|Year : 2018 | Volume
| Issue : 3 | Page : 153-160
Epidemiology of violence against medical practitioners in a developing country (2006-2017)
Rajesh Ranjan1, Meenakshi2, Mitasha Singh3, Ranabir Pal3, Jayanta K Das4, Sanjay Gupta5
1 Department of Community Medicine, Saraswathi Institute of Medical Sciences, Hapur, Uttar Pradesh, India
2 Department of Obstetrics and Gyneacology, Lady Harding Medical College, New Delhi, India
3 Department of Community Medicine, MGM Medical College and LSK Hospital, Kishanganj, India
4 Director, National Institute of Health and Family Welfare, New Delhi, India
5 Department of Epidemiology, National Institute of Health and Family Welfare, New Delhi, India
|Date of Submission||07-Oct-2017|
|Date of Acceptance||24-Sep-2018|
|Date of Web Publication||24-Dec-2018|
Dr. Mitasha Singh
Department of Community Medicine, ESIC Medical College and Hospital, Faridabad - 121 001, Haryana
Source of Support: None, Conflict of Interest: None
Aim: Incidents of vandalism on doctors is increasing by alarming rate. It has been observed in all types of government and private set ups. This trend is observed pan India as well as globally. Methods: A descriptive analysis of reported data on vandalism on doctors from the Google search engine, all national and local news websites of the last 11 years from January 2006 to May 2017. Results: The number of cases reported was counted yearly which showed a remarkable increase in crime against doctors. Majority of the cases have been reported in media from Delhi and Maharashtra in the last 11 years. Out of 100 cases reported majority were witnessed in 2015 and 2016 (17 each) and followed by 2017 (14). Majority of the males suffered grievous injury (52.1%); this distribution was statistically significant (P = 0.001). The night shift contributed higher proportion of grievous injuries (52.9%) (P = 0.003). Conclusion: The source of this intolerance toward health-care providers stems from unlimited expectation (magic cure) from doctors on the one hand and unjustified expectation and limited health education of patients and their caregivers (attendants and bystanders) led them to believe that medical science has a curative solution for all the health problems even in the resource-rich settings.
Keywords: Doctors, physical, predictors, trend of strike, vandalism
|How to cite this article:|
Ranjan R, Meenakshi, Singh M, Pal R, Das JK, Gupta S. Epidemiology of violence against medical practitioners in a developing country (2006-2017). J Health Res Rev 2018;5:153-60
|How to cite this URL:|
Ranjan R, Meenakshi, Singh M, Pal R, Das JK, Gupta S. Epidemiology of violence against medical practitioners in a developing country (2006-2017). J Health Res Rev [serial online] 2018 [cited 2019 Aug 18];5:153-60. Available from: http://www.jhrr.org/text.asp?2018/5/3/153/248449
| Introduction|| |
Historically the doctor has played the three roles concurrently - “Healer,” “Teacher” and “Preacher” and enjoyed prestige in the community as second God or saviors of life. But slowly this image has been tarnished due to many factors including the profession itself. The craziness for easy money, commercial approach, earning fame at any cost, competitive attitudes, corruption, etc., vices has slowly engulfed this noble profession. This has led to distrust among the stakeholders and the common mass of people has equated this stressful profession with all other professions. As a downstream effect, since few decades attack on treating physicians, is taking an epidemic form in third world countries like India. The seriousness of the attack regarding brutality has also become alarmingly life-threatening. Doctors on duty are being systematically attacked by the caregivers and bystanders on the plea of maltreatment of patients have increased in dangerous proportion to become a matter of concern. This has also resulted in temporary and mass interruption of duty by the doctors. Strike is a one of the nonviolent and legitimate forms of protest in a democracy, which is done collectively in mass mostly to get one or more demands to be fulfilled. It is well-known fact that the creamy layer of best students of the society chooses this profession and goes through a long period of training to become eligible for healthcare by regulatory body in India which is usually 10 years or more after school leaving examinations. Today, the safety of doctors both in public and private sectors has become a big issue as there are increasing reports of vandalism and mishandling of doctors at the hands of angry attendants of patients following any death or alleged medical negligence. The article deals with the trend of vandalism against healthcare providers from 2006 till 2017 at various healthcare facilities of India.
| Methods|| |
This was a retrospective record-based analysis.
