Change is the only constant that drives our life towards growth. Looming in the coronavirus pandemic, the healthcare system of India has been on a transformative journey over the last couple of years. The competency of healthtech proved itself for the first time during the pandemic. When hospitals and local clinics became life-threatening zones because of skyrocketing Covid cases, the people who were suffering from other illnesses adopted telehealth.

When people were locked in their homes, fighting their own battle against all those pathogens, the health-tech sector attempted to connect them with the fragmented medical community. The fact that India is the 3rd largest smartphone market in the world has been a big support for the healthtech system to grasp a strong foothold. Digital devices that are currently playing the most significant role in people’s lives, became the means to reimagine a virtual healthcare management system. Adoption of this ever-upgrading digital healthcare method is now completely revolutionizing the healthcare system for the betterment of people and the nation as a whole.

PATIENT-CENTRIC APPROACH

The on-demand healthtech system has made people more conscious about their health. With all their health data at their fingertips and with the option to consult doctors online — anytime, anywhere, people have become focused on self-care more than ever. There is a noticeable decline in the number of cases when patients would avoid consultation, as now it can be arranged as per their comfort.

The 24/7 availability of doctors is now enhancing the scope of preventive care meanwhile minimizing the chances of diseases reaching their severe stages. With patients becoming more conscious of the quality and cost of healthcare, hospitals and other healthcare providers have begun to emphasize delivering more personalized treatments.

EXPANDED REACH OF HEALTHCARE

Limited medical facilities and insufficient manpower has always forced patients from remote areas to travel to metropolitan cities in search of quality treatments. The huge crowd in the premises of AIIMS hospitals has been clear proof of the same.

Healthtech has strengthened the care delivery system in such rural areas where even availability of doctors was a huge concern. By furnishing in-home patient monitoring services, it has prominently improved the situation of patients who are aged or suffering from chronic conditions. Additionally, technology has also been a boon for doctors from the standpoint of obtaining case management support by specialists. One-click case history of patients is the easiest means to share data and get suggestions from peers.

SENSORS, WEARABLES AND IMPLANTABLES

These electronic devices help doctors monitor patient health and keep track of vital signs via smartphone connectivity. Empowering medical professionals to keep a real-time update on a patient’s situation and providing timely remote care has been a successful change for the healthcare industry.

AI IS SHAPING THE FUTURE OF MEDICINE

Human intelligence has come up with artificial intelligence which creates a healthcare system that releases the burden of doctors from administrative tasks and promotes precise diagnosis. Complimenting the efforts of doctors, AI-enabled care helps to define and decide the treatment regimes for patients suffering from complex diseases. The databases generated out of the entire AI integrated system have the potential to shape the foundation of predictive healthcare.

The current growth of the telehealth sector is just the beginning of many more advancements which are yet to revolutionize the healthcare industry.

Docty, a Telehealth Startup is helping people access integrated healthcare — regardless of their geography, through online consultations. Keeping the patient’s safety at core, this platform aims to strengthen the three pillars that are the biggest concerns of our healthcare system, i.e., Availability, Affordability, and Accessibility.

Improving transparency while maintaining quality healthcare has been the motto of this data-driven human-centric telehealth platform. The purpose is to serve convenience in healthcare appointments and digitizing records. With a customizable search function, the portal allows patients to explore and find the best-suited doctor for themselves instead of compromising with the locally available medical professionals. Docty has embraced the smarter way of healthcare and it has been an uphill climb of success for its users as well as the doctors associated with the platform.

Dr Priti Shukla (MS, MCH, Plastic Surgery) is the founder of Hyderabad’s Ambrosia Clinic, and a user of the telehealth app, Docty.

Every story has a past and the story of mental health is no different. It took us some hundred-odd years to move from the Lunacy Act of 1912 to the Mental Health Act of 1987 and then to Mental Healthcare Act of 2017. But in these 100 years, mental health has been badly ignored and relegated to an insignificant appendage. Mental healthcare gives a gloomy and dark picture. The real picture of mental hospitals, psychiatric wards, and mental retardation homes is a tale of neglect, abuse, victimisation, violation of rights, depravity, and the dark and denied part of ourselves which we want to do away with. Progress has been made, the chained patients are now drugged with obedience, but the abandoned women, children, are still witnessing the hell. The taboos around mental illness and the unsaid fear of a mentally ill, lead one to either negate, deny or ridicule a person who suffers from mental illness. A visit to a mental hospital should be a must for people to understand the dark underbelly of civil society.

Our performance today hasn’t improved. According to WHO (2020), the mental health workforce in India is not up to the mark and there is a huge shortage of psychiatrists and psychologists in the country as compared to the number of people suffering from mental health issues in India. WHO states that in India, (per 100,000 population) there are psychiatrists (0.3), nurses (0.12), psychologists (0.07), and social workers (0.07), while the required number is anything above three psychiatrists and psychologists per 100,000 population. WHO also estimates that about 7.5 percent of Indians suffer from some kind of mental disorder and has also predicted that by the end of 2020 and 2021, almost 20 percent of India will suffer from some kind of mental illness. According to the numbers, 56 million Indians suffer from depression and another 38 million Indians suffer from anxiety disorders. India also accounts for 36.6 percent of suicides globally, and that suicide has surpassed maternal mortality as the leading cause of death among women and teenage girls aged between 15 and 19 years. Further according to WHO, the burden of mental health problems is of the tune of 2,443 disability-adjusted life years (DALYs), per 100,000 population and years lived with disability (YLDs), and the age-adjusted suicide rate per 100,000 population is 21.1. WHO also estimates that, in India, the economic loss, due to mental health conditions between 2012 and 2030, is $1.03 trillion.

In simple words, this data depicts certain concerns and the first concern is the demand of mental health professionals that far exceeds the supply and the gap is humungous. Second, mental health problems are almost becoming a pandemic. Third, mental health problems lead to poor quality of life and are debilitating, and it also hinders performance and causes economic loss to the nation.

