Presidential Address at the 55th National Conference of Indian Academy of Pediatrics

Respected Chief guest Shri Nitin Gadkariji, esteemed dignitaries and guests, fellow office bearers, my beloved Indian Academy of Pediatrics (IAP) members from far and near, friends, ladies and gentlemen. At the outset, I wish to confess that one’s formal installation as the President of a prestigious national body is always a moment of personal glory for the incumbent, and no pretense of humility can hide the joy and thrill one feels on this momentous occasion.

But never in my wildest thoughts had I ever imagined that this intimate moment of mine would be made so much more memorable by the distinguished presence of Shri Nitin Gadkariji, Honorable Union Minister for Road Transport & Highways, Shipping and Water Resources, River Development & Ganga Rejuvenation. Hence with the deep respect, I wholeheartedly thank you sir for gracing this occasion with your blessings. I might also add here that, as the new President of IAP, I solicit your continued support for shaping a better future for our profession through collaborative effort with the government, which I shall present in greater detail later on in my speech.

Life, they say, is a series of moments. And every moment in itself, is an opportunity to make a fresh new beginning. Friends, today I stand before you with a dream to make a fresh new beginning for IAP. A dream that nurtures a new vision for our organization based on our commonly held, time honored ethos of harmony, growth and fraternity. A dream that is idealistic, inclusive and progressive. A dream which honors our glorious past, pragmatically embraces the present, and envisions the infinite future with imagination and determination.

As I stand before you, my thoughts go out to a day not long ago when my initial attempt to serve you in this capacity was defeated by a humble margin of only 13 votes. Indeed, it was a situation of being ‘so close, yet so far.’ At that downcast juncture, when I pondered over the unfortunate outcome, brought on that too by a so-called ‘unlucky number 13’, it was the spontaneous encouragement that come from so many of you who cared for me, which motivated me not to lose faith, but instead to persevere further. Therefore this moment is all the more precious for me because it has not only reinforced my self confidence but also my faith in my fellow IAPians. This is surely is one soul-enriching experience that neither money nor fame can buy, and I am immensely grateful to each of you.

My thoughts also go back five decades, when I began my life journey as a playful little boy in the small coastal town of Kundapur, which is situated about 90 kilometers from my present hometown of Mangalore. At that time, I never dreamed that I would one day be so fortunate as to one day share my life with you all. Like other kids of my age, all I wanted was to live happy. My life-changing moment came much later when, as a young and upcoming doctor, one day I decided to join IAP with the mentoring of Prof Sanjeev Rai. The ideals of this great organization and the opportunities it gave me for rendering service to my profession fascinated me and inspired me to wholeheartedly involve in all of IAP’s multifaceted activities. Now, three decades into the timeline, I have reason enough to be grateful to this national body for recognizing my potential and giving me opportunities for continuous growth culminating with the trusteeship of this high office.

Friends, today, I am proud to lead an organization that draws on the combined talents of 27,000 members from across India, each of whom is a gifted professional in his or her own right. It has truly been my privilege to know a great many of you personally who have enriched my life in ways too many. Those whom I am yet to meet, it shall be my endeavor to do so in the years ahead.

It has been my long-held belief that ‘A good leader is not one who attracts more followers, but rather, it is the one who creates more leaders.’ In the highly federal structure that we have as a national body, it is the hundreds of sub units, made up of the specialist cells and specialty chapters, the regional, state level, district level and city levels units that form the pillars of strength for IAP. Each of these units throws up numerous opportunities for nurturing leadership at every level. Little drops of waters make up an ocean. Likewise, the essence of the IAP universe gets enriched from the valuable inputs from each of you.

Hence, as I hereby accept this rare honor to lead the Academy as the National President for the year 2018, I invite each and every one of you to join hands with me and assume leadership in our noble quest for creating a better future for IAP. This is not only a personal gesture of my deepest gratitude to you all for reposing your confidence in me in such an overwhelming manner electorally, but also it is my own way of fulfilling a promise that I made to you through the slogan ‘TOGETHER LET US BUILD IAP.’

Organizations are only as great as the people who make it up. So in a profound sense, IAP needs you more than you need IAP. Today we are straddling a unique point in our organization history. Having completed 55 years of seamless growth spearheaded by stalwarts all along, the responsibility is now ours to take the big leap forward. Global advances in technology are fast outpacing us. The boom in medical education is adding an unprecedented number of young pediatricians to our profession every day. There is a huge spurt in lady doctors too. The rapid economic progress and the accelerating urbanization of our country is pushing a larger segment of the population towards our care. We shall be failing in our duty if we do not recognize these emerging realities and respond with strategy and precision to realize their dreams and aspirations, their hopes and expectations. Let us look upon the present phase as the better half of our centennial milestone and strive to develop IAP with a tough long-term vision.

