Published:November 15, 2017
Aggression and Violence against primary care physicians is reportedly common in Pakistan but there is no any documented study to-date on this burning issue.
A formed written questionnaire was distributed among 769 primary care physicians aged 31 Â± 7.68 years. Apart from the demographic data, the questionnaire included questions regarding the level of safety that primary care physicians felt during their work setups and on-call duties, along with the experience of aggression against them by the perpetrators & the support provided by the hospital management in such cases.
Response rate was 68% i.e. 524 physicians agreed to participate in the study. It was found that majority (85%) of the physicians has faced mild events, 62% have faced moderate events and roughly 38% were subjected to severe violence. Some physicians revealed more than one form of aggression being faced by them in 12 months preceding months which makes the collective percentage greater than 100%. Verbal abuse is the most frequent type of mistreatment faced by the doctors from the patients or their attendants.
A considerable number of physicians participated have faced mild violence in which verbal abuse was commonest; followed by moderate and severe events.
Literature suggests that aggressive behavior against doctors is significantly prevalent and encounters such as these make doctors vulnerable to anxiety. Not only this, they suffer a shaky confidence and results fall in commitment to their duties. Studies from all around the world shows high percentages of such cases.
Aggression and violence against doctors is reportedly high in Pakistan yet no peer reviewed published studies addressing this issue could be found. This explains that this subject has hardly been given its due attention in medical education and continuing medical education (CME) in Pakistan.
Due to the above evidences from international studies regarding the violence and aggression experienced by primary health care physicians from patients and their attendants, we conducted a survey with following objectives: To quantify the sense of safety felt by male and female primary care physicians in work setup and during on call duties, to determine the proportion of doctors who experienced aggression and violence from the patients or their attendants and to determine the type of aggression or violence.
A multi institutional survey was conducted in Karachi, Pakistan. The Sample size was 769, calculated by using www.OpenEpi.com, taking figures from a recent study with similar objective at 1% margin of error and confidence interval of 95%. An informed verbal consent to participate in the study was taken from the doctors which was adequate as no intervention was done. Taking oral consent also facilitate the investigators to explain the purpose of the study and explanation of objective freely on direct conversation. Moreover it also helped to minimize the time for filling up the questionnaire. Out of 769 doctors, 524 consented to participate in the survey. Thus the rate resulted response was 68%. The mean age of the respondents was 31 ± 7.68 years. Ethical approval was not sought, since no experimentation was done on human beings. Convenient sampling technique was utilized. The researchers there selves collected the data and took care of its safety and integrity.
A formed, written questionnaire was made and approved by 2 professionals consisting of demographic factors and questions related to aggression and violence faced by the doctors. A pilot version was tested qualitatively and quantitatively. Demographic parameters include age, gender, family members and income. There were 20 questions approximately related to violence and aggression. Each question was to be marked on the 5 point scale ranging from Very safe (number 1) to Not at all safe (number 5). Questions included the scale of safety while working at a hospital setup and during on-call, number of violent events faced by the doctors, gender of the last perpetrator, age of the last perpetrator, educational background of the last perpetrator, number of the last perpetrators and whether/if the doctors received any help from hospital administration. Our questionnaire also included the forms of aggression faced by the doctors. Individual forms of aggression are defined into categories such as mild/slight, moderate, and severe/serious ones. The forms of aggression are listed below;
- 1.Verbal abuse (Mild)
- 2.Threats (Moderate)
- 3.Intimidation (Moderate)
- 4.Sexual harassment (severe)
- 5.Physical attacks (severe)
- 6.Weaponry attacks (severe)
- 7.Theft (severe)
- 8.Damage to family or property (severe)
We analyzed our data and found out that there was a difference in the safety level felt by male and female physicians. The association between dependent and independent variables were accessed. Dependent variables were; the perception of the safety of doctors, the number of violent events that took place & the help assured by hospital administration. The questionnaire is validated in terms of its content since the variables were taken from various studies. The statistical analysis was done using SPSS version 20.0, and frequencies, mean and percentages were calculated.
The results were drawn at 95% confidence interval The response rate of the participants in this study was 68%. Majority (71%) were females while 29% were males. The mean age of the participants was 31 years Â± 7.68.
Of all female doctors, 48.11% (n = 179) reported that they felt safe as compared to 70.39% (n = 107) males (p = 0.001,CI = 95%). Relatively safe or partly safe-partly unsafe option was chosen by10% (n = 37) females, as compared to 23% (n = 35) males. Approximately 42.20% (n = 157) females reported of feeling a â€˜less sense of safety to not at all safe in contrast to 7.2% (n = 11) of males (p = 0.001,CI = 95%).
The results varied in female physicians working during on-call duties. However, there was no difference reported in the sense of safety felt my male physicians during everyday practice or while attending night duties (on-call duties). The sense of safety felt by the females decreased dramatically to 7.2% (n = 27) during calls than males which was 75% (n = 114). Around 50% (n = 186) female physicians ticked relatively safe & partly safe-partly unsafe than 22.3% (n = 34) males. 43% females felt unsafe as compared to only 7.5% males, who reported to have felt unsafe during on-call duties.
Around 6.2% (n = 33) physicians reported that they were falsely accused of harming the patients and hence they had to face violence from the patients & their attendants. Approximately, 88% (n = 462) physicians reported that the last perpetrator was uneducated and 92% being males.
