Workplace Violence Against Doctors in India: A Traditional Review

Workplace violence against doctors is not new, but in recent times, it has grown up in epidemic proportions. Doctors are more worried about their safety and life in the workplace. Meager government spending on healthcare associated with the poor socioeconomic status of the patient and the ever-rising cost of treatment had worsened the situation in present times. The article aims to address this critical issue and try to find possible ways to prevent it.


Introduction And Background
According to the WHO framework Guidelines (2002), "Workplace violence is defined as the situations where staffs are ill-treated, intimidated or attacked in conditions linked to their workplace, including commuting to and from the workplace, involving an explicit or implicit challenge to their safety, well-being or health" [1]. Compared to all other workers, workplace violence seen in healthcare workers is four times higher and hence requires a longer time away from work [2]. It can be physical violence or psychological violence or a combination of both. It can be in any form like assault, abuse, bullying, mobbing, harassment either sexual or racial or psychological, threat, etc. [1].
Workplace violence against doctors is a global phenomenon. It has neither any region nor religion. It is prevalent not only in India, Pakistan, Bangladesh but also in developed countries like the USA, UK, and China. It is spread across the continents from Asia to Australia, Europe to America to Africa. Data shows that in the UK, one-third of healthcare workers had faced violence at the workplace [3]. In India, almost 75% of the doctors had dealt with one or the other form of violence during their practice [4]. Nearly 50% of violence were reported in intensive care units (ICUs), and in 70% of the cases, the patient relatives were actively involved [4]. Israel, Bangladesh, and Pakistan had also reported similar incidents [5][6][7][8]. The flawed healthcare system had led to a deteriorating relationship between the patient & doctor in China as well [9]. The Chinese Medical Doctor Association had reported more than 105 violent incidents between 2009 and 2015, where doctors were badly injured [10]. More than 100 healthcare workers died due to violence in the USA, between 1980 and 1990 [11]. As per the Indian Medical Association, over 80% of doctors are stressed out in their profession and nearly 56% don't sleep comfortably for 7 hours a day ( Figure 1).

FIGURE 2: Fear and stress factors among Indian doctors
Timeline of major recent incidents in India 31 October 2019: Two residents of Banaras Hindu University, were beaten by patient attendants and goons in the parking space who escaped after the assault on motorbikes in Varanasi [12].

Causes of violence
In India, more than 80% of doctors are stressed out due to various reasons like violence against them, harassment by police as well as politicians, long duration of the study, lack of personal or social life, etc as illustrated in Figure 3.

FIGURE 3: Factors stressing Indian doctors
The setting of violence against healthcare workers in India is different from that in the West. In India, violence perpetrators are mainly patient relatives, unknown sympathizers, criminal offenders, and even politicians [30]. In India, hardly 33% of the healthcare expenditure is borne by the government, the rest by the patients themselves. Low insurance penetration is another factor [31][32]. Unexpected healthcare expenses often push families into a trap of debt and financial instability. Here, within the background of smoldering anxiety of financial implications, verbal abuses easily escalate to violence. However, in the western world, the majority of the incidents occur during the night, in intensive care units and psychiatric and pediatric wards. Financial anxiety is not a causal factor in these countries as the healthcare expenditure is borne by the government [33]. The main offenders are the patients under the influence of drugs, alcohol, or psychiatric patients or their close relatives [34][35].
The causes of violence can be broadly categorized as poor quality healthcare in the majority of govt sector, the negative image of doctors and the role played by media, poor socioeconomic status of the patient and the ever-rising cost of the treatment, poor communication, vulnerability and susceptibility of hospitals, low awareness and knowledge about health-related issues, lax security or Inadequate security arrangement, mob mentality, and instant justice.
A study by Verma et al. showed that young doctors are more prone and female doctors face more violence [36]. The highest rates of violence were reported in the Obstetrics and Gynaecology department, followed by the Department of Internal Medicine and Surgery. The same study also mentioned that the most common causes of violence are longer waiting periods, delay in attending the patient, and admission denial.
Most commonly, workplace violence against doctors is seen in the Casualty or Emergency department followed by other departments. Almost all doctors had reported verbal violence in the emergency or casualty department. Invariably the resident doctors are the first target of the irate mob. Male doctors face workplace violence more often than females.
Violence against doctors can be of any form like verbal abuse, physical violence, mob lynching harassment, etc. as can be seen in Figure 4. Verbal violence was the foremost common sort of violence.