In this context, I must refocus on the Academy’s primary role as an academic body dedicated to the cause of research, gathering and dissemination of knowledge. Regrettably, in the course of the recent decade, core academics has taken a back seat. Hence the need of the hour is to give more impetus to intense academic activity and create the new organizational structures required to facilitate the desired outcome.

On a more reflective note, our organization has gone through many ups and downs. And there have been bad experiences and there have been times of struggle. Such instances, when they occur can have a demoralizing impact on the organization as a whole. Fortunately, we have also found the internal strength to overcome every crisis whenever it came up. In large organizations, conflicts and differences of opinion are unavoidable despite everyone’s best efforts to prevent them. Such instances should always be resolved in a democratic manner and we should also develop a sporting spirit to forget the past, to shed any bitterness, and work towards the future without loss of enthusiasm. Remaining disheartened can never be a worthwhile solution. Hence our immediate goal should be strike for restoring our internal harmony and credibility keeping the organization’s best interests in mind.

It is in the overall backdrop of these determining factors, that this year I have decided to take the innovative path and solicited the co-operation of President Elect Dr Digant Shastri to formulate the first ever ‘Joint Presidential Plan’ which will include the combined goals of both our terms of Presidency. The objective of this experiment is to ensure perpetual continuity of vision and also to give the future Presidents the chance to provide better leadership by invoking the confidence of both their successors and their predecessors. In short, this is an attempt to bridge the Past-Present-Future into one continuum. This plan which comprises 31 individual agendas is designed for the integrated development and the resurgence of our mother body into a thriving new entity, which is member-centric, issue-based and futuristic in orientation. Dear IAPians, having presented this ‘Joint Presidential Plan’, I solicit support from each of your for its successful outcome.

More particularly, at this juncture, I call upon Shri Nitin Gadkariji, Honourable Cabinet Minister to extend his best possible help in improving our Academy’s interface with the government. Our Honourable Prime Minister Shri Narendra Modiji has won the heart of every Indian through his visionary leadership. On this august occasion, I request you sir to lend us your good offices and the benefit of the close rapport that you enjoy with the Prime Minister to lead our delegation to him and enable us to contribute to nation building through our professional expertise. We pediatricians are the privileged members of the medical professional who nurture the future generation. The nation has a great responsibility for their best care, and we as a national apex body of pediatricians are ready to render whatever assistance is required to improve the child health indices.

Moreover, as you would be aware, medical discipline has lately been facing immense challenges. We can overcome these challenges only with government’s support. Hence we also look forward to your sympathetic understanding and wise counsel in effectively addressing the many issues that confront us at the governmental level.

In conclusion, I wish to express my gratitude to those dear to me – my family members who continue to sacrifice a lot for my sake, my friends who stand by me like a rock, my management, colleagues and student body of AJIMS who have readily supported me in all my endeavors, all the past presidents of IAP and my immediate predecessor Dr. Anupam Sachdeva for their constant guidance, my teammates, especially President Elect Dr Digant Shastri, Honorary Secretary General Dr Bakul Parekh, Treasurer Sandeep Kadam, all EB members of 2017, 2018 and office bearers of all IAP units whose support I shall always need; Central Office staff who strive for me day in and day out.

No venue would have been better for my installation than Nagpur, and I congratulate the entire IAP fraternity of Maharashtra and Nagpur in particular on hosting this conference under the leadership of Dr Uday Bodhankar, Organizing Chairman Dr Vasant Khalatkar, Organizing Secretary Dr Jayant Upadhye, and entire team Nagpur for their organizational skills.

And most importantly my deepest gratitude goes out to every IAP member on the rolls.

‘TOGETHER LET US BUILD IAP’

Jai IAP, Jai Hind.

Beneath the White Coat

The White Coat that each of us learned to wear while at medical school is the unmistakable symbol of the doctor’s profession. It was introduced as part of our professional attire sometime in the late 1800’s as a symbol of cleanliness. That was the time when modern medicine was gaining respect as a scientific discipline, and there was a great need to distinguish it from quackery and mysticism. Hence to emphasize the transition to the more scientific approach practiced in modern medicine, physicians sought to represent themselves as scientists, and began to wear the most recognizable symbol of the scientist – the white laboratory coat. Today it is the distinctive dress of physicians and surgeons, which often stereotyped in representing our profession in popular culture ranging from cinema to advertising. 

