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The Anatomy of Violence

Jul 03 | 2:30 PM

Every day we hear about incidents of violence against doctors. It affects everyone - residents, consultants; public hospitals, private setups. In this session, we try to understand how the incidents flare up, and what we can do as doctors and hospital owners to prevent them or nip them in the bud.

great with that i think everything sounds uh better now uh very good evening everyone i am dr jagdish chaturvedi i'm an ear nose throat surgeon and uh i live a very dangerous life i'm very likely to be a victim of what we're talking about very soon if i continue the way i'm doing but uh but jokes about i think today we're here for a very serious topic it's a topic that we really need to talk and uh and you know and address a lot of the concerns that are related to our safety and safety of our peers and safety of the patients also because they are also adversely affected uh when any doctor is assaulted and we have uh two uh very well known voices who always voiced out you know the right things uh during times of assault on doctors uh so i'd like to uh welcome dr ajay and mr noumaan welcome and i'm it's a privilege to be uh you know moderating this session it's uh it's become so normal now which you know when we uh when we hear a doctors being assaulted uh you know by relatives and families sometimes i mean this is very recent that i've noticed uh you know even around my relatives or friends or or when any time when this is discussed it's becoming more and more normalized it's like yeah so what's what's so new about this you know it's it's becoming like that and that is what is scaring me the normalization of assault the normalization of entitlement to demand treatment to demand an outcome when you may not have any control on the on the disease and on the time and and you know all of that thing all of those things will go there um so so why is this happening you know is it is it because we as doctors are not communicating uh to the patients in the right manner or is it that they don't have the awareness or maybe have the they don't have the ability to have that awareness because we study for like decades and then still many times we understand new things after 10 years like oh you know there's a lot of knowledge and a lot of practicality to understand certain things about certain diseases even if you look at covid you know how much we have involved in its understanding over the last two years because we do grant rounds with the country right we do grant rounds with the prime minister we do the grand rounds with the world uh how many cases are there today how many deaths are there today right so there's so much of discussion you see how much it evolves but imagine that for so many diseases and so many conditions or is it that is media painting an evil picture of doctors that is you know preset uh in relatives or in attenders mind that i'm anyway going to be cheated or i'm likely to be cheated so they see something out of order and they take things in their hands what is it that is causing this and um i think in today's session i would like to understand what what both of you think is the reason for it but before that um i would request you to kindly introduce yourself and give some background good evening everyone yes you're honorable yes great so just a brief background i started my career in medical publishing around the year 2000 it's almost 21 years that i have been working with the healthcare sector and i spent around 15 years in consulting with healthcare organizations on the communication mandates so you know right from violence in hospitals to mergers and acquisitions and fundraising one has worked across the spectrum of communication that works in the healthcare sector there is some special interest in the subject of violence against doctors for two reasons when i started in 2000 one of the things i had to do in my job is travel across the country participate in most of the medical conferences because we used to generate content from there so you know one has seen healthcare up front on the ground how healthcare delivery happens in big cities in smaller towns so that was one then you know during those travel you met up with the postgraduate students you interacted with them in their hostels and you saw how they lived so there was some kind of an understanding of the life of doctor that was one the second was in 2011 i was doing a research paper on risks for hospitals as a dissertation and during that conversation one of the questions i asked the respondent was in terms of reputation and i listed down some five professionals started accounting for a lawyer and doctors were the highest in terms of reputation so that was one good insight that i had but in terms of reputation doctors still enjoy very good reputation with the respondents but what is it that is going wrong and that is what led to my curiosity in the subject and then i studied this further and i presented at some international conferences and it has got published to answer your question i think we need to make a distinction between the violence that happens in private hospitals and the violence that happens in public hospitals because the reasons are completely different many times we try to paint it with the same brush but it's not the case so that is point number one point number two is there is a reactive way to deal with any issue you know something has happened we will protest we will ask the government to bring a law is a reactive way of dealing with it and in any issue there is a proactive way of dealing with it so proactive ways what are the safeguards that i can put that will become a mitigation mechanism that this kind of things doesn't happen last month harvard has published a research that a little bit of nudging with the caregivers and patients who create empathy and understanding about the doctors will reduce the risk of violence in hospitals so there's a lot of this kind of things appearing during the conversation we'll touch upon that over to the doctor now for the introduction and answer to this hello mr qureshi thank you um uh my name is dr ajay ramesh i'm a junior doctor studied at bangalore medical college graduated 2019 i'm also a youtuber with 60 000 subscribers and i've been always very active with the resident doctor association back in medical school but um i mean i was just part of it i was part of youth red cross uh all these voluntary activities but then um in 2019 something happened um if you all remember the NRS medical college incident where uh intern was beaten up two interns were beaten up so that was sort of a turning point in how i saw the situation because till then it just felt like uh yeah something like this happens i mean i was part of a few protests with my seniors but it never you know hit close to home but this i was in it and these people were intern and the only difference between me and the person who got beaten up was that we were in two different hospitals literally the same age the same position the same work it could have been me so that was sort of an awakening and i was in the rda so we got all of of our people together we organized the biggest strike in south india at bangalore medical college uh when that happened back in october 2019. so after that i've been quite vocal about it on my social media platforms and all that but again coming back to uh uh dr jagdish's question um so i believe violence happens again mr qureshi you know like gave a very valid point of uh you know it is different how in private hospitals and in government hospitals and we can't paint it in the same picture very valid point but the way i see it there are two reasons why you know violence against doctors happen the first is that the attender or the patient themselves are very unruly they're probably there to cause some trouble which is not very often it's quite rare like it doesn't happen very often but the second thing is something goes wrong in between the patient doctor conversation somewhere and there could be many reasons for this and i think one of the main reasons is because as doctors if we have to look at our part in this the whole scenario why some a situation like this even arises it would be um wrong if we don't realize that there's a bit of mistake on our part too especially when it comes to communication this is something that we are really lacking in we don't communicate properly to the patients attenders what is happening we don't give them regular updates and even when we you know like say if unfortunately a patient has passed away we don't we don't break the news in a proper manner like the breaking bad news is not taught it's not learned people don't put effort into learning something