What exactly does mental illness and health mean? When one talks about mental health, we presume we are talking of all those people going to the psychiatric wards and hospitals totally crippled with their suffering and not able to function normally, and we are right. But this is not the whole picture, mental health also includes many children, adolescents, adults, and old people who are able to carry on their daily routines, hold a job, go to school, but are having difficulty coping with the problems of everyday living and thereby their quality of life and happiness is affected. Mental health also includes coping strategies, lifestyle measures that we take for a healthy and happy life. Mental health encompasses both health and illness. It includes those we call mentally ill and all those who are going about their daily life with visibly obvious issues of coping and adjustment. And mental health includes all the population irrespective of age and gender because we all need training in managing effectively our emotions, thoughts, and behavior to better our lives and those of others around us. 

Determinants of mental health include individual attributes such as the ability to manage one’s thoughts, emotions, behaviors, and interactions with others. In addition, social, cultural, economic, political, and environmental factors have a role to play as do the specific psychological and personality and genetic factors. And mental health affects all of us equally, be it children, adolescents, adults, elders, and even animals. Positive mental health is a need for all life forms. It is the basis of happiness and also the reason for living.

It is ironic that we take care of our physical body and right from our birth, we are taught how to eat, what to eat, how to dress, how to look, how much to weigh, and many other things through socialisation, but all our life what troubles us are our emotions, thoughts and consequent behaviour. When it comes to a person’s physical health, people are so conscious and aware these days—they also have access to a lot more things to maintain their health, they know everything about superfoods, the latest diet trends or workouts, but when it comes to mental health, the awareness just isn’t there. So many people aren’t even aware that they may be suffering from some form of mental health issue. So many people aren’t even aware that happiness is the result of a healthy mind.

We are literate as far as our body is concerned, but emotionally, mentally, and spiritually we are illiterate. We have been taught how to manage and beautify our body, but no one has taught us how to handle and deal with our thoughts and emotions. Nobody has taught us how to have a beautiful and peaceful mind. Happiness is a by-product of our mental state, it is contemplating that we rank 139 out of 149 countries as per the happiness index ranking. The biggest myth that people believe is that thoughts, emotions, and personality are all innate and unchangeable, whereas the truth is that they are not inborn and permanent, but through training and practice one can have control over them.

Our personality, attitudes, and other psychological aspects are all skills that can be acquired. This needs to start right from childhood. The other myth is that the mind, emotions, and thoughts have no role in maintaining body health. All physiological diseases have a psychological origin. Psychosomatic diseases are the direct result of stress, that is psychological factors affecting the body. Some examples are heart attack, asthma, and many more which are fatal and can cause death. If something is psychosomatic, it does not mean it is not life-threatening.

What then is the answer to all of that? How does one move forward? How does one ensure that all programs are structured for the rural and urban population? How does one bring about change and how does one effectively reach out to all those that require counseling by mental health professionals? How do we train and produce more mental health professionals? How does one educate, train and empower people emotionally, mentally so that they can improve the quality of their life? How does one create awareness and increase the acceptability of the mentally ill, differently-abled, or challenged to make them socially inclusive and friendly?

What we propose in a nutshell is a three-pronged approach to mental health literacy:

1) Create awareness and build acceptance about mental health, mental illness, psychological wellness, and well-being by building inclusive classrooms, workplaces and make diversity a way of life for the urban as well as rural population.

2) To provide counselling and mental health services to people who are also contextualised and customised.

3) Capacity buildingand scaling through training and skilling, we can increase the number of mental health workers so that mental health services can be made available to the entire society.

We can build a mentally literate society through the following endeavours:

Psychological Counselling and Psychotherapy: Talking is therapeutic and cathartic if we provide a safe space for people to talk without any fear of being judged, ridiculed, or admonished about right and wrong in complete confidentiality and secrecy. It can be both individual and group counseling and therapy.

The counselling should be contextual and accompanied by Western techniques, and it should be culture-specific too. It should be in various areas: Mental Health Counselling; Relationship and Family Counselling; Guidance and Career Counselling; Rehabilitation Counselling; Educational Counselling; Substance Abuse Counselling and Sports Counselling

Psychological/Psychometric Assessment and Testing: A wide range of scientific, standardized tests, measures, and psychological instruments can be used to measure and test various aspects of one’s behaviour, personality, attitude, mental status, aptitude, career interests, career skills, relationships, adjustment, leadership skills, emotional intelligence, social intelligence, etc.

Child and Adolescent Care: Life skills training, employability training, psychological assessment to know themselves, and positive psychology training can be given to enable and empower them with the skills, knowledge, and techniques needed to live a fulfilling and productive life.

Research, Assessment, and Development: An intellectual foundation is necessary and research is the answer. One needs to specifically focus on Indic systems and solutions where at least in psychology not much has been done. The psychological counseling and therapy and everything else that is followed is very western knowledge-centric and that is one of the reasons why psychology, unlike the west, has not made itself an indispensable part of the mind space of the individual, community, and society. By working and doing innovative, contextual, culture-specific, and applied research in this realm, we can hope to find answers to making mental health an indispensable part of everyone’s life.

Life Skills Training/Behavioural Skills Training/PersonalityEnhancement Training: We have not learned nor been ever taught how to manage our emotions and thoughts to lead a healthy life. Through training in emotional intelligence, social intelligence, spiritual intelligence, and more we seek to empower individuals- children, youth, adults, and elders to live with dignity, respect, and self-reliance while helping others to do the same. With the help of positive psychology, mindfulness, we can improve the quality of life, increase the happiness and wellbeing index of the person, and then eventually the nation.

Capacity Building through Counselling Skills Learning Programme: In a scenario where the number of people suffering from mental illness far exceeds the number of mental professionals available how does one scale up so that one can reach villages too along with the cities. The way out is capacity building of primary healthcare workers, teachers, and community members. Teachers are the first people who can be the torch bearers in ensuring mental health becomes a household term. School is where discrimination and abuse of differently-abled people begin. Students are beaten, ridiculed especially children with learning disabilities because of lack of knowledge. Training teachers in counseling skills, psychological first aid, and crisis intervention will not only help in easing the pain of the children, youth, adults, and elders who are facing the challenges but will also help in building inclusive classrooms and communities and accepting diversity. Internships and mentoring can be other modes of capacity building.

