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Violence and civilisation have co-existed since times immemorial and healthcare professionals are no exceptions. Against whom and when violence was unleashed can be found in the annals of history but now, I would like to talk about the situation in the present day and age. Violence today can be directly linked to the changing social and economic circumstances.

We all know that anyone comes to the doctor only when they are suffering from pain, malady or discomfort and hardly anyone comes calling on a doctor if they are perfectly all right. Thus, in a hospital on one side there is pain, fear, suffering and debilitation, and on the other are healthcare workers who are engaged in diagnosing and treating patients with dedication and empathy. It is highly desirable that any healthcare worker be a sensitive and empathetic soul and towards the inculcation of these qualities, the healthcare worker as well the medical education system as a whole are eternally making efforts.

However, for the past few years, there is a growing feeling of angst and lack of trust towards the healthcare workers which sometimes manifests as an outburst of violence. I am trying to list some reasons which have led to this unwanted situation. The relationship between a patient and doctor is directly or indirectly impacted by other stakeholders like the hospital administration, politicians, policy makers, and society as a whole. Let us focus on these stakeholders one by one.

• • Patients: In the times gone by, any patient would come to a doctor with a feeling of complete surrender. The doctor would be seen as a manifestation of God who would do everything in his or her control to cure the patient and the same time there was also an unsaid understanding that not everything was in the control of the doctor. A similar mindset would also prevail amongst the relatives and well wishers accompanying the patient. On one hand there was faith and trust in the doctor and on the other the doctor would reciprocate it by a selfless sense of service. Even amidst the crowds and long waits characteristic of most healthcare setups, the patients or their attendants would usually maintain their composure because they would understand the patients being seen ahead of them were also in pain and the doctor was busy attending to their concerns. They would also put up with occasional rude behaviour by doctors or other healthcare professionals. With economic and scientific advances, the mindset of the patients and their relatives has undergone a sea change. Rather than considering healthcare as a noble profession, it is being seen as a business and they feel that if I am paying fees for seeking healthcare, the doctor is also accepting the fee to run his or her household. As consumer, the patient expects to be at the centre of the business model which he sees healthcare services to be- right from not having to wait for a long time before consultation, to early diagnosis and precise treatment sans side effect and demanding the courteous most of behaviour from all healthcare providers. Moreover, there is a widely held and oft-repeated belief that healthcare has advanced so much that no disease is left without a cure now. The sprawling buildings and state of the art technology in modern day hospitals only serve to strengthen this belief and this renders the patient or their family members unable to handle any unfavourable outcomes. What further exacerbate the problem are advertisements by the doctors and hospitals which make people believe that there exists a magical wand which will take care of all their maladies. Another reality of the modern age is the nuclear family, where every member is precious and losing any of them is beyond their imagination and cure at any cost is their expectation.
• • Doctors: Not so long ago, most doctors were well equipped with the skills and abilities required not only to pass exams but also the sensitivity and empathy required to understand human emotions and sufferings. There were two main reasons for this- firstly, there were very few MBBS seats and thus only the cream of the society would qualify for them and secondly, the dynamics of families and society as a whole endowed most individuals with enough humanity and empathy. Even the teachers to whom a medical student would become exposed to in a medical college had ample of these desirable qualities and thus the students would get adequate opportunities to observe and imbibe them. The fame and societal respect accorded to their teachers would inspire their students to emulate them. Faculty members in medical colleges would have adequate incomes to sustain a decent lifestyle. Earning and learning would go hand in hand soon after passing out of MBBS, job opportunities were available aplenty and corporate culture was unheard of in the medical field. Medical colleges would cater to patients from all strata of society (politicians included), had state of the art technology and resources and would attract the best of the talent among the medical fraternity to come and work there.
  With the passage of time, commercialisation of healthcare and health education has led to many changes. The speed with which MBBS seats are being added every year is scary and there are as many private medical seats as there are government ones and in private medical colleges the fees are hefty. There has also been a change in the abilities and skills of an average medical graduate. Even average students are able to enter MBBS along with the brightest ones, whereas with rapid strides in medical science, diagnostic and therapeutic modalities are becoming more and more complex and to understand them is more challenging than ever before. Even the familial and societal realities have changed and the medical professional of today is more likely to chase a higher income instead of fame or respect.
  There has been a precipitous decline in the standard of faculty members in medical colleges. Ghost faculty and those seen once in a blue moon are the reality of many private medical colleges. The behaviour of faculty members when dealing with patients has gradually become less and less courteous and the same is imbibed by their students. From being a noble mission, medical education has transformed into a rat race of running after promotion. Number of medical graduates being churned out every year vastly outpaced the number of job vacancies available. Moreover, unlike earlier when earning and learning would go hand in hand post MBBS, the trend of the day is to sit at home and prepare for specialisation or super-specialisation entrance exams. The students who attend dummy schools in their 11th and 12th grade while preparing for MBBS entrances, carry forward the same habits into MBBS and learning has become mostly theoretical for them. An MD or MS graduate of today has more or less the same skillset which an MBBS graduate would have a few years back. With the advent of super-speciality courses, an average medical student spends a minimal of 12-13 years only studying. Due to all the above mentioned factors, standard of medical education has seen a drastic decline and the same is being reflected in the practice of medicine as well. The health administrators with their moorings in the corporate sector, advise doctors to adopt all sorts of means to maximise earnings, not all of which are ethically sound. Those working in the government sector are frustrated with the burgeoning patient load and go on to develop a perennially irritated demeanour.