like that they're very blunt about it there's no sympathy there's no empathy i've noticed a lot of my colleagues being extremely rude with patients and we have to note that when patients come to us they're probably at the lowest point in their lives and if you're not being you know sympathetic to their feelings or being empathetic to their laws and you're being rude and arrogant i mean one of the outcomes of this situation is violence and that is probably what happens in a lot of situations and again i was uh speaking to dr rohan desai the other day and we were discussing how you know we have to be trained to diffuse situations like in the letter five minutes before a doctor gets hit is like the golden period and um the doctor the doctor also plays a bit of a part in not defusing the situation so i believe the how to tackle this i mean we can do a lot of things the government can do a lot of things they can bring laws can have strict security measures and all that but as doctors as healthcare workers what we can do is to learn effective communication especially when it comes to breaking bad news and keeping you know like patients updated regarding you know either theirs or their relatives health status i think this is something like i mean we learn a lot about uh effective history taking like the 100 different ways of taking history and all that in medical school but absolutely nothing has been taught on how to you know like speak to the patients and i'm currently in the UK i'm studying for the plab exams and what i've noticed here is that uh in the plab exam which is a clinical exam the main thing that they look for is for interpersonal skills like many of the stations are breaking bad station like telling a patient that you know like your wife has cancer or your mother is going to be passing over there we are going to put on palliative care and i see a lot of you know doctors trained in india pakistan bangladesh arab countries they're very bad at it because they have absolutely no idea how to do it because back home we just we are very blunt about it but if you see the way uh doctors here are trained to do it they're very sympathetic they're empathetic they know how to break it they know how to defuse the situation so um i mean violence on healthcare workers happens everywhere in the world i'm not saying india is like some place where this specifically happens but i think one of the reasons could be like this terrible communication skills that we doctors have that we can you know put efforts into learning and making ourselves better but i think that i think would be like a very good i'd like to uh add to what dr ajay is saying and uh and you know mr qureshi communication being one of the important things let's just take something that both of you have mentioned uh over here my perspective uh is is there have been some small tiny points where i have reflected on how we doctors speak about patients amongst each other and i don't know whether it's that that feeds into our subconscious but but here's one thing generally as human behavior well we are not nobody is usually very emotional about their work you know uh like when you say the word work you think of yeah something boring repetitive uh something that is mundane you know papers accounting work right work does not always sound enjoyable i know some people are passionate about their work but work as um as an entity is usually considered to be you know serious and repetitive and all of that like it's like you know get to business move on move on right uh but when it's something personal when you are in a problem you are more emotional about it you are not rational or practical about it and we as doctors are a profession that deals only with problems like if people don't have problems we have a problem i mean you know semantically right i mean we don't have a purpose to exist if everyone's fine right and we deal with problems if you see 100 people we see 100 people with their individual 100 problems and sometimes one person comes with many problems so for us looking at people and their problems 100 200 a day for years together i think somewhere makes it into that work zone you know i remember when i used to talk to my colleagues you know when my junior doctor or a junior resident is on call and they're telling what happened over the last six hours you will hear something like this we have three foreign body knows we removed it uh three of them i referred out because of something else two of them uh you know did not make it four got admitted into the ICU we got five cases posted tonight it's like numbers cases you know discussions right there's no emotional quotient to it is nobody's saying that you know i had a child who was crying for four hours and to console their parents and the parents were extremely worried what to do with this you know this is going to be something serious and all of that and maybe you should also talk to the family and explain to them that's not the kind of thing we usually talk about no i think they you move the patient with OT you know get this thing out refer that patient if you can't see it it's like that right and i think somewhere in the subconscious when we are with the relatives i think that reflects you know because it's a it's one case out of ten that you're seeing in a day right it's one out of many things that you're doing and i think from from people uh uh you know uh i have had close shapes uh not personally but um you know there have been situations around me where patients have got agitated doctors have gotten agitated and um and i come from a observant theatrical background generally observe behaviors and observe how people talk and sometimes i go and talk to these people why did they get upset and why did they get angry and one of the things i've seen most common that patients relatives say is that i am not treated with with the empathy or as a human i'm treated like a file i'm treated like a case now somebody is treating me like that is it even going to uh be doing justice right am i just a part of your your money making system or am i a part of your whatever you know so i think there is that disconnect which starts uh melting away the trust i guess and i think then like you rightly said uh you know internationally they don't have these kind of uh workloads you know i mean in UK um you would see five or six patients a day and the one patient doesn't show up you've got 30 minutes to do nothing right we would probably see 300 patients in four or five hours and then not even have lunch and go for rounds and then probably you know do all these things uh so so one is the system doesn't allow us a time and the second is uh there is a benchmark or uh comparison to a lot of other settings and creates this um but but before i ramble on i want to ask you know one question and i think dr ajay you mentioned and even you uh mr qureshi that there is a golden window there is a way to pick when this is going to happen and being through as a doctor what do we usually do and we'll follow that order over here what is the early signs and symptoms of assault or a potential assault like what is it that typically happens in the change of behavior in the patient or the change of behavior or it could be any other factor what are these early two or three things that we should be a little more cautious to remember that this may go this may go bad and maybe assaulted to us dr ajay mentioned that sometimes doctors also push it to the limit and that could also be because they're busy and they're doing important work and they don't have time for this and they get irritable very quickly but what are the early signs if let's just get some consensus on that uh mr qureshi why don't you go first one i have some contrarian views to this because this is a little narrative that is floated but my research is mostly qualitative so i dig a little deeper into why certain things are happening and yes all these episodes happen and like doctor mentioned about UK and i was discussing with somebody that this idea of signages and making people aware is a very important part so if you travel at least two years back when i traveled in the trains in UK they have this posters saying elizabeth is the mother of whatever the child's name is and is the daughter of this and is the wife of this and she is a conductor on this train to treat her respectfully so bringing that empathy about the person that he's not only the person who's dealing with you but is also a family member of somebody else you know brings lot of this empathy as an idea in the conversation now all those kind of things maybe are lacking in the healthcare sector and just coming to public health where you know where doctor is referring to the violence that happens against doctors