8-38% of health workers suffer physical violence at some point in their careers

1.6 million people die due to poor quality of healthcare, which often leads to violence against doctors

Highest rates of violence occurs in the Obstetrics & Gynaecology Department, followed by Medicine and Surgery Departments

75% of doctors face assault at the workplace

70% of doctors feel unsafe while treating a patient

Sassoon General Hospital-August 2016 [9]: Two postgraduate resident doctors at Sassoon General Hospital attached to B.J. Medical College in Pune were severely assaulted, following the death of a male patient suffering from liver cirrhosis. The doctors were Dr. Abhijit Jawanjal and Dr. Sadiq Yunus.

Dhule Civil Hospital-March 2017 [10]: Dr. Rohan Mhamunkar, a resident doctor of Dhule Civil Hospital in Dhule, Maharashtra was severely beaten up. He received multiple injuries, including an orbital fracture, which caused blurring of vision in the affected eye. The medical fraternity across the country protested against the incident. Many doctors wore helmets to work to express their solidarity.

JJ Hospital-May 2018 [11]: Two doctors at the Sir Jamsetjee Jeejeebhoy Hospital, popularly known as JJ Hospital in Mumbai were violently assaulted, following the death of a patient. The two doctors were Dr. Atish Parikh and Dr. Shalmali Dharmadhikari. The former suffered a fractured cheekbone, while the latter sustained injuries in her arm. Resident doctors across Maharashtra protested about the unsafe conditions in hospitals, making doctors vulnerable to attacks.

NRS Medical College-June 2019 [12]: A violent attack on doctors that made the headlines took place at the Nil Ratan Sircar (NRS) Medical College in Kolkata on 12^th June, 2019. In this incident, two interns received near-fatal injuries at the hands of a 200 strong mob after a 75-year-old patient died. The relatives of the patient alleged medical negligence on the part of the doctors. Of the two doctors, Dr. Paribaha Mukherjee sustained severe head injuries. The protests by doctors spread from Kolkata and became a nationwide protest in which over 800,000 doctors went on strike. On 18^th June, 2019, after 7 days of protest, the junior doctors at NRS Medical College called off the strike after meeting the Chief Minister Mamata Banerjee.

Teok Tea Estate Hospital-August 2019 [13]: The latest heinous attack took place on 31^st August, 2019 at the Teok Tea Estate Hospital in Jorhat, Assam. A 73-year-old doctor, Dr. Deben Dutta, was brutally beaten-up by a mob of 250 tea garden workers, following the death of a tea plantation worker. Dr. Dutta suffered severe head and leg injuries and was shifted to Jorhat Medical College and Hospital (JMCH), where he later succumbed to his injuries. Subsequently, 21 people from the tea estate were taken into custody. Following the incident, there were widespread protests by doctors in Assam and elsewhere. Doctors at JMCH, Jorhat Civil Hospital, family referral units, and Primary Health Centres (PHCs) in Assam called a one day strike. Moreover, the Indian Medical Association (IMA) strongly condemned the attack.

Healthcare budget [15]: The health spending in the public sector is deplorable- a meagre 1.15-1.5% of the Gross Domestic Product (GDP), compared to USA’s health spending at 18% of GDP. As per the National Health Profile of 2018, the per capita expenditure on health is a paltry USD 100 (after adjusting for purchasing power parity), compared to the US, which spends USD 10,224 per capita on healthcare annually.

Miscommunication [3,6,16]: Doctors often lack the skills required for effective communication with patients. Essential information such as risks, costs, and complications of various medical procedures, especially surgery, should be communicated to patients and their families in a lucid language without using any medical jargon, as this can lead to confusion. Moreover, breaking shocking news such as the death of a patient should be done with empathy, so as not to hurt the sentiments of the family. Poor communication is an important cause of violence against doctors in India.

Health awareness [16,17]: Lack of health awareness among patients and their families is an important cause of simmering anger against the health system, which erupts into violence, especially when a patient dies. Ignorance about heath issues is a major reason behind critical patients being brought to hospital when it’s too late and if the patient expires, violence is inevitable. In other instances, particularly in case of poor patients who lack health insurance, a serious diagnosis could spell financial disaster, causing emotional turmoil. As a result, they often vent their anger on doctors who are the most vulnerable and have to bear the brunt of the violence.

Health infrastructure [17]: Poor health infrastructure is another major factor, albeit indirect. If the PHCs and Subsidiary Health Centres (SHCs), or even the district hospitals were adequately equipped with trained medical personnel and sufficient instrumentation to cater to the rural population, then there would be much less pressure on medical colleges and hospitals in metropolitan cities.

Doctor-patient relationship [14]: There is growing mistrust in the health system in India, which is increasing day-by-day. The deterioration in doctor-patient relationship plays a major role in this regard. Doctors sometimes disregard patient and family concerns and apprehensions. Coupled with this, patients are often prescribed unnecessary tests and recommended needless invasive procedures, which has appreciably contributed to the growing distrust. Moreover, with the advent of corporate hospitals, leading to commercialisation of healthcare, the mindset of many doctors has changed from a charitable to a lucrative one, which in many instances, has resulted in adopting unethical practices. This has considerably tarnished the image of doctors in the public eye.

Doctor’s misbehaviour [18]: Doctors have been reported to misbehave and abuse women during labour-termed as “obstetric violence”. This is an umbrella term that includes disrespectful behaviour, bullying, coercion, discrimination, forced procedures such as Caesarean sections, as well as sexual abuse, especially during gynaecological examination and delivery. This type of misconduct can lead to violence against doctors. It should be noted that in many countries, including Argentina and Venezuela, obstetric violence is regarded as a punishable offence.

