On Medical Errors and Negligence

Medical professionals like everybody else are prone to errors. These errors are pretty much an essential part of being human. No one is infallible and therefore to expect our clinicians to be free from mistakes is foolishness. In the case of medical professionals, however the consequences of a medical error can be horrendous. A small error can leave a patient in a wheel-chair for life or can lead to life threatening complications and even death. A recently published report by John Hopkins University School of Medicine estimated medical errors to be the third largest cause of death in the US accounting for a little over 250000 deaths in a year. In India, these numbers are difficult to estimate. Business Standard quoted a Harvard study in Oct 2018, estimating that a staggering 5 mn lives are lost to medical errors annually in India.

Medical negligence on the other hand implies that an adverse medical outcome occurred because a clinician or a care-giver failed to adhere to well-established standards of care. This happens because the care givers were too casual in their approach, did not take their onerous responsibilities seriously, failed to adhere to well established medical processes and procedures or were simply careless. Often, clinicians in busy hospitals are over-burdened, are constantly multi-tasking and perennially dealing with highly stressful situations. This leads to short-cuts, a deviation from the norms and established procedures causing a catastrophic outcome. Sometimes, medical negligence can be traced to over-confidence where a clinician has supreme belief in his own abilities and becomes a little cavalier in treating patients leading to a stupid unforgivable mistake.

As patients and consumers of healthcare services it is imperative for us to understand and recognize the difference between a genuine medical error and medical negligence. Patients often tend to blame doctors for an unexpected adverse outcome, not realizing that the practice of medicine is inherently fraught with risk and an adverse outcome is always in the realms of possibility. A doctor can only try and minimize this risk by his knowledge, skills and work-ethics, he cannot eliminate it or wish it away. Medical errors can also be significantly reduced by establishing a hospital-wide culture of patient safety. The use of cutting edge technology, which warns clinicians, nurses and care-givers whenever a deviation from an established process is detected, allows clinicians to review their decisions and stop just before an error was about to happen. Many private hospitals in India now use these smart systems to prevent medical errors thus improving their medical outcomes. (At Max Healthcare, we run a program called ”Chasing Zero”, which through multiple initiatives helps weed out clinical errors. While, this program is almost invisible to patients and consumers, it is one of the most important initiatives, running silently in the background ensuring greater patient safety and better outcomes.)

Medical Negligence, of course is completely unacceptable. That a clinician or a care-giver failed to adhere to a well-established standard of care is an egregious failure and must not be countermanded or swept under the carpet. Even a single case of medical negligence is a blot and the hospitals should not shy away from accepting the mistake and taking remedial action. Sadly, many don’t, fearing a media backlash and legal liabilities.

From a patient’s perspective, being a victim of either a medical error or medical negligence is terrible. Patient’s go to the hospitals in search of a cure and an enhanced quality of life. To emerge from a bout of hospitalization in a worse condition is a tragedy. It is hardly a consolation to know that the medical error was either ”unforeseen” or ”unavoidable” and a result of human fallibility. These patients have to learn to live in altered circumstances and daily face up to the new reality of their diminished lives.

It is thus imperative for hospitals to continue to invest in technologies, which help avoid medical errors. The hospital leadership teams should continuously work towards creating a culture which respects and honors professionals who are always vigilant, all the time looking over their shoulders and going out of their way to help ensure minimal medical errors. There can’t be anything more important in a hospital than patient safety.

If we have to err, let us always err on the side of caution.

The views expressed are personal

The World Medical Tourism and Global Healthcare Congress – A Tame Affair.

The 12th edition of the World Medical Tourism and Global Healthcare Congress was quite a tame affair. The meeting was held earlier this month in Abu Dhabi, UAE. Compared to some of the events in the past, this was in many ways a damp squib.

However, first all that was good about the event.

The organizers, The Medical Travel Association (MTA) had changed the format this year and made it a more business to business (b to b) event and had restricted access to only people who were actually connected to healthcare and medical travel. This in itself is not a bad thing to do as it brought greater focus to the business aspects of the meet and eliminated frivolous visitors who would just visit the exhibition out of plain curiosity. The organizers had also cut out the song and dance and the hoopla, which was a part of the earlier events. Thus, the event had a more business feel to it and all our meetings were with serious and relevant people who had good reasons to be at the event.

