Beyond Scrubs: Understanding the Root Causes of Violence Against Doctors

Workplace violence (WPV) against doctors is a growing epidemic in India, with at least two-thirds of doctors facing some form of abuse during their careers. Verbal abuse is common, but doctors are also subjected to brutal attacks that endanger their lives. This review lists abusive incidents reported by the media since 2021. Despite increased respect for healthcare professionals during the COVID-19 pandemic, doctors in India are under significant stress due to inadequate medical infrastructure, mismanagement of young doctors, increasing mistrust between doctors and patients, a shortage of doctors, and overworked healthcare workers, leading to delays in attention and treatment. Additional factors contributing to the situation include the lack of proper insurance coverage, weak primary healthcare with overburdened tertiary care, the lack of an effective grievance redressal system, and the poor state of medical education. To combat this epidemic, collaborative efforts are needed between doctors, hospitals, the government, and society. Improving communication skills and treating patients with empathy are essential for healthcare workers. Meanwhile, hospitals should implement an efficient security system, a transparent billing system, and an active complaint system to prevent incidents. Unbiased reporting and adequate documentation are required to further investigate this occupational health hazard. The government should focus on building better medical facilities and passing a strict law against violence against doctors to ensure the safety of medical professionals. This review presents some solutions, along with the current legal coverage provided to healthcare professionals regarding WPV.


Introduction And Background
In India, the medical community is facing a silent epidemic of violence against doctors. A study by the IMA (Indian Medical Association) discovered that a staggering 82.7% of doctors experience anxiety and stress. Another study published in the Indian Journal of Psychiatry suggests that approximately 75% had encountered some form of violence during their careers [1,2]. Despite the devastating impact of the pandemic on the medical profession, with nearly 2000 doctors lost since 2020, violence against doctors remains a persistent threat [3]. Most of these incidents, ranging from 60% to 70%, take the form of verbal abuse or hostile gestures [4]. Unfortunately, even during the peak of the pandemic, workplace violence (WPV) remained constant, occurring in COVID-designated hospitals, quarantine centers, and even at the residences of medical personnel. However, India's principal public health concern, which has been developing for decades, still has not been addressed. Based on an extensive literature search, this review article examines the violence against doctors in India, the contributing aspects, and possible tactics for avoiding it while demonstrating the gap in the legal measures already available to doctors.

What is workplace violence?
According to the World Health Organization (WHO), "incidents where employees are abused, threatened, assaulted, or subjected to offensive behavior in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being, or health are defined as Workplace Violence (WPV)" [5]. Violence against doctors can be classified into the five grades displayed in Figure 1 [6].

FIGURE 1: Grades of violence directed at doctors
The illustration of the data derived from a study by Kumari et al. [6] has been created by the authors.
A study published in 2020 on the pattern of WPV against doctors suggests that physicians are often verbally abused (91.2%) and verbally threatened (60.8%) [4]. Non-physical modes of violence are also the most common sort of violence doctors confront globally. Several incidents of similar violence have been documented throughout this pandemic, pointing toward the country's poor public health system (see Appendices for details on major incidents of WPV targeted at doctors from 2021 to 2023, state-wise distribution of WPV against medical personnel, and links to reported and publicized incidents of WPV against doctors).

Review Factors contributing to the epidemic of violence against doctors
Violence against doctors is a multifactorial public hazard. In this review, we examined several factors directly or indirectly associated with this epidemic (Figure 2).

FIGURE 2: A chart depicting the factors contributing to the WPV epidemic
The illustration of this input has been created by the authors.

Mismanagement of Interns and Junior Residents and a Demanding Competitive Work Environment
Interns spend their internships preparing for postgraduate (PG) entrance exams, which reduces their engagement with patients and practical knowledge as well. No national policy handles their stipend, job hours, or welfare. This mishandling results in a lack of work ethic, which is worsened by the pressure of PG entrance exams. Bullying, abuse, intimidation, slander, and gender-based humiliation by seniors make the workplace environment uncomfortable. With high patient turnover and limited resources, fresh graduates must manage patient care and exam preparation. This uneven work-life balance invariably affects the social lives of doctors. All these circumstances cause concern, forgetfulness, and lack of sleep or rest, which lead to therapeutic errors. It diminishes job satisfaction, self-confidence, and psychological anguish among professionals, which ultimately affects patient care [6,7]. Figure 3 describes these circumstances that create a vicious cycle leading to violence.

FIGURE 3: The vicious cycle of mismanagement of young doctors
The illustration of this input has been created by the authors.