i have done field study in mumbai hospitals with medical colleges by the time somebody reaches the ward to get admitted it's a frustrating experience you know so many wards so many papers and for them doctors become the ultimate face of what is going wrong with healthcare so all that inbuilt frustration just comes out in that particular episode that is part one part two is the more you say that doctors lack communication skills internationally literature is available which says that this happens with doctors across the world and in US especially the best of doctors have the highest number of litigation going against them because they are so technically good but not able to communicate with the patient that you know patients actually go to vote against them so there's a lot of data there are a lot of views so you know one can't ever clear view that this is correct and this is wrong but generally coming purely to a indian perspective one the doctor operates in the ecosystem that ecosystem has to be managed better how do you lessen the frustration of the person coming to the hospital because in a public hospital he is traveling maybe hundreds of kilometers so how do you tackle that doctors only becomes the end point second is at least my data indicates most of the time in public hospitals where doctor who face violence are the young doctors not the senior doctors is there a requirement for some kind of a SOP in terms of who conveys and how that person conveys a serious news to the patient's relative is it a senior doctor who communicates is there a trained counselor who does that is there a separate place where this is conveyed all those are very important issues now that is where the reactive and the proactive part of communication comes into play you face the situation you react to it what do you do over a period of time is an important thing now most of the time doctors you know doctor association or doctor ask for some law to be brought against violence now when i did this question with a lot of health care journalists and lot of healthcare activists their point was you know bringing a law in one part implementing the law is another part and there are lot of social evils against which there is a law which exists but there is no guarantee that those social practices don't exist in our society so law is only one part but what are those other things that you will do that will make the situation better i think the conversation has to move there because now this has become the dominant narrative that you know there is a communication issue doctors are not communicating well and that's why violence is happening we are not addressing the issue on a long term basis and and that is where i think some intervention is required and younger generation can take that owners i don't want to get into the discussion of medical associations and what is the perception outside in the activist community in the media fraternity that's a separate conversation one question i ask many senior people in administration of public hospitals there is violence and new phenomena when when you were doctors or when you were studying this was not happening so their answer was yes it was happening with us as well now it has become you know more visible because the younger generation of doctors is also on social media they talk about it so it looks like a big thing but this has always exist existed the incidence has gone up you brought up very excellent points uh the first being you know how a law can be a deterrent but it won't stop uh events happening completely like how we have uh you know laws against murders and that doesn't mean we don't have murders i mean it is an effective deterrent if you don't have the law there probably be more murders or something like that but on the same scale um yes there are a lot of things the government and say even the hospital authorities can do but what i'm specifically talking about is what can a doctor himself do to prevent that and again you brought up the point of you know doctors in the US the successful doctors uh who are you know like have been sued quite often and again like the problem i see here is uh lack of communication there's some gap in communication even even if they are like amazing doctors even if they're the best in their fields if they're not communicating it properly to the patient uh when the patient sees the patient just sees like someone who's not interested and disinterested in their case or someone who's not putting you know enough efforts you know to understand the problem that they are going through i mean uh for us like again uh dr jagdish said uh for us it's just another patient that we see out of hundreds in a day but for them um it is their life it is their uh you know loved ones life and they are obviously very concerned would be very concerned about it again another point uh that i wanted to specifically bring up is this again with the communication like you what you mentioned like uh you know having a specific person to you know like break bad news breaking bad news and all that we we do have CMOs who are you know sort of like uh quite experienced in that we have that in the ICUs like we have a separate counselling room where we we have our cameras and everything so that the doctor can you know like speak to the relatives and you know break bad news if there are any and give updates to the patients so it will have a visual recording of what happened just for you know like legal purposes or what whatever but again my whole idea is why not train doctors every single doctor like you could be like a one the only single doctor who's working in a very far away rural area and if you know how to communicate and if like doctors are you know like me to you know attend like a compulsory workshop or if it's made part you know compulsorily a part of curriculum like how we you know spend so much time learning how to take a history or like how to give a diagnosis uh dr jagdish i'm pretty sure you'll agree with me like we spent so much time you know like how to you know like put across the diagnosis properly so that the examiner is impressed and if you put half of that effort into you know like how to tell the patient what is wrong with them or with their loved one in a way they would understand in a way that we we don't have to again like dr jagdish brought up very valid points that we'll be seeing hundreds of patients and if we involve ourselves into you know how hundreds of these patients are feeling we won't be able to do our job properly because then we would just be affected by all of their problems as well but you have to actually seem that you care you have to seem into like you are you know you care for their problems and i think all these it doesn't have to you know like come very genuinely like you don't have to actually care for them much i mean we do all care for our patients otherwise we wouldn't be doing this but you don't have to go the extra step and be that but at least show to them that you care when you break the bad news just do it in the right way and i think this training has to be brought about um this is what i have noticed like even in a lot of my colleagues uh communication is very rude uh specifically one instance that comes to my mind um sorry if i'm lapping just my memory right now is when i was in i was an internship and there was this patient who had had a cardiac arrest and it was decided to do CPR and the consultant came and he was doing CPR and just then the relatives you know somehow passed in um and they were all like you know they were saying that the doctors you know like pressing on the patient's chest and they the doctor is killing him i mean it's it's because they don't know what's happening and instead of you know actually you know telling them like look this is what has happened and we are actually trying to save him and this is what we are doing the consultant was very rude you know he was like how did he even come in and he just had the you know security you know like throw them out i mean when something like this happens and people don't know that people are gonna see it like instead just make them sit tell them that this is what has happened and we are actually trying to save his life i'm pretty sure that they will appreciate you for what you're doing i'm sure you're putting so much effort into doing it but it just takes five minutes to communicate that to the patients and i think that is where we are lacking and you'll see me repeating this point again and again uh but i i feel very strongly about this so just one point and then move to the next part in a country with you know 20 languages and different dialects that is also a challenge because you know somebody if you are in maharashtra somebody coming from