Community Focused Projects, and Volunteering: What mental health needs is social action research and interventions based on the primary research to make long-lasting and deliverable changes and build an inclusive, diverse community, and a society that makes psychological wellness, happiness, quality of life, and mental health literacy as the benchmark for a progressive society.

Dr Chavi Bhargava Sharma is a psychologist with more than 29 years of expertise in the area. She is also an educational entrepreneur who is involved in academics and research.

Violence against Doctors: Causes, Effects, and Solutions

Dr Sundeep Mishra

Violence can never be justified, least of all against someone

who is ostensibly attempting to save a person’s life.

– Sumanth Raman

INTRODUCTION

Sacrifice is part of the great tradition of medicine, a tradition that compels doctors into one of the mosthazardous occupations. The list of dangers is actually quite long; risk for communicable illnesses, bothcommon and rare, stresses that lead to extremely high rates of burnout, depression, substance abuse andsuicide that outpace other professions (of similar level of education, gender, generation), serious occupational hazards like workplace violence both physical and verbal. Each and every practicing doctor has been touched by these issues, either directly or as witness. As per an Indian Medical Association study, more than 3/4^th of physicians have witnessed some form of violence at workplace. On the other hand, individuals entering the profession are either completely unaware or have only limited understanding of the potential long-term consequences that are often understated or ignored. Some occupational hazards have indeed been studied, but there is no comprehensive analysis of workplace risk for physicians like those that have been done for other professions especially those related to workplace violence.

Violence directed against the physician and the health-care workers seems to be a common phenomenon world-wide. However, this phenomenon has been given a scarce consideration and minimal lip service not only in lay public, media and law administrators but even in medical community. As a matter of fact, the subject of aggression and violence against physicians and its remedies does not figure anywhere either in medical curriculum or continuing medical education. Multiple anecdotal reports suggest that the problem is increasing globally but systematic data is lacking. However, it is likely to be more prevalent in those health-care settings like India, which were traditionally socialistic but have recently turned to capitalistic model of health-care.

Although violence is common in many work-place settings especially those dealing with social and financial sectors it can under no circumstance be condoned in hospitals. Although in reality in-hospital violence is just a superficial symptom of a deeper malady afflicting overall health-care system, the hospitals cannot be allowed to become battlegrounds for the simple reason that sick people need a peaceful environment where they can get sympathy, empathy, support etc. At the same time, the health-care professionals also need a stable and peaceful environment if they are ever able to give self-less care (rather than worry about their personal safety). On a long term basis, the threats and violence could have a bad impact on the physician’s psychology leading to Post-Traumatic Stress Syndrome (PTSD) in majority of the physicians, something which is akin to a problem faced by war veterans. This manifests as a physician feeling helpless, becoming irritable, introverted and having thoughts of abandoning medicine or even contemplating suicide. Even more stable personalities might be forced to practice defensive medicine, intent on saving their own skin rather than considering for the patient.

DEFINITION

Many people think of violence as a physical assault. However, violence in healthcare setup is a much broader problem; it is any act of aggression, physical assault, or threatening behavior that occurs in a health-care setting and causes physical or emotional harm to a health worker. It can range from telephonic threats, intimidation, actual verbal abuse, physical but non-injurious assault, sexual harassment, and physical assault causing injury; simple or grievous, weaponry attacks, and homicide to vandalism and / or arson. Verbal abuse is the most common type of violence encountered but there seems to be some gender bias as well, sexual abuse being nearly exclusive in female workers.

FACTORS PREDISPOSING TO VIOLENCE

The root cause of the problem is the growing distrust between health-care sector and lay community compounded by poor patient-doctor communication. The whole society is getting materialistic and health-care sector is no exception to this. With private capital being infused into health-care sector; corporate hospitals, pharmaceutical and device industry, business professionals in the hospital administrator seat, the mentality of physicians has also changed from a charitable to a profit making. Instead of quality of patient care, the focus has shifted to numbers and “targets being achieved” in terms of patients seen in OPD, investigations and therapeutic procedures done and often the doctor’s re-imbursement is based on these numbers. However, health-care is unlike any other capitalistic profession due to several factors but the most important is that for its proper conduct it relies on empathy and communication skills. Unfortunately while doctors and health-care staff are trained in their own technical profession they often lack training in communication skills or empathy skills. Currently no medical curriculum teaches communication skills or gives lessons on empathy. The basic instinct of an intellectual is to have freedom, i.e. freedom of choice, which comes only through information. While in internet-age a lot of information is available online, the patients/attendants still depend on the treating physician to give them accurate and honest information about the cause of disease, the disease process, the options for investigation and treatment, the course and prognosis and finally the costs involved in the therapy. However, when this information is not adequately communicated to them it leads to trouble. Thus, the crux of whole problem in majority of cases is a lack of proper communication.

SITUATION UNIQUE TO INDIA

1. General low awareness of health issues.
2. The primary health-care infrastructure in the country is eroding perhaps related to general lack of awareness, low priority accorded to it, low investment in this area and perhaps a peculiar tendency to directly consult the specialists / super-specialists has led to the fact that patients who could have been diagnosed in the earliest stages of their disease often slip through the primary care net to present at some super-specialist / tertiary hospitals with disease far advanced, even incurable.
3. Low coverage of population with health insurance.
4. Lack of communication skills in physicians which contributes very tenuous patient-doctor relationship which isespecially prone to breaking down into violence.
5. Rudimentary health insurance structure.

WHAT LEADS TO VIOLENCE BY ATTENDANTS/RELATIVES?

