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Year : 2019  |  Volume : 67  |  Issue : 7  |  Page : 981-984

It's a doc's life – Workplace violence against doctors

1 Ocular Oncology Service, Centre for Sight, Road No. 2, Banjara Hills, Hyderabad - 500 034, Telangana, India
2 Editor, Indian Journal of Ophthalmology, Centre for Sight, Road No. 2, Banjara Hills, Hyderabad - 500 034, Telangana, India

Date of Web Publication25-Jun-2019

Correspondence Address:
Dr. Santosh G Honavar
Editor, Indian Journal of Ophthalmology, Centre for Sight, Road No. 2, Banjara Hills, Hyderabad - 500 034, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1166_19

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How to cite this article:
Sen M, Honavar SG. It's a doc's life – Workplace violence against doctors. Indian J Ophthalmol 2019;67:981-4

How to cite this URL:
Sen M, Honavar SG. It's a doc's life – Workplace violence against doctors. Indian J Ophthalmol [serial online] 2019 [cited 2023 Jan 28];67:981-4. Available from: https://www.ijo.in/text.asp?2019/67/7/981/260966

The recent incident at Nil Ratan Sircar Medical College and Hospital, Kolkata, is not the first of its kind, and going by the trend, it is unlikely to be the last. The medical fraternity today stands united against the increasing incidents of violence against doctors with vociferous nationwide protests. It is imperative that we look at the causes of this malady and try to find practical solutions for the same.

Workplace violence has been defined by the World Health Organization as incidents where staff are abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.[1] It has been estimated that healthcare workers are four times likely to be injured and require time away from work due to workplace violence than all other workers combined.[2]

Let us first look at some facts and figures. Violence against healthcare workers seems to be a global problem. A survey by the Emergency Nurses Association conducted in 2010 showed that more than half of the emergency room personnel had suffered from some form of physical violence with one out of four reported being assaulted more than 20 times over 3 years.[3] Notably, 52% of healthcare workers in the United Kingdom have faced violence at work.[4] Physician Practice Report issued by the Chinese Medical Doctor Association in 2015 lists more than 105 incidents of violence, resulting in severe injuries to doctors in China between 2009 and 2015. This gives a glimpse of the alarming rate of attacks on doctors in our neighboring country.[5],[6] Similar incidents have been reported from Israel, Pakistan, and Bangladesh.[7],[8],[9],[10] In India, up to 75% of the doctors have been victims of assault at work,[11] 50% of the incidents have taken place in the intensive care units (ICUs), and in 70% of the cases, the relatives of the patient have been actively involved.[12]

The setting of violence against healthcare workers in the West is different from that in our subcontinent. In the United States and Europe, the majority of the incidents occur during night house calls, in psychiatric wards, ICUs, and pediatric wards. The main perpetrators are the patients under the influence of alcohol, drugs, or by patients suffering from mental illness or close relatives.[13],[14] In many of these countries, the cost of healthcare is borne by the government, so financial anxiety is not a causal factor.[15] In India, on the contrary, the committers of violence are the relatives or unknown sympathetic individuals, habitual criminals, and even political leaders.[16] Only about 33% of the Indian healthcare expenditure is by the government, the rest the patients must pay themselves. Insurance penetration is also low.[17],[18] Unanticipated healthcare expenses often push solvent families into a trap of debt and financial instability. Here, in the background of smoldering anxiety of financial implications, verbal abuse can quickly escalate to full-blown violence.

In a study conducted on workplace violence experienced by doctors in a tertiary care hospital in Delhi, 151 doctors participated. Of these, 47% had experienced violence at work. Verbal abuse was the most common form and physical violence was reported more among the younger doctors. Many of the cases were found to be in the Obstetrics and Gynecology department followed by Internal Medicine. Most of the incidents took place during peak clinic hours or during night shifts and the majority were within the hospital premises. In all, 73% of the respondents considered a long waiting time to be the main cause of violence. Only six of the respondents had received some formal training in effective communication skills in handling such situations, which was part of their curriculum, being from the psychiatry department. In only 14% of the cases, the head of the medical unit took cognizance of the matter and escalated the issue to the concerned authority. No police complaint was initiated by any of them.[19]

A retrospective study conducted to analyze the reported data on violence against doctors from 2006 to 2017 included 100 incidents and showed an increasing trend in recent times. Delhi and Maharashtra ranked the highest in the state-wise distribution. Among the top 10 institutions, three were from Delhi, including the All India Institute of Medical Sciences; 51% of incidents were in public hospitals and 72% were on resident doctors. Injuries were more grievous during night shifts and 45% were in the emergency wards.[20]