However, wearing the white coat itself in no way makes us into better practitioners of our profession than for that matter, merely possessing the relevant university degree. Indeed, the standards that determine our professionalism run much deeper than the external markers. So what are these precious elements that mark us out as professionals? And what is it that we can all do to make ourselves into true professionals? 

DEFINING PROFESSIONALISM 

The dictionary defines professionalism as “the practicing of an activity by professional rather than amateur players.” Yet another definition goes on to say that “professionalism is skill or behavior that goes beyond what an ordinary person would have or behaving in a more formal or business-like manner.” In ordinary parlance, we understand professionalism as the act of extending an expert service in exchange for a financial consideration. In short, we are paid for rendering our expertise within business-like settings. However, relying on dictionary definitions to determine our professional conduct would be to skim the surface. Such definitions should only serve as an overall framework for us to lead to a better understanding of the subject. 

A HISTORICAL PERSPECTIVE 

In exploring the subject, we might be tempted to view ourselves as products of a modern era, and that the idea of professionalism is the outcome of 20th century thinking. Yet, the very first thing we do on entering the profession lays bare the historical depths in which this concept is rooted. The Hippocratic Oath that we commit ourselves to, which can be dated to as far back as the 3rd century BC, is one of the first declarations of the professional aspirations of the healing science. 

Similarly, the unique concept of mentoring of juniors by the more experienced seniors of the profession, the evolution of protocol-based treatment regimen, the practice of continuing medical education and the proliferation of knowledge through peer-reviewed academic literature are some of the other means by which medicine has tried to establish professional formats that seek to ensure standardized delivery of healthcare at the applied level and present medical science as an integrated discipline before the patient community. 

PROFESSIONALISM VS. ETHICS 

While it is easy to confuse the one for the other, the moot question to ask is: are they in fact one and the same? From a practical perspective, ethics can be considered as guidelines for individuals, which clearly state the dos and don’ts. Ethics exists in many contexts and pertains more to acceptable and unacceptable behaviors in individual situations. Professionalism, on the other hand, refers to the skills, the competency levels and the conduct displayed by an individual within the larger context of a certain profession. Thus professionalism is a wider umbrella within which ethics also operates. In order to be professional, one should also be ethical; but being ethical alone does not increase one’s professionalism. Hence for the purpose of this article, let us focus only on professionalism; the question of ethics is something that I hope to touch upon at a future juncture. 

THE FOUR PILLARS OF PROFESSIONALISM 

The Indian Academy of Pediatrics in its mission statement professes to “provide and promote ethical and professional standards among the members.” The American Board of Pediatrics (ABP) endorses the Physician Charter, also known as the Charter on Medical Professionalism. Quoting ‘Medical Professionalism in the New Millennium: A Physician Charter’ on the theme, it states that “Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health [1].” 

I consider the following as four pillars of professionalism that every medical professional should follow: 

1. Trustability and Reliability: The foundation for doctor-patient relationship is personal trust. When compared to other professions, medicine is considered to be one of the trusted professions. But this notion is taking a beating these days. In an article published in The New York Times on January 23, 2018 entitled ‘Do You Trust the Medical Profession?’, Dhruv Khullar writes: “In 1966, more than three-fourths of Americans had great confidence in medical leaders; today, only 34 percent do. Compared with people in other developed countries, Americans are considerably less likely to trust doctors, and only a quarter express confidence in the health system [2].” In India too, we are witnessing a drastic decline in public confidence in doctors. We have only ourselves to blame for this sad outcome. With rampant commercialization of the profession, we have become unwitting contributors to people’s negative perception of us. It is about time we regained lost ground and earned the trust before it gets forfeited forever. For this to happen, we should take pains to ensure that the patient sees us as having their interest foremost at heart. In India, fortunately the referral system is still the basis for the initial doctor-patient contact. So we are already starting on a positive note. It is up to us to take it forward from there. Exhibiting personal integrity, practicing truthful communication, and displaying sensitivity to patient needs and sensibilities plays a great role in this regard. Treat patient trust as sacrosanct, and do everything it takes to honor it. 