The event also attracted buyers from a large number of countries. From the perspective of Indian hospitals, many people came from countries, which are relatively new and fairly unknown to Indian hospitals. These were clearly opportunities and I am sure many hospitals and healthcare facilitators (HCF) from India would have benefited from these interactions. I was quite surprised to see large delegations from China, Russia and South Korea and we had good meetings with them.

Now the not so good, which frankly outweighed the good.

The entire event appeared to have been sold to the Abu Dhabi’s, Department of Health. The MTA must have made tonnes of money, however the credibility of the event was seriously compromised. Thus, the inaugural day only had escorted visits to various Abu Dhabi hospitals aspiring to attract patients from various parts of the world. Buyers and hospitals participating from other parts of the world were not invited (they are after-all competition) on these tours.

The plenary session the next day was an extended advertisement for Abu Dhabi medical tourism and the medical infrastructure, which has come up there. The speakers including the CEO of Cleveland Clinic in Abu Dhabi had no insights to share except highlighting the facilities and services they offered to patients wanting to travel to Abu Dhabi. This is hardly the stuff of serious global conferences. While, I understand the commercial nature of these events, the organizers usually aim for a balance between sponsor’s propaganda and genuine high value content. Sadly, in this conference the organizers did not even pretend to be not a mouth-piece of their sponsors.

The rest of the conference content too was quite lack-luster. Most of the sessions and the speakers were predictable and were happy to plug in for Abu Dhabi, Department of Health. In one session involving a benefits manager from a US company, the interviewer wanted to know if they would be interested in sending their US employees to Abu Dhabi for medical treatment!!! No wonder, I counted 5 people in the hall listening to this conversation.

Most of the buyers were those whose travel and stay has been paid for by the MTA. This was perhaps a desperate bid to get them to the event and ensure that they visited the Abu Dhabi hospitals and also met the sellers (mostly hospitals from different parts of the world). In my view quite a few of these were non-serious buyers who had been flown in to make up the numbers. A rather sad state of affairs.

In conclusion, the conference was high on hype and low on substance and content. From a b to b perspective and purely as a platform for meeting new buyers from different parts of the world, it scored reasonably well. However, from the perspective of enhancing knowledge, offering newer insights on what is happening in the world of Medical Value Travel (MVT) and showcasing the best in the MVT, the conference was quite a disappointment.

The views are expressed are personal.

Medical Value Travel in India-A promise yet to be fulfilled.

For at least the last 10 years one has been hearing about the Medical Value Travel (MVT) market in India touching a whooping USD 5bn, 8bn or even 10 bn by 2020. These are breath-taking estimates provided by venerable consulting firms from almost 10 years ago. These had been quoted ad-nauseum by all manner of people (including, I must confess, myself) as the potential of MVT in India in presentations made to likely investors, foreign governments and indeed overseas hospitals with the potential to send patients to India. Many analysts have cited it as the next big thing after India’s dominance in exporting software to all parts of the world. It has been touted as the real big thing about to hit our shores.

Sadly, the reality has turned out to be a little different. The big wave hasn’t really reached our shores. The MVT business including those flowing into sectors like travel and hospitality would today be well under USD 2 Bn.

So, what worked and what didn’t and more importantly what needs to be done?

In my view what has largely worked for MVT in India has been the outstanding medical services and world class outcomes that our clinical teams continue to generate. The commitment of the clinicians, private investments in additional beds, equipment and technology has helped deliver cutting-edge care to thousands of patients who continue to travel to India in search of better health. Increased competition among private hospitals have also ensured that pricing hasn’t gone through the roof and India still is by far the least expensive destination for high-end medical care.

Medical outcomes and care are just one part of what patients look for when they wish to travel abroad for healthcare. Sadly, we have not done as well in almost everything else.

The government of India is still not very friendly towards medical travelers. In many countries the Indian missions have archaic rules for issuing medical visas, often the patients themselves have to spend time in long queues outside the embassies to apply for visas and touts merrily ply their trade. The International airports even in major Indian cities do not have adequate facilities to receive sick patients. While, immigration counters for people traveling on medical visas have come up, a lot more can be done at the airports to ensure greater comfort for weary travelers who are also sick, often seriously.

