Violence against doctors: A viral epidemic?

Abstract

Violence against doctors at their workplace is not a new phenomenon. However, in recent times, reports of doctors getting thrashed by patients and their relatives are making headlines around the world and are shared extensively on social media. Almost every doctor is worried about violence at his/her workplace, and very few doctors are trained to avoid or deal with such situations. This article aims to discuss the risk factors associated with violence against doctors and the possible steps at a personal, institutional, or policy level that are needed to mitigate such incidents.

INTRODUCTION

Social media portrays almost one incidence of violence against doctors every couple of days, which goes viral instantly. Violence against doctors is not only localized to the Indian subcontinent, but also rather prevalent throughout the world.[1] Earliest studies of violence against doctors from the USA date back to the 1980s[2] where 57% of emergency care workers have been threatened with a weapon,[3] whereas in the UK, 52% of doctors reported some kind of violence.[4] In Asia, violence against medical professionals has been reported from China, Israel, Pakistan, and Bangladesh,[5,6,7,8,9,10,11] and prevalence rates have been higher when compared to those of Western countries. The Indian Medical Association suggests that up to 75% of doctors have faced some kind of violence at work, which is similar to the rates from other countries in the continent. This violence may comprise telephonic threats, intimidation, verbal abuse, physical but noninjurious assault, physical assault causing simple or grievous injury, murder, vandalism, and arson. Medical professionals who faced violence have been known to develop psychological issues such as depression, insomnia, posttraumatic stress, fear, and anxiety, leading to absenteeism.[12] Many have lost their clinics, injured themselves, lost lives, and also tarnished their reputation as a professional due to these incidents.[13,14]

CAUSES OF VIOLENCE

Policy factors

If we look at a policy level, India's health-care spending is close to 2% of the total budget, which is dismal when compared to other countries. The Indian government's share in the health-care delivery is around 20%. The most dominant role in the health-care delivery is provided by small hospitals having up to thirty beds, but here, due to poor insurance penetration, the patient has to spend money from his/her own pocket to the point of catastrophic poverty. As a result of this, small medical establishments are particularly susceptible to violence and aggression at the time of billing.[15,16] Even government hospitals are not spared of violence due to poor availability of facilities, which is highlighted by the fact that only 1 lakh doctors are working in government sector as opposed to a total of 9 lakh doctors in the country. This translates to long working hours and poor work environment for government doctors, which makes them susceptible to making mistakes and prone to violence.[17]

Social factors

Traditionally in India, medical professionals have been treated with respect by the society. However, the present impression of profit making of few in the profession has crippled the image of the doctors. With the advent of modern medicine, the cost of health care has increased globally,[18] but due to low literacy rates in India, there is an unrealistic expectation that paying more money should save one's life, i.e., better outcomes are expected even for risky procedures. While a doctor may receive only 20% of the total amount, it is his/her decisions that determine the total expenses.[19] This, coupled with so many sensational news reports of doctors overcharging for various tests and reports of violence in the media, has led the common man to believe that it is but natural for a doctor to write excessive tests to earn money. The public feels that media shows so many doctors getting beaten up every day and perpetrators are never shown punished, so perhaps, they can take the matter into their own hands when they feel cheated by a doctor.

Professional factors

As part of the medical curriculum, all doctors are taught clinical behavior but not all are taught empathy. Whereas in clinical practice, effective patient–doctor communication involving receiving an explanation for the occurrence of the symptom/sign, likely duration of treatment, the lack of unmet expectations, and empathy are associated with overall patient satisfaction with the services.[20,21] Many a time, the patient does not comprehend the gravity of the situation and expects a better chance of complete recovery due to improper explanation by the treating doctor. In a country like India, due to the scarcity of doctors and health-care facilities, these issues are seldom given importance, which makes this one of the important causes of rising violence against health-care practitioners in the country. Statistics from a recent Indian study of 151 doctors, evaluating workplace violence, suggested that only six of them had received some formal training in effective communication and five of these doctors belonged to psychiatry department where it is a part of the curriculum.[22] This suggests that there is an urgent need for improving the communication between the patient and doctor by imparting training to the current generation of doctors.

