indian heart journal 68 (2016) 231–241
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ihj
Correspondence
Is changing curriculum sufficient to curb violence against doctors? Dear Sir, ‘‘Other side of the moon, Violence against Doctors: The Class wars’’ by Sundeep Mishra, Indian Heart Journal, 67 (2015) 289– 292 has discussed the most important issue, the medical profession is facing today, of violence against doctors. Doctors being roughed up, beaten, and even killed, by patients' disgruntled relatives is in the news with ever-increasing frequency.1 Dr. Sundeep has very intelligently discussed various predisposing causes and what needs to be done,2 but I do not see it as class wars, because neither those who have and those who do not nor the rich and the poor are at war; so, it cannot be seen as a class war. I think violence against doctors is a symptom of the collapsing capitalistic society and increasing distrust and suspicion in the doctor–patient relationship, which is multifactorial. Moreover, changing medical curriculum may have some effect, but it will not at all be able to curb the increasing violence against doctors, because it will be really impossible to teach empathy, sympathetic communication, ethical practice, curbing unnecessary investigations, etc. to a medical student admitted after paying a hefty capitation fee without having the right commercial inclination. Moreover, medical colleges are teaching preventive and social medicine for about two and a half years, and it is an open secret how well our medical graduates practice preventive and social medicine in real life. So, it will be really a very far-fetched idea to think that changing medical curriculum will have any significant effect in curbing violence against doctors.
1. Social degradation and intolerance as a contributing factor The combination of forces of economic aspirations, greed, extreme stress and frustration of modern living, competitiondriven society, and distorted, misplaced, and false religious, cultural, educational, and social values are increasing intolerance in the society as a whole. The art of happily, healthily, and contented living has been eroded where love for permanency and tradition has been replaced by the utilitarian
approach, plastic goods, plastic hearts, plastic minds, and things of temporary, short-lived value. As a medical professional and human rights activist, I feel that three decades ago, people with inclination to serve the suffering mankind opted for the profession and were trained by teachers of high academic and moral standard. But now, mostly people join the profession after paying hefty donation or fee only to make a lot of money later on. Excessive commercialization of medical care has paved the way for increasing greed, the proliferation of unethical practices – conducting unnecessary tests and investigations, adopting unnecessary procedures and surgeries, etc. – leading to increasing distrust between patients and doctors. Doctors in India were treated as demi-gods and commanded vast respect without questioning their treatment, but now with little attention to the humanities, ethics, the social context of illness, or lack of communication in conflict situations, doctors are increasingly being projected as demons all out to earn money at any cost.
2. Reasons for increasing violence against doctors: The reasons for patients' relatives becoming violent can be: relatives impression of neglect in patients' care, lack of communication, unnecessary investigations, delay in attending patient, request of advance payments, or withholding a deceased body until settlement of final billing. Ultimately, the medical trade now involved in this noble profession has resulted in doctors, patients, and relatives' unrest.3 As a Health and human rights activist, I see the following most important factors leading to increasing violence against doctors: False assurances given by the doctor to relatives leading to high expectations for recovery with treatment and prognosis under the hypnotizing influence of earning money or fear of losing the patient to some other doctor. Economic shock for the patient/relatives as there is no health budget being kept by the households in India and
232
indian heart journal 68 (2016) 231–241
majority are middle class or poor people, and are without any economic stability or health insurance. Lack or sometimes total absence of communication between the patient's relatives and the doctor for medical condition and its risks along with failure to devote time for serious patients. Ever-increasing tendency of relatives to blame doctors for any death may be because of lack of medical knowledge, ineffective communication between doctor and relatives, economic stress, and greed to extract money or blackmail the doctor. An important contributing factor for increasing violence against doctors is poor image of medical professionals projected by the media leading to general belief that doctors are the greatest villains and extortionists who exploit patient's miseries to extract money. Moreover, public's lack of faith in judicial system, the inactivity of the police, and the impression that the police will take no action and can easily be bribed are other contributing factors. On the other hand, majority of the doctors are hesitant to file any complaint or an FIR against the patient or relatives because of fear of getting involved in a time-consuming judicial process or creating more enemies with the local population affecting their practice; so, doctors often try to hush up the incident, and simply carry on, albeit demoralized. Since there is no conviction of persons known to have assaulted doctors, it always leads to more lawlessness among the public. Most of the times, the Indian police often seem to be unaware of the recently enacted laws and judgments, or feigns ignorance or ignores law under public or political pressures. It is a common sight to see numerous small-time politicians throw their weight around in busy hospitals to impress their vote bank, which I feel is a common prelude to violence against doctors. When a patient suddenly and unexpectedly dies, it is far easier for relatives to blame the doctor and quickly demonize the doctor, resulting in violence. Violence against doctors is being reported from all over the world. A study4 from China has highlighted numerous cases of violence against healthcare professionals leading to death of some doctors, as well as nurses, by patient's relatives, and the reasons are poor quality of services, increased awareness of patients about their rights, and their willingness to knock the doors of courts to seek justice. Negative media reports about hospitals and doctors, out-of-pocket medical expenditures by the patients, and lack of trust in doctors and hospitals have been reported to be some of the causative factors in China.5,6
3.