2. Competence and Excellence: Patients seek us out for rendering our services primarily because they see us as experts in our respective domains. So it is imperative that we live up to this promise by keeping ourselves updated on our knowledge, which should be the latest and the best. Excellence is a fast moving target and we need to keep pace with it through continuous endeavor at updating our knowledge and skill base. Wide clinical exposure, constant reading and participating in CMEs, academic interaction with peers, and insightful engagement with patients are the means by which our competence gets sharpened in real time. Failure to do so would prove disastrous to our professional standing in the long run. 

3. Appearance and Demeanor: There was a time not long along when intellectual arrogance was considered fashionable even among the medical community. A doctor could get away with acting busy or even verbally abusing patients who are annoying or not likeable. Today the tables are reversed, and it is considered unprofessional to be unfriendly with patients. That the demand is more so for pediatricians who deal with children goes without saying. Being well groomed and maintaining friendly and approachable demeanor is vital to the equation. Cultivating patience, civility and basic good manners go with the job today. So is keeping a professional distance, and remaining open, yet nonintrusive. Striking this balance between being personal and being professional at the same time is a huge challenge. But then the patient is with us out of choice and this position is inviolable. 

4. Organization and Accountability: This has more to do with the logistics of maintaining one’s practice. Having the right secretarial assistance to see that appointments are met and that the documentation maintained is available at the press of a button serves to highlight one’s professional decorum. Neat and clean premises, confidence-building ambience, comforts in the waiting room plus clinically and socially well trained human assistance are the essentials of the doctor’s eco-system. The ability to explain a clinical decision when called for, and the humility to accept when one is at fault add to one’s paradigm of accountability in the profession. 

ROLE OF MEDICAL EDUCATION 

With the idea of medical professionalism getting deeply embedded in the contemporary social environment, it would be a grave mistake not to instill this in the upcoming generation of healthcare professionals. It is only in the last two decades or so that the subject of medical professionalism is getting some sort of mention in the medical education system. The focus so far had only been on developing technical competency among the medical students, and professionalism was something that one had to learn on the job. While the curriculum these days does touch upon cultivating professionalism, the effort in this regard is simply not enough. 

As Shrank, et al. [3] commented: “Unfortunately, the culture of academic medical centers and the behaviors that faculty model are often incongruent with our image of professionalism.” Authors further proposed that “the incentive structure be adjusted to reward professional behavior in both students and faculty” and that “the next critical step is the assessment of professionalism and the construction of incentives that demonstrate that the profession truly values these qualities [3].” 

In the final analysis, professionalism is not just a set of commitments but more so an attitude. But as David H. Maister, a former Harvard Business School professor and management expert implies, the proof of the pudding is in the eating. Says he in his book ‘True Professionalism’: “Professional is not a label you give yourself. It’s a description you hope others will apply to you. You do the best you can as a matter of self-respect. Having selfrespect is the key to earning respect and trust from others. If you want to be trusted and respected you have to earn it. These behaviors lead to job fulfillment [4].” 

Professionals take pride in their work. Be proud to be a doctor and a pediatrician. 

REFERENCES 
1. The American Board of Pediatrics. Medical Professionalism. Available from: https://www.abp.org/ content/medical-professionalism. Accessed February 15, 2018.
2. Khullar D. Do You Trust the Medical Profession? The New York Times, January 23, 2018. Available from: https:// www.nytimes.com/2018/01/23/upshot/do-you-trust-themedical-profession.html. Accessed February 15, 2018.
3. Shrank WH, Reed VA, Jernstedt GC. Fostering professionalism in medical education: A call for improved assessment and meaningful incentives. J Gen Intern Med. 2004;19:887-92. 4. Maister DH. True Professionalism: The Courage to Care about Your People, Your Clients, and Your Career. New York: Simon & Schuster, 1997.

Copyright of Indian Pediatrics 2018 

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Crouching Tiger, Hidden Dragon

Pondering on the issue that I wish to explore through this article, I was instantly reminded of the title of Crouching Tiger, Hidden Dragon, which is a famous film directed by Ang Lee, the same filmmaker who also gave us Life of Pi. In the original movie, the title refers to a Chinese aphorism about hiding strength from the world. But here I use it in the negative context – to highlight the untold dangers lurking in the shadows that we doctors have to face every day. The recent case reported from Max Hospital in Delhi is a grim reminder of the fate that could await any of us on any given day. At this hospital, a preterm baby was declared as dead and later found to be alive; though scientifically these instances can occur, there was a terrible backlash. Luckily there was no violence in this episode but the credibility of the medical profession took a sound beating. The hospital license was also suspended.

