Chapter 24. How to prepare yourself to survive violent patient encounter?

Dr. Yeshwanth K. Amdekar, DCH, MD (Pediatrics), FIAP

Most violent element in society is ignorance

                                                                        Emma Goldman

Aggression is the first step on the slippery slope of

Selfishness and chaos

                                                                        Anne Campbell

What constitutes violence?

WHO defines it as intentional use of force or power, threatened or actual, against oneself, individual, group or organization which results in or has high chance of resulting in hurt, damage, destruction or even death. It is an emotional outburst of destructive nature, an intentional use of physical force, an act of power of one person over another.

Changing scenario of medical practice

Physicians of yester years commanded respect from the community to an extent that doctor’s views were sought not only for health issues but also in every other familymatters. Community had faith in their doctors as they witnessed how much doctors cared for them and community did not care about how much doctors knew. Doctors showed concern with empathy as they communicated, counselled and stood by their patients in times of stress. Patients felt confident and had tremendous belief in their doctors. Things changed for the worse with rapid deterioration in doctor-patient relationship. It is a great irony that medicine, the epitome of healing profession is now often exposed to violence. It is a paradox.

Genesis of this change

Both doctors and community have changed. There is a brutal dimension to medicine in that what is intended to heal may cause pain, damage or even death. Doctors often succeed but at times fail in their goal. Physicians don’t get pleasure in causing pain to their patients but their brains react to viewing pain less strongly than what patients feel. In fact, it is an adaptive response to be able to function effectively in the face of patient’s suffering. This may blunt their response to patient’s pain. This may lead to confrontation as doctors use harsh words, show rudeness, authoritarian approach and often intimidating behavior. On the other hand, community believes and expects that doctors should cure all problems and save every life. If outcome is short of desired, it is seen as carelessness, negligence and incompetence of doctors. With such a dichotomy of what doctors can deliver and what community expects, irrational behavior of few members of the community sets up a trouble that may escalate to any level with mob mentality.

How to avoid situation that may lead to violence?

When patient under your care does not progress the expected way, you must suggest to shift the patient to a better facility at optimum time. Doctor must anticipate poor outcome at the time when things are not looking so bad. One major problem arises when patient is shifted too late and hospital where he is shifted, doctor may loosely make a comment that patient should have been shifted much before. In the hospital setting, doctors should be cautious to explain real situation in a manner that seriousness is subtly conveyed. It is best to say that outcome depends on how patient responds and that will be known over next few days. In other words, patient’s relatives understand the seriousness and are sensitized to an inevitable outcome. At such a point, relatives start losing cool and try to find mistakes including most trivial issues such as they were not allowed to enter the hospital and security person was rude. You must maintain calm, be empathetic to their problems but at the same time, justify the action that is in the interest of the patient. You must allow relatives to vent their frustration and anger, listen to them without interrupting and finally counsel them tactfully. It is the arrogance of a doctor that often sets up a problem and so learn to remain calm and confident. Another important fact is to allow relatives to witness care being taken, within limits and spend time talking to them periodically. It often avoids trouble.

Finally let one doctor remain in communication as a spokesman so that there is no confusion created by different ways of expressing same message. It is at times conceived as opposing views and becomes bone of contention.

 

Personal experience

In a general hospital, child was brought in a state of septic shock and attending doctors had appraised relatives about seriousness and danger to life. However,the next day when child was sinking, mob appeared in the hospital and started fighting with doctors and threatening them. Attending doctors anticipated bigger problem and summoned me as a senior doctor. First step I took was to make all of them sit in a room and told them that I would listen to their complaints and find a solution. I allowed them to talk as much as they wanted. They wanted to know why child was not improving in spite of correct diagnosis and proper treatment and so in their views, doctors were negligent and incompetent. As a lay person I thought they had a valid question. Before answering their question, I asked them whether any of them was a teacher in school and luckily for me one of them was. I asked this teacher whether every student in his class scores good marks and passed. He said not all pass, to which I told him that he is responsible for bad teaching. He immediately said that it was not correct because he did his job well but few children did not study or understand and so he was not responsible. I explained to him same thing has happened in this child, Treatment is correct but child fails to respond. He understood my point and I requested him to explain to others. I waited as mob became quiet. This teacher told me that I should try my best and I assured him that it was already being done. Other doctors were surprised how I could douse the fire within this mob so easily.

Take home message

One must anticipate trouble and act in time to share responsibilities. Doctors must learn to avoid harsh words and rudeness that always fires back. We have to remain cool and not shout but explain in a way that relatives cool down. Force of any kind and authoritarian attitude leads to trouble. We must not forget that a failing situation results in inappropriate behavior of relatives and they need support rather than arguments. Doctors must follow what previous generation of doctors did. They were good listeners, empathetic and caring. If one follows this rule, trouble would be avoided. Of course, there has to be deterrent by law for such a violence against doctors.

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