Violence Against Doctors

Published July 2010
Voltaire once said that – the physician amuses the patient while nature cures the disease. But today’s scenario is not so amusing. Even when this article was being written three
doctors were assaulted. The very common scenario in our mainstream movies is not so different, as one after another, the hero seems to grab the doctor by the collar and teach
him a physical lesson for not being able to cure his beloved one in a whiz.
Law Encyclopedia states that “Assault is an act that creates an apprehension in another of an imminent, harmful, or offensive contact. The act consists of a threat of harm
accompanied by an apparent, present ability to carry out the threat, whereas Battery is a harmful or offensive touching of another. The main distinction between the two offenses is
the existence or nonexistence of a touching or contact. While contact is an essential element of battery, there must be an absence of contact for assault.”  Violent acts against workers have been defined as “any event that the worker is threatened or attacked by another person due to his job” . The Health and Safety Executive define violence as ‘any incident in which an employee is threatened or assaulted by a member
of the public in circumstances arising out of the course of his/her employment’ .
Of all work settings, medical sites carry the greatest risk to staff of verbal abuse and threats, with 73% of staff on medical premises suffering abuse, compared to 65% on recreational premises and 63% for transport and public administration .
Physicians in emergency medicine, psychiatrists and those involved with primary care are at increased risk of violent acts from patients and families. What leads to these
acts? Does the place influence these incidents? The trend of violence varies where it is more prevalent towards general practitioners in European countries. It has been seen that
hospital physicians are exposed to confrontations with patients’ family members who visit their hospitalized relatives and often want to be involved in decisions relating to them.
Family members may feel less constrained to confront hospital physicians whom they don’t know than family physicians with whom they may have an ongoing
relationship. Over a 12 month period 63% of family physicians had some experience of violence, while 18% experienced some sort of abuse at least once a month in a
city in UK. The actual rate is even higher as there is under-reporting of violent incidents. Regarding the cause of this under reporting, various explanations exist. Some doctors
do not even know what constitutes aggressive behaviour. Some other factors such as lack of time, reluctance to fill in forms, and fear of being blamed for incidents also can be
considered. Some doctors feel coping with aggression as part of the job and some feel too guilty or embarrassed to report events.Verbal abuse is the most frequent type of
violence reported by British physicians compared to physical violence. In the US the rate of violence is even higher. Between the years 1980–1990, 106 healthcare workers died as a result of violence: 27 pharmacists, 26 physicians, and 53 nurses. Another survey of 170 university hospitals in the US showed that 57% of all emergency room employees had been threatened by weapons over the five-year period prior to the survey. A small single centered study showed as much as 41% was assaulted, while no injury being reported. Seventy percent of the physicians and 90% of the support staff working in a hospital emergency room in Israel reported violent acts, mostly verbal abuse. Younger doctors are more likely to be victims of violence as they are unable to handle certain situations and patients tend to look down on them.
What leads to these incidents- well no single cause is apparent. Among many causes, possible circumstances surrounding violence against physicians are – delay in

