ASSAULT ON DOCTORS
Introduction
Assault on the medical profession is a worldwide phenomenon. According to Merriam Webster dictionary, assault means ‘a violent
physical or verbal attack or a concerted effort (as to reach a goal or defeat an adversary)’. Violence has many causes and manifests in
many ways. It can lead to physical injury and material damage. It causes a tremendous psychological strain on the medical personnel and
services. It can cause severe emotional long term damage.
There are two different modern concepts of violence, one the "minimalist concept" of violence as an intentional act of excessive or
destructive force, the other the "comprehensive concept" which includes violations of rights and other aspects.
Definition:

Violence is defined by the WHO as "the intentional use of physical force or power, threatened or actual, against oneself,
another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death,
psychological harm, mal development, or deprivation".
Other definitions also emphasise on ‘excited’, ‘verbal’, ‘oral or written’ and psychological aspects.

Types: Violent acts can be: physical, sexual, psychological and emotional.
Triggers:










Sudden death
Denial of admission
Delay in providing care
Shortages of drugs, manpower and equipments
Negligence by staff
Death announcement by junior doctors
Ignorance about natural course of disease
Alcohol consumption,
Violence in the media,
Overcrowding / person being disrespected.
Law: The Delhi Medicare service personnel and Medicare institutions Act 2008 has the following features:

Cognizable and non bailable with imprisonment up to 3 years and fine or both.

Offender to pay a penalty of twice the amount of damage.

If offender fails to pay, then it shall be recovered as per land revenue recovery.
Vulnerable areas




Major hospitals – especially in Casualty, Emergency, OT and ICU
Smaller private nursing homes and clinics.
Crowded and poverty stricken areas
Feudal mindset areas
Violence is due to a more demanding and aggressive society. It also has more available knowledge. Violence in any form is the net result of
two forces. An inciting force and a pacifying force. The inciting forces are guided by a mindset of feudalism, male dominance and a violent
society depicted by a lesser evolved media. The greatest pacifying force is ‘reasoning’. Education helps people to think more universally,
and this decreases violence. Reason replaces morality of feudalism and authority, with fairness. Empathy helps prevent violence.
Stakeholders
To understand the issues of assault on doctors / medical establishments, the existing role of the following stakeholders has been
considered:







Individual / Community
Police
Political functionaries
Media
Legal /Judiciary
Doctors
Medical establishment
 Delhi Medical Council (DMC)
 Students
 Health employees
Causes: The following are the major causes of assault on the medical profession.

Poor image of medical profession e.g. delay in examination of patients, death while shifting, unacceptability of negative
outcome.







Billing issues and after death billing.


Insufficient security, insufficient laws and weak justice system.
Growing intolerance of society and excess money, mob mentality.
Poor attitude, behaviour and communication skills of both sides.
Poor infrastructure for medical personnel e.g. bad hostel / poor quality mess etc.
Irritated doctor on duty – long hours and fatigue. Shift duties, uncertain future. Over worked.
Delayed professional start, inadequate compensation as compared to colleagues in other professions. Decreasing respect.
Weak administration and negligible administrative control. Misbehaviour by paramedical staff. Frustration with government
hospitals.
Political motive.
Effects of Violence:
1.
2.
Immediate

Trauma - Physical injury / Emotional

Damage to property

Police

Crowd

Media
Short term

Reputation damage

Social impact

Impact on medical practice

Financial issues

Rehabilitation role
Factors: These are complex and occur at four-levels:
1.
2.
3.
4.
Biological and personal factors that influence how individuals behave: age, education, income, genetics, brain
lesions, personality issues, substance abuse, and witnessing violent behaviour.
Close relationships, such as family and friends who engage in or encourage violence.
Community i.e. areas with drug mafia, absence of social dealing and concentrated poverty.
Societal factors in which violence is encouraged or inhibited e.g. responsiveness of the criminal justice system, social and
cultural norms, gender and income inequality, social acceptability of violence, exposure to violence in mass media, and political
instability.
The same conditions also cause poor mental and physical health, addictions, illiteracy, unemployment and poverty.
Components: Two components basic to a violent act are:


The Propensity to be Violent - is a personal factor - it resides within the individual committing the act i.e. intrinsic.
The Trigger to a violent act - is a social factor, which resides outside the individual committing the act i.e. extrinsic.
Mostly, triggers lead to violence only when the propensity to be violent also exists.
Cause and effect relationship:
There are many causes and antecedent factors which affect the perpetrator of the assaulting person. These factors require a trigger. Poor
conviction rates and political patronage to anti-social elements decrease restraint. The weak guidelines of Medical councils and strong anti
professional response, adversely affect the situation. To prevent such a situation from arising, the medical community has started taking
certain precautions. These are:

Defensive practice e.g. detailed investigations,

Avoidance - of medically and socially high risk cases.