Even those private hospitals in India who are teeming with thousands of international patients have very scratchy patient services. Almost every aspect of non-medical services is neglected. The interpreters are few and of dubious quality, patient concierge services do not exist and hardly any hospital makes the effort to serve the patient’s preferred cuisine. Information regarding the treatment plan, medical risks involved, and prognosis is usually scarce, and patients must depend on unreliable sources such as clinician’s secretary and other assistants to get whatever information they can get.

The biggest bugbear of all remains the unreliability of patient estimates. Healthcare is an inexact science, it is almost impossible to predict with great accuracy the course a patient may take in a hospital. However, hospitals wishing to treat international patients must come up with fixed price packages for at least the most commonly done procedures and surgeries and ensure that the bills of foreign patients do not escalate.

To make matters infinitely worse, often the patients are assisted by the so-called Healthcare Facilitators (HCF’s) who are still largely individuals (and not well organised institutional service providers) looking after ”their” patients. Most of them have the right intention to assist the patients during their stay in India, however they are seriously hampered by a lack of organised resources and well-established processes. Sadly, some are plain opportunists, who dump patients in hospitals, which pay the maximum commissions and disappear thereafter. There is a crying need and a great opportunity for medical concierge services providers to set shop and look after foreign patients in need of assistance. The established hospitals must also encourage and support the emerging organised players in this space.

MVT in India (also healthcare in general) remains unregulated. It is extremely important that the government urgently creates an independent regulatory body, which works closely with MVT stake-holders to set up rules for all those involved in medical value travel. These will include airlines, hospitals, hotels, spas, ayurveda centres and HCFs. Quality standards need to be developed and implemented in all the aspects of MVT. Accreditation norms must be a lot more stringent and command greater respect.

The other big problem that remains unaddressed is the sheer lack of information and knowledge about modern India and its medical capabilities. Most people abroad have preset notions of India being largely an over-crowded nation of over a billion people mostly mired in crushing poverty and squalor. This is clearly a uni-dimensional and dated narrative completely at variance with reality. All stake holders in MVT in India including the government and private healthcare providers must join hands to work towards dispelling this notion about India. A campaign like ‘’Incredible India’’ is sorely needed.

Essentially, MVT in India has not done as well as expected because of a lack of vision on the part of key stakeholders namely the private hospitals, the government and the HCF’s. All three need to seriously introspect. The hospitals and the HCFs need to look beyond just the next patient and invest in better infrastructure, better systems and processes, better quality people and a greater commitment to overseas patients. The government needs to create a regulatory and supportive environment, which allows them to function well and with greater efficiency.

This can’t be too difficult.

All it requires is greater alignment, focus and commitment among all MVT stakeholders.

The views expressed are personal

The National Medical Council (NMC) is a flawed Regulator

The parliament of India recently passed the NMC bill and the President Ramnath Kovind swiftly gave his assent to make the bill the new law. The bill has been in the works for a while and one can’t really say that it has been passed in haste. Yet, some of the features of the bill seem to be completely detrimental to the effective regulation and administration of medical education in India.

The law now envisages the abolition of the erstwhile, Medical Council of India, which had so far governed and regulated medical education in India. It is no secret that MCI had over the years become a den of corruption and had fostered an opaque system of patronage, which has done a huge disservice to the medical education sector in the country. Thus, the demise of MCI should not be much lamented. However, the NMC Act too does some serious injury to the very sector it professes to reform.

The Regulator is not Independent

Members of the NMC will include the Chairperson, four Presidents of the Boards set up under the NMC, Director Generals of the Directorate General of Health Services and the Indian Council of Medical Research, five Directors of medical institutions including the AIIMS, Delhi, five members (part-time) to be elected by the registered medical practitioners, and three members appointed on rotational basis from among the nominees of the states in the Medical Advisory Council. Most of these members will essentially be drawn from the government and will be expected to toe the government’s line.

A search committee comprising of the Cabinet Secretary, Union Health Secretary, CEO of NITI Aayog, and four experts nominated by the central government (of which, two have experience in the medical field), will recommend the name of the chairperson of the NMC, which will be duly appointed by the government. While, the search committee is quite high-powered, its composition once again reflects the bias they will have, while selecting the NMC Chairperson.

To make matters more explicit section 46 of the act says ” “Central Government which will direct, as it may deem necessary, to a State Government for carrying out all or any of the provisions of the Act and the State Government shall comply with such directions.” This is in fact an assault on the rights of the states and clearly concentrates unnecessary powers in the hands of the federal government.