We comprehensively searched the Google search engine, all national and local news websites for the reported data of the last 11 years on cases of vandalism from January 2006 through May 2017. We also searched for related anecdotes from blogs and literature on Google scholar and National Library of Medicine's PubMed database.
We used combinations of medical subject headings and free text words that included search terms related to the outcomes, i.e., strike by health-care workers across India and the factors resorting to strike, namely assault/attack on doctors/healthcare staff, violence/bullying/mobbing of health-care staff and destruction of hospital. The filters included were English for the language category and humans for the study category. We identified news articles eligible for further review by performing an initial screen of identified titles, followed by a full-text review.
In this analysis, verbal abuse has not been included as none of them are reported in media.
Assault/attack has been defined as intentional behavior that harms another person physically, including sexual assault.
Physical violence is defined as the use of physical force against another person or group that results in physical, sexual, or psychological harm. It includes among others, beating, kicking, slapping, stabbing, shooting, pushing, biting and pinching, whereas psychological violence includes verbal abuse, bullying/mobbing, harassment, and threats. Bullying/mobbing has been defined as repeated and over time offensive behavior through vindictive, cruel, or malicious attempts to humiliate or undermine an individual or groups of employees.
Strike was defined as per the definition given by Industrial Dispute Act, 1947 as cessation of work by a body of doctors employed in health industry acting in combination, or a concerted refusal, or a refusal, under a common understanding of any number of persons who are or have been so employed to continue to work or accept employment.
The research was formulated in a phenomenological theoretical framework and data were collected in the following sequence:
- Hospital names and cases of strikes reported from 2006 through May, 2017
- Total number of cases reported yearly
- Reasons involved for these strikes especially the harmful attitudes toward doctors were included in this analysis
- Types of injury encountered by doctors due to physical assault by relatives
- Other demographic details related to outcome variables were also noted
- The common variables in all the reported events were independent variable of the analysis like time of incidents, area of the hospital where it occurred, gender of doctor, designation of doctor, type of hospital (public/private sector), etc.
Study period including planning, data collection, and analysis was 6 months (May through September 2017).
Data and statistical analysis
Data were entered in Microsoft Excel 2003. The quantitative data were categorical in nature hence presented in the form of frequency or proportions. The test of significance applied on categorical variables was Chi-square with 5% as a cutoff for level of significance. For continuous variables such as duration of strike and number of people involved in attack on doctors were presented as median and interquartile range. Due to nonnormal distribution of these variables, the nonparametric test (Kruskal–Wallis) was applied. Statistical analysis was conducted using SPSS version 21 (IBM Corp., Armonk, NY, USA).
Ethical approval was obtained from an independent ethical approval committee with approval number HIEC/001/2017.
| Results|| |
Hospitals were line listed to create a database of the cases of attacks especially destruction against hospital and doctors by the caregivers of patients to prioritize the outrage faced by doctors at different levels and also to raise questions on the stringency of laws which are still fragile in preventing the modesty of a doctor. The search engines initially identified 340 reports of vandalism, and a total of 298 were screened by inclusion criteria. Based on the search conducted for different states of the country, 100 cases of vandalism resorting to strike for 11 years were finally included for analysis.
The state wise list of reported cases of attack against doctors till May 2017 is tabulated for ready reference of the prospective readers [Table 1]. Majority of the cases have been reported in media from Delhi and Maharashtra in last 11 years. Out of 100 cases reported majority were witnessed in 2015 and 2016 (17 each) and followed by 2017 (14) [Figure 1]. The maximum number of such cases was from public sector as compared to private sector. A higher number of cases have been reported from Government hospitals of Delhi and Uttar Pradesh (UP); however, Maharashtra and Rajasthan reported more number from private sector. The south Indian states reported an almost equal number of cases both from private and public sectors. Overall, the majority of cases were reported from North and West part of India.
|Table 1: State-wise distribution of cases of vandalism resorting to strike by doctors across India from 2006 through 2017|
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|Figure 1: Trend of case of vandalism resorting to strike reported in India from January 2006 to May 2017|
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The numbers of cases reported were counted yearly which clearly showed a remarkable increase in strike by doctors. The trend of vandalism cases resorting to strike in [Figure 1] shows peaking of cases in 2007 and 2011. After 2013, the cases have been on rise.