Overworked Healthcare Workers
Interns and residents who put in long hours are more exposed to violence than older doctors. Despite government instructions to work 48 hours per week with one day off and up to 12 hours per day, junior doctors are overworked [8]. Over the last two decades, surveys indicate that interns work more hours than residents, and surgical subspecialists tend to work the most, ranging from 35 to 120 hours per week on average [8]. A study done by Howard suggests that respondents believe that longer work hours negatively impact patient care and safety [9]. This causes long wait times and delays in treatment, which increase patient and attendee stress and worries, leading to violence [10]. Overburdening and following triage even in normal times induce patient mismanagement. A study conducted in a tertiary care hospital in New Delhi found that 73.5% of doctors mentioned long wait times as a cause of violence [11]. Multiple studies have discovered that violations of visiting hours and long wait times are the leading causes of violence toward healthcare professionals. Due to a lack of staff, relatives of patients helped the on-duty doctor during the second wave of the pandemic. Leaving patient attendants (and even patients) to undertake unpleasant chores accelerates viral infections and mortality into violence [6,12,13].

Underpaid Doctors
Many protests by doctors have called for higher residency and internship stipends [14]. Medical interns from government medical colleges (GMCs) across various Indian states are being paid a monthly stipend of rupees (INR) 11,000 (on average), but several private institutes across the nation are not following the same path. This low stipend impacts the quality of work management [15].

Inadequate Medical Infrastructure
India spends 1.3% of its gross domestic product (GDP) on health care, reflecting that it has never been a priority. Universal Health Coverage by National Health Policy suggests allocating 4% of GDP to health, while India plans to increase it to 2.5% by 2025 [16,17]. Currently, India ranks 145th out of 195 nations for healthcare access and quality. Overcrowding, long wait times, and substandard infrastructure result in multiple visits, delayed initial contact, poor emergency care, excessive referrals, and a hostile environment, which all contribute to violence. All these factors exposed the already crumbling healthcare system during the second wave of the pandemic [10,[18][19][20][21].

Patient Out-of-Pocket Expenditure
In India, the government covers up to 33% of healthcare costs. Over 67% of healthcare costs are motivated by patients' mistaken belief that spending more money will save their lives, primarily in critically ill conditions [22]. Constantly low healthcare funds lead to a shortage of vital pharmaceuticals, causing physicians to ask patients to purchase medicines from other sources, putting patients' funds at risk. An estimated 60 million patients (about twice the population of Texas, USA) each year pay out of pocket for testing and medication, resulting in rising costs of therapy, vulnerability, unrealistic expectations, and financial stress [23]. These insecurities and stress among patient attendants result in greater vocal communication, abuse, and violence.

Lack of Medical Doctors
The Indian government estimates that there are around 10 lakh doctors in the country, both in the public and private sectors [24]. This number is not sufficient to meet the healthcare needs of India's population of 1.35 billion people. The shortage is particularly acute in rural areas, where access to healthcare is limited. The shortage of doctors in India is mainly due to the uneven distribution of healthcare resources, with a concentration of healthcare professionals in urban areas, leaving rural areas underserved. The lack of infrastructure, facilities, and training opportunities in rural areas exacerbates the issue. The shortage of doctors is putting a strain on the existing healthcare workforce, leading to stress and burnout among overworked doctors and nurses, which can cause a decline in the quality of care and a higher incidence of medical errors and adverse outcomes.

Poor Status or Lack of Standard Medical Education
Standardized medical examinations ensure that medical students acquire the knowledge and skills to become competent doctors. In India, the lack of standardization in testing across medical colleges poses serious implications for patient care [13]. The Medical Council of India (MCI) sets minimum standards for medical education, but there is significant variation in the quality of education across the country. The lack of standardization in testing leads to variability in the quality of doctors graduating from different colleges, which can result in inadequate patient care. Furthermore, it becomes difficult to evaluate the effectiveness of medical education programs without a common standard for comparison.

Private Health Care System
As healthcare in India becomes more commercialized, patients are increasingly being treated as consumers and hospitals as shops or establishments. Private hospitals are required to pay market prices and taxes, while government insurance policies often do not include private hospitals, which provide 80% of the country's healthcare services [25]. These factors force private hospitals to charge unreasonable prices and, in some cases, even raise facility treatment expenses. Additionally, the prevalence of fraud in the private sector further exacerbates the issue. Data from 2017 to 2018 indicates that only 37.2% of Indians had health insurance coverage, with 82% of urban residents lacking insurance altogether [26,27]. Furthermore, there is currently no community-wide health insurance program at government hospitals.