Roughly 63% (n = 331) physicians indicated that the perpetrator attacked singly than in groups. It was found out that majority (55%) of the perpetrators who attacked the participants belonged to the age group of 30-40 years, 22% reported that the age group of the attackers was 20-30 years, 15% said that they were some 40-50 years old, roughly 6% stated that the age group was 50-60 years old while only 2% said that they belonged to extremes of age i.e. <20 &>60 years of age.
Around 74% (n = 388) physicians have discussed last incident with people, but 88% (n = 462) physicians received no help from the Hospital Administration. Approximately 85.11% (n = 446) physicians have faced mild/slight aggression by the patients like verbal assaults, while 62% (n = 325) have faced moderate incidents; however 38.1% (n = 200) physicians have met severe violence from the patients & their attendants.
Our results showed that almost every primary care physician had faced at least one violent event, be it mild, in the preceding 12 months of their work. In contrast, other international studies documented high percentages of violence however in those some participants were spared such mistreatment. One such study carried out in Japan from 2007 indicated that 84.8% of the doctors have experienced violence during their practice. About 72.1% were verbally abused and alcohol associated harassment accounted for 51.8% (4). A study from Victoria, Australia published in 2007 showed that 57% of the doctors experienced aggressive behavior during the 12 months preceding the survey. Of these affected doctors, majority (44%) experienced milder aggressive events, for example, verbal abuse. 23% experienced moderately aggressive events, for example, damage to property. Severely aggressive behavior was experienced by doctors in the form of sexual harassment (8%), physical abuse (3%) and sexual assault (1%) (5). A survey from Turkey, published in 2005 reported that 72.3% of doctors experienced some form of violence in their carrier. Out of these, 69.5% experienced mild form of aggressive events, for example, verbal and emotional abuse, followed by moderate form, for example, intimidation and 8.5% experienced severe form of aggressive events, for example, physical assault.
Verbal abuse is the most frequent (85%) type of mistreatment faced by the doctors from the patients or their attendants which is more frequent in our population but is in coherence to other studies that depicted 44 -72.1%, According to statistics, approximately 85 doctors out of 100 doctors received verbal abuse, which had a bad psychological impact on their lives (8). Roughly 62% physicians have reported moderate events like threats and intimidation. In our setup, around 38.1% physicians have met serious events. Our results are no doubt worrisome for healthcare community. They really look formidable in comparison to the statistics of an Australian study that found 22-23% moderate and up to 8% severe events.
Our data showed gender difference in the safety level felt by the physicians. Female physicians felt lesser safe than male physicians, both at work setup and during on-calls. Female physicians reported to feel safer at work setup than during on call duties. However, the difference in the male physician’s level of safety at work setup and during on-call duties is non-significant. A similar study suggests that the only significant gender difference for aggression faced by the physicians was sexual harassment, which was faced more by the females than males.
The most common cause of violence by the patients is long waiting time and second most common cause being dissatisfaction with the treatment. Sometimes, the patients falsely accuse the doctor of harming them, which leads to aggression by the patients and their attendants. In our report, 6.2% of doctors faced such situations.
Usually, the perpetrator is the patient himself in primary care (56.9%) and attendant (45.3%) in hospital care. Emergency departments are commonest spots (35.5%) where violence takes place. Mostly, factors associated with health system organization and socio-economic statuses of the population are the reasons of patient’s aggression. According to our survey, the perpetrators were usually uneducated, belonging to middle age group (30-40 years old) & mostly of the male gender.
It is notable that majority of the hospitals have failed to provide protection to their physicians. A Japanese study said anger being frequent response of the physicians to violence. The threats and violence thus have a bad impact on the physician’s psychology leading to Post-Traumatic Stress Syndrome (PTSD) in majority of the physicians. This has led to the doctors being irritable, helpless and has resulted in having thoughts of abandoning their jobs. The primary care physicians have met more violent events while working in surgical wards than in internal medicine wards. Not only the doctors are targeted by the patients, but also medical assistants like nurses, have to tolerate violence on daily basis; especially the verbal attacks.
The patient-doctor relationship at stake and continues to be worsening. In order to achieve a lavish life, many doctors prescribe unnecessary investigations and medicines; to enjoy undue benefits from pharma companies. The relation further tangles in public sector hospitals, where doctors are coerced to unnecessary admissions by the politicians and doctors lose their self-esteem looking at the seriousness of the issue shown by the statistical results, many governments have found it virtually pressing. Countries like Canada and Australia have introduced programs for the safety of their health care providers
The only limitation we faced was generalization of the study nationwide and inability of comparison with other professions.
It is evident from the results that primary care physicians in Pakistan should prepare themselves for any adverse situation as it is highly likely that they might face violence and aggression in their working environment. This issue is not perceived in Pakistan to the extent as in some other countries. Hence, there is no program at local or national level that addresses the issues of safety of primary health care physicians. In general, the security arrangements across the hospitals in Pakistan are not enough to prevent any aggression and violence against doctors. This provides a sense of freedom to the patients and/or their attendants to express their stress and anger towards the hospital staff in any legal or illegal manner. The fact that the number of female health care providers is also increasing, it is necessary that certain strategies are devised to guarantee the safety of health care providers in Pakistan.
Link – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725205/