Quackery is In

NMC acknowledges the emerging shortage of doctors in India. However to combat this, the Act resorts to legitimizing quackery!!! It is a well known fact that all over the world, it takes several years of study and training for someone to qualify as a doctor. NMC through, what can only be called as a sleight of hand, proposes to offer a 6 month ”bridge course”to the practitioners of Ayush systems of medicines. This will qualify them as ”Community Health Practitioners” (CHP’s) and these CHP’s will be allowed to prescribe allopathic medicines. Essentially, the CHP’s, after a bridge course of 6 months, will be able to independently practice medicine. While, the act does mention about the possible supervision of the CHP’s by medical practitioners in a timely manner, it isn’t clear about will this work in a country the size of India. To say that this will help solve the shortage and uneven distribution of medical practitioners in the country is pure chicanery.

The Central Government is the final arbiter

It is strange that the appeal against an order of the NMC can only be to the government. Thus, if a doctor is aggrieved with any decision of the NMC he can appeal to the Government of India. With the NMC largely populated with government nominees, government servants and officials, this hardly looks like a fair recourse. It is not clear, why a judicial body is not an appellate authority against the decisions of the NMC.

India certainly needs a regulator for medical education. The regulator however has to be an independent body, comprising of eminent persons from the relevant fields and free to carry out their work in a transparent manner. Moreover, the regulator must be above any possible or likely political interference.

Unfortunately, NMC as envisaged in the present Act is just not that.


 
 

The Mess at CGHS

While the government has ambitions of running and efficiently managing the world’s largest public healthcare program called Ayushman Bharat, the much smaller and much older healthcare scheme meant for the employees of the Central Government is in a complete mess. The Central Government Health Scheme (CGHS) website loftily proclaims that it” is the model Health care facility provider for Central Government employees & Pensioners and is unique of its kind due to the large volume of beneficiary base, and open ended generous approach of providing health care”. It is anything but that.

CGHS is over six decades old and is run under the Ministry of Health and Family Welfare of the Government of India. It is meant to provide subsidized healthcare to government servants through a network of primary clinics, dispensaries and em-paneled hospitals, which are mostly in the private sector. The private hospitals are required to treat the CGHS beneficiaries in a cashless mode and claim reimbursements at subsidized and pre-agreed rates from the CGHS organisation. The participation of the hospitals in the scheme is voluntary.

Recently, on July 2nd, the Minister of State for Health and Family Welfare, GoI, Ashwini Choubey, stated in the Rajya Sabha (the upper house of the Indian Parliament), that the government has received some complaints regarding private hospitals em-paneled with CGHS refusing to admit the CGHS beneficiaries and that show cause notices have been issued to these hospitals and strict action is contemplated against them. As usual, the government is stating only one side of the story.

Here is the other side.

CGHS had entered into an agreement with private hospitals in 2014. The agreements were valid for 2 years. Since 2016, the CGHS organisation has been arbitrarily extending these agreements for a period of 3 months. Fresh agreements that should have been signed in 2016 have not been floated and the em-paneled hospitals just receive a communication from the CGHS organisation that the agreement is extended by 3 more months.

Interestingly, the agreements signed by the hospitals in 2014 were sent to CGHS for the signatures of CGHS officials. These have not even been returned to the hospitals. This essentially means that the hospitals do not hold with them any legally valid agreement duly signed by both the parties.

To make matters infinitely worse, the pricing that the hospitals had agreed to in 2014 for a period of 2 years remains unchanged even in 2019. Thus, the CGHS organisation has not increased the price that they pay to the hospitals in the last 5 years. The price of a consultation with a specialist is fixed at INR 150 (approx. USD 2) !!!! The hospitals’ costs of course keep going up year on year. There is no justification offered for this stasis.

If this was not bad enough, the CGHS never pays the hospitals on agreed credit period. The payments are delayed for months, while the hospitals are expected to continue treating CGHS patients without a pause. One clause in the CGHS agreement states that 60% of the bill will be reimbursed by the CGHS with-in one week of the submission of the bills. This, of course remains only on paper. The CGHS owes hundreds of crores of rupees to private hospitals in the National Capital Region of Delhi alone. Effectively, the private hospitals end up locking their working capital in treating CGHS beneficiaries.