attending to patient, asking patient to do something, restraining patient, administering medications, patient physician altercation, physically guiding or leading patient,
alcohol or drug intoxication or patient with a psychiatric history has been implicated . A study in Israel showed that the most common causes of violence were long waiting time
(46.2%), dissatisfaction with treatment (15.4%), and disagreement with the physician (10.3%).
The scenario in Indian subcontinent is not so bright. Doctors are frequently assaulted in India as well where doctors are shot, even stabbed. There are no authentic studies in Bangladesh regarding the incidence or predisposing factors leading to violence against doctors where surprisingly it’s not a very rare phenomenon. This occurs mostly in hospital setting, and also in private care setting.  In this perspective we can only speculate regarding the cause of these heinous acts. Lack of Communication between doctor and patient or their anxious relatives is a very important factor. Due to the pressure in emergency setting, it is not always possible to give extra time in this regard. Sometimes evasive answer is interpreted as lack of responsibility on the part of doctors.
Poor image of medical professionals projected by the newspapers has led the general people to belief that doctors are the greatest villains, extortionists. Lack of faith in judicial
system, the inactivity of the police and the impression that the police will take no action and can easily be bribed is another contributing factor. Since there is still no conviction of even a single person known to have assaulted doctors, has led to this lawlessness among public. Despite the risks of aggression and the legal obligations, even in UK only 43% of hospitals have a policy on violence; 3% of hospitals offer special staff training; 50% of hospitals give no training at all to staff; only 25% of hospitals advise staff on reporting procedures; and 87% of the health service staffs are worried.
No such laws exist to protect doctors in Bangladesh. So it is not surprising that when patients or their attendants know that they can get away with assaulting a doctor, they are tempted to do so. On the top of all, newspaper and electronic media play an important role by putting up negative reports about doctors, portraying them as the villain. Very often, they misrepresent the facts while quoting only the patient’s version of the incident and the physician are not given one but important fundamental right of self defense. Lets get the facts right, – who is going to read a newspaper that publishes reports about doctors saving lives, helping poor patients. It simply won’t make any sell!! So without any law, any trial, any conviction, and no right of self defense, helpless doctors are guilty as charged.
The effect is not so trivial. Those physicians who were exposed to it had depression, insomnia, post-traumatic stress disorder, agoraphobia and even a level of fear and/or anxiety that can cause work absenteeism. Studies from around the world show that acts of violence have a negative effect on the physician’s family life and quality of life. In the study conducted in Kuwait 86% of the physicians who experienced violence reported that it caused insomnia, depressions and other effects. A study in Israel showed that 36.2% of the community based physicians reported a negative impact on their family life and quality of life who were victims of violence. Those who were victims of aggression had a change in behaviour. Among the coping strategies among GPs included increasing prescribing, referring threatening patients to secondary care services and taking threatening patients off their lists . Among hospital doctors 27% reported that their approach to work was changed due to violence or the fear of violence, although the nature of this change was not specified .
When we think how do we get rid of this situation, we must remember that practice of medicine is really about providing service, not just science. It is basically a combination of art, science and professionalism. The fundamental of medicine is that it is principally a human activity aimed at helping the sick through healing, alleviating suffering and caring for people with respect and dignity. This role of physician must be guided by the codes of ethics governed behavior. The financial incentive is not negligible but the principle remains the same- serving humanity. The lucky doctors of the past were treated like God and people revered and respected them.
There is no single step that will protect doctors. The most important step in providing professional safety is to ensure that violence against doctors is made a non bailable offence. Since the press has taken a stance against members of medical
profession, concept of medical press should be emphasized where we publish our own news; we tell people our version of the truth. It must be ensured that only limited number
relatives should be allowed at the patient’s bedside. Entry should be restricted strictly by passes and this must be implemented through good security. Improving doctor –
patient relationship is another important factor. There must be no communication gap between the doctors and the patient or their relatives. The previous hospital or referring
doctor be should not be criticized under any circumstance. When the prognosis is serious the senior doctor must talk to the relatives. In the short term it is important to organize
workshops to train physicians to prevent and deal with violent incidents. In these training sessions physicians will be taught to be patient, to provide appropriate and relevant

information, and to show respect towards patients and family members . In the light of recent events, private practitioners should also be prepared by ensuring the basic principle of practice-a chaperone should always be present while attending a female patient. Predicting the human nature is not easy, and predicting the nature of Bangladeshi people is
even more difficult. So even after taking all these steps, things still can go wrong and in that case we cannot but agree with, P Madhok who wrote “There is something to be said for young doctors who should learn martial arts. The world is increasingly progressing towards violence. So karate, taekondo and other martial arts are worthwhile learning for
self defense. It will boost the doctor’s confidence even if not used.”
Courtesy: ResearchGate

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