Way forward
I strongly feel that solutions to curb violence against doctors and improving trust between the patient and the doctor cannot be isolated from other socio-economic problems plaguing the increasingly market-oriented Indian society, which will definitely require a complete overhaul of the existing economic system and healthcare system, with increased communication between the doctors and patients, filling crucial gaps in communication between doctor/patient/
relatives, sympathetic attitude instead of mechanical attitude, curbing low-level political bullying with tougher laws, both for medical negligence and violence against doctors, and removing frustrating shortfalls in the public health system along with strengthening and promoting low-cost efficient universal public healthcare, incorporating global vision and local actions, keeping in mind aspirations and well-being of sick people, will provide solutions to decrease violence against doctors. Professional organizations should play a proactive role to ensure ethical medical practice. Definitely curriculum should be changed to incorporate necessary communication skills, etc. Media can play a larger than life role in improving the image of the medical profession, projecting role models amongst the doctors, which will definitely motivate other medical professionals to follow ethical, empathic, and patientfriendly practice.
4.
Conclusion
Violence is dominating our lives like never before. A violent society is detrimental to the well being of the society as a whole and in particular to practice humane medicine, and negates all the 'achievements' of modern medicine. It is our combined ethical responsibility to respond strongly and firmly to curb the ever-increasing violence against doctors. All stakeholders should strive to transform the doctor's mentality and build trust between the society and the medical profession, along with strong punishments for perpetrators of violence against doctors as well as medical negligence. No doubt it seems impossible, but we must do our bit before it is too late and beyond repair.
Conflicts of interest The authors have none to declare.
references
1. Arun B. A doctor's murder. Med Ethics. 2001;39. 2. Mishra S. Violence against doctors: the class wars. Indian Heart J. 2015;67:289–292. 3. Bawaskar HS. The medical trade. Indian J Med Ethics. 2013; 10:278. 4. Hongxing YU, Hu Z, Zhang X, Li B, Zhou S. How to overcome violence against Healthcare professionals, reduce medical disputes and ensure patient safety. Pak J Med Sci. 2015;31:4–8. 5. Ending violence against doctors in China. Lancet. 2012; 379:1764. 6. Chinese doctors are under threat. Lancet. 2010;376:657.
a
Vitull K. Guptaa,b,* Consultant Physician, Kishori Ram Hospital and Diabetes Care Centre, India b Associate Professor, AIMSR, 5042, Afim Wali Gali, Bathinda 151001, Punjab, India Navjot Kaur Assistant Professor, Dept of Pathology, GMC, Amritsar, India
233
indian heart journal 68 (2016) 231–241
Available online 11 January 2016
Meghna Gupta Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India *Corresponding author E-mail address: [email protected] (V.K. Gupta)
http://dx.doi.org/10.1016/j.ihj.2015.10.381 0019-4832/ # 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
Author's disclosure A doctor is a caregiver and a teacher. As a teacher, a doctor has to write. Treatment heals one but writing down a novel experience or innovation saves many lives. The latter in clinical medicine happens to a few but it is a routine happening on the editorial desk. A genuine author or researcher states that success is a path but not a destination. Most of the time, the editorial board is successful in convincing the author about the opinion.1 There are instances, wherein a rejected paper has no scientific reason. Such irrational act hurts both manuscript and author like ‘‘throwing a baby along with tub water’’. In the context, the victimized or humiliated authors have often murmured what happened in ‘‘AREPR’’ (AUTHOR, REVIEWER, EDITOR, PUBLISHER and READER) interface (Table 1). Aha! is it not painful? This has been well documented by the comments made to the article titled ‘‘Peer-Review Fraud—Hacking the Scientific Publication Process’’ by Haug.2 Acceptance for publication in a reputed
medical journal is an exciting moment for awaiting author. The approval acknowledges an arduous process of long journey from hypothesis to acceptance. The most important unmet needs for writing down a novel happening or innovation are command on language, basic computer knowledge, rough sketching of imagination, basic statistics, and not the last but the least is passion. Start with debate, give your best, and do not ignore co-authors. Editorial board is the highest jury to decide the fate of manuscript. The board also watches for the highest ethical standard and quality writing. Through a good writing, a research can be practiced by all the levels of physician. The appointed reviewers or referees are the experts to find science and its novelty to open the door to a newer level of evidencebased practice but at no cost or no reward. Of late, some publishers have added a page for contributing reviewers including Plublons as thank note. George Santayana told once ‘‘Those who cannot remember the past are condemned to