Lack of an Effective Grievance Redressal System in Government Hospitals
Government hospitals in India lack an effective grievance redressal system. Although a mechanism exists for relatives to express complaints, it often falls short of providing solutions. Doctors are left to handle the emotional responses of grieving relatives going through various stages of grief, including blame or condemnation towards doctors for a loved one's death [10]. Unpleasant medical events or the untimely death of a patient can also lead to mob mentality, with caregivers threatening doctors and damaging hospital property [6]. A robust grievance redressal system is essential to providing swift and effective solutions while ensuring the safety of doctors and hospital staff.

Underreporting of Cases: A Major Barrier
Workplace violence is a pervasive issue that affects employees across a wide range of industries and sectors. While many organizations have implemented strategies and programs to prevent WPV, underreporting incidents remains a major barrier to effectively addressing this issue [6,28]. In India, violence against doctors is a significant issue that is largely underreported. The fear of public, administrative, and law enforcement persecution is one of the reasons behind this trend. According to the study conducted by the Institute of Medicine and Law, only 52.1% of WPV incidents were reported to seniors and/or department heads, 32.8% to administrators, and 24.5% to the police. This suggests that a significant portion of WPV incidents go unreported, hindering the ability of healthcare organizations to address this issue. Moreover, the study found that only 9.9% of the study participants who reported an incident of violence were redressed adequately [4]. This highlights the need for healthcare organizations and other employers to take a more proactive approach to addressing WPV.

Doctor-Patient Mistrust: Causes and Consequences
Trust is the foundation of the doctor-patient relationship. However, in recent years, there has been a growing sense of mistrust between doctors and patients. This mistrust can have serious consequences for the quality of healthcare and patient outcomes.
Causes of mistrust: There are several factors that contribute to mistrust between doctors and patients. Patients now have access to vast amounts of health information, some of which may be inaccurate or misleading. This can lead to patients questioning their doctors' advice and recommendations and sometimes seeking alternative treatments that may not be effective or safe. Another factor is the increasing commercialization of healthcare. Patients may feel that their doctors are more interested in making money than providing quality care, particularly if they perceive that their doctor is recommending unnecessary treatments or procedures [29].
Consequences of mistrust: Mistrust between doctors and patients can have serious consequences. Patients who do not trust their doctors may be less likely to follow their recommendations, leading to poor health outcomes. They may also be more likely to seek out alternative treatments or delay seeking medical care, which can exacerbate their condition. Doctors, on the other hand, may become frustrated with patients who do not follow their advice or question their recommendations. This can make it more difficult for doctors to provide effective care and can lead to burnout and dissatisfaction with their profession.

The Psycho-Social Impact
Medical professionals are in distress. Most doctors describe insomnia, melancholy, worry, and an inability to visit patients without fear. An IMA study revealed that over 82.7% of Indian doctors feel stressed, with 46.3% citing fear of violence as the main cause. Around 62.8 percent of doctors are unable to treat their patients without any fear of being abused, and 24.2% fear being sued. When left to their own difficulties, doctors' morale decreases [1]. The detrimental impact of these episodes extends beyond doctors' physical and mental health to job performance, burnout, and the intention to leave, all of which can affect patient care quality. Uninformed civilians and overburdened doctors are forced to confront uncompromising authorities.
In extreme cases of WPV, healthcare workers strike to protest the authorities' response. These massive strikes could result in lost work days, staffing shortages, and a load on the healthcare system [6,30]. Violence and stress often compound, establishing a vicious cycle [4,30]. Due to these circumstances, young doctors are moving abroad for better workplace security and better opportunities instead of staying in India, worsening the problem. It is estimated that anywhere from 20% to 50% of Indian healthcare workers intend on searching for employment overseas [31].

What can be done to address WPV against medical personnel
To reduce violence against medical professionals, better healthcare facilities, crisis management, employee training, and strict laws are needed. Recommendations include changing the curriculum, understanding violent patients, and educating patients and relatives. All stakeholders must work together to prevent this public health hazard.

