Violence against doctors is a symptom. What is the disease?

Research has found that violence is mostly directed at junior doctors and residents, especially at female doctors, and happens in high-stake settings.

May 23, 2023 03:30 pm | Updated 03:30 pm IST

Doctors and staff protest at the Kottarakara government taluk hospital following the murder of house surgeon Vandana Das.

Doctors and staff protest at the Kottarakara government taluk hospital following the murder of house surgeon Vandana Das. | Photo Credit: C. Sureshkumar/The Hindu

One chilly evening, I sat at the computer desk in the hospital I worked at as a junior doctor, typing out the discharge summary of a patient who was meant to go home in an hour. Suddenly, I saw a man twice my size charging at me. He slammed his hand loudly on my desk and my heart raced. “You guys have overcharged us for this admission,” he shouted as he loomed over me. Then he walked away to pay the bill, leaving me to collect my pounding heart and sweaty palms enough to finish typing the summary.

On May 10, 2023, Dr. Vandana Das was stabbed to death in the line of duty in Kollam district. Amid searing outrage from the medical fraternity, the tragedy brought to the forefront the increase in workplace violence faced by doctors all over India.

Who faces what kind of violence?

It was not the first time such a thing had happened. Over the years, there have been several episodes of physical and verbal violence. Each episode has the people at large passionately arguing the issue for a few days, only for their words to fade away until the next brutal incident. Doctors also stage protests but are ultimately honour-bound to return to duty, to reprise their roles as healers. The issue remains largely unaddressed.

According to a systematic review of recent research, published in the Journal of Postgraduate Medicine in July 2020, “In developing countries, more than 50% of doctors have faced patient-led verbal and physical abuse.” Such violence has been on a rising trend in economically developing countries, and is lowest in the developed ones.

Research has also found that workplace violence is mostly directed at junior doctors and residents, with the incidence progressively dropping against more senior healthcare workers.

The violence also happens more often in high-stake settings, such as the emergency department and intensive care units, as well as in departments with patients with compromised mental function.

The perpetrators of workplace violence against physicians are family members or relatives of the patient in 82.2% of cases, per a paper published in PLoS ONE in 2020. Some perpetrators become violent over concerns for the patient’s condition, such as actual or perceived deterioration of their condition or doubts about the wrong treatment being administered. Some others become violent due to issues such as high payment dues and protracted waiting times. Doctors aren’t responsible for either.

Studies also show that female medical professionals with fewer years of experience are objectively more at risk of being on the receiving end of both physical and verbal workplace violence.

What effects does violence have?

According to a 2016 paper in the National Medical Journal of India, 75% of the violence against doctors is verbal, including intimidation and threats. Most doctors who suffer them never report them; some notify their department seniors but are often told that these experiences are “part of the job”. The PLoS ONE study noted that only 25% of doctors who experience such violence complained to the police and only 10% of them believed their complaint was addressed adequately.

Most doctors don’t report at all as they think that doing so will accomplish nothing.

However, being on the receiving end of verbal or physical violence has an immense psychological impact. Some studies have reported symptoms of post-traumatic stress disorder, anxiety, and depression in doctors who have faced violence from patients or their kin. In a country with a skewed doctor-patient ratio (1:854, including Ayurveda and homeopathy practitioners), doctors often decide to operate in resource-abundant settings also for their own security. But this affects rural healthcare, of course.

After experiencing violence, the PLoS ONE study found that doctors wish to stop offering emergency services, refer patients sooner to more specialists, and over-investigate symptoms and prescribe more tests. They also tend to offer less of the lifesaving medical and surgical interventions that a patient may require, over fear that any risky procedure may provoke violent action. This also negatively affects the quality of healthcare.

What is the disease?

Healthcare professionals need to work on their communication skills and ensure meticulous documentation. At the same time, measures to mitigate workplace violence towards them must be multi-pronged and focus on institutional and policy measures.

Often, patients or their relatives turn to violence because the healthcare system hasn’t met their expectations. To eliminate this ‘threat’, we must spend more money to strengthen the system from the grassroots level, such as reducing the long waiting-time for treatment. The availability and accessibility of medicines, tests, and financial aid for those in need will greatly reduce their stress, instead of leaving them to hold their physicians responsible for it.

Blame for the system’s failures can’t be pinned on a person who is expected, in order to surmount the resource constraints, to work several hours of overtime and deal with large patient loads.

Institutional measures like installing CCTV cameras and metal detectors at hospital entrances, to deter relatives from carrying weapons, are workable, but they are currently easier to realise in private settings, not at public facilities. Ensuring that there are counsellors to help patients and relatives in times of high emotional distress (together with people who can translate between languages) can also eliminate any miscommunication regarding a patient’s condition and the treatment plan.

In addition, a robust security system and not allowing more than a few relatives by a patient’s bedside may also be important – as will enforcing the law well enough to bring perpetrators to book in a reasonable span of time. It is notable that despite several demands for protective legislation by doctors, such provisions have not been made to this day.

Will a law work?

Like India, China has contested doctor-patient relationships as well, to the point where it has drawn international attention. A February 2016 study published in the Journal of Medical Internet Research reported that several policies introduced by the Chinese government to strengthen their healthcare, punish illegal medical activities, and provide transparent medical-risk assessment of certain health conditions was able to partially improve public trust in healthcare workers and the healthcare system.

The finding is an indication that we can expect a similar law and policies in India could improve Indians’ trust in the Indian system as well.

A senior doctor told me how he was almost beaten up once, after he was unable to resuscitate a patient who was brought in almost dead. His mistake was to use the defibrillator to deliver a shock to the patient’s heart in an attempt to restart it. Doing this is a part of the standard protocol to revive a patient in cardiac arrest due to some heart rhythm abnormalities, and he was doing things by the book.

However, the patient’s relatives threatened him because they believed the patient had been electroshocked to death. The senior doctor hasn’t offered emergency services since that day.

Dr. Christianez Ratna Kiruba is pursuing her MD in general medicine at Christian Medical College, Vellore.

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