In another incident which occurred at Fortis Hospital, Gurgaon, a 7-year-old girl died after her treatment for dengue failed, despite the best efforts of doctors. The hospital bill, which included prolonged intensive care unit (ICU) care, was over Rs. 16 lacs. As a result of public outrage, the intensivist concerned was held responsible and a police case was slapped on him. This doctor happens to be a renowned expert and a pioneer in this field. From the information available, it appears that nearly 95% of the amount involved went to the hospital expenses and government kitty. The doctor’s fee was nominal, his efforts highest, and the blame total. Thus it is clear that he has been made a scapegoat because it is very convenient. We often hear of similar instances elsewhere in country, and they are rising at an alarming rate. Physical assault, verbal abuse, vandalizing of premises and harassment are only some of the other ways in which doctors are victimized for alleged acts of professional negligence or failure.

This is not a new, India-specific or specialty-specific phenomenon. Writing as long as two decades back on the topic, Morrison, et al. [1] observed: "One of the most difficult situations that physicians face is being threatened, abused, or physically harmed by one of their patients. This is not an uncommon problem: Bureau of Labor Statistics (BLS) data for 1995 indicate that more workplace assaults and violent acts occur in health care and social services industries than in any other. Health care patients, the most common perpetrators of nonfatal workplace violence, were responsible for 45% of all nonfatal assaults in 1992. Although the majority of such incidents involve nursing staff, all health care workers are at risk, and physicians are no exception. From 1980 to 1989, 22 physicians were killed while at work. This represents almost one-fourth of all workplace-related homicides among health care workers during this time period" [1].

Writing earlier this year on volence against the medical profession, Mukul Chandra Kapoor noted: "Violence is increasingly being used against doctors and other medical personnel. More than 75% of doctors face violence during their practice. Almost half of the violent incidents occur in critical care units…There are regular reports of doctors being abused, threatened, bullied, manhandled, and even killed. The issue is not restricted to our country but is a worldwide phenomenon. Multiple reviews and studies have been published in contemporary literature, with the largest number originating in China. The World Health Organization has drawn out a global action plan to prevent this violence" [2].

Hence we can see that there has been a steady trend of doctors being exposed to increasing risk of unwarranted behavior from patients, and if the patient has died, from their relatives. It is true that occasionally patient grievances are genuine. It is also true that in most cases the doctor’s decisions are based on perfectly valid medically accepted norms. For every child that dies, hundreds more are saved from the jaws of death by the pediatricians. Many times, it is the host response to the pathogen that determines what happens. Of course when everything is tried to save the patient, very costly drugs are used and every expensive technology is employed to diagnose hidden problems. Use of disposable equipment to prevent infection is also bound to increase the cost of treatment.

I do not wish to get into a detailed analysis of all this here except to state that this subject has not got a well reasoned and properly formulated response from the medical profession as a whole. A lot of hows, whats and whys as already being hotly discussed on social media platforms and also in the mass media. Hence rather than delving into the details, I wish to only present a few of my broad observations on how I feel this menace should be tackled with the hope that it will contribute to an evolving consensus on the future course of action, especially under the auspices of Indian Academy of Pediatrics (IAP).

It’s an ever-changing world out there

Historically, doctors have been hailed as members of the ‘noble’ profession and their knowledge and wisdom were never challenged. With the advent of universal education and the general advancement of society, this position has undergone a paradigm shift. Today’s generation only sees us as service providers of our respective domains of expertise and their relationship with us is more like that between seller/vendor and buyer/consumer. The proliferation of information technology and social media platforms has further flattened the world. The birth of superspeciality hospitals and corporate hospitals has blurred the role of doctors as individual experts in the eyes of the public. High-end technology, while improving the health prospects of patients, has also made treatment exorbitantly costly. The glut in mass media has led to a hypercompetitive environment in which everyone has become vulnerable to the glare of the camera and its intensely cynical scrutiny. And lastly, the political sensitivity of issues relating to healthcare give them a dimension far more catastrophic than all of the above.

A call to adapt

All these are important changes that have taken place in the last few decades or so. I believe that our present problems have more to do with not fully digesting these dramatic changes and coming up with suitable adaptation strategies. Constant and continuous change is the reality of life. We as doctors have absolutely no control over what course life can or will take. It might console us to know that it is not just medicine but also that almost every other field of human endeavor has experienced similar upheavals during the same period, especially in the wake of globalization and liberation that has swept the country for the last two decades. The future will bring in more challenges of unimaginable nature, and we cannot even flatter ourselves that we are capable of comprehending them. We can only develop the flexibility of mind and openness to accept change and try to use it to our advantage. While I believe that we have been quick to absorb technology and modern management practices, we have lagged behind in two aspects: (i) understanding and safeguarding our role as individual experts in the context of the large organizations that dominate the healthcare landscape, and (ii) understanding and effectively addressing the social dimension of our profession. The sooner we catch up with this, the better it is for all.

