The Resident Doctors Association of the All India Institute of Medical Sciences in Delhi has attracted significant attention recently for its decision to offer taekwondo classes to equip doctors to defend themselves against violent patients. This follows a protest in which resident doctors walked around the campus in motorcycle helmets, which in turn came in the wake of a five-day strike by doctors in Maharashtra in response to three incidents of violence against doctors in three days.
Abuse of any kind in the workplace is obviously unacceptable, and I do not seek to condone or dismiss the incidents of violence that periodically occur around the country. However, this moment does offer an opportunity to consider the spectacular power imbalance between doctors and patients that may contribute to violent encounters, and to think about the role that medical education plays in this equation.
The Indian Medical Association reports that 75% of doctors have experienced physical or verbal violence during their careers. A variety of factors have been identified as contributing to the recent high-profile incidents. Time pressures that impede consultation quality, high expectations of patients who are increasingly informed by the Internet, and a distrust in an inadequate public health system. Some doctors have reasonably argued that they feel like scapegoats for this broken system. Little attention has been given, however, to how Indian medical education informs the relationship between doctors and patients.
Not all doctors are heroes
At the root of the more hyperbolic outrage over the Maharashtra attacks is an enduring narrative about the nobility of the medical profession, which pits heroic doctors against ignorant and dangerous patients. Yet, any assertion that all doctors are motivated by a commitment to the remedying of human suffering is disingenuous. Above all else, as demonstrated by my research with MBBS students at AIIMS, it ignores the vast numbers of young people who find themselves studying medicine for reasons other than vocation. These include family pressure to continue a tradition or to pursue medicine as a route to social mobility, and the forced choice between medicine and engineering as the only two perceived pathways to a respectable career. One of my MBBS interlocutors switched to medicine having found he disliked engineering. It was not, he said, “that I was interested or something like that”. A senior resident said that he was encouraged into medicine by his parents and had thought little about it. “I never thought… I just thought that I have to do this, I have to do this, and things went on their way,” he told me.
In combination with the apathy that afflicts many young medical students is the narrow nature of the education they receive. There has long been a malaise in Indian medical education, now augmented by the cynical profiteering of many private colleges. Communication is not part of the MBBS curriculum, and as a result is reduced to a vague notion of etiquette, with no attention to how communication acts as a conduit for the uneven power relations between doctors and patients, which may on occasion lead to conflict. More broadly, the efforts of some community medicine departments and individual faculty members notwithstanding, Indian medical education lacks the vision and the engagement with the history, philosophy, and sociology of medicine necessary to educate beyond the technical, to encourage well-rounded professionals equipped to empathically interact with different types of human being.
Patients’ point of view
Let us be clear that in the current narrative, the patients considered physically threatening are not those occupying chairs in air-conditioned waiting rooms of corporate hospitals, who share the class position of most doctors. They are those forced to travel significant distances to seek affordable public care that they cannot access closer to home. Those who sit on the floor, having queued since dawn for an appointment; who stay with distant kin if they are fortunate, and sleep in the metro station or the bus shelter if they are not. They should be angry.
Yet as is so often the case in India, these latest incidents of violence, while deplorable, simultaneously illuminate the millions of deprived patients who bear daily hardship and structural insult with a stoicism, or a resignation, that is neither a threat to the doctors who treat them, nor to the politicians who persistently neglect the desperate need for an effective system of public healthcare.
This moment also offers an opportunity for a necessary conversation about the various guises of violence in medicine and medical education. After all, campuses on which some doctors claim to fear attacks from patients, are the same campuses on which some students from reserved categories periodically commit suicide, on which SC/ST faculty members experience discrimination in hiring and promotion practices, and on which patients report feeling bullied and disrespected by doctors they have waited hours and sometimes days to see. The type of violence that attracts the greatest outrage is telling. As are the responses it receives.
Meanwhile, in an inverse example, the Delhi High Court has ruled that schoolgirls should learn self-defence “as a preventive precautionary measure”, placing the responsibility for personal safety squarely on individual women, while ignoring the causes and encouragements of sexual violence. Martial arts are not the remedy for India’s inequities.
The writer recently completed her PhD in anthropology at King’s College London, for which she produced an ethnographic study of medical education at AIIMS.