Local factors

Certain local factors such as mob mentality and politicians play an important role in inciting violence which frequently develops into crisis in hospitals. Death of a loved one is often used by the local politicians as a show of strength by ransacking and damaging hospitals’ property. This problem is very common in small primary health centers which lack facilities and where even trivial problems cannot be dealt with properly, but when doctors deny the availability of these facilities, they are faced with threats and intimidation to treat at any cost by the local politicians who are involved by patients’ relatives, often even. This, combined with almost a complete lack of security in government hospitals, primary health centers, and community health centers, makes these highly susceptible to mob attacks.

RISK FACTORS FOR VIOLENCE AGAINST DOCTORS

Health-care professionals are at the highest risk of violence in their workplace among all professionals.[23] Health-care workers are four times more likely to be injured and away from work as compared to other professionals, particularly because a doctor often deals with a person when he/she is in a stressful and emotionally taxing situation.[24]

A study of risk factors associated with violence against doctors found the following:[22]

• Younger doctors face more physical violence

• Female doctors are more likely to face violence

• Department of obstetrics and gynecology reported the highest rates of violence, followed by the medicine department with allied specialties, and surgery with allied specialties

• Verbal violence was the most common form of violence. In the emergency department, 100% of doctors reported some kind of verbal violence.

The same study also showed the top perceived causes for violence to be long waiting periods, delay in medical attention, and denial of admission, among other factors.

VIOLENCE AGAINST MENTAL HEALTH PROFESSIONALS

Literature suggests that 40%–50% of psychiatrists will be physically attacked by a patient, and these events tend to occur early in one's career.[25] This is different from violence faced by other specialists, as in their case, it is the relatives who become violent, whereas here, both the patient and the relatives may get violent against the psychiatrist. Dr. Wayne S Fenton, Assistant Director of the National Institute of Mental Health was killed by his own patient with schizophrenia during treatment in 2007, and similar cases have been documented in the literature.[26] It has been observed that patients with severe mental illnesses such as schizophrenia, bipolar disorder, substance abuse disorder, and antisocial personality disorder are more likely to be violent during treatment and attempt to harm the psychiatrist.[27] Majority of these violent incidences have occurred in acute wards while trying to calm the patient down, but it is also imperative that psychiatrists are better trained at handling these situations than other specialties.[22]

PREVENTION OF VIOLENCE AGAINST DOCTORS

Due to the rising rates of violence, doctors are reluctant to take up serious cases, compromising health-care delivery.[28] Thus, there is an urgent need to make health-care facilities safe havens for doctors as only then can they work with complete dedication. This needs to be done at various levels by the government, media, and medical professionals alike.

Responsibility of the government

Our country's health budget spending is meager as compared to that of Western countries. As the saying goes, “health is wealth.” Policymakers need to understand that the overall health of the people contributes to the efficiency of the workforce, in turn, contributing to the growth of the economy. More health budget spending would translate to better facilities and increased doctor–patient ratio, leading to a decrease in violence related to these factors.[28] Furthermore, there is an attempt by relatives to allege negligence in cases of sudden death of a patient; this leads to first investigation reports being lodged for murder, culpable homicide, and cheating many a time. This practice needs to be discouraged by making legal provisions deterring relatives from doing so unless evidence is present.[1] There have been attempts by the state government to make laws to prevent violence against doctors, and the first such law came into existence in Andhra Pradesh during the tenure of Chief Minister YS Raj Shekhar Reddy in 2007 who was a doctor himself. The law stated that any violence against doctors would be treated as a nonbailable offense with a penalty of up to 50,000 rupees and a jail term of up to 3 years.[29] This was followed by states such as Delhi, Haryana, Rajasthan, Tamil Nadu, Odisha, and others, making such acts for prevention of violence against doctors. In total, 19 states of India have some kind of act for protection of medical professionals and health-care establishments. However, inquiries into its effectiveness in the states of Punjab and Haryana have revealed that very few cases have reached courts after filling of a challan, but no person accused of assault on a medical professional or hospital has yet been penalized under the said acts till 2015.[1] Thus, the law needs to be enforced strictly along with the deployment of adequate security personnel in government hospitals to ensure a safe workplace for doctors.