A small industry thrives on recovering dues from the CGHS. Sundry companies offer their services to private hospitals to help get their bills cleared by the CGHS. Many hospitals employ a small army to chase their bills across the dusty desks of the CGHS mandarins. They literally move the files in the CGHS corridors, from one desk to the other and from one office to the other. All this means additional expenses for the private hospitals, just to recover their legitimate dues.

Finally, when the money arrives after a valiant effort stretching over months, the hospitals discover that their bills have not been paid in full and deductions have been made for reasons, never specified. The hospitals often make representations to the CGHS to understand the reasons for these deductions and seek the recoveries, which of course is another herculean task. Some simply do not bother and accept whatever CGHS deigns to pay them.

The genesis of the problem lies in the fact that CGHS is under-funded and monumentally inefficient. No one is actually bothered to take a broom and clean up the mess. No one has a real incentive to do that. While, perverse incentives to let things be, continue unabated.

Rather than threatening private hospitals, Minister Choubey will perhaps do well to have a look right down the corridor from his office and do something about the mess in CGHS.

The views expressed are personal and do not necessarily reflect those of my employers.

Resisting the advance of Medical Value Travel is Futile

As I travel to various parts of the world promoting Medical Value Travel (MVT) to India and Max Hospitals, in New Delhi, I am increasing becoming aware of a certain kind of resistance bordering on hostility in different quarters. The last time I was in Kenya I happened to meet a local parliamentarian in Nairobi. The parliamentarian articulated this phenomenon rather well. As per his world view MVT entails a significant leakage of foreign exchange from impoverished sub-Saharan African nations to wealthier nations with fancier (and not necessarily better) healthcare systems. He felt that hospitals chains from India and Thailand and elsewhere tend to ”lure” away gullible patients to their shores even though the patients can be treated locally as well. The MP was of the view that only those patients should be allowed to travel abroad, who cannot be treated in Kenya itself.

Sadly, a similar view is also being articulated by many local clinicians as well as various Medical Associations and regulatory bodies in several parts of the world. They are making it difficult for foreign clinicians to come and work in their countries by raising inappropriate barriers such as the requirements of multiple licenses and permissions from sundry agencies. Essentially, behind all this lies fundamental insecurities and an almost cavalier disregard for what might be the best for the patient.

People travel far away from their homes in search of quality medical care for three main reasons.

  1. The Services are not locally available or are scarce.
  2. The services are available but are too expensive.
  3. The services are available but are not easily accessible to patients.

Unless a nation addresses these issues, MVT is unlikely to go away.

By being mean spirited and denying foreign doctors and hospitals to collaborate with local medical establishments is clearly foolhardy. International medical collaboration leads to exchange of knowledge and transfer of skills. That is usually the quickest way to upgrade local expertise and instill confidence in local clinicians to take up difficult cases initially under the guidance of foreign experts and later, on their own. There is nothing shameful in learning from someone who has greater knowledge or expertise.

Moreover, such practices are against the best interests of the patients, which all doctors are under oath to protect. ”As a father of a sick child with a congenital heart problem, why should I be denied the opportunity of seeing a foreign expert if he is willing to travel and visit me in Nairobi? Why should I not have the opportunity to take his opinion and compare it with what is available locally and decide for myself, what might be the best for my son?” asked John Kutolo, whom I met in Nairobi in October 2018.

The argument that people should not be allowed to travel abroad if the clinical service is available locally is quite disingenuous. The availability of service is just one aspect of the decision to travel abroad for treatment. The big question really is the quality of the service available and more importantly the trust that one has in the local medical services. Thus, it is possible that Kidney Transplants may be happening in Nigeria, however if I, as a patient or a care-giver do not trust the local hospital, why should I be forced to get my transplant done there?

Often people travel abroad for treatment because healthcare costs in many countries are humongous and insurance coverage either non-existent or severely limited. If the patients and the care-givers have confidence in their decision of traveling abroad, where they can possibly afford good quality healthcare, they should certainly have no difficulties in accessing such services. Similarly, if one chooses to get treatment done at low costs in a foreign country rather than wait for months in some places like Canada, UK or Russia, they should be able to do so unhindered. False pride in one’s country’s medical systems should not come in the way of offering foreign treatment options to patients who can than decide what might be the best for them.

While, I do realize that most hospitals sending their doctors and medical teams to war ravaged countries like Iraq or under-developed nations like those in the Sub-Saharan Africa clearly have a profit motive in encouraging patients to travel, the fact is that patients travel only when their clinical needs are not satisfactorily met locally. No one really wants to be thousands of miles away from family and loved ones during a risky medical procedures.