1. Physician related factors
2. Misunderstandings: Miscommunication at any level from explanation of etiology, disease course, prognosis, need for investigations and treatment options.
3. Mis-happenings: When the disease course and prognosis is not properly communicated to the patient, if a mishap occurs the treating doctor and staff may be perceived as callous or inconsiderate.
4. Dissatisfaction with the course of treatment.
5. Disagreement with physician on modalities, option and course of treatment.
6. Malpractice.
7. Conflict of interest: Inability to obviate the feeling that many doctors prescribe unnecessary investigations and medicines to obtain undue benefits from medical industry.
8. Perceived lack of communication (collaboration) or inability to share information between doctor and patient
9. Casual opinion: Criticism by other/2^ndopinion doctor.
10. Patient related factors

The second problem is that the patient and their attendants are in a most vulnerable phase of their existence, i.e. faced with temporary or permanent disability even death. In this state they are fearful, anxious and in doubt. Here what they require is empathy and humane behavior and not challenge by the doctor or staff.

1. In many government hospitals there is overcrowding, long waiting time to meet doctors, absence of a congenial environment, multiple visits to get investigations done and then subsequently to consult doctors, concept of bed sharing by two and sometimes three patients, floor beds and poor hygiene and sanitation.
2. Even in private hospitals there could be prolonged waiting times: delay in attention or admission of sick patient or perceived delay in investigation and treatment.
3. Perceived (and real) lack of availability of doctor (senior doctor). Currently, there is a shortage of trained specialists. Furthermore, even in the available specialists there is a skew in distribution in favor of urban areas. As a consequence, very few experts are available in low resource setting which has even led to quacks occupying this medical space.¹⁷
4. Perceived lack of caring by physician or staff. Many physicians especially in governmental sector are overburdened by the clinical load due to twin reasons of paucity of staff and inability of private sector to cater for really poor and low middle-class. Hugely overburdened OPDs, casualty and wards in governmental hospitals are a common sight which contributes to overstretching not only infrastructure but also medical manpower, contributing to a perception of a lack of caring by the hospital staff.
5. Altered states of attendants: intoxication, mental illness, severe anxiety or stress.
6. Problems of public hospitals: dysfunctional equipment, poor quantity and quality of paramedical and supportive staff (and doctors being at apex have to take blame for it).
7. Low insurance cover of the general population is also a big contributing factor, being one of the commonest causes of leading a previously middle class family into poor class. It is a common knowledge that most incidents of violence occur at the time of preparing and payment of the medical bill.
8. Low health related literacy. While overall literacy has improved in the country, health-care literacy still remains very low. Many care-givers fail to understand the disease process and even more importantly the available therapeutic options.
9. Hospital related factors

Hospitals are a home to medical equipments and facilities but often do not pay much attention to security. At least most government hospitals in India are deficient in security.

1. Lack of security personnel in casualty, ICU and other risk prone areas. Lack of police post nearby, and even when available ineffective so much so that it is more often than not completely useless.
   1. Lack of security equipment; metal detectors, scanning devices etc.
   1. Lack of security protocols. Who will respond when?
   1. Percentage expenditure in health-care is amongst the lowest all over world. This has led to very few government hospitals in the country and it has been estimated that less than 20% of health needs are catered to by government hospitals. Furthermore, even these government hospitals are at present plagued by poor infrastructure and lack of adequate manpower undertaking health-care. Thus, majority of lay public is forced to go to private sector for health needs. Despite few large corporate hospitals bulk of health-care service is provided by small and medium private healthcare establishments (accounting for 7/6^th of private healthcare institutions)which isolated, disorganized and woefully lack in security arrangements.
2. Role of community
   1. Weak and ineffective laws. While some laws are present they are ineffective for the protection and safety of the medical personnel in private arena. In government sector while it is a non-bailable offense to assault a any uniformed public servant like a government doctors, the rules are hardly ever strictly enforced and lay public being aware of this weak implementation has no qualms in “exacting revenge” from the doctor and the hospital staff in any eventuality of mishap with their patient. Rather, since these acts go regularly unpunished it provokes mob violence, one incident after another.
   1. Community leaders. Another problem could be small time community leaders/troublemakers – This is more of a problem in government hospitals or employee insurance hospitals who cater to a significant population of working class (unlike corporate hospitals which deal nearly exclusively with intellectual or elite class). These individuals might consider the health crisis an opportunity to “show off” their leadership skills or they may grudge the perceived power enjoyed by the physicians (at that point of time) and feel that their own power is in jeopardy and may feel slighted. They may react by organizing others from patients’ relatives and friends, inciting violence against so called established power i.e. the heath-care professionals including doctors. On the other hand what the professionals being an intellectual class dislike most is ego basing and thus the doctors respond back even more vehemently to the perceived slight starting a vicious cycle.
   1. Lack of faith in judicial process. In India, lay public does not have adequate faith in the legal process of the country. Society, in general, believes that the doctorsareoften‘well connected’ and will get away with anything, forcing a common man to take law into his/her own hand.²¹
3. Role of Media

The media is forever in search of a good story. The story of an underdog fighting a huge establishment is ever popular. In this whole schema the poor, defenseless patients become an underdog fighting against the huge and established but corrupt medical system led by highly intellectual and “powerful” physicians. This is a good recipe for any successful journalistic endeavor but gives a very poor image to an average doctor. Thus, press indulges in the sensationalization of every related news item, often completely ignoring the real facts.

HOW TO ANTICIPATE VIOLENCE IN HEALTHCARE SETTING?

The key is to remain alert to this eventuality. There are certain tell-tale signs which can be looked forto anticipate any violence, easily identified as an acronym STAMP:

• Undue staring is an important early indicator of possible violence. This is generally deployed on mid-level health workers like nurses to intimidate them into improper action, but if they refuse can culminate into violence.
• Lack of eye contact / shifty gaze is another important cue which is reflective of anger and passive resistance although there could be some cultural reasons to avoid eye contact.
• Tone and volume of voice is a very important clue to impending outburst but caustic and sarcastic replies with a normal tone are also important.
• Signs of anxiousness, frequently rubbing hands, tapping hands or feet, non-seasonal perspiration should be accounted for before they reach a dangerous level.
• Signs or substance abuse or drug intoxications should be kept in mind and appropriate steps taken.
• Mumbling, using slurred / incoherent speech or repeatedly asking the same question or making the same statements are important signs to be recognized. Mumbling can be interpretive of mounting frustration and a cue for violence.
• Pacing is another indication of mounting agitation as well as staggering, waving arms or pulling away from healthcare personnel attempting to treat them.