side and somebody coming from golden side you might think that talking the same language but there might be a difference of dialect one word here and there and the other person takes it in a different manner so you know we have to understand all those complexities for uh in a other country maybe two languages or three maximum in a country with 20 22 languages and multiple dialects this is a challenge that one has to think about how words can be misinterpreted by the other party and that sometimes that can lead to confusion so point for further distance absolutely fully noted um i think this is a a very good space we are at with this discussion after talking about signs and symptoms that we start involving some of our audience members comments i have some pretty interesting comments that have been floating i just like to get a very quick and short reaction of both of you on some of these things so that we can cover a lot of these discussion points and and then take the conversation forward uh i see this comment that uh you know people uh that someone has written over here is that is it okay to quit a specific job just because i feel i may be assaulted in this workplace so we talked about signs and symptoms but is this a treatment or a preventive measure that is uh realistic what do you think dr ajay let's hear your thoughts first on this yeah i mean i think it's a very valid question and it's probably could be bothering someone uh quite a lot you know like especially if they've seen violence uh you know happen with their colleagues but again uh one thing that we have to note is that this is part of this has sort of unfortunately this has become part of our everyday working so it is there it's like a real threat like for example working with covid getting covid and you yourself passing away because of it is a real threat but does that prevent you from stopping and going to work so i think you have to see it this way uh we'll obviously have to do everything that we can to prevent it just like how we take protective measures against covid but it is a real real really existing threat it probably is going to be there for quite some time so we just have to find uh measures to you know keep ourselves safe and also our colleagues safe in that situation i think uh mr qureshi will have a better insight into this [Applause] so let me tell you this and this i tell most of the people that an automobile industry maybe impacts 15 percent of the population and aviation impacts maybe 5 to 7 of the population but healthcare is one sector which impacts everyone okay so the dynamics of the sector in that sense are very very different nobody beats up a lawyer or a chartered accountant if their communication skills is bad but the doctor has to face that so one realization that you know i agree with both the doctors here that there has to be orientation in terms of you are not doing a regular job because like you know senior people in administration told me that look at the life cycle of a doctor an 18 year old comes to a medical school and is in the medical school for five six years and most of the time is on duty or study so you know by the age he is 20 23 most of the time he's cut off from reality in that sense the other part is some years back we had done some research with medical students and one of the insights from that research was medical students felt they are better off than other students because they are very close to reality so other students have fun in life but medical students are you know bordered with one studies and second they're dealing with emotional issues all the time so there's a lot of emotional trauma so one right from the time a youngster enters medical school the kind of orientation that is given because you are not entering a normal profession this is going to be something different where you are going to make an impact now the other thing is and dr jagdish rightly pointed out most of the time media points highlights these issues of violence against doctors or whatever and let me you know put this across that actually publicizing this more is having a negative impact for doctors because the general perception then is our doctor it is actually having a negative impact so one this orientation that happens with doctors that you are not entering a normal profession and second all the two things that happen with doctors or what doctors do in multiple cities you will know that in public health centers there are scenes where a doctor you know is moving to some other place and all the villagers come crying and breeding don't go kind of a thing there are great doctors in multiple cities in the country who are doing good work now those cannot highlight it so if there is a narrative which is going against you you need to have a counter narrative you can't be you know using force and intimidation to convey your message like in one of the ICU i saw one security sitting with an automatic weapon so i asked the head of administration that why is the person with a weapon sitting outside of ICU so he said it's like a deterrent so you know should fear be the approach to deal with the situation or should it be empathy making people realize the life of doctors or they also be part of somebody's family rather than doing this intimidation tactics of bringing law or you know bringing armed policemen to the hospital is it helping in any way the other part is most of the incidents of violence and at least my data is indicating happens when there are more than one person when there are two or three people that is when violence happens okay now when you go to public hospitals at least there are no you know lower-ranked staff available for doing rudimentary things and that is where relatives are required to be in the spots most of the time and that is why you have drought so there are multiple things that have to be handled it's not a single issue i think i fully agree yeah sorry no point finish please finish saying there are multiple issues that have to be tackled and it can't be a reactive approach that while it's happened we protested if i come to you purely from a reputation management perspective like you asked what happens in other industries so when any any entity wants to do a reputation management there are certain things that they will do kind of an audit one they will try to find out what is the narrative about us and overall about our sector that is happening correctly okay they will try to find it out the second thing they will try to find out is what are the changes happening in the political economic social and technology space that is having an impact on our in our business and the overall economy and once they identify those gaps they will try to build a communication for their organization or entity that this is what we want to communicate now honestly that is what you know medical association individual doctors need to be doing that what is it going against us and then there has to be an approach now in an organization a CEO is the custodian of the reputation of that organization who's the custodian of doctor's reputations what happens if one doctor doesn't happen with that one doctor it has a rubber impact for the whole doctor community the whole medical community so the response has to be at that level not individual level that a situation arises and how do i deal with that so those are my points points and i think it perfectly segues into the next thing i would like to talk about we talked about etiology of this we talked about signs and symptoms and going clinically the next thing should be investigations and diagnosis so how do we investigate to identify high risk uh like you mentioned multi-factorial environments mr qureshi and dr ajay also mentioned that you know there's a particular pattern to these things uh yeah and unlike most other corporate or most other working organizations we don't really have an HR HR as doctors i think we are all our own HR the department head basically decides who comes in the rules at the layout right we don't have somebody a third party looking at it from a neutral eye saying are you doing the right thing or are you need to improve this or your communication stuff like that so i think we are we are a community that is usually self-driven uh and driven by uh you know key opinion leaders so to say uh which people follow and you know uh they admire or they get inspired and they follow what some of the doctors like i follow some of my senior doctors they're my gurus and that's what i do and similarly people follow me um but is there is there an investigation can um you know if somebody uh you know like even if you take a you know what a tenant you do a background check now here i see some in some of the comments it may appear like we are taking a site