Physical security e.g. barriers, guards and bouncers

Greater unity among doctors and staff

Cultivation of media, social and political contacts

Heavy insurance premiums for professional indemnity, property insurance and personal insurance.

The net effect is increased cost of services and decreased trust in the doctor – patient relationship.
Management goals: These are
1.
2.
3.
Crisis mitigation – Communication; Arrange for help; and Numerical strength.
Short term –Impact reduction and Rehabilitation
Long term – Prevention and Remedial measures
Prevention strategies: These are:

Primary prevention – before the violence occurs.

Secondary – crisis management

Tertiary – short term and long term
Primary Prevention: Modifiable factors are

concentrated poverty

income and gender inequality,

alcohol abuse

unstable family life.
General aspects of violence prevention:














Communication skills
Group deterrence
Disease education
Empathy
Medical training
Respect patients, give more time, explain , empathise, encourage second opinion
Cost containment. Avoid charging for complication
Inform about anti violence act
Restrict entry
Increase positive news
Accept limitations of self, hospital and medical science
Poor prognosis cases to be explained by senior doctors
Appreciate difference between complication, negligence and wrong intent.
Cure where possible, care always and communicate maximum.
Discussion:

Role of Individual / Community
Crisis mitigation: Prevent further violence. Help catch the culprits. Help provide treatment to the injured. Call the police and
other appropriate authorities.
Short term: Counselling of perpetrators of violence. Channelize energy towards constructive works.
Long term: Violence appears whenever power is in jeopardy and is purposeless. It is part of socio-political power struggle. The
community support to violence must end. There should be adequate forums for expression and redressal of grievances.

Role of Police
Crisis mitigation: Reach promptly and act effectively. Inspire confidence in the victims. Register an FIR and arrest the culprits
immediately. Prevent further harm to people and property. Enforce all laws strictly and justly in a non partisan manner.
Short term: Intelligence gathering, preventive and persuasive measures are more effective for focussed attention. After an
outbreak of violence, the police must help and protect the victims. It should initiate action and build a strong case against the
culprits.
Long term: Community and problem-oriented policing should be strengthened to reduce crime and violence. The police should
primarily function as a crime prevention agency.

Role of Politicians
Crisis mitigation: Pacifying role & crowd management. Facilitate justice and defuse situation.







Short term: In every major violence act, they have a role as instigators or pacifiers, political information gatherers and
providers; modifiers of police and administrative action and finally the arbiters of political response to such incidents. They
have to create conditions for a stable and just society.
Long term: They are the leaders of society. They provide political patronage to their supporters and also are close to those in
authority. They are likely to have a vested interest either in retaining the status quo or bringing about a change.
Role of Media
Crisis mitigation: This can be done by a responsible media which projects a balanced view. It should avoid negativism and
sensationalism.
Long term: Avoid violence on TV. It provokes predisposed people. Avoid partisanship, sensationalism and distortion of facts.
This gives satisfaction and justification to the perpetrators of violence. This can also negatively mould public opinion. They must
follow a model code of conduct with reinforcement of a positive message.
Cinema glamorises negativity for 3 hours and projects a positive message in last 5 minutes.
Print media also needs to publish responsibly.
Role of Legal experts / Judiciary
Crisis mitigation: Prompt and swift action along with speedy trial and justice must be ensured.
Long term: Ensure proper compensation is awarded to the victims. The judiciary enforces laws against violence and ensures
that justice is done. It ensures offenders are properly identified, their degree of guilt is ascertained, and they are punished
appropriately. It relies primarily on deterrence, incarceration, punishment and rehabilitation of perpetrators.
Role of Doctor / Medical establishment
Crisis mitigation: Do not argue or join issue with the agitated person. Reassure and try to calm them. Call for help from
colleagues, association, police, community leaders and Professional Indemnity Company. Complete all the medical records, get
photocopies and keep them ready for giving to patient /attendants and the police if required. Arrange for adequate private
security and legal help. Ensure personal staff safety first and foremost. Then secure your property. Limit access of sensitive
areas to public. If damage has occurred, then secure video recordings from CCTV cameras and take videos of damage
committed and identify the mob leaders for police FIR. Issue a press statement for presenting the doctor / medical
establishment version.
Short term: Ensure proper follow up of police FIR, legal and insurance issues. Decrease stress and look ahead. Take adversity in
stride. Tough times do not last; tough people do!
Long term: Follow the MCI / DMC Code of Ethics properly. Maintain records properly. Take proper informed consent for any
treatment / procedure. Restrict professional work to core competency. Take adequate care of the patients for early detection
of problems.
Maintain a close and cordial relationship with the community leaders and the police of the area. Have empathy. Be true leaders
to the community that is served. A realistic picture of safety aspects of the procedures undertaken should be disseminated to
public. Explaining cost inputs in its entirety including manpower training costs. Emphasis should be on Health promotion and
disease prevention.
Role of Students
Crisis mitigation: Join seniors to have a numerical advantage. This acts as deterrence and also provides useful insight in
handling these situations.
Short term: Help restore the affected services at the earliest possible.
Long term: Department of PSM should be requested to add a chapter on ‘Mechanisms for coping with Assault on doctors’. It
should devote fifteen days of Internship in PSM to imparting knowledge and practice of ‘Basic Managerial Skills’. It can add
teachings involving morals, ethics, etiquettes, general conduct, professional conduct and patient interaction skills. Students
should be encouraged to create greater awareness towards: Higher calling, Purpose of life, Role of money, and positive aspects
of the medical profession.
Role of DMC
Crisis mitigation: No role at present. We request the DMC to play a greater role in the protection of its members.
Short term: Consideration of micro-environment and conditions of practice. A systemic rather than individual based response
should be followed for alleged ethical and other transgressions. Medical code of ethics needs to be redefined and aligned with
changing social environment. Impact of social and economic reservation in the practice of medicine needs evaluation. Focus
should be on preventive rather than punitive focus. It should have a greater corrective and reformist role.
Long term: To initiate steps for the following: clinical audit as a routine in all establishments; protocol based treatment
justifying any deviations; indications and types of common medical and surgical procedures should be protocol based; detailed
and universal documentation format; and errors of omission and commission to be monitored.
DMC Act - Section 10 (f) and (g)
Section 10 (f): ‘and similarly to take action against frivolous complaints’.
Section 10 (g): ‘To provide protection to its members in discharging professional duties’.
According to Merriam Webster dictionary, protection means ‘the state of being kept from harm, loss, etc’. Section 10 (g) needs
to be prominently displayed in the DMC website. It will instill confidence among doctors and encourage public towards a
rational behavior. The form and scope of protection from harm and loss can be clearly defined. It should also include protection
from harm or loss due to compliance with ‘code of ethics’ and create a proper environment for compliance with ‘code of
ethics’.
Role of Medical associations

