Violence against the medical profession

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. Anesthesiologists, especially those working in intensive care units (ICUs), face it almost every day. 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.[1,2,3] The World Health Organization has drawn out a global action plan to prevent this violence.[4]

Till the end of the 20^th century, the medical profession was considered the most noble of professions. As a mark of respect, in cinema, in India as well as in abroad, someone always carried the iconic satchel of the doctors. The pendulum has now swayed the other way and the medical profession now falls within the ambit of trade and the patient being considered a consumer. Doctors are depicted as extortionists who extract money even for treating dead bodies. Unfortunately, some black sheep in the profession have been caught on camera seeking bribes/commissions, in exchange of favors for pharmaceutical companies, and the media portrayed all doctors as commission agents. Nobility has gradually taken a backseat and so has the respect accorded to the treating doctor. There is no doubt that there are corrupt and unethical medical practitioners, but the general perception is that the entire profession is corrupt and gold diggers. Corruption is a malady afflicting all professions, with the media and judiciary are no exceptions.

Health-care staff are the most exposed professionals to workplace violence.[5] A survey of violence against general practitioners (GPs) in Birmingham found that 63% had suffered abuse or violence in the previous year, with 0.5% suffering a serious injury. Another survey of GPs found that over 60% of GPs experienced abuse or violence by patients or their relatives over a 1-year period and nearly 20% reported some sort of abuse at least once a month.[6] To combat this problem, the United Kingdom National Health Service issued “Zero Tolerance” guidelines.[7] A German survey, published in the year 2015, reported that almost 50% of GPs were confronted with aggressive behavior, with 10% of them experiencing critical to violent attacks, such as criminal damage to property and/or physical assault.[8] A study from India reported that about 87% of violent incidents were verbal while 8.4% were physical.[9] About 87% of respondents, in a survey in China, reported an increasing trend of violence against doctors.[3] Patients are becoming more aggressive in their demands and are much more likely to resort to aggression if not satisfied with health care.

Poor quality of medical services and increased awareness among patients have resulted in an increase in medical disputes and at times violence against health-care professionals. Adverse medical events evoke a violent response from the lay public. Emergency and ICU physicians face violence almost every day while dealing with the kin of patients. People attending private hospitals expect exceptional quality service from doctors, as they have paid for it. The majority of the recent violent incidents have, however, occurred in public hospitals, where treatment is free. A major reason for such violent outbursts is inadequate workforce and infrastructure to treat the huge patient load. Poorly developed and funded health insurance schemes restrict options for the sick and make health care unaffordable.[1] Long waiting times, short consultation times, and poor doctor–patient communication can easily trigger tension whenever doctors fail to meet patients’ high expectations. Doctors being caregivers are an easy target for patients’ and attendants’ frustration. Studies attribute this increased incidence of violence to commercialization of medicine; poor government investment; adverse media reports; high medical expenses; and lack of trust in doctors and hospitals.[10] In a study in New Delhi, 73.5% of doctors attributed long waiting periods as a major cause of violence. Other causes perceived were delayed medical provision, visiting-hours violation, and dissatisfaction with nursing staff. Doctors felt that patients came late to hospitals when complications had set in and then get impatient and violent in hospital.[9]

The news-hungry media regularly publish sensational stories of organ theft, medical negligence, prescription of expensive branded drugs, and malpractice. Movies and television are not far behind. The regular portrayal of doctors in poor light, with the objective of sensationalizing news, has played a major role in painting the medical profession as Satan. The media is the window of society. They should stop demonizing physicians and rather report medical errors with a sense of responsibility rather than as scandal. The media should be sensitive to the fact that medical science cannot replace the almighty God and make all immortal.

The doctors are the favorite bashing boys of the politicians. Doctors are regularly advised publically to perform the social duty of treating the needy free. For cheap vote-bank politics, senior government ministers issue statements demeaning the medical profession and painting the entire profession as corrupt. A court of law recently legitimized violence on doctors and commented that those who cannot face violence should not practice medicine. To overcome these shortcomings, governments need to be sensitive to the expectations of the common man and improve/enhance the facilities in public hospitals. Doctors must, on their part, sharpen their communication skills and should take time to clearly explain patient prognosis to attendants as they may harbor unreasonable expectations. Counselors for emotional support should be available.

Building a patient–physician relationship is essential to practice clinical medicine. This mutual trust is crucial to ensure cure, apart from maintaining a respect for each other. The doctor–patient relationship, historically defined as the legendary Hippocratic Oath, is now unfortunately reduced to a commercial transaction. The notion that the practice of medicine is a social service, and not a profession, aggravates the situation. Patient perceptions of societal injustice and commercialization of medicine lead to patient–physician mistrust. Physician training lacks core humanistic components that nurture empathy and caregiving. The public at large feel that health care is a fundamental right and they should not have to pay for it. On the other hand, governments have been shrinking health-care budgets overtime and gradually want to shirk off this burden. Limited government financial support to hospitals (about 4.4% of the overall budget in India) encourages these structural distortions. Hospitals refuse care to poor patients and the prolonged illness devastates families financially.

Ever since the incidence of violence has increased, there has been a demand to boost up security and to introduce martial personal protection training of doctors. The way to abet this violence is not to hit back but rather prevent it. The need of the hour is to develop better health-care facilities; develop crisis management teams; better patient flow management; training of employees/security to defuse crisis; and analysis of potential hazards and measures to control them. New laws need to be framed to deter the public from indulging in such acts. Most government hospitals in India lack security personnel. While it is an offense to assault a public servant, there are no laws for the protection and safety of the medical community. Assaulting medical personnel on duty should be made a serious cognizable offense. Unconcealed closed circuit television with video recording may serve as a deterrent, as well as be used to record evidence.[11] Hospitals and clinics must have panic alarms and all threats/episodes of violence should be recorded in a critical incident book.[12] There must be a zero tolerance policy for abuse. This policy must be embraced as a universally applied core institutional value rather than an imposed bureaucratic requirement.[13]

The medical profession is not attracting the best talent due to concerns of poorer remuneration, limited job options, difficult working conditions, phenomenally long training, and loss of professional glamor. The profession is also suffering from a loss of face due to low-quality training in new medical institutions, admission/recognition scandals, and the financial burden involved. The news of violent events spreads like wildfire on the social media leading to fear, insecurity, and low morale in the profession. Patients’ aggression is making an adverse impact on doctors’ job satisfaction. Doctors are discouraging their progeny from taking up the profession.[14] China is finding it difficult to recruit and retain doctor due to low morale in the profession. In a study in China, 49% of doctors said that they intended to leave the profession,[2] while in another study, 76% of doctors felt that they would not choose the profession, if given another chance, and 78% did not want their children to be doctors.[15]

The world is getting more violent. Violence is there in all fields of life. However, the medical profession is increasingly facing physical violence at work. Workplace violence has been shown to be linked to staff sickness, absence, turnover, and loss of productivity.[7] Governments need to initiate health-care insurance schemes to ensure affordable health care for all. Major reforms, in terms of availability of medical facilities in public hospitals, are needed to regain the lost prestige of the profession. Unless doctors regain their most-favored status, such violence will not be ebbed.