where we are finding the fault of assault being with doctors it's not true doctors are trained to introspect for any drug or any medication or any disease we introspect what we're doing today is introspection it is not finding fault that doctors are the cause of violence we are not saying that patients and attenders have the right to assault doctors and we are not saying or any of this is normal and fine we are just trying to understand in this discussion with experts today is that though we understand why it occurs we know it's multifactorial we know the early signs and symptoms of how this happens can we screen for this and be better prepared for it can we screen for factors amongst patients like you said when there are more than couple of attenders that are there it's more likely that the mob mentality may sink in versus a couple of people or one person who's dealing with a bad news or an unexpected information normally the expectation mismatch is something that we've seen very commonly over here when you expect something and you don't get that outcome you you will originally react in denial and denial leads to anger before acceptance and if you are around before that acceptance during the anger phase then things fire up like dr ajay mentioned that could be something that could be triggered by the other side because at the same time the attenders are not empathizing with the work of the doctors at that point of time also right there's an equal part at play and uh and both both can be justified though i'm not saying it is justified but they can be with their own reasons so can we do something to investigate if there is a doctor who's known to be extremely angry generally with his peers and juniors is that when when he or she is talking with patients relatives can sum up some people accompany to ensure certain things or similarly when you see a patient uh relative and attenders and you've seen some traits of getting irritated and upset for trivial things or they already had a bad history with doctors and they're already very skeptical can that be flagged in some way whom do you flag it to what can be done we'll come to the treatment and solution aspect and there's some very interesting comments but i want to give you a quick thoughts on what investigation do you think we can do to pick this up doctor i'd like you to talk about that first uh um you know like starting with you know doctors again like what you mentioned like if there's a doctor who has a history of uh you know bad communication or a history of violence that may have been caused like again we're not saying that doctors are the reason why violence happens happens and we're not condoning violence we're not saying uh you know doctors are at fault or anything but what i'm saying is if if it's if it's not like i i don't want like i don't want to specifically mention any situation here but i have a few of my colleagues who are known to be not very empathetic and it so often happens that when these people when these specific colleagues are speaking to the patients there's a high chance that uh you know the situation turns a bit hostile you know i've i've been the moderator in this situation for a quite a long time like i have four five experiences like this where i have had to you know go and defuse the situation myself and i think i saw one of the comments where one of the doctors mentioned that you know doctors think that some in the medical profession tend to feel they are the best at everything which if we don't agree with that i think we'd be just fooling ourselves that that sense of uh like i am better than other people is certainly there amongst doctors and that is something that we have to um talk about first you know like at least i'm not saying i'm not whitewashing the entire medical community that you know everyone feels that way there are certain like you would have experienced some of your colleagues being that way so i think if there are any problematic people like this keeping a special eye on them or you know just having someone to you know like manage if something goes wrong would be one of the uh first places to start with but i think mr qureshi would be the better person to answer the specific question if it's supposed somebody's brought into emergency and situation happens you don't know when it will go out of hand so it is actually very difficult like one of the teams i was talking to and i asked them that you know they had started some communication training for doctors some years back so he said you can give all the communication training to people but but when a situation arises you all the communication training goes for a pause because you are dealing with a very emotionally volatile person at the other end so you know it is very difficult to predict situations but if there are clear traits that somebody is showing it is a better idea that a doctor doesn't deal with that situation individually like while it happens in a group then you also don't deal with the situation as a single individual then you are also two three people or other people in the staff who are managing it you don't become the face of that issue it's like in a crisis situation it is not always the CEO who front-ends sometimes the functional head of an organization also front-end because there are specific reasons for that so it may be a good idea that you know an individual doesn't handle the situation if there are some one to more people it may be a diffusion tactic that you can so it's very on the ground kind of a thing that one has to do what in the corporate world is called crisis preparedness so they actually undergo you know listing down all the things that can go wrong in the organization so a list is created or these are the things that can go wrong the second step is if something goes like this goes wrong with the person who tackles this yeah so that kind of and the third is a training that is given to all the people on something called as a crisis team that if something like this happens in the social media you don't have time to sit and think what to respond you have to quickly respond so how do you think on your feet those kind of trainings are done which unfortunately i think doesn't happen with doctors and if this is such a major issue then it should become part of the you know training that how do you deal with this situation and how do you communicate or how do you handle situations now this doesn't definitely in public hospitals you see private hospitals also where it may not be the doctor who faces violence but the other staff like front-end staff and others who face this violence so you know multiple things that one has to do absolutely i think some of these points in terms of what can be done in terms of training in terms of exposure and all of these things uh definitely play a role but that segment is uh completely towards what follows after investigation which is treatment and i see majority of the comments are suggestions for solutions um you know to this problem and i see a couple of interesting ones i see uh in particular dr avinash khari being extremely proactive thank you dr sorry you i also read that you've been a victim of this as a violence as well and you've uh resumed work the next day and uh you know it's the kind of strength uh that you know uh we need to cope up with so uh that's uh overwhelming to read but i see some of the suggestions that you've been uh putting out so i'll just share a couple of suggestions here with the panel over here uh in terms of what can be done about this and what your thoughts on whether uh these these treatment options or these so-called solutions would be effective now i'd like to i also know the government policies are there in its place law is there its place but enforcement is a problem and training and awareness is an issue but let's look at something more practical that we can probably implement in our own hospital level or clinic level or at our own level to start off with while other things fall into place and one such issue over here is can we use technology to curb violence now here's one thing i talked about the stages of bad news receiving bad news or stages of grief there is denial there is anger then there is uh acceptance right and so there is all those faces now in that stage of denial and anger let's say there is a technology that tells you first and then the doctor comes into the picture somewhere when you are already melting towards acceptance because even for family relatives and attenders when they hear something going really bad with their family members somewhere they feel they are to blame or they want to find something to blame it's a displacement right they may think that they've done the right thing getting their patients on time but the hospital