Warning signs of violence
The STAMP (Staring, Tone, Anxiety, Mumbling, Pacing) approach alerts the physician by looking for early warning signs of violence. The STAMP approach consists of the following [37]: Staring is a prospective sign of violence. Staring was to threaten them into a quicker response.
The tone and volume of voice are connected with violent episodes. Most cases involve not only raised voices and yelling but also sarcasm and caustic replies.
Anxiety in coming to the emergency department makes patients stressed out. Before it reaches dangerous levels, ideally the doctor intervenes, but sometimes, it escalates to violence due to patient anxiety.
Mumbling is an indication of violence as it reflects frustration. Pacing by relatives is seen as a symbol of agitation.

Prevention of violence against doctors
With the rise in mob violence incidents, doctors are also becoming cautious and reluctant to take up serious and grave cases, which in turn compromises healthcare which defeats the purpose of the healthcare delivery system. Unless we make the hospital environment free from fear and violence, the doctors won't be able to work to their maximum potential, and hence, stopping the violence against doctors is of paramount importance ( Figure 6).
The standard operating procedure should be made and followed strictly. Code Purple should be declared and all measures should be taken in case of violence. Security staff to respond and assist immediately. All staff (except Operation Theatre & ICU) should form a human chain. All staff should remain calm & practice restraint. Closed-circuit television (CCTV) monitoring in sensitive areas is a must and should report to the Police immediately

Steps to be Taken by The Patient
Be aware of the health situation. Doctors practice medicine they can't do magic and certainly, not everyone can be revived. Doctors cannot be held responsible for every death occurring in the hospital on the ground of negligence. Cost increases with the type of treatment & its advancement. If not satisfied with a doctor can speak to the concerned authority and take an appropriate decision to continue treatment or not.

Steps to be Taken by Media
Must put forward the unbiased news. It shouldn't sensitize the news. It should highlight the doctor's predicament and the causes for the rise in violence against them.

Role of Medical Schools
The medical school can play an important role in creating awareness about workplace violence against doctors. Along with the medical subjects they should also teach about patient-doctor relations, communication with the patient in an effective way, empathy towards the patients and their relatives. The school should also teach them how to handle tactfully when the patients or their relatives behave aggressively and the situation turns chaotic and violent. They should teach them how to remain calm and responsible during those times without compromising the quality of patient care as well as safety.
The above steps can prevent workplace violence against doctors but the most important thing among them is communication by the doctor and the hospital. Proper communication can allay the situation or defuse the crisis. A senior doctor or someone from the management (preferably a senior one) should be able to communicate the condition and seriousness of the injury/disease of the patient to the relatives or attenders. A calm composed doctor with good communication skills can avert the situation most of the time. Along with that, the hospital security staff has to take steps to diffuse the mob and prevent violence against doctors and these hospitals. Police should be informed and kept vigilant if there is any suspicion of potential mob violence.
On the other way, the government should make stringent laws for violence against doctors in the workplace and punish the culprits. The government should improve the infrastructure of the hospitals and spend at least 5% GDP on healthcare which is neglected a lot. The media should avoid sensationalizing the news and put forward the unbiased news. Last but not the least patient education and creating awareness is a very important step towards preventing workplace violence against doctors.

Conclusions
Unless there is an entire overhaul of the prevailing healthcare system, it is a herculean task to curb violence against doctors. The medical curriculum should include soft skills and communication skills required to empathize, remain calm, and twiddling my thumbs regardless of repeated prodding by the anxious patients. Along with this increased communication between the doctors and patients, filling crucial gaps in communication between doctors, patients, and relatives will help in mitigating the violence in a long way.