Doctor’s errors and mistakes [19]: Although it is said that “to err is human”; but for doctors, there is no room for error, as this can cost precious lives. Therefore, if a doctor commits a mistake, especially during surgery, resulting in the death of a patient, this can have dire consequences for the surgeon.

Overwork [19]: Doctors in government hospitals face very long work shifts, which often results in burnout. The Central Government directive to hospitals has fixed 12 hours as the maximum length of work at a stretch (in reality: 36 hours); 48 hours of work per week (in reality: 108 hours); and one weekly holiday (in reality: 2 per month).

Demand and supply gap [20]: A recent study conducted by the Centre for Disease Dynamics, Economics and Policy (CDDEP), a non-profit organisation based in Washington, USA, found that in India, there is one government doctor for every 10,189 people, as opposed to the WHO recommendation of a doctor:patient ratio of 1:1,000. This translates into a deficit of 600,000 doctors. The nurse:patient ratio is equally dismal at 1:483, which translates into a shortage of two million nurses.

Societal factors [6]: Society is now much more demanding and people’s expectations are sky high. There is also more aggression in society, sometimes referred to as ‘mobocracy’. This is reflected in violent incidents on roads arising from ‘road rage’, increased acts of violence in public places, schools, colleges, and even in hospitals. In medical settings, attendants have unrealistic high expectations of patient recovery, without understanding the gravity of the situation. In case of death of the patient, the attendants take immediate revenge by acts of violence rather than taking legal action, which could arise from a lack of trust in the Indian judicial system.

Other factors: Several other factors that instigate patients’ relatives to resort to violence include unnecessary investigations, long waiting times leading to delays in consultation, dissatisfaction with doctor’s attitudes, high out-of-pocket expenses, scarcity of hospital beds, requirement for advance payments, as well as withholding a dead body until final settlement of bills.

Health policies and legislations [21]: Around 18 states in India have laws for violence against doctors. However, these Medicare Acts are largely ineffective due to poor implementation, weak clauses, and inadequate knowledge of police personnel. In order to address this problem, the Central Government is in the process of framing a law to bolster the states in their fight against violence on doctors.

Knowledge dissipation [17]: The general public should be educated about various diseases and associated health issues through print media, TV, radio, social media, as well as health portals. This will generate health awareness and equip patients with knowledge that will be useful for them to make informed choices about their health.

Strengthening primary healthcare [22]: Strengthening of infrastructure in PHCs and SHCs in rural areas and their equivalents in urban areas, such as Delhi’s Mohalla Clinics and Mumbai’s Swasth Clinics would significantly reduce the patient load on tertiary care hospitals and medical colleges. This will help to improve doctor-patient relationships and promote greater patient satisfaction.

Communication and empathy [6]: Studies have shown that effective doctor-patient communication is correlated with higher patient satisfaction. Spending a little more time with patients to explain different issues pertaining to their treatment, such as the treatment modality, likely duration of treatment, costs involved, possible complications, and prognosis would help immensely to clear their doubts and apprehensions. In this regard, the doctors should show empathy towards their patients. The importance of empathy is encapsulated in the words of Sir William Osler, the famous Canadian physician: “The good physician treats the disease; the great physician treats the patient who has the disease,” indicating that the latter understands the patient and the context of the illness.

Workplace safety [16]: A safe work environment and congenial atmosphere for doctors would significantly enhance their efficiency to deliver quality healthcare to their patients. Therefore, the hospital administration should make changes to the physical environment and workplace practices to improve the safety of doctors.

Proactive media [17]: Media may be considered to be the window of society. It plays an instrumental role in bringing to light the happenings of the healthcare system in our country. Therefore, it is the obligation of the media to cover the positive news of the medical profession and not just the negative news and should avoid sensationalism of news. They should also desist from media trials of doctors, which should be left to the courts.

Security and monitoring [19]: Security in government hospitals is grossly inadequate. There is an urgent need for more guards to regulate the admission of attendants of patients into hospitals. Additionally, monitoring by CCTVs should be made mandatory in hospitals. In case of an outbreak of violence in health settings, the police should respond swiftly. Moreover, warnings about violence against doctors could be displayed at all hospitals to deter miscreants.

Political interference [16,19]: Politicians should refrain from interfering with hospital matters. They should also discourage the ‘VIP Culture’ prevalent in government hospitals, as many acts of violence on doctors are perpetrated by individuals having strong political connections. Moreover, some politicians do not hesitate to publicly reprimand doctors, which is very insulting for the medical profession and should be avoided.

Strict punishment [23]: There should be strict convictions and fast track proceedings in courts of justice. For example, Andhra Pradesh was the first state to enact a law in 2007 to discourage violence against doctors. As per this law, any violence against doctors would be treated as a non-bailable offence, with a fine of up to INR 50,000 and a jail term for up to 3 years.

Doctor’s attitudes [3]: There is a need for a change in the attitude of doctors towards their patients. Sometimes, arrogant behaviour and a condescending attitude displayed by doctors lead to altercations. Every medical professional should receive adequate training in anger and stress management, as well as developing refusal skills and the ability to be assertive without hurting the sentiments of the patients and their attendants. In case of volatile situations where violence can erupt, it is important for doctors to be vigilant and look for early warning signs. Importantly, the doctors should not respond to anger with anger. They should calmly address the grievances, but at the same time call for backup.