Finally, it all boils down to a patient exercising a choice over who and where she gets treated. I believe that the patients should have complete access to information regarding all relevant options and they should be free to choose. If this means that they should get to interact with visiting clinical teams from foreign lands, than they must be able to do so without hindrance.

The only way to counter MVT is for the governments and private enterprises to invest in healthcare infrastructure, build world-class, technology led institutions and have a steady supply of trained and experienced clinicians. All this must also be easily accessible to most citizens and at competitive prices.

Unless that happens, MVT is here to stay.

The views expressed here are personal

The Aggressive Patient

Why are we intimidating and beating up our doctors ever so often these days?

Every other day one see’s newspaper headlines where doctors find themselves facing angry patients and their attendants who believe that misbehaving with hospital staff and doctors is no big deal at all. That breaking furniture and maybe a few bones will get them better service or perhaps the hospital will waive off a portion of their bills. Doctors and hospitals today are quite scared of such hooligans, who create a nuisance in the hospital demanding better treatment for their patients without realizing that their behavior is putting other patients at grave risk.

Part of the reason for this I suppose is that we are becoming a more aggressive nation. The road rage that one witnesses on the roads in Delhi everyday, the ugly fights among neighbors usually for parking spots, the crazy honking even on a red light are perhaps all a manifestation of this malaise. The medical profession too I suppose cannot escape its share of problems in a society becoming louder, more aggressive and more demanding. Everyone seems to be on a short fuse.

In hospitals, where life and death situations are routine, people are perhaps a lot more stressed and express their frustrations by mishandling the folks right in front of them. These are mostly doctors and nurses, who bear the brunt of their anger. Little do they realize that beating up the doctor won’t help them get better care. And that beating-up anyone is no solution to any problem.

The other reason that I find for all this anger in the hospital is a lack of communication between doctors and the patient’s attendants. Usually, the clinicians are very busy folks who have very little time for patient’s attendants. They believe that their primary duty is to look after the patients, without realizing that in today’s world they also have an equal duty towards addressing the attendant’s fears and concerns regarding the patients. Hospitals spectacularly fail in impressing on the clinicians that they must meet the attendants regularly and address all their queries as honestly and as transparently as possible. This must be a part of a process and not a random meeting in a corridor or when a patient’s attendant catches hold of a doctor fortuitously. Better communication will help reduce these unsavory episodes far more than more security guards manning the hospital doors.

I also look upon these incidents as reflective of a loss of respect and trust between patients and doctors. With the media awash with stories of profiteering hospitals and grasping clinicians engaged in dubious practices, no wonder that the relationship between patients and doctors have almost broken down. The noble profession has been reduced to no more than a transaction. There is no longer the old world courtesy and respect that clinicians commanded not so long ago. No longer are they the Gods of their realms. This is rather sad. The relationship between a doctor and a patient and their care givers has to be a a bond of great trust. The patient willingly allows the doctor to treat and operate upon him believing that he will do so to the very best of his skills and ability. The doctor on the other hand accepts this as a huge and crushing responsibility and does his best to ensure that the patient comes to no harm, while under his care. This is the covenant that has always existed between doctors and patients. This sacred bond is now stretched almost to the breaking point.

What is it that we can do to get back from the brink??

As hospitals and clinicians we have to understand that the patients are increasingly getting impatient and we must learn to deliver all that we commit. We must find more time to address their concerns and not just fob them off with some sarcastic remark about their limited understanding of medical matters. We must engage with them more, learn to treat them as equals and partner them in their treatment. A dialogue is essential.

As patients and their attendants we must understand the tremendous pressure and responsibilities each clinician carries. We must also have an unshakable faith in their good intent, skills and abilities. This has to be a given. We must also have the wisdom to realize that in medicine an adverse outcome is not necessarily the fault of the doctor or the hospital. Actually, at times it is no one’s fault. We must treat our doctors and nurses as fallible humans, just like ourselves.

Finally, there will always be those who believe that creating a ruckus helps get things done in the hospital. In my view the hospital must deal with them firmly and take whatever action is required to ensure orderly conduct.

Violence can not be justified, whatever the reason or the grievance. Beating up ones doctor is almost the most stupid thing imaginable that one can do.

The views expressed are personal