HOW TO MANAGE VIOLENCE IN HEALTHCARE SETTING?

At the Time of Violence

If violence is impending or actually occurring:

1. Remain calm in the face of provocation and don’t raise your voice but try let things blow over.
2. Obtain all the documentary evidence of violence. It is a good idea to earmark some hospital staff who will take photographs, audio/video records of the violence.
3. Immediately all medical record of the patient should be photocopied because there is a huge possibility that interested person / mob could carry away the original record.
4. Inform the legal counsel / lawyer immediately.
5. Inform the police immediately by phone, sending someone to police post, sms but importantly keep a record of such attempts to contact law enforcing agency.
6. Identify the troublemakers/ community leader / s inciting violence.
7. Get written, signed statements from all individuals present (physicians, nurses and other para-medical staff, patients, relatives, and other bystanders) in context of the violence.
8. Lodge an First Information Report with the police.
9. While registering a complaint make sure that it is registered under the relevant act i.e. Protection of Medical Personnel.
10. It is very important not to try to ‘settle’ the issue by paying hush money which seems more as an admission of guilt than otherwise.

PREVENTING VIOLENCE IN HEALTHCARE SETTING

Preventive Tips for the physicians

1. Better communication: This is the most workable strategy with the intellectual class:
   1. The physicians have to understand that patients and relatives are going through extra-ordinary fear, anxiety and doubt and may not thus behave rationally. Further the doctors have to understand that patients come from a variety of background, class, educational and economic status.
   1. Patient / their care-givers should always be kept in loop at each and every medical step: investigation, diagnosis or treatment.
   1. Don’t make the patient feel that the doctor is in a big hurry and that patient is wasting his time, rather devise a strategy to over-come the problems of time constraints suffered (by physicians) probably by having more supportive staff specializing in counseling.
   1. Avoid inculcating fear in patient or make them feel that they are somehow responsible for their state (to which patients respond by putting the blame on doctors).
   1. Patient satisfaction comes from being heard and being understood.
   1. In case of complications/death a senior doctor should talk to patients/relatives which gives them assurance that best treatment is being/was given to the patient.
   1. Doctor–patient communication is a two-way street. While it is the patient’s right to get accurate medical information, it is their responsibility as well. The way doctors can facilitate this process is by prescribing information: i.e. by providing patients with educational handouts, putting up their own websites, or referring them to health libraries. This way the patients will know more about their conditions and available options and also obtain realistic expectations of what their doctor can do for them. At the same time it is the patients / attendants responsibility to give accurate information to the health-care providers and not hide inconvenient facts from them. There should be no use of either hyperbole or at the same time under-statement. As far as possible exact situation must be communicated.
2. Incorporating discussion on philosophy of medicine, ethics and empathy training in medical curriculum. Medical philosophy needs to be reoriented towards changed structure and accompanying perceptions of society. Classic parental doctor–patient relationship no longer works, now it has to be a participatory approach. It has to be effectively communicated that doctors can’t perform miracles, indeed they can modify disease process but they cannot prevent eventual mortality. At best they can help patients to adjust with disease its morbidity and mortality. Likewise, the importance of teaching empathy to budding doctors cannot be over-stressed. Studies reveal that good empathy training could lead to good doctors.  It is particularly important to show empathy for suffering and sympathy in financial dealings. The patient should be treated as a fellow human and not some abstract problem or worse made fun of or treated with ridicule.
3. Proper and written consent in word and spirit in the patients’ own dialect and language with witnesses must be obtained before undertaking major investigations or treatments especially of interventional nature. The consent should delve upon the purpose of investigation/intervention, its possible outcome, clearly detailing commonly occurring life-threatening/non-life-threatening complications, the available alternatives, advantages/ disadvantages of each one of them. In case the patient refuses, the consequences of refusal must be discussed and mentioned explicitly in the consent form. While performing an intervention only those procedures be done for which consent has been obtained unless it is life-saving.
4. Second opinion should be given very carefully, with careful choice of words. At the same time patient may be encouraged to seek a second opinion as a strategy to build confidence. If second opinion is different from your own opinion, the reasons for difference must be discussed and the final choice strictly left to the patients / care-givers.
5. Effective management strategy should be put in place: a damage control plan, when violence against heath staff seems imminent (not to react tit for tat – anger for anger) and address patient grievances.
6. Give a sense of security to the patient and relatives: a sense that everything is going as per plan. In other words, they should try not to frequently change the treatment plan as well as the cost. The cost of managing complications should as far as possible be incorporated in the initial costing.
7. It is important never to over-reach in attempts to treat a patient. One should realize the limits of what medicine can do as well as limit of available infrastructure and most importantly of self. Never do any procedure beyond the scope of one’s training and facilities. The dictum “do no harm” holds true for entire medical specialty.
8. Proper documentation is the key to all successful modern medical practice. Accurate and proper documentation may not directly prevent violence but after violence records may be seized by police. Unfortunately, in very sick patients the focus is entirely on saving life and documents are not in order but it is always important to keep this in mind, even keep photocopies of important documents because they might be lost in the chaos of ensuing violence. It may be a good idea to employ a staff or at least delegate the work of record keeping to one of the medical staff, so that this aspect is not overlooked.
9. Certain safety habits can be suggested;
10. Play a close attention to surroundings when you come out of office; avoid looking at your phone as you walk in hospital area.
11. Pay close attention to the cars parked around when coming and leaving the hospital premises
12. Lock the car door immediately after entering.