Having stated the facts, let us look at the situation from the social and humanitarian points of view. Patients come to the hospitals looking for cure, remedy, assurance, and, more often than not, miracles. Because of inherent low health literacy, it is often difficult to make the family understand the grave implications of the disease and potential complications of its treatment. For the patient and their relatives, an illness is a stranger who has suddenly come into their lives and uprooted their existence. It is bound to cause anxiety and distress. Added to this is the financial setback, not just for the treatment but also the travel, logistics and medical investigations. Often the ailing person is the only earning member in the family or a child and emotions are high. If after all this, the patient does not survive or a major adverse event occurs, the discontent and grief are quite natural. In the ICU and emergency departments, the situation is even more tense, and people are at their most vulnerable and volatile selves. The other complaints by patients and relatives are the long waiting hours, very little time given by the doctors, junior doctors attending to patients, frequent referrals to other hospitals and not admitting patients. There is also a growing perception that doctors financially gain by ordering many tests, making them buy expensive medicines and charging exorbitant fees. There are no proper grievance redressal systems in place. The judicial system in the country is an extremely long drawn process. So, the people decide to take law into their own hands and deliver the only form of justice that they feel is right for their loss by attacking the treating doctor. The more educated and affluent lot use the social media platform to deliver their verdict against the doctors and assassinate their reputation.

In China, there is the Yi Nao phenomenon, where mob becomes violent and assaults healthcare workers, destroys hospital property, and disrupts normal functioning to retaliate against real or apparent medical negligence and extort money.[21] India is facing a similar problem with rising mistrust toward doctors, high stress levels, frustration and intolerance among masses. Herd mentality rules with political flavor added to nearly every such event. Mobs attacking doctors with some time lapse after the inciting incident indicate that these may be planned and well thought of strikes and not simply random acts committed in the spur of the moment.

The media is never shy from creating a poor image of the medical profession and propagating an anti-doctor fervor among the people. They present often inaccurate, warped, and sensationalized news aimed at garnering higher target rating points. Death of a patient in the hands of a “killer,” “money-minded,” and “monster” doctor sounds so much more exciting than “overworked and sleep-deprived doctor” or a “patient dying due to inherent complications in the last stage of the disease” or “lack of infrastructure in government hospitals leave doctors helpless.” They are meant to provide news, neutral and unbiased, not form opinions and baselessly malign individuals and institutions. The political leaders of the country also take advantage of the situation and are always ready to give an incident a communal color. There have been several incidents where government ministers, lawmakers, and political party workers have vandalized hospitals, and threatened and attacked doctors.

India spends a measly 1.02% of its gross domestic product (GDP) as public expenditure on health when compared with 6.5% by Australia, 7.4% by Canada, 7.7% by the United Kingdom, 8.5% by the United States, and 9.5% by Germany and hopes to increase it to a suboptimal 2.5% by 2025. Only 106,415 doctors are employed by the Government in India, of the 938,861 doctors registered to provide healthcare to a population of over 1.2 billion. Of these, only 27,355 are posted at primary health centers, which typically serve the rural population. Poor infrastructure and lack of manpower in government hospitals make the situation further grim.[22],[23] Government hospitals suffer from overcrowding, long waiting time, shortage of staff dysfunctional equipment and suboptimal infrastructure and thus the need for multiple visits, absence of a congenial environment, lack of beds for admission, poor hygiene and sanitation.[22]

There are laws in place – 19 states in India have laws for the protection of medical professionals and healthcare establishments. According to the Maharashtra Act XI of 2010:

  • Any damage or act of violence against Medicare professionals is an act punishable by law. Medicare professionals include doctors, nurses, paramedics, medical students, hospital attendants/staff
  • Any damage to the property or the Institution of Medicare service is prohibited. Destruction of hospital beds, burning of ambulances, smashing medical stores is punishable by law
  • Imprisonment to lawbreakers for a minimum period of three years and a fine of INR 50,000 to be imposed if found guilty
  • Offenses can be cognizable or non-cognizable crime
  • Damage to any medical devices and equipment is a punishable offense and the offenders are liable to pay twice the amount of the damaged equipment's cost.