Need for rational response

In the course of the recent outrageous occurrences in different parts of the country, I have often participated in discussions with other doctors, both in person and on social media. While many attempt to come up with constructive observations and suggestions, I am also struck with awe that an equal number express anger and resentment against all sorts of targets like the aggressive patient parties, the intrusive media and the opportunistic political classes. They demand tough punishment for the wrongdoers, legal retaliation and other punitive measures. Being a colleague, I find their anger understandable as it does seem unfair that we should be rewarded so shabbily after a hard day’s work. But the moot question is this: has anger ever solved any problem? True, most of the states now have good laws in place to specifically protect medical personnel. But just having these laws have not resulted in any decline in the occurrence of unsavory incidences [3]. Hence angry response – while giving us temporary satisfaction – will only further aggravate the vitiated atmosphere. Hence the need of the hour is to come up with a rational response to the problem. For this to happen we first need to put our minds together and commit ourselves to honest introspection and courageous reform.

Communicate to connect

For all issues involving human beings, there is a thumb rule that 50% of the problem can be solved by just listening, communicating and connecting. This is a trick that most managerial experts are masters of. This involves going back to our roots and establishing our lost human connect with the patient by exercising our compassion, sympathy and all other qualities that make us human. Today technology has overtaken us to such an extent that we are probably more distant to the patient than we might imagine. We as a profession have also failed to sufficiently communicate to the patient regarding matters like the complexities involved in patient care and the reasons for high cost of treatment. We also need to develop a strategy to communicate with society at large. This invariably happens through a friendly – rather than adversarial – mass media. For this to happen, we need to establish a Media Cell that can develop rapport with the media people and be available to respond to their queries. The Media Cell can also identify good spokespersons from amongst us who can represent us in television debates, press interviews etc. As there is obviously a trust deficit between the public and the medical profession, we could engage a Public Relations agency to conduct research and come up with solutions. Yet another proactive initiative could be to arrange sensitization workshops for journalists regarding medical issues by aligning with press clubs, journalism schools and so on.

An integrated approach

Lastly, we need to recognize that not everything is in our hands. The problem is much larger than ours alone. Hence we must identify where the interventions are needed to be made, and push for the correction. As Neeraj Nagpal writes: "Violence against doctors is on the rise all over the world. However, India has a unique problem. Meagre government spending on healthcare has resulted in poor infrastructure and human resource crunch in government hospitals. Hence, people are forced to seek private healthcare. Small and medium private healthcare establishments, which provide the bulk of healthcare services, are isolated, disorganized and vulnerable to violence. Violence against health service providers is only a manifestation of this malady. The Prevention of Violence Against Medicare Persons and Institutions Acts, which have been notified in 19 states in the past 10 years, have failed to address the issue. To prevent violence against doctors, government spending on healthcare must be increased and the Indian Penal Code should be changed to provide for a tougher penalty that could act as a deterrent to violence against doctors" [3].

In conclusion, I would like to draw attention to an integrated approach, which could provide a long lasting solution to this vexing issue once and for all. This idea is best described by Morrison, et al. [1]: "addressing violence and aggression requires an integrated, multidisciplinary approach. A common link among the three cases that we presented is the failure to recognize the systemic causes of frustration and the resulting vulnerability of the physician who seemed responsible, as an individual, to deal with the aggression. Violence prevention and control is a systemic problem that requires the input of administrators, educators, security personnel, and legal staff" [1].

So ‘Crouching Tiger, Hidden Dragon’ are the hidden ghosts lurking in our practice. We are still a long way from warding them off. The least we can do is to acknowledge the real magnitude of the problem and shape a sustained and effective response based on hard facts and strong reason.

References

1. Morrison JL, Lantos JD, Levinson W. Aggression and violence directed toward physicians. J Gen Intern Med. 1998;13:556-61.

2. Kapoor MC. Violence against the medical profession. J Anaesthesiol Clin Pharmacol. 2017;33:145-7.

3. Nagpal N. Incidents of violence against doctors in India: Can these be prevented? Natl Med J India. 2017;30:97-100.