Crisis mitigation: Rush to help the members of the association in distress promptly and appropriately. There should be a ‘Rapid
Action Team’ of nearby doctors and security agency which should reach the site and help defuse the crisis and prevent any
untoward turn of events. They should assure the agitated complainants of a non partisan and objective assessment of their
grievance in a time bound manner. They should liaison with the police and other agencies.
Short term: Arrange for appropriate support to reduce the stress and mitigate any personal hardships being faced by the
victims. Show solidarity with your professional colleagues. There should be ccontinuous interaction with media and it needs to
be cultivated for positive impact on public. Direct interaction by every branch with the general public with talks, exhibitions etc.
Presenting the correct state of medicine as an imperfect science and toning down unrealistic expectations. Form a ‘Grievance
Redressal Committee’ for patients and address the concerns of patients in a just and time bound manner.
Long term: Bridge the trust deficit in the doctor patient relationship by promoting measures for: Patient education about
medical issues, enhanced patient participation in decision making and greater transparency in treatment decisions and billing.
Explore the possibility of bank guarantees for recovering costs of damages to private medical establishment property.
Role of Health employees
Crisis mitigation: They must collect in large numbers to act as deterrence to violence. They must help restrain the agitated
individual / public and prevent damage to property. Help provide treatment to all the injured.
Short term: After the completion of legal formalities, they should quickly try to restore the functioning of the set up. Make an
assessment of the broken items and help the employers move ahead.
Long term: The health employees are an important part of the health care system. They have a tremendous impact on the final
impression created and subsequent outcome of the treatment. A robust technical training program, good interpersonal skills,
empathy, commitment to work and proper work ethics are essential objectives to be achieved. These qualities have a cost
attached to it. There is a wide disparity in the salaries of health employees in the private and the government sectors which
needs urgent attention. Wage disparity between health employees and other employment sectors fails to attract better talent
into the private health sector. Greater administrative empowerment in government hospitals will aid in toning up the
employees and achieve better patient outcomes and satisfaction.
Conclusion:
The creation, nurturing, growth and protection of vital components of a healthy society, is the responsibility of all segments of society.
Distortions that creep in have to be prevented and corrected. The expectations of the people and their non fulfilment by the medical
profession, is a multi-factorial distortion.
An assault on a doctor is not a correction of any distortion but a distortion in itself. It is a collective failure of all segments of society. It sets
in motion a chain of reactions and counter reactions which lead to a negative vicious circle. Ultimately, this will culminate into events
beyond our comprehension at present. It will attract those elements into the profession who are a direct antithesis of its requirements.
Thus, the price of such incidents will be paid not only by the victims of violence, but by every segment of society.
If we wish to create a stable and civilized society, then we need to ensure the ‘minimalist’ concept of violence. If on the other hand, we
aspire to be a progressive and developed society then the requirements of ‘maximalist’ concept of violence will have to be attained. This
effort is an attempt towards creating that awareness. Come let us take the first steps towards this beautiful dream.
Dr Rakesh Taneja,
Convenor,
Planning Committee,
Delhi Medical Association.