But it has not been implemented effectively because of the lack of concern from the administrators. Very few cases have reached courts, and none accused of assault on Medicare establishments has been penalized under the said Medicare Service Persons and Medicare Service Institutions (prevention of violence or damage or loss of property) Act.[22]

While we are not stating that medical negligence does not occur, we should also see the other side of the coin, the life of the doctors. A majority of the incidents occur in public hospitals which are understaffed and ill-equipped. The hospital's machinery runs on the junior and senior resident doctors who are often the victims of violence. These are the students who were among the brightest minds of their schools. Many of them had ample choices to take up any profession and opportunities to leave the country, but decided to take up medicine and stay back in India to stabilize a skewed doctor: patient ratio and serve the people to the best of their abilities. And they do try very hard. They spend at least ten years more than an average engineer counterpart, studying and learning the skills. They give up the prime of their youth to casualty and emergency duties without complaining. They live in hostels housing sometimes six to seven people in a room or the side rooms of the hospital wards with very basic amenities and hygiene. They work continuously for 36–48 hours without sleep and often without food. Public holidays are a thing of school days. The interns often spend over 12 hours just sitting in a corner and cannulating hundreds of patients crowding around, with no light or fan. This is very different from the working conditions in the West and is bound to take a toll on their physical and more importantly, mental health and functioning abilities. On an average, doctors see 150–200 patients in the outpatient department daily, perform life-saving surgeries, treat critical patients, analyze every investigation and laboratory report, and even have to take important decisions in tense situations. On top of this, the doctors do chores beyond the boundaries of their routine work, including attending to untimely calls from patients, moving equipment and patients in stretchers because there is no time to wait for the hospital staff who are supposed to do it, running from blood banks to operation theaters in the dead of night, giving personal money to patients who, they can see, will never be able to pay for the treatment themselves, and working in the hail, storm, and deluge of flooded wards so that the patients still get the treatment. Nobody feels as helpless as the doctor who has to turn away a patient because there are not enough beds or ventilators or ask a patient to buy equipment and medicines because they are out of stock in the hospital or get computed tomography/magnetic resonance imaging done from outside laboratories because of long waiting lists in the government hospitals.

Despite all that the media tells because it sells, a doctor will not discriminate on caste, creed, religion, or financial status. He treats patients with tuberculosis, human immunodeficiency virus infection, hepatitis B, getting pricked and inhaling droplets, but he still does his work. This is because treating a patient is their biggest satisfaction. If after all this, all that the society gives back to them is a slap, a punch, a broken skull or a lost eye, is it wrong on their part to demand safety or justice? They are left with no choice but to go on strike so that their voices are heard. There has been an increase in the strikes by doctors indicating their growing discontent. Of the 38% cases resorting to strike, the emergency services have not been deterred in any of them.[20] Forms of violence against doctors in India include telephonic threats, intimidation, oral/verbal abuse, physical but not injurious assault, physical assault causing injury, murder, vandalism and arson. Doctors have been known to go into depression, suffer from insomnia, post-traumatic stress disorders, fear and anxiety leading to absenteeism from work.[22]

So, what can we do about it? Well, a lot!

What the government can do: The government and its leaders are the ones the public looks up to for guidance and solutions. They should lead by example and not by force. They should condemn such acts rather than perpetrate them. There is a need to implement uniform stringent laws safeguarding the rights of doctors all over the country. Violence against healthcare workers should be included in the Indian Penal Code and the Indian Criminal Procedure Code as a cognizable offense with strict punishment. An appeal filed by the patient's family should be deemed infructuous if proof of violence by patients or relatives can be provided by the doctor/hospital.[22] The government must also pay attention to improving the conditions of the hospitals it runs and fill the vacant positions to account for the shortage of staff. Equipping the primary and secondary centers with adequate drugs, instruments, and staff can result in many conditions getting cured at this level itself, thereby leaving the doctors in the tertiary care centers to give more time and attention to cases which require skilled intervention from them. National policies for education, health awareness, immunization, sanitation, clean drinking water and unadulterated food will go a long way in reducing the burden on an already choked healthcare system. A major problem is delay in reaching the hospital. Building roads to connect remote villages to the nearest healthcare centers and ensuring a network of ambulances equipped with life support systems to facilitate the transport are absolute necessities. Paramedical training should be given more importance so that cases of trauma can be attended to on-site and during transportation. In bigger cities, green corridors are a step toward achieving this goal. If patients can reach the health centers in time, and are taken care of during the transit, the doctors can also do something to save them.

