request is initially ignored, than politely refused. When they insisted, they were shouted at, by the sister that can’t they see, she is busy. Then there is an argument between both the parties on who is right in their situation, and the mercury begins to rise. What ensues is heated argument, exchange of threats followed by obscenities and sometimes a fight.
After this, the system gets up from its slumber. Faculty rushes in, and so are more security guards. But the media person and the police from local chowki arrive first. Police pacifies both the parties; media person gets the news for next day. Relatives take their patient to some other facility and residents go to strike. After few days they come back to the ward for duty, and the routine continues.
Now the question is , do we need a strong and effective Central Medicare Act or a policy to limit the number of patients a doctor should attend to in a given facility and time ? May be both.