The institutes and centers of the country reporting the highest number of vandalism cases against doctors have been listed in descending order in [Table 2]. The three hospitals which topped were from the capital state of the country; one of which was the apex institutes of the country. Other institutes which had frequent history of attack on doctors were from Maharashtra, Punjab, and Bihar.
Cases of vandalism resorting to strike were analyzed to identify the predictors of type of injury occurring among doctors from the available data in [Table 3]. In among 6.0% cases, there was no reporting about type of injury suffered from the above-mentioned data sources. Majority of the attacks were on males (73.0%), resident doctors (72.0%), and in public sector hospitals (51.0%). More than half (51.0%) of the incidents were reported in the night shift and 45.0% in the emergency ward. The type of injury in all the cases was reported as grievous (41.0%) and simple (51.0%). Majority of the males suffered grievous injury (52.1%) as compared to females on whom simple injury was mostly reported (80.0%), and this distribution was statistically significant (P = 0.001). The time of attack had a significant pattern of type of injury. The night shift contributed higher proportion of grievous injuries (52.9%) (P = 0.003). Majority of the cases were reported in the months of March, April, and September. Two deaths were also reported one each in May and August [Table 3].
|Table 3: Predictors of the type of injury due to vandalism against doctors resorting into strike|
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| Discussion|| |
The current analysis reported data on attack on doctors, and the trend over 11 years shows that the incidents have increased, and majority has been reported from government hospitals of Delhi and UP. The numbers of such destructive cases are on rise after 2013. The number of cases in the majority of North Indian states has been from public sector in contrast to South Indian states. Among the probable reasons, the important ones are overworked junior doctor or health-care staff with continuous 36 h duty leading to increase in irritation and stress, nonspecialist junior doctors on duty are more dedicated in preparation for their entrance tests rather than patient care, and shortage of faculty and staff in public sector as they find private sector luring in terms of money and duty hours. Even shortage of basic medicines in public sector hospitals (especially those on the National List of Essential Medication) forces doctors to ask patients to buy medicines from outside, which adds up to the suspicion of patients and their attendants. Another is lack of working equipment in hospitals which results in referral of patients elsewhere, and adds up to the suspicion of doctors being hand-in-glove with laboratories when actually they are helpless. Similarly, the perceived reasons and risk factors of workplace violence quoted by doctors of India, Israel, and Greece were long waiting hours of patients in public sector, dissatisfaction with behavior of nursing staff, delayed medical provision, drug addiction by attendants of patients, overcrowded hospitals, shortage of medicines, and poor working condition of doctors.,,,
China's ministry of health statistics in the number issued by them on violence attacks on doctors and medical staff increased from about 10,000 in 2005 to more than 17,000 in 2010. A study by Yu et al., from China have reasoned that this violence is due to poor quality of services, increased awareness of patients about their rights and their willingness to knock the doors of courts to seek justice. According to a study conducted in Pakistan, almost 77% of physicians have faced either verbal or physical abuse. Another study from public sector healthcare facility in Lahore and Saudi Arab reported that 74% and 67.4% of respondents were victims of violence during the preceding 12 months, respectively, with verbal abuse being the most common.,, Nearly 83.3% exposure to workplace violence and 68.9% reported non-physical violence among health-care workers in North Chinese hospital reported. Verbal and physical abuses have been reported by 8.7% and 1.0% of physicians of Myanmar, respectively.
A national survey in Australia revealed that 58% of General practitioners; more with lesser years of experience had experienced verbal abuse and 18% experienced property damage.
Such destructive acts have led to death in many cases and the proportions of grievous injury have increased over 10 years. Probably, it could be due to intoxication of patient or patients' relatives with alcohol; attacks might also have been aggravated by stress due to poor communication, financial loss and longer waiting time. In addition, there are very high expectations about quality of care and a hope for complete and quick improvement. Due to the rise of “consumerism” in healthcare, the obligation of physicians to recommend interventions based on evidence of benefit, and harm is challenged by patients who have the expectations of a consumer., Hence, even if the health-care providers might have been over-worked and burnt out, it is expected that they should behave empathetically with delivery of best possible clinical insight in the infrastructure and logistics available on the spot. The breakdown in the trust in the doctor–patient relationship is also attributed to the menace of corruption, overcharging for services and the so-called referral system, in which referring doctors get a cut on tests they prescribe.