  Medical colleges tend to begin with a bang but over time, their standards usually follow a downward trajectory. Faculty members working in medical colleges also end up knocking the doors of corporate health setups to upskill themselves. Well-to -do and well-connected individuals including politicians, policy makers and bureaucrats stay away from government hospitals and prefer seeking the refuge of the private hospitals. In the private sector, while the owners mint money, all the flaws of the system are linked to the doctor alone in the eyes of the public, regardless of whether the doctor, who is merely an employee, has anything under his control. In the pursuit of more earnings, some doctors tend to over investigate and unnecessarily prolong intensive care unit stays; at least this is what is the perception of the general masses.
• • Society: Indian society and civilisation has historically prioritised family over individual and tribe over family. All segments of the society were interdependent and would share their joys and sorrows at the village ‘chaupal’ every evening. The joint families of the era gone by have now shrunk to nuclear ones and most of the time is spent in jobs and chores of daily living. Most of the learning of children is restricted to school hours and there is no time or opportunity for mutual discussions amongst family members and relatives. As a consequence, the basic etiquettes of social living which a child would naturally pick up at his or her home are no longer being imbibed. The pedagogy in schools has also undergone a sea change and leave alone corporal punishment, now even mildest of the scoldings are looked down upon. Rather than seeing themselves as catalysts of change in their students’ lives, teachers have begun considering teaching as a profession like any other. In today’s cities, owing to lack of access to playgrounds near their homes, children are not able to indulge in outdoor games and thus lose another opportunity of interacting with a large group of peers.
  As a result of all this, the doctors, patients and relatives who are products of this changed society have also changed substantially. Because of living fast paced lives with little time to spare for others, patients and their relatives have begun expecting instant treatment, quick tests for diagnosis and rapidly acting medications and want all this provided to them with a smile on the face of the provider and at affordable rates. So when they have to face the prospect of waiting in queues, revisit on a different day for a particular test or repeat consultation, get into waiting lists for a procedure, spend time and efforts in gathering financial resources to enable treatment, it naturally breeds dissatisfaction, frustration and nudges them towards violent outbursts. Sometimes aggressive behaviour also seems justifiable to them as a means of throwing around their weight and social status. Today’s generation treats all professions as equally important and thus the privileged position accorded to medical practitioners is increasingly under siege. The end result of these significant societal changes which have affected doctors, patients and their relatives alike is a vicious cycle of dissatisfaction which under some circumstances can spiral into violence.
• • Policy making bureaucrats: Sardar Vallabhbhai Patel once described our bureaucracy as the ‘steel frame of India’. In those days, not only were bureaucrats the most cerebral of the lot, they also had a tendency to keep their spines upright. They were not only impartial in dispensing their duties but had adequate domain knowledge related to their field of work. They were looked up to as role-models by the society because of their knowledge, working style, demeanour and politeness in their interaction with citizens as well as colleagues. Gradually this steel frame has rusted to the extent where the bureaucrats have become yes-men of politicians and are more interested in accruing wealth and power rather than their actual work of policymaking.
  The tenure of a typical bureaucrat in any particular post is increasingly becoming shorter and in that limited duration it is unrealistic to expect them to develop a thorough understanding of the field and also deliver something worthwhile. So the dependence of bureaucracy on third party consultants and agencies is increasing. This has made policy making prone to fall victim to the tussles and vested interests of various national and international stakeholders and politicians rather than being in-sync with the aspirations of the masses. Healthcare is a complicated system and bureaucrats working in it not only need the help of domain specialists but also a lot of time to understand the nitty-gritties. Because of all the abovementioned factors, Indian bureaucracy is unable to do justice to policymaking. Moreover, the realisation that doctors are as intelligent as them and also have knowledge and experience of medicine, breeds jealousy and contempt in the minds of policymakers.
• • Politicians: The breed of political leaders who led the country in the immediate post-independence era had come out shining like diamonds from the independence movement and were grounded, perseverant, honest, intellectual and dedicated. Without a doubt, their decisions always kept in mind India’s interest and progress. Neither were they interested in minting money through illicit means, nor were they tempted by the lure of limitless power. If anything, many a times they did not think twice before relinquishing power when it clashed with their ideals and morals.