Table 1 – The improvement in the interface of ‘‘AREPR’’ (AUTHOR, REVIEWER, EDITOR, PUBLISHER and READER) improves the quality of publication. Contributors Author
Reviewer
Editor
Publisher
Reader
Dos
Do not
Give your best, why not when you are talking to world Keep up the most recent literature to avoid repetition Choose reputed journal, your work would not die Keep talking to your co-authors and do not forget to mention their individual contribution in the cover letter and copyright: ‘‘Many eyes, less mistakes’’ Choose OPEN ACCESS when you can afford, it makes the science to reach far and wide Take reviewers and editorial comment positively and seriously, address those best Enjoy the scientific novel, as you are lucky to be get invited Ignore the author but respect the science he or she has brought If you do not have access to a recent literature which would help reviewing the current manuscript, ask your friend for help Maintain the highest ethical standard and quality of content in publication Retract ruthlessly when plagiarism or fake reviewing is established Appreciate the reviewers Preserve copyright as it is Preserve the work to the eternity Watch for plagiarisms Appreciate the author for his work As an end user, you are responsible for bridging the gap between bench and bedside.
Hurry Choose reviewer in favor or against Criticize the editor and reviewer as they introduce you and work to the world Create false reviewer by using your and your friend's email
Hurry as medical science is the fastest growing science and very difficult to keep up with Ignore reviewer's view point
Charge more than what is reasonable
Not encourage anything which is not evidence-based and updated
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ihj
Correspondence
Is changing curriculum sufficient to curb violence against doctors? Dear Sir, ‘‘Other side of the moon, Violence against Doctors: The Class wars’’ by Sundeep Mishra, Indian Heart Journal, 67 (2015) 289– 292 has discussed the most important issue, the medical profession is facing today, of violence against doctors. Doctors being roughed up, beaten, and even killed, by patients' disgruntled relatives is in the news with ever-increasing frequency.1 Dr. Sundeep has very intelligently discussed various predisposing causes and what needs to be done,2 but I do not see it as class wars, because neither those who have and those who do not nor the rich and the poor are at war; so, it cannot be seen as a class war. I think violence against doctors is a symptom of the collapsing capitalistic society and increasing distrust and suspicion in the doctor–patient relationship, which is multifactorial. Moreover, changing medical curriculum may have some effect, but it will not at all be able to curb the increasing violence against doctors, because it will be really impossible to teach empathy, sympathetic communication, ethical practice, curbing unnecessary investigations, etc. to a medical student admitted after paying a hefty capitation fee without having the right commercial inclination. Moreover, medical colleges are teaching preventive and social medicine for about two and a half years, and it is an open secret how well our medical graduates practice preventive and social medicine in real life. So, it will be really a very far-fetched idea to think that changing medical curriculum will have any significant effect in curbing violence against doctors.
1. Social degradation and intolerance as a contributing factor The combination of forces of economic aspirations, greed, extreme stress and frustration of modern living, competitiondriven society, and distorted, misplaced, and false religious, cultural, educational, and social values are increasing intolerance in the society as a whole. The art of happily, healthily, and contented living has been eroded where love for permanency and tradition has been replaced by the utilitarian
approach, plastic goods, plastic hearts, plastic minds, and things of temporary, short-lived value. As a medical professional and human rights activist, I feel that three decades ago, people with inclination to serve the suffering mankind opted for the profession and were trained by teachers of high academic and moral standard. But now, mostly people join the profession after paying hefty donation or fee only to make a lot of money later on. Excessive commercialization of medical care has paved the way for increasing greed, the proliferation of unethical practices – conducting unnecessary tests and investigations, adopting unnecessary procedures and surgeries, etc. – leading to increasing distrust between patients and doctors. Doctors in India were treated as demi-gods and commanded vast respect without questioning their treatment, but now with little attention to the humanities, ethics, the social context of illness, or lack of communication in conflict situations, doctors are increasingly being projected as demons all out to earn money at any cost.