There is evident increase in number of cases in metropolitans of Delhi and Maharashtra. The two metropolitan cities in the two states are different from the rest of the country in that they cater the majority of the migrant population from nearby states. Migration has been proved not only to lead to stress but also anxiety and depression for immigrants. This further can be a probable reason of agitated behavior of attendants of these migrant patients. Two descriptive studies in public sector tertiary care centers of Delhi reported 40%–47% doctors experienced violence in last 12 months., The finding supported our study regarding males experiencing more violence, during night shifts and more than three-fourth in the emergency area. Another study from Maharashtra reported 63.41% prevalence of violence at workplace in the last 12 months.
Emergency department has been recognized as violence-prone environment due to anxiety and stress of relatives of critically ill patients. In India, there is increased concern about the safety of doctors during night shift and weekends due to paucity of consultants for second opinion and consequently increased workload. This is evident from our analysis too, that more than half of such cases occur in night shift and among resident doctor on duty. A previous study also showed that doctors especially females were more dissatisfied on a night shift than working on day shift. Kumar et al. reported females experiencing more violence that too majority from Obstetrics and Gynecology Department and Anand et al. reported that the residents of medicine department were the most affected lot. Above two studies were single-centric public sector based, they reported data department wise whereas our analysis was based on reports from media which resorted to strike and hence resident doctors of public and private sector were the prime victims in majority of cases. The single-centric descriptive studies have also reported the verbal violence in majority which was not included in our analysis as these are less likely to be reported with police or media and do not resort to strike.,,
As a result of increasing violence against doctors and destruction in hospital campuses by patients and their relatives, few state governments have passed state Acts for the safe guard of treating first contact physicians, for example, Maharashtra, Haryana, Punjab, Delhi, UP, Tamil Nadu, and Karnataka; however, it has not been implemented even in those states effectively due to resistance from administration. Impact of such act and its implementation is a future area of detailed research. Strike is a one of the nonviolent and legitimate forms of protest in a democracy, which is done collectively in mass mostly to get one or more demands to be fulfilled., Physician in India either in private or public sector is undergoing alarmingly increasing number of strikes in the last few decades. In our analysis, with only 38% of the cases resorting to strike the mean duration remained to be 2.7 days, with a maximum of 10 days. However, emergency services have never been deterred during the times of strike. When the health-care providers are forced to go for strike in desperation, even then they need to ensure that no one in critical condition suffers due to strike to prevent isolation from common mass in general.
The soft approach to people who target hospitals and health workers encourages potential assailants. This is high time for our government to formulate more effective health policy to address workplace violence in the health sector.
The potential source of bias in our study was the data source and this was the limiting factor also. Many cases have been missed due to nonreporting or reporting in the news channels which are not available on web. Inclusion of search engines available on web was also one of the limitations of our study because of which many cases may have been missed which must have been published in local newspaper of the region. In addition, missing information in regard to various parameters predicting the potential attacks led to the exclusion of those cases in the study. Moreover, we presented the tip of the iceberg in our analysis in the form of physical violence which are reported and resort to strike. In addition, we discussed the health-care providers' perspectives; the patients' perspectives need to be explored.
| Conclusion|| |
To conclude whatever be the cause of violence, the impact is grievous. The loss of property or life clearly questions the current modalities and laws created for the protection of health sector from patients and their relatives. Cases of verbal abuse and minor altercations are not counted in these counts. The soft approach to people who target hospitals and health workers encourages potential assailants. Many times, it has been noted that political leaders do not play positive role to save the persons engaged in this noble profession from the wrath of irresponsible caregivers, bystanders, or even unrelated hooligans as noted on national as well as local levels. Public should be educated to seek for legal action for professional misconduct on the part of doctor, if any.
Last but not the least, if these types of relentless attack on this health-care profession is unchecked by the policy makers, political leaders, regulatory bodies and administrative authorities, then brilliant students will be scare to opt for this profession and the needs of the people in healthcare will be disregarded by the backbenchers of the school.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shekhawat A. Democracy and protest-an interlinked phenomenon. IOSR J Humanit Soc Sci 2013;9:59-63.