  Gradually things deteriorated to an extent that politics began to be seen as a synonym of corruption and the lofty words and promises of politicians were not even worth the cost of the paper they were printed on. Politics began to be dominated casteism, regionalism, linguistic chauvinism, corruption, money power, muscle power and dynasty. The literacy rate may have surged, but the number of people who live with morality has declined.
  The prospects of making money from the burgeoning private medical college and hospital sector attracted the attention of greedy politicians, who started influencing policy decisions. Many politicians established their own private medical colleges and hospitals and this led to an obvious conflict of interest when it came to making policy related decisions.
• • Medical education: On the eve of independence, there were medical colleges in most big cities of India and they would attract the best brains of the country at both teacher and student level, whose voice would seldom be ignored by the powers that be. Their institutional framework was best among the contemporary institutions, there was no lack of resources and state of the art equipment would be available. Teachers in this college were of the stature and calibre that students would learn not only in classes but also by observing them. Medical education in India was at par with that in the west.
  In the 21st century, to overcome the shortage of doctors, private medical colleges were encouraged and with this began the rat race of opening more and more of them while diluting the set benchmarks required to be met before granting permission for them. For example, since land availability was limited in cities, the minimal requirement of land for opening a medical college was decreased, the number of faculty was brought down and even the number of patients to which a medical student would be exposed to became limited.
  Because of the single-minded focus on quantity (new medical graduates), quality standards began to be compromised. As a result, come inspection time, the same faculty member would be shown as being empanelled in more than one medical college. Not faculty members, some medical colleges would call patients also only at the time of inspection. Thus, medical graduates began passing out without having interacted with most faculty members as well as adequate number of patients. This was not of concern to the medical students who were more interested in getting a degree and prefix of ‘Dr.’ and thought that they could learn the requisite skills over the rest of their lives. The same culture penetrated lower and students started attending dummy schools and coaching classes instead of serious schooling from 10th class itself. Likewise, coaching culture has now spread to MBBS also and instead of learning by experience and through patients, MBBS became confined to theoretical learning alone. In contrast to earlier times when a medical student would gain exposure to various specialities in their internship before making up their mind about which speciality to pursue at post-graduate level, internship began to be fully dedicated to preparing for post-graduate entrance examinations. In the same manner, post-graduation has been reduced to a mere springboard to enter super-speciality courses. Medical education in the private sector is exorbitantly expensive.
  Expensive equipment, expensive medications and expensive education have all contributed towards changing the ethical landscape of medicine and led to increasing commercialisation and corporatisation. Due to government interventions like Pradhan Mantri Jan Arogya Yojana (PMJAY), the number of patients visiting government health facilities has come down. Consequently, even the broad exposure which a student would get in a government medical college has also reduced. Departments have been compartmentalised and specialised to an extent that names of many departments are not even familiar to an average medical student, let alone their location and function.
  In 2019, the erstwhile Medical Council of India (MCI) was replaced by the National Medical Commission (NMC) and it brought along changes like introduction of CBME (Competency Based Medical Education) and AETCOM (Attitude, Ethics and Communication) modules in undergraduate education. NMC also focused on training of faculty members with special attention being paid to skill acquisition at MBBS levels rather than mere theoretical knowledge. Though all these steps seem impressive on paper, there are two crucial components in their implementation. Firstly, they need a larger number of faculty members and secondly every faculty member is required to put in more time, efforts and dedication. As elaborated in the preceding sections; to boost the numbers of medical graduates, we are allowing more and more medical colleges to mushroom without paying adequate attention to the number of faculty members being employed in each of them, which has led to overburdening of the existing faculty members.
• NMC Act 2019 envisages to ensure that there is an adequate number of doctors in India to match the demand but as on date, there is no reliable data regarding how many medical professionals belonging to various schools of medicine are there in our country at present. Sadly, no concrete steps have been taken towards compiling this data. There is also a glaring lack of co-ordination between the government and private healthcare institutions and medical colleges. Moreover, the distribution of doctors and medical colleges is not uniform across the country.
• Corporate hospitals prefer employing BDS and MAMS doctors over MBBS because they are ready to work for less salary. General practice by MBBS doctors is also not easy due to quacks competing with such doctors and grossly outnumber registered medical practitioners. We have no mechanism to decisively decimate this unlawful menace leading to many untimely deaths in the country due to wrong treatment by quacks.
• Many Indians going out of country to study medicine don’t pass foreign medical graduate examination and result remains abysmally low. Having invested 6-8 years of their life in the study of medicine they have no choice but to work in hospital setups as skilled manpower without registration or to go to far flung areas and start practice without license.
• In the coming years, artificial intelligence (AI) is expected to come up in a big way and we need to prepare our medical colleges to understand, cope and benefit from this new technology. Further complicating matters is that healthcare is a state subject and medical education is in the concurrent list leading to large degree of variation from state to state when it comes to rules and regulations, be it related to bonds or salaries of doctors.
• In short conditions are not good and if timely steps are not taken then world class doctors in India will become a distant dream.