2. Reasons for increasing violence against doctors: The reasons for patients' relatives becoming violent can be: relatives impression of neglect in patients' care, lack of communication, unnecessary investigations, delay in attending patient, request of advance payments, or withholding a deceased body until settlement of final billing. Ultimately, the medical trade now involved in this noble profession has resulted in doctors, patients, and relatives' unrest.3 As a Health and human rights activist, I see the following most important factors leading to increasing violence against doctors: False assurances given by the doctor to relatives leading to high expectations for recovery with treatment and prognosis under the hypnotizing influence of earning money or fear of losing the patient to some other doctor. Economic shock for the patient/relatives as there is no health budget being kept by the households in India and
232
indian heart journal 68 (2016) 231–241
majority are middle class or poor people, and are without any economic stability or health insurance. Lack or sometimes total absence of communication between the patient's relatives and the doctor for medical condition and its risks along with failure to devote time for serious patients. Ever-increasing tendency of relatives to blame doctors for any death may be because of lack of medical knowledge, ineffective communication between doctor and relatives, economic stress, and greed to extract money or blackmail the doctor. An important contributing factor for increasing violence against doctors is poor image of medical professionals projected by the media leading to general belief that doctors are the greatest villains and extortionists who exploit patient's miseries to extract money. Moreover, public's lack of faith in judicial system, the inactivity of the police, and the impression that the police will take no action and can easily be bribed are other contributing factors. On the other hand, majority of the doctors are hesitant to file any complaint or an FIR against the patient or relatives because of fear of getting involved in a time-consuming judicial process or creating more enemies with the local population affecting their practice; so, doctors often try to hush up the incident, and simply carry on, albeit demoralized. Since there is no conviction of persons known to have assaulted doctors, it always leads to more lawlessness among the public. Most of the times, the Indian police often seem to be unaware of the recently enacted laws and judgments, or feigns ignorance or ignores law under public or political pressures. It is a common sight to see numerous small-time politicians throw their weight around in busy hospitals to impress their vote bank, which I feel is a common prelude to violence against doctors. When a patient suddenly and unexpectedly dies, it is far easier for relatives to blame the doctor and quickly demonize the doctor, resulting in violence. Violence against doctors is being reported from all over the world. A study4 from China has highlighted numerous cases of violence against healthcare professionals leading to death of some doctors, as well as nurses, by patient's relatives, and the reasons are poor quality of services, increased awareness of patients about their rights, and their willingness to knock the doors of courts to seek justice. Negative media reports about hospitals and doctors, out-of-pocket medical expenditures by the patients, and lack of trust in doctors and hospitals have been reported to be some of the causative factors in China.5,6
3.
Way forward
I strongly feel that solutions to curb violence against doctors and improving trust between the patient and the doctor cannot be isolated from other socio-economic problems plaguing the increasingly market-oriented Indian society, which will definitely require a complete overhaul of the existing economic system and healthcare system, with increased communication between the doctors and patients, filling crucial gaps in communication between doctor/patient/
relatives, sympathetic attitude instead of mechanical attitude, curbing low-level political bullying with tougher laws, both for medical negligence and violence against doctors, and removing frustrating shortfalls in the public health system along with strengthening and promoting low-cost efficient universal public healthcare, incorporating global vision and local actions, keeping in mind aspirations and well-being of sick people, will provide solutions to decrease violence against doctors. Professional organizations should play a proactive role to ensure ethical medical practice. Definitely curriculum should be changed to incorporate necessary communication skills, etc. Media can play a larger than life role in improving the image of the medical profession, projecting role models amongst the doctors, which will definitely motivate other medical professionals to follow ethical, empathic, and patientfriendly practice.
4.
Conclusion
Violence is dominating our lives like never before. A violent society is detrimental to the well being of the society as a whole and in particular to practice humane medicine, and negates all the 'achievements' of modern medicine. It is our combined ethical responsibility to respond strongly and firmly to curb the ever-increasing violence against doctors. All stakeholders should strive to transform the doctor's mentality and build trust between the society and the medical profession, along with strong punishments for perpetrators of violence against doctors as well as medical negligence. No doubt it seems impossible, but we must do our bit before it is too late and beyond repair.