Responsibility of media

Doctors are almost always portrayed negatively by the media. There are sensational news reports of death and sting operations against doctors. Media needs to understand that the practice of medicine is not a black-and-white subject. Diagnosis of a patient is essentially a hypothetico-deductive process, and with the appearance of new evidence through investigations and knowledge, the diagnosis of some of the cases continues to be questioned and refined. However, whatever the diagnosis be, there is always a risk of negative outcomes.[28] Doctors cannot be held accountable for every death that occurs in the hospital on account of negligence.

Responsibility of the doctors

Modern medicine is reaching new frontiers, but at the same time, a negative public perception of doctors is leading to an increase in litigations. Thus, every doctor should follow the cardinal principle “do not overreach,” i.e., do not treat beyond the scope of one's training and facilities to prevent both violence and litigations against themselves. Second, all doctors should ensure that a valid and informed consent is taken properly and not just considered a formality. Extra efforts should be taken to explain the condition to the relatives because health-care literacy is low in the country. Thus, training on effective communication needs to be imparted to every medical professional which should include assertiveness training, refusal skills, anger management, and stress management. Psychiatrists should be actively involved in such workshops for the benefit of medical professionals. Apart from all these steps, it is important to be vigilant and look for early warning signs of violence by using the STAMP approach as follows:[30]

• Staring is an early indicator of potential violence. Nurses have felt that staring was used to threaten them into a quicker response and when they responded to this, violence tended to be avoided

• Tone and volume of voice have been associated with violent episodes. Most instances involved raised voices and yelling, but some also involved sarcastic and caustic replies

• Anxiety in many people who attend the emergency department can make the visit stressful. Doctor should intervene before the anxiety reaches dangerous levels, but sometimes, the patient's anxiety does escalate to violence

• Mumbling is a cue for violence as it suggests mounting frustration

• Pacing by relatives has been observed in instances that resulted in violence and is seen as an indication of mounting agitation.

Responsibility of institutions

If violence occurs despite taking all precautions, it is important for the institution to protect the doctors involved, but at the same time not meet anger with anger. A standard operating procedure may be developed for such situations like Code Purple[31] used worldwide to alert medical staff to potential violence. It includes the following measures to be taken in case of violence:

1. An announcement on the hospital's public address system, giving the exact location of violence to disseminate the information. A distinct siren may also be installed to alert everyone in case violence occurs

2. Security staff to respond immediately and assist if needed

3. All the staff except that of intensive care unit and operation theater to come to aid and form a human chain around the professional under threat. The personnel involved in the chain need to remain calm and avoid any altercation which may escalate the situation

4. A senior member of staff not involved in treatment may try to communicate with the patient's relatives and try de-escalating the situation

5. All the members of staff to practice restraint and not lose their control

6. Once the situation is under control, an announcement on the public address system should be made

7. The practice of this drill should be done monthly in every medical establishment.

Apart from this, all medical institutions should have closed circuit televisons installed and have a zero tolerance to workplace violence. Such steps have been taken already in countries like the UK and Australia where there is mandatory organizational and police reporting of violent acts.[32,33] Perhaps, we need a social shift toward a culture that does not accept that violence is necessary or an unavoidable component of behavior. Such a culture is not simply about individuals, but extends to communities and nations. We hope no more doctors lose their lives to violence before action is initiated by organizations and the government.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.