didn't do the right job they're looking at money the doctors came late the nurses were not doing the right thing and that is the reason and not me it's not me bringing the patient late it's not me not uh keeping my relatives aware of the illness it's not me picking it up early so there is somewhere in internal conflict that you know people in their healing or whatever reaction like you men mention how people react uh you know that could be one thing that that takes uh you know uh place but but to that point uh can technology know you can never be upset with technology like uh the maximum you can get upset but technology is what is this you know i mean if your if your app doesn't work like yeah what is this where headphones what is it do something you know that's it you you're not gonna break your phone or neither are you gonna slap yourself and neither any of us can get hurt by any of these audience members here today regardless of what we say because we are interfacing through technology right we could be in an open discussion over here and say something controversial and still get into a fight but we are on an app far away and i'm zooming in so you don't know where i'm sitting right now but you will not be able to find me if you want to hit me because i am in the technology right now and think about this i saw a parallel with tellers you know in banks when they have to give money and there are a lot of queues people used to get angry people used to fight why is it taking so long why are you counting the money not right all of that and that get replaced by atms and you cannot get upset if the atm goes bad that the most you'll be like okay let's find another one you deal with it you move on right if you look at aeroplane uh the pilots right if things go bad you just get very little information through some audiophone or something like that we are facing turbulence and clean for your life that's it that's it you're not going to say where do you get your degree from and you know how can you ride a flight like this i paid my money over here you know you're not doing that you're like where's the oxygen even come from there do i even have a lifeboat under my seat who is there next to me this is the last person i want to talk to you are dealing with it because the information is coming from technology what happens in the medical fraternity is doctors are on the front end of delivering that information they are not prepared to hear you are not prepared to say and you don't know what can happen right would like someone mentioned uh dr avinish itself mentioned uh can we use uh ml or ai you know artificial intelligence or machine learning or some sort of uh information uh you know replacing the doctor to provide that information to uh you know early on and then a doctor comes to explain it this is what happens with reports on diagnostic labs whenever somebody has uh cancer you first see it in your report you know and then you you deal with it you know why what does this mean what is this metastatic cell why why am i nuclear like large like what does this marker mean they have questions by the time they reach the doctor but they've received the news through a paper they've received the news through an online report right we don't have that system when we have to declare someone dead when we have to declare someone dead there are technology bad news or at the part where you're going to say something that a patient like that i think that would be quite good um not just with breaking bad news even just providing like constant updates to the patients relatives of family as to whatever is happening so you can have like sort of uh probably you know sms based or email based or whatever like you send them an update every day saying look at all these you know this is what has happened in the past one day or past 12 hours or whatever so your patient's condition was like this and either is recovering or is deteriorating or whatever so if you keep them updated i think uh if a patient is going to say pass away uh with some even an acute condition you are you know like uh warming them up to uh potentially um you know disastrous situation like instead of just you know telling them uh i mean we are doing everything to save your son or daughter and then you know coming out after uh to us saying uh we tried everything we could i'm sorry we couldn't save him instead of that if you have like a graded approach to help you give updates to them uh say in an acute acute medicine scenario it could be hoverly updates in a more uh classical hospital based scenario it could be daily updates so that's where i see uh technology coming in um breaking bad news yes it can be done on a on a zoom call like one of the doctors mentioned but again it just takes it just makes it more more impersonal uh like uh that's what how i would feel like but it may be 10 years down the line when this generation which is attending online classes become the decision makers so we'll have to wait for 10 years but till that time we'll have to live with the reality of what we are facing correctly and uh like doctor mentioned uh technology makes it a little more impersonal the second is the content part who writes the content and how do you you know customize it because you can't have a standard message going out to all the people that might be the challenges going forward but i think for the next 10 years this is a reality we'll have to live with that is point one point two is the decision that doctors have to take and you know make this as a conversation in their associations respective specialities or you know the general associations that are there that one is dealing with this issue on a technical level of violence happened and how we deal with it and second what are the things that have to be done to bridge this trust deficit if i were to use that term that is developing between the medical fraternity and people and what my research is indicating that and if you look at lot of research in conflict resolution in international diplomacy sometimes when the conversations reach a dead end where you are not moving ahead it is always a good idea to bring a third player in the conversation who's like a neutral party who is not taking positions and conveying both sides and just to give you an example if you see the media coverage in the first phase of the pandemic of 2020 you know private hospitals and healthcare actually got a bashing for the fees that was being charged and you know staff getting infected and hospitals getting to shut down so in the first phase you had a lot of bashing in the second phase where the situation was more severe and this is what my next research is you suddenly find that the private hospitals are not getting bashed up because the conversation has moved somewhere else about oxygen shortages and other things and suddenly it is not the private hospital the narrative has moved some other direction so what is that that has happened around that time that has changed the narrative now those are very interesting things to study as a communication professional that in a span of one year similar incident but what has happened that has changed the whole narrative in both the faces that is an important thing the second [Music] than other students now imagine the same guy gets beaten up if me or my friend get beaten up how am i going to grow up with that trauma and how will it impact my relationships 10 years down the line when i have become the practitioner and the consultant those are some things to study going forward which is something that i will study going forward so you know the trauma that people face in violence how does it impact their behavior when they become the practitioner or the consultant five or ten years down the line so those are things that will give some insights i agree here uh partly with both of you and i also disagree here partly with both of you i thought let's just have that as an interesting uh you know perspective now the part that i agree like with dr ajay his patients deserve to be updated and the relatives deserve to be updated on a much more frequent basis and what i agree with mr qureshi is also that you can't just be giving breaking bad news or you know uh or you know just all of a sudden on a zoom or on any other technology uh platform uh but there are two things that i disagree with one is i don't think we are ten years away from the technology and i will give you some examples of how the technology is being used today right now with our generation to curb some of these issues and and i think the other misconception that i want to clear out over here a lot of medical students and doctors over here is that breaking bad news is not just that bad news statement of somebody lost or having cancer or