Conflicts of interest The authors have none to declare.
references
1. Arun B. A doctor's murder. Med Ethics. 2001;39. 2. Mishra S. Violence against doctors: the class wars. Indian Heart J. 2015;67:289–292. 3. Bawaskar HS. The medical trade. Indian J Med Ethics. 2013; 10:278. 4. Hongxing YU, Hu Z, Zhang X, Li B, Zhou S. How to overcome violence against Healthcare professionals, reduce medical disputes and ensure patient safety. Pak J Med Sci. 2015;31:4–8. 5. Ending violence against doctors in China. Lancet. 2012; 379:1764. 6. Chinese doctors are under threat. Lancet. 2010;376:657.
a
Vitull K. Guptaa,b,* Consultant Physician, Kishori Ram Hospital and Diabetes Care Centre, India b Associate Professor, AIMSR, 5042, Afim Wali Gali, Bathinda 151001, Punjab, India Navjot Kaur Assistant Professor, Dept of Pathology, GMC, Amritsar, India
233
indian heart journal 68 (2016) 231–241
Available online 11 January 2016
Meghna Gupta Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India *Corresponding author E-mail address: [email protected] (V.K. Gupta)
http://dx.doi.org/10.1016/j.ihj.2015.10.381 0019-4832/ # 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
Author's disclosure A doctor is a caregiver and a teacher. As a teacher, a doctor has to write. Treatment heals one but writing down a novel experience or innovation saves many lives. The latter in clinical medicine happens to a few but it is a routine happening on the editorial desk. A genuine author or researcher states that success is a path but not a destination. Most of the time, the editorial board is successful in convincing the author about the opinion.1 There are instances, wherein a rejected paper has no scientific reason. Such irrational act hurts both manuscript and author like ‘‘throwing a baby along with tub water’’. In the context, the victimized or humiliated authors have often murmured what happened in ‘‘AREPR’’ (AUTHOR, REVIEWER, EDITOR, PUBLISHER and READER) interface (Table 1). Aha! is it not painful? This has been well documented by the comments made to the article titled ‘‘Peer-Review Fraud—Hacking the Scientific Publication Process’’ by Haug.2 Acceptance for publication in a reputed
medical journal is an exciting moment for awaiting author. The approval acknowledges an arduous process of long journey from hypothesis to acceptance. The most important unmet needs for writing down a novel happening or innovation are command on language, basic computer knowledge, rough sketching of imagination, basic statistics, and not the last but the least is passion. Start with debate, give your best, and do not ignore co-authors. Editorial board is the highest jury to decide the fate of manuscript. The board also watches for the highest ethical standard and quality writing. Through a good writing, a research can be practiced by all the levels of physician. The appointed reviewers or referees are the experts to find science and its novelty to open the door to a newer level of evidencebased practice but at no cost or no reward. Of late, some publishers have added a page for contributing reviewers including Plublons as thank note. George Santayana told once ‘‘Those who cannot remember the past are condemned to
Table 1 – The improvement in the interface of ‘‘AREPR’’ (AUTHOR, REVIEWER, EDITOR, PUBLISHER and READER) improves the quality of publication. Contributors Author
Reviewer
Editor
Publisher
Reader
Dos
Do not
Give your best, why not when you are talking to world Keep up the most recent literature to avoid repetition Choose reputed journal, your work would not die Keep talking to your co-authors and do not forget to mention their individual contribution in the cover letter and copyright: ‘‘Many eyes, less mistakes’’ Choose OPEN ACCESS when you can afford, it makes the science to reach far and wide Take reviewers and editorial comment positively and seriously, address those best Enjoy the scientific novel, as you are lucky to be get invited Ignore the author but respect the science he or she has brought If you do not have access to a recent literature which would help reviewing the current manuscript, ask your friend for help Maintain the highest ethical standard and quality of content in publication Retract ruthlessly when plagiarism or fake reviewing is established Appreciate the reviewers Preserve copyright as it is Preserve the work to the eternity Watch for plagiarisms Appreciate the author for his work As an end user, you are responsible for bridging the gap between bench and bedside.
Hurry Choose reviewer in favor or against Criticize the editor and reviewer as they introduce you and work to the world Create false reviewer by using your and your friend's email
Hurry as medical science is the fastest growing science and very difficult to keep up with Ignore reviewer's view point
Charge more than what is reasonable
Not encourage anything which is not evidence-based and updated