Marwah A, Ranjan R, Singh M, Meeenakshi, Das JK, Pal R. Safety of doctors at their workplace in India perspectives and issues. Indian J Public Health Res Dev 2018;9:139.
World Health Organization. Framework Guidelines for Addressing Workplace Violence in the Health Sector. International Labour Organization, International Council of Nurses, World Health Organization and Public Services International; 2002.
Kumar M, Verma M, Das T, Pardeshi G, Kishore J, Padmanandan A, et al.
A study of workplace violence experienced by doctors and associated risk factors in a tertiary care hospital of South Delhi, India. J Clin Diagn Res 2016;10:LC6-10.
Anand T, Grover S, Kumar R, Kumar M, Ingle GK. Workplace violence against resident doctors in a tertiary care hospital in Delhi. Natl Med J India 2016;29:344-8.
] [Full text]
Ambesh P. Violence against doctors in the Indian subcontinent: A rising bane. Indian Heart J 2016;68:749-50.
Koukia E, Mangoulia, P, Gonis N, Katostaras T. Violence against health care staff by patient's visitor in general hospital in Greece: Possible causes and economic crisis. Open J Nurs 2013;3:21-7.
Yu H, Hu Z, Zhang X, Li B, Zhou S. How to overcome violence against healthcare professionals, reduce medical disputes and ensure patient safety. Pak J Med Sci 2015;31:4-8.
Mirza NM, Amjad AI, Bhatti AB, tuz Zahra Mirza F, Shaikh KS, Kiani J, et al.
Violence and abuse faced by junior physicians in the emergency department from patients and their caretakers: A nationwide study from Pakistan. J Emerg Med 2012;42:727-33.
Imran N, Pervez MH, Farooq R, Asghar AR. Aggression and violence towards medical doctors and nurses in a public health care facility in Lahore. Pakistan: A preliminary investigation. Khyber Med Univ J 2013;5:179-84.
Algwaiz WM, Alghanim SA. Violence exposure among health care professionals in Saudi public hospitals. A preliminary investigation. Saudi Med J 2012;33:76-82.
Sun P, Zhang X, Sun Y, Ma H, Jiao M, Xing K, et al.
Workplace violence against health care workers in North Chinese hospitals: A Cross-sectional survey. Int J Environ Res Public Health 2017;14:96.
Kasai Y, Mizuno T, Sakakibara T, Thu S, Kyaw TA, Htun KA, et al.
A survey of workplace violence against physicians in the hospitals, Myanmar. BMC Res Notes 2018;11:133.
Forrest LE, Herath PM, McRae IS, Parker RM. A national survey of general practitioners' experiences of patient-initiated aggression in Australia. Med J Aust 2011;194:605-8.
Williamson L. Patient and citizen participation in health: The need for improved ethical support. Am J Bioeth 2014;14:4-16.
Charles AG, Ortiz-Pujols S, Ricketts T, Fraher E, Neuwahl S, Cairns B, et al.
The employed surgeon: A changing professional paradigm. JAMA Surg 2013;148:323-8.
Sharma DC. Rising violence against health workers in India. Lancet 2017;389:1685.
Hollifield M, Warner TD, Krakow B, Westermeyer J. Mental health effects of stress over the life span of refugees. J Clin Med 2018;7: Pii: E25.
Pund SB, Kuril BM, Doibale MK, Ankushe RT, Kumar P, Siddiqui N. Study of workplace violence, its risk factors and perceptions about workplace security in doctors of Paithan. Int J Community Med Public Health 2017;4:1987-92.
Stene J, Larson E, Levy M, Dohlman M. Workplace violence in the emergency department: Giving staff the tools and support to report. Perm J 2015;19:e113-7.
Stevenson KN, Jack SM, O'Mara L, Le Gris J. Registered nurses' experiences of patient violence on acute care psychiatric inpatient units: An interpretive descriptive study. BMC Nurs 2015;14:35.
Nagpal N. Incidents of violence against doctors in India: Can these be prevented? Nat Med J India 2017;30:97-100.
Loewy EH. Of healthcare professionals, ethics, and strikes. Camb Q Healthc Ethics 2000;9:513-20.
[Table 1], [Table 2], [Table 3]