What the patients can do: Be aware. With Internet facilities abound, most patients can read about the diseases and find out about the treatment options and the best doctor for the same. Awareness should be coupled with the realization that Internet search engines can give information but not treat. That is why, even with science and technology taking giant leaps and Alexa becoming the modern pet, artificial intelligence has still not replaced the doctors. However, doctors practice medicine and not magic, some patients can be saved while others cannot. Immortality is still out of bounds for modern medicine. The doctor has to make decisions based on what the patient tells him, so patients should provide the facts. Patients should understand that with advancements in the field of medicine, the cost of treatment will also go up. If a patient is not satisfied, he should take the matter up with the concerned authorities, the senior doctor, the grievance redressal department, or the law. Violence is not an answer.

What the hospital can do: There should be a sound security system in place. Closed circuit cameras are essential to identify the miscreants and provide the necessary proof. The number of relatives entering the hospital or a doctor's office should be restricted. Screening should be done at the entrance to ensure that no armed person can enter the premises.

A very important and necessary step to improve patient satisfaction is to have a transparent billing system and a grievance redressal department. The patients should be prepared for the expected waiting period at the time of giving an appointment. Displaying the number of available beds so that the doctor on duty does not have to prove, convince, or even beg the patients to understand why he cannot admit them.

There should also be a standard operating procedure in every institution to handle such a situation if it arises. A Code Purple is used worldwide to alert the hospital personnel of potential violence.[24] In such cases, the following measures need to be taken:

  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 ICU and operation theater, to come to the 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.

What the doctor can do: The doctor should know his abilities and limits and when to refer a patient to more competent colleagues. He should be patient and calm. He should try to address the concerns of the patients, giving due importance to their problems and their primary complaint. Communication skills should be developed for building a better doctor–patient relationship. Patients and families must be explained about the illness, possible treatment options and their potential complications, alternatives to the proposed management plan, expected duration of treatment, possible outcome if untreated, overall prognosis and financial implications. Daily updates on the condition of the patient and video-counseling of the family at critical points during the delivery of care are important measures that need to be implemented. He should take informed consents and document everything meticulously. While this paperwork is often neglected and considered useless, this is often the most important evidence that can save a doctor from lawsuits and defamation. The doctors and nursing staff should be trained, with refresher courses from time to time, on basic and advanced life support measures. There should be workshops on how to break sad news to patients and how to handle a situation that may turn violent. Senior doctors must step in when the situation demands. The presence of a senior doctor with experience can often diffuse the situation when the relatives feel that the patient is being adequately cared for.

The doctors should also be alert about signs that a patient or relative may turn violent. Look for STAMP:[25]

  1. Staring to intimidate
  2. Tone and volume of voice, yelling, sarcastic and caustic replies
  3. Anxiety approaching dangerous levels
  4. Mumbling suggesting increasing frustration
  5. Pacing around the room in agitation.

What the society can do: The society should embrace the doctors because, after all, they are one of them. One thing, which the doctors are deeply hurt by, is the apathy of the non-medical community toward their woes. When the doctor treats each one of them, why cannot one of them speak up for the doctors? The media must put forth unbiased news to the public and not dress them up in the garb of fancy stories to grab the front page. They should also highlight the plight of doctors and the reasons for the increasing violence against them. The general public and bystanders should try to mitigate such situations rather than turn into hooligans and blind followers of the mob, or worse, stand there and record the incident.

Given the crucial nature of their jobs, how do we expect the doctors to work soundly, in such a hostile environment, when they have to fear for their own lives, how can we expect them to save lives? Many doctors are now refusing to take on complicated cases just to avoid being heckled or abused if there is an adverse outcome.

Violence against medical professionals is only a symptom of a deep-rooted malady, imbalance, and incongruity in the public healthcare delivery system in India. Unless the government takes up the issue expeditiously with due seriousness that it deserves and effectively rehauls the public health system by allocating an optimal proportion of GDP, the situation is only likely to slowly slip into an irrecoverable deep coma.

The doctors will stand by each other and will somehow survive. But will society be able to do the same without them?

I've paid my dues

Time after time

I've done my sentence

But committed no crime

And bad mistakes

I've made a few

I've had my share of sand kicked in my face

But I've come through

I've taken my bows

And my curtain calls

You brought me fame and fortune and everything that goes with it

I thank you all

But it's been no bed of roses

No pleasure cruise

I consider it a challenge before the whole human race

And I ain't gonna lose

We are the champions, my friends

And we'll keep on fighting 'til the end

(From Queen, We Are the Champions)

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