Preventive Tips for the Hospital Administrators

1. Strengthening theSecurity.
2. Security personnel (preferably army background) should be posted at the entrance of every hospital, ICU and operation theaters and should not let anyone through without checking for appropriate identification. 
3. Weapons / weapon like objects should be confiscated before allowing passage to anyone. 
4. All attendants must register at the front desk and be given a visitor badge to be worn at all times.                                               
5. Restrict entry of attendants to clinical workplace.  No more than two attendants should be allowed with the patient.
6. Establish a Hospital Committee (PRO) specializing in effective communication which can satisfy the patients/attendants.
7. Trained Psychologists (counselors) should be available to cater for emotional needs of patients and their care-givers when required. 
8. Since India is a diverse country with several official languages and also medical tourism is showing a huge growth, language translators should be available who can prevent incidences of miscommunication. 
9. Hospital workplaces should establish a policy for assessing and reporting threats, which would allow employers to track them to see whether prevention strategies are working.
10. Reduce the waiting times for everything and if they cannot be done at least explain why these times are there in the first place.
11. Every hospital should have an emergency algorithm including an evacuation plan in case of a major act of violence.
12. At the time of designing a hospital attention should be directed to workplace’s landscaping, parking lot and outdoor lighting keeping in mind security aspects.
13. Displaying information and also the laws governing the safety of doctors up-front:
14. To satisfy the intellectual class
15. To make them aware of consequences of violence against doctors
16. Involving media in their activities.
17. Health care personnel must have some training in martial arts, which might save their life in some instances.

STRONG &EFFECTIVE LAWS: Essential in fight against Violence.

1. Strengthening theLaw against Violence:

It is very important to make ‘violence against doctors’, a non-boilable offence for all medical areas; private or public. There is indeed a need to modify the Indian Penal Code to allow for tougher penalty against the perpetrators of such violence.

2. Implementation of Effective Laws:

Often, the real challenge faced in preventing violence against doctors is poor implementation of existing laws. A lack of implementation of existing laws has obstructed efforts to protect doctors from the menace of violence.Law meant for protection of doctors against violence needs to be stricter and should be implemented promptly and effectively.Law enforcing authorities should be particularly sensitized to this aspect and must realize that their mandate is to maintain law and order. The Rule of Law must be respected and adhered to by the society at large.

Role of Media in preventing Violence:

Media has a very important role to play: They should also write positive things about the profession or at least both sides of the issue in situations like this; they should avoid journalism of sensationalism and avoid provocative head-lines. While in short term these kinds of reports get a few eye-balls but in long run might prove counter-productive for the society.

Health related Literacy

There is a need to educate not only lay public but even fist-contact physicians in some cases for example myocardial infarction. There is need to be clear guidelines and management algorithms forlay public and even physicians.

Insurance Schemes

Mass insurance schemes should be offered to cover the whole population. Several states have their own schemes but National schemes like the currently launched PM JAY scheme and older RashtriyaAyraogya Nidhi for BPL patients are revolutionary steps in this direction.

CONCLUSIONS

In a predominantly capitalistic society health-care and primary education are perhaps the only remaining professions in India, which lay public expects to function on socialistic model. This would ensure a cost-effective, high class health-care delivery to practically entire population. However, in reality medicine (as also education) is no longer treated as a welfare activity but rather a profit making venture, at least by corporate sector. This difference in perception between the society in general and the health-care deliverers has led to serious gap between what is expected and what is delivered on health front. One of the outcomes of this mis-match is violence against doctors (among other problems) which is seriously threatening the status quo in this profession. On the other hand while violence on road (road rage), public places, even schools is common (though not condone-able), it can under no circumstance be acceptable in hospitals. The hospitals simply cannot be allowed to become battlegrounds for the simple reason that sick people need a peaceful environment where they can get sympathy, empathy, support etc. Even health-care professionals need a stable and peaceful environment if they are ever able to give self-less care rather than worry about their personal safety. Thus, if the hospital environment is exposed to violence its practitioners might start practicing defensive medicine, and focusing on saving their own skin rather than treating a patient. One of the major factors contributing to violence is not only monetary considerations but also a lack of communication and a failing doctor-patient bonding. Solution lies in not only in changing attitudes and practices of physicians and hospitals but also regulators, media and even lay public.

Every time we hear another doctor being assaulted in the hospital, a sliver of shock and disgust goes through people, the medical fraternity, and the media.

We have watched ad nauseam these scenes repeating all over the country. Doctors getting beaten up, hospital equipment being broken down, health workers being assaulted.

The scenes shown on media are deja vu.

The visuals are re-run, again and again.

They did not stop even during the pandemic.

Even for very sick patients with covid on a ventilator.

Why should the healers deserve so much hatred?

Why should such a noble profession become the epicenter for such violence?

Is something fundamentally wrong with medical training?

Or something that we are missing in our public?

Is this because of the gap between the expectations and the reality?

Are doctors soft targets for the institutions and hospitals not meeting up to what society requires?

Spending more than 30 years in this profession, we feel that this angst goes deeper.

Perhaps, we see only the tip of the iceberg.

It is essential to look at a problem pragmatically and concentrate on the solutions and not on the issue.

Everything in health is connected. The whole health infrastructure is one connected, seamless system.

Nothing in a health system is independent.

Fundamentally, the cogs of the wheel are the health personnel, the hospital, and the patient who make up this eco-system.

Each of these elements contributes towards health care both at the local and national levels.

At the local level, the doctors need to be trained personnel. We cannot have untrained professionals dealing with the lives of the patients. But it would also be necessary for doctors to be more trained explicitly in ethics and patient counseling. Unfortunately, there is no separate training for doctors in our profession, specifically on these subjects.

Health systems in some countries, including the United Kingdom, give a great emphasis on this. For example, students from India who wish to pursue a career in the UK need to undergo specific training in this area. The PLAB II examination, which qualifies an international medical graduate to practice in the UK, looks explicitly into these areas.

Coaching is provided to the students on how to speak, interact, and react and understand patients’ needs before the students appear for the PLAB II.