disease that is not breaking bad news breaking bad news starts much earlier uh from the deterioration of health from the prospects of treatment options from the outcomes that you need to be ready with all the way till you accept the outcome and that is the art of breaking bad news so if you are thinking that you know i put the relative code of patient into the hospital five days later they have no information and somebody comes out and says in the most nicest manner that the patient has lost their life that the art of telling bad news was so good that they will not get angry i don't think that is that is true they are still going to take it as a shock and they still got a question i put that my relative with very mild symptoms and you're coming out and telling me the news of the person being dead how what went wrong what did you do there are hundreds of questions popping in their head and however nicely you say you come to the group of people and everything like that that is not breaking bad news guys breaking bad news is preparing and everyone has the right to be prepared for bad news now let me give you an example of two places where there used to be a lot of anger and especially uh there a lot of roadside brawns and fights with auto drivers not willing to come cab drivers not willing to come but you see what ola and uber have done they give you periodic live updates that even today if an ola guy or uber or any of these guys they're coming and they cancel your trip you don't care because like no worries i'll get another one i already thought you will cut because you were not coming or you were asking these convoluted questions of where the drop location is i know you're going to you know cancel the right and you accept it right but otherwise you're in a situation on the road you stop an auto the auto guy says i won't pull him or why won't you go you have to take me what do you think you know there have been so many of those incidences are probably coming down because now you have an expectation you are updated i have had this personal experience where you know a cab is coming it's coming from very far and it cancels last minute but i know it was stuck in one place for a long time and then he says actually my tire is flat and i can believe it because i saw the progress i thought okay maybe it was stuck somewhere in traffic or something like that and this is the answer for a nice circumvention i'll book another one um same thing with sweetie in your food and this trend of regular updates uh is not um you know it's not a symbol of being shallow to you it is probably a symbol of respect to let you know what's happening with your if you can do that with your right and your food you should do that with your loved one why is it that your you have zero information about your person or your family member when they're in the icu but during this forward pandemic i cannot count the number of calls where people call me from the hospital when i work that our relatives in the icu we have no clue what's going on can we just find out we don't even want to know the treatment we want to know where are they and are they okay that is all and we are not able to provide that update we are not able to provide that information to them and they only hear the final news and that i think is unfair and i'm not justifying that they should get angry for it or they should fight about it but there's somewhere there is that lack winner where we have the existing technology we have the existing ability to give them updates and we have the ability to grade the information towards acceptance we have the ability for them to prepare for it we have the ability for them to think about options they should have the right for second opinion they should have the right to take the person off for palliative care everything should be given to them they feel cheated if they're just given the outcome and i'm sure you would feel that too so why can't we provide that when it exists for things like food for things like your ride which you probably don't care much about anyway so that so when i'm saying technology can replace the vulnerable part i'm not saying the technology is going to replace the most important part of breaking the news but you can do a lot before it uh to allow people to come up to that space and i think you know we have a right to information for all sorts of things there is no process for right to information of what happens to your loved one and people are scared to go to the hospital because they think they're going to lose control on information and decisions and and that's valid i think i would do i mean if it was my parents or my relatives or my child they go to hospital i want to know what's happening with them i don't want to question the treatment i am willing to accept the outcome but i need to know what's happening and needing to know is something that we have excelled in as technology updates and information is very well advanced today and why don't we include that i don't think it will take too long for someone to bring such a solution uh into that place the problem that comes is uh with patient information and confidentiality and hipaa all of those kind of things but i guess there is a role that technology can play but that's just my two cents and it's just an opinion it doesn't it doesn't mean anything other than that um but i had another uh interesting solution over here uh dr ajay yes i definitely think increasing resources one of the big steps in the right direction because um just to give you an exam on experience uh in internship uh we used to have these you know duty shifts where we'd work 34 36 hours and you can't expect any person to work that long and have a steady state of mind you know to react to things in a rational sense so if say i was at the last few hours of my very long shift where i've barely got enough sleep and i've seen probably 500 600 patients and some patient might come to me with his issues and it might seem trivial to me but it's not triggered to him and of course like i won't have the patience to explain it and even if there's a even if a patient passes away i won't have the proper courtesy or the proper way of breaking the bad news like we've been discussing all through so again once if we have more resources i think this um the whole concept of you know physician fatigue and you know healthcare worker fatigue and all that could be reduced and maybe with resources we can have more people you know like we can put more money into training people on communication and we can have probably you know specialized people like mr qureshi mentioned we can have more specialized people who are who can handle situations when they go bad so yes definitely increasing resources would be a very big step in the right direction that's what i think but uh let's see what mr qureshi thinks i think beyond the medical doctor's control we can't do that it is somebody else's responsibility i think we should focus on what we can deal with the situation all right uh point well taken uh and i think i don't think there are i think maybe in private hospitals there is a shorter bureaucratic process to increase positions like you know your recruitment of junior residents or interns or manpower but i guess at a public level it is a policy decision or i guess the number of pg seats could be a policy decision but i think if you look at one doctor for 1700 people in india and i would probably say a fairly good amount of chunk of these freshly passed out doctors are out of the healthcare system probably preparing for higher education or probably preparing for something else or getting through with their bonds that they have to do with their colleges uh you know i think their recruitment is probably uh a quicker and more practical way and that's probably just a decision at the level of a private hospital or deemed hospitals or government hospitals that have independent decisions but i guess to some extent uh larger policy decisions are going to be not something that is you know immediate and before we conclude uh on complications uh let us talk about what do you think is happening in terms of our dynamic between doctors and patients because of all of this uh i know mr qureshi you mentioned that the social media discussions on these points is making it look like it's happening more but it has been happening before i know it's been happening before i also know it's been happening internationally in other countries uh but uh the incidence and frequency have definitely increased because of stressful times like the pandemic someone also wrote in the comment section that these are unclear times and when people are scared and they don't know what's going to happen they tend to react in that way but as a in terms of a