Interestingly, during the PLAB II examination, students interact with actors, and the examiners assess how good the student is in communication skills with the patient. For instance, if a patient is angry, the doctor would be expected to empathize and say, “I can see that you are angry” and not say “I can understand why are you angry” as the English language demands proper vocabulary from the doctor to convey their feelings.

Counselling a patient and his attendants in India could be different. But the same degree of empathy and emotional connection needs to be present between the doctor and the patient. In India, doctors are expected to learn this on the job.

So, how does a young intern who is hardly 22 years old handle the relatives, breaking the news of the death of their near one? How should they react when the relatives break down on hearing the news?

This may be too much for a young doctor to handle, hence the importance of training and including this in the medical curriculum.

Doctors need to have access to standardized operating protocols (SOP’s) and management algorithms at a national level. The National medical council (NMC) or similar apex body needs to create the availability of such material through mobile applications and websites.

We also need to urgently create a national database to store patient information (electronic medical records). So, if a patient goes to any hospital, that hospital should be able to access all the previous investigations and any pre-existing illness of the patient.

From the patient’s perspective, the dissipation of public knowledge over social media, newspapers, and television regarding correct behavior is important. Notice boards should be placed at several places indicating severe penalties for any uncivil behavior. Every hospital should invest adequately in the security and protection of health personnel. Education is very important. The patient and relatives must understand limitations for treatment for every disease. Education pamphlets regarding every disease must be distributed to patient attendants. The prognosis and outcome of the disease must be clearly understood by them. The caregivers cannot expect a cure in conditions which have a limited lifespan. Similarly, complications may arise from treatment of every disease. It is mandatory to record the informed consent properly in the medical records. In addition, it will be important to develop video recorded consent which should be stored by the hospital.

At a National level, alternate judiciary systems should be made available to tackle medical negligence. Senior doctors or even retired doctors should be made to preside over such legal hearings. It may not be a bad idea for senior doctors to undergo training for few years and take a whole career in medical jurisprudence, where doctors can occupy the same role as judges.  Such legal proceedings may occur in separate buildings and not the usual courts to allow expeditious settlement of such cases. This is important as the current legal systems may not cover enough knowledge base to understand and judge the negligence which arises from the complexity of medical pathologies. Hence the need for experts to preside and take such decisions.

One must understand the among all professions, the medical profession is among the longest and most difficult. It takes almost ten years to become a specialist and another decade to gain good experience. This involves years of personal sacrifice, several doctors marrying late, or some even not having children (many of our colleagues had adopted children as they were too old by the time they graduated). Among these, some sub-specialties like neurosurgery, neurology, and cardiac surgery have exceptionally long and grueling hours. By the time a doctor becomes a specialist, several professions are already preparing for their retirement! Hence, it becomes even more critical to make this profession attractive for future generations. Otherwise, we will end up having no one taking medicine or only the best brains and intelligentsia will take up other occupations and not be interested in medicine.

We should now consider the third component of the ecosystem- the hospital.

We, of course, need to increase our national GDP for health care.

But what prevents us from improving the current systems. Some nations spend much less on health care but have better-organized health care systems.

Indian currently has one of most advanced health systems globally. International medical ‘tourism’ is increasing exponentially. Indian doctors are recognized world over for their skills and expertise in view of their vast experience

However, It is imperative for us to understand that we are dealing with two extreme tertiary health care systems in India, both being on either end of the healthcare spectrum. On one hand, we have government institutions, where everything is subsidized or free. They are also places that handle large volumes and crowds. Doctors are usually overworked and have additional teaching and research responsibilities, all this with fixed pay and no incentives. Some medical colleges have their faculty private practicing at their clinics during the evenings. This creates a conflict of interest with their primary job. It is thus a little wonder that the quality of training in most medical colleges is going down.

The government institutions currently form the temples of learning. Therefore, they cannot be compromised as this will lead to a progressive deterioration of healthcare standards as the training of a future generation of doctors will be sub-optimal.

On the other end of the spectrum are the private medical colleges and hospitals. Large corporates usually run them. Most of the smaller hospitals are constructed with a very high debt-to-equity ratio. This places unnatural pressure on doctors to earn more money for the hospital.

So, the doctors joining such places at a young age of their career are faced with a challenge for which they have not been trained for- be part of the revenue generation for the hospital. Opening the medical profession to market forces is a clear and present danger to the profession.

Doctors are healers by profession. They should be given that job only to preserve their efficiency and dignity. Demanding that they should now become financial managers as well will be the last nail on the coffin.

It’s thus no wonder that all the young doctors, after having paid a large sum of  fees for their studies, now may have only one goal in their life- to have a payback time.

We think that it’s time to create a middle path. Something not significantly different from the UK has- a National health service but based on healthy public-private partnership.

So, if it wishes, every private hospital could become part of this health service for which they would get the benefit of joining hands with the government for better security and services without losing control over their hospital.

We have to understand that while health is a human right, no country may not afford to make it free and accessible for every citizen. It cannot be a business venture, but it could be made into a healthy, transparent, and compassionate business.

Every citizen needs access to a sound health system.

Even the richest in the country cannot deny that. And the pandemic has proven it.

Health care cannot happen in one day.

Nor does it mean creating luxurious hospitals with sparkling floors and “ultra-deluxe” rooms (and overpriced charges for treatment).

Hospitals are very different from hotels; the ecosystem is more complex.

It’s the people who are behind it that matter- the doctor, nurses, and paramedics.

If they are happy, the patients will be satisfied.

The happiness of doctors depends not just on financial remuneration.

It depends on the quality of training they receive, the continued medical education they will have, the hospital environment they work in, the sound ethics and principles that they are nurtured in, the bonding they develop with patients, and the contribution they make towards education and research to train the younger generation.

To move forwards after 75 years of independence, it’s time we stopped ignoring the elephant in the room.

People mostly like to have a gleaming white smile, not just for the perfect picture but also because it’s considered healthy. Various studies have suggested that whiter teeth not only help in boosting confidence but also give a competitive edge in job interviews.

Recently in India, the demand for teeth whitening has increased many folds. Growing awareness of oral hygiene, easy availability of teeth whitening OTC products, are some of the driving factors which are propelling the teeth whitening market. Sharing his views on the same, Dr Mohendar Narula, Founder, MyDentalPlan said, “We have seen a considerable surge in demand for teeth whitening services recently. With increased social media exposure and dental care awareness post Coronavirus is pushing Indians to focus on teeth whitening.”

He further added that “at least 7 out of 10 Indians have searched for teeth whitening clinics on our platform with the majority of them being adults or from the working class.” Stating the low cost of dental whitening in India, as the other reason for increased demand for teeth whitening, he said, “India offers the best dental whitening services at a nominal cost across the globe.”

The occurrence of stains and discolouration in teeth can be attributed to an increase in prolonged smoking habits, tobacco and alcohol consumption, unhealthy food habits, and higher fluoride concentrations in community water supplies.

While they are the most evident cause of stains on our teeth but they are not the only reasons. Some of the foods that we love such as coffee, colas, and even red wine can cause teeth to discolour.

Now, there is another reason that is being added to this long list, which is Coronavirus. People who have recovered from the infection have shared stories of how their teeth or gums weakened, with many complaining that their teeth have become discoloured post-infection.

There is a whole range of products that are available in the market that claim to make teeth pearly white again. However, most of these are only a temporary fix and even harm the gums and erode the teeth’ enamel. A more permanent solution that experts recommend is teeth whiting.

In teeth whitening, the colour of the teeth is lightened using only chemicals (bleach, hydrogen peroxide) or in combination with radiation (UV light or lasers). The whole process is carried out by the professional taking care that it causes minimal harm to the enamel and the gums.

Before starting with teeth whitening, it is recommended to get teeth properly cleaned and polished. It is also recommended to remove plaque and debris from the enamel and bleach to smooth the teeth surface as that helps in getting a better outcome.

Dr Mohendar Narula shed more light on the process and said, “Professional way for teeth whitening is getting them bleached in the dental clinic. The dentist applies whitening gel on the teeth surface and by using a special light or laser, the teeth get lighten by 6-8 shades. Generally, the complete process is into multiple visits and the objective is to provide best results keeping the teeth and enamel intact.”

Dr Narula added, “Another way of attaining whiter teeth is at-home bleaching. For this, the dentist fabricates customised dental trays that the patient wears at home after applying the whitening gel for a prescribed duration that lightens the teeth by three to four shades”.

It is a big myth that teeth whitening is a waste of time and money or that it can cause great harm to teeth. If done under the supervision of experts, it can help people achieve great results. In addition to this, maintaining good oral hygiene practices and regular professional dental cleanings every six months can preserve a long-lasting smile.

A new study has found that eating a diet rich in vitamin K can lower the risk of atherosclerosis-related cardiovascular disease (conditions affecting the heart or blood vessels).

The findings of the study were published in the ‘Journal of the American Heart Association’. Researchers examined data from more than 50,000 people taking part in the Danish Diet, Cancer, and Health study over 23 years.

They investigated whether people who ate more foods containing vitamin K had a lower risk of cardiovascular disease related to atherosclerosis (plaque build-up in the arteries).

There are two types of vitamin K found in foods we eat: vitamin K1 comes primarily from green leafy vegetables and vegetable oils while vitamin K2 is found in meat, eggs and fermented foods such as cheese.

The study found that people with the highest intakes of vitamin K1 were 21 per cent less likely to be hospitalised with cardiovascular disease related to atherosclerosis.

For vitamin K2, the risk of being hospitalised was 14% lower.

This lower risk was seen for all types of heart disease related to atherosclerosis, particularly for peripheral artery disease at 34%.

ECU researcher and senior author on the study Dr Nicola Bondonno said the findings suggested that consuming more vitamin K may be important for protection against atherosclerosis and subsequent cardiovascular disease.

“Current dietary guidelines for the consumption of vitamin K are generally only based on the amount of vitamin K1 a person should consume to ensure that their blood can coagulate,” said Dr Bondonno.

“However, there is growing evidence that intakes of vitamin K above the current guidelines can afford further protection against the development of other diseases, such as atherosclerosis,”he added.

“Although more research is needed to fully understand the process, we believe that vitamin K works by protecting against the calcium build-up in the major arteries of the body leading to vascular calcification,” explained Dr Bondonno.

University of Western Australia researcher Dr Jamie Bellinge, the first author on the study, said the role of vitamin K in cardiovascular health and particularly in vascular calcification is an area of research offering promising hope for the future.

“Cardiovascular disease remains a leading cause of death in Australia and there’s still a limited understanding of the importance of different vitamins found in food and their effect on heart attacks, strokes and peripheral artery disease,” said Dr Bellinge.

“These findings shed light on the potentially important effect that vitamin K has on the killer disease and reinforces the importance of a healthy diet in preventing it,” he concluded.

NEXT STEPS IN THE RESEARCH

Dr Bondonno said that while databases on the vitamin K1 content of foods are very comprehensive, there is currently much less data on the vitamin K2 content of foods.

Furthermore, there are 10 forms of vitamin K2 found in our diet and each of these may be absorbed and act differently within our bodies.

“The next phase of the research will involve developing and improving databases on the vitamin K2 content of foods. More research into the different dietary sources and effects of different types of vitamin K2 is a priority,” said Dr Bondonno.

Additionally, there is a need for an Australian database on the vitamin K content of Australian foods (for example, vegemite and kangaroo).

To address this need, Dr Marc Sim, a collaborator on the study, has just finished developing an Australian database on the vitamin K content of foods which will be published soon.

The research is part of ECU’s Institute of Nutrition Research. It was a collaboration with researchers from the University of Western Australia, Royal Perth Hospital, Herlev and Gentofte University Hospital in Denmark and the Danish Cancer Society Research Centre.