complication do you think the doctor patient dynamic has been tarnished beyond repair or do you think uh this is a phase that will just continue as status quo uh dr ajay what do you think are the complications yeah first to begin with the whole doctor-patient relationship is kind of a bit more strained now than it was probably 10 years ago and one of the main reasons i believe why this is happening is like if something like this happened you know like 10 15 years ago it wouldn't have been reported it would have probably gone unreported and probably like you know like the doctors association in that area would know about this and they would probably do something about it but certainly you know people in other cities or other states wouldn't get to know about it but now because all of these are being reported so often there's this sort of normalization of this like this happens everywhere so somewhere if i'm agitated it's okay to do this so this that sense probably built into some of patients minds and again like um there was other research interesting research that i was reading the other day where when one when a specific grotesque crime is reported like say a rape is reported the number of rapes happening in that time period is probably higher than normal so probably the same logic works for this as well maybe they are reported more often or more like for example if let's say some uh some grotesque crime happened and it was reported and something similar happens there's more chance that that's going to be reported in otherwise if it was just an isolated event that was that would have probably gone unreported so maybe it's just that all this uh exposure to you know like uh news after news of both the doctors and patients are gonna have some better insight into this whole thing and like any problem that arises i think we are going to come up with solutions and uh one of the effective ways of doing it is having discussions like we are doing right now so i believe this is um this is not going to be uh like you know beyond repair i think this is still quite salvageable that's what i believe uh mr qureshi what do you think if you look at the depiction of doctors in bollywood okay so in 1940s you have a movie called so that's 1940s and then in the 1950s and 60s you have this doctor who's like a super human being and he meets his ex-girlfriend who's now married and to save that ex-girlfriend husband now he will go and do study and save the husband and himself died so some kind of a superhuman being in the 1960s and then in the 70s you have anand incidentally it is 50 years for anand this year and another is like a game changer movie because it shows a doctor i hope everybody has seen anand movie there's a friend of amitabh who's also a doctor and how he deals with different kinds of patients some of the patient is just writing vitamins and all those things that is a game changer and then you come to the 1980s and you have all these gangster movies and in the gangster movie somebody has got injured and they land up and then in the 2000s you have movies like back and there was one more movie where you know this gentleman goes and occupies the hospital saying get my child operated those kind of movies so if you see in this whole period how the whole depiction of doctors has changed in bollywood i don't know if anybody is engaged with different people in bollywood saying what kind of implication it will have on the doctor patient relationship absolutely so you know that is one part of the narrative the second in mass communication when we study media we don't only look at news media we look at entertainment which is say bollywood we also see books and literature in the last 10 years i will tell you at least four books which have come on the healthcare sector written by doctors which is very critical of the whole system right now especially about doctors so that means the narrative is not getting impacted in a single way between doctor and patient everything that influences the thinking of a patient is sending a negative narrative about the doctor if you have to deal with that and one of the things i quickly tell doctors that whenever there is an election in a state your association should not be going in meeting the government the new government you should be going and meeting the opposition because most of the time if you see the incidents it is the opposition party leader who come and create a request in hospitals because they have to show that they are doing something those are things that have been taken at a higher level which individual doctors can't deal with that is where the associations are to play a role that is part one and second i agree that the relationship has got impacted to a level where a third party has to intervene like we see in international diplomacy when two countries are unable to speak a third country intervenes creates a platform where you know says okay what are you saying what are you saying and tries to come at an understanding unfortunately in the medical center in this case in india that neutral party can be governed it could be media but if you see the narrative from both sides i don't think it is positively driven towards the doctors so that means the only third party that is left for the medical fraternity is the civil society or the not-for-profit sector which can intervene and convey both sides of the story and that creating understanding about the lives of doctors is very very important if the end person doesn't understand absolutely i don't know the doctor has spent eight hours sitting in this opd since morning and has not taken a bio break or has not taken food that kind of empathy understanding the example i told you about this train in uk which talks about this attendant is also a brother a child or you know the mother of somebody and bringing that empathy those are all important elements that have got in the narrative absolutely i think that's a very very important point mr qureshi i think one of the takeaways i take from you is i think doctors should start making some more positive bollywood uh you know films showing more realistic things maybe web series or media content that can actually put out a balanced and more realistic view out to kind of change some of these opportunistic narratives that have been probably taken because of a story that might fly better with audiences but also at the same time about neutral parties and their roles that they can play uh yeah mayhem thank you web series like starting troubles absolutely unplanned promotion of my web series can it help our cause in some way so if we can have you know some sort of uh uh some some technology assist uh in sort of like a pager or like you know sort of like an app on your phone that is given to all the doctors where if you feel like you the situation can go bad or if you feel threatened um you know just with the uh you know like with a hit of a button it you should be able to communicate it to some central team in the hospital or like another group of our senior doctors or someone like that just to get the word out that i think i might be in danger and i need help so i think that would go quite a long way you know especially into bringing technology into the whole equation here and also yeah i think that would make doctors feel a bit more safe you know like how police officers have their communication devices the walkie-talkies to you know communicate if they feel they're in danger or threatened if you have something like that like a small sos button or something for doctors i think that would be a very good thing so that's one comment that i picked up on again dr meha this i has been mentioning about the vip patients how hospital administrations should stop giving important to so-called vip patients this is something that we really see on a day-to-day basis that you know sometimes the administration or sometimes even the senior doctors tend to give a bit more attention to specific uh specific patients or specific group of patients or anything like something like that and if another doctor can pick that up another patient can also pick that up and it will always be a sense of they're doing more for them than they're doing to us and if for some reason if there's any other miscommunication that happens and if there's any other cause for any uh anger or something that comes up i think this is going to be one of the deciding factors in how they view the whole situation as to they might probably see it as you know i wasn't given enough attention because they were busy treating the wave patient or something like that so i think this is something that we can we should uh you know keep in mind but i'm not hoping it would change any time

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