What a Doctor Can Do
The doctor should know his/her limits and when to refer a patient to a more skilled colleague. They must be calm, and composed and know how to break bad news. Doctors should try to reduce patient wait times and inform patients well in advance in case of unavailability. Doctor-patient communication should be improved to bridge the gaps in information. The ailment, available treatment options, its side effects, alternatives to the indicated management plan, expected treatment duration, likely untreated outcome, overall prognosis, and financial consequences must be shared with patients and their families. Daily updates on the patient's status and video counseling with the family are important practices. Empathy and clear communication help reduce misunderstandings. Better and prompt communication with patients and their families can reduce inevitable violence and adverse events. In those potentially violent situations, doctors should watch for signs of hostility in a patient or their relative. One of the preventive strategies includes looking for STAMP, an acronym for the following red flags [32]: 1) Staring to intimidate, keeping continuous eye contact; 2) Tone and volume of voice, yelling, sarcastic and caustic replies; 3) Anxiety approaching vicious levels; 4) Mumbling suggests increasing frustration and anger; 5) Pacing around the room in agitation.

What a Hospital Can Do
The hospital's security needs efficient people and rapid communication with the police station. Developing a hospital security system equipped with alarm bells at critical areas to alert, closed-circuit cameras in public spaces, and practice exercises or mock drills to assess standard operating procedure (SOP) compliance are examples [10,16]. A live digital board showing the availability of ER and ICU beds should be put at the hospital's entrance to allow attendants to make a prior decision so they can transfer the patient to another hospital in time once primary care is delivered [13]. The hospital needs an effective complaint process for patients and professionals. Employees should be encouraged to call out any incident of any kind of abuse. Additionally, organizations should ensure that employees who report incidents are adequately supported and that effective measures are taken to address the root causes of WPV.
An accurate account of a violent incident can offer pertinent data for planning prevention and intervention reforms. The management should provide emotional assistance to counselors and social workers to reduce anxiety in a tense situation [10,16]. Improving patient satisfaction requires a transparent billing system and a grievance bureau. Hospitals and clinics should post patients' rights and duties along with the legal consequences of any abuse of healthcare workers. Posting signboards and banners informing patients and their attendants of the act and ordinances against violence, at some strategic locations would be a step in the right direction. Associations should coach doctors on etiquette, decorum, and ethics, along with anxiety alleviation techniques. Patients should be counseled on informed consent, emergency triage, and the difference between error and carelessness.

What the Government Can Do
State governments should enforce strict rules on violence against doctors. Workshops, seminars, and other events should be conducted for doctors to familiarize them with the rules and laws they can rely on. Strengthening the legal framework and good national policies are needed to preserve doctors' rights. Violence against healthcare providers should be a punishable offense under the Indian Penal Code and Criminal Procedure Code [17]. Figure 4 describes the legal coverage doctors have against WPV at present in India.

FIGURE 4: Existing laws in India that address violence against doctors
This illustration of the data derived from an article written by Ram AB [33] has been created by the authors.
The government must also improve hospital facilities and fill unfilled positions to address the personnel shortfall [16]. Skills enhancement for new recruits should be more focused. The COVID-19 pandemic has been a reality check for healthcare, and it revealed the dire need for an increase in the health budget, strong preventive medicine, and improved primary healthcare. By supplying medications, devices, and staff to primary and secondary care centers, many diseases can be treated at this level, allowing tertiary care doctors to focus on patients requiring specialized care. Mass education and greater access to primary healthcare are needed to avert violence against healthcare staff [7]. Medical schools can raise awareness of violence. Along with medical difficulties, they should educate students about better patient-doctor interactions, good communication, and empathy. Medical education should incorporate soft skills and communication qualities needed to sympathize with fearful patients [11,17,[34][35][36][37][38][39][40].

Role of the Media
Media platforms must report responsibly, raise awareness, and facilitate constructive dialogue to prevent violence against doctors in India [13]. Both print and electronic media should report unbiasedly, without prejudice, unfairness, or fakery [7]. Social media, along with mainstream media, can encourage constructive dialogue between doctors, patients, and policymakers to address the root causes of violence. This can help put pressure on authorities to take timely action and form strict laws. Sensible reporting on healthcare can create a safer and more supportive environment for doctors to provide essential healthcare services.

What Society Can Do
Patients, their families, and society all share responsibility for preventing violence. Vandalism and violence in a hospital or clinic are crimes, and civilized society should have no space for any act of violence [41]. Social leaders must denounce violence against doctors and healthcare workers, and there should be awareness that medical costs can rise with technological improvements. Understanding the complexities of medical treatment, including diagnosis and uncertainties, is essential. Patients and their families should seek redress through the appropriate channels, such as senior doctors, grievance departments, or the legal system, instead of resorting to violence. They must be cognizant of the fact that the worldwide web can only provide information but not medical care.

Conclusions
Violence against doctors jeopardizes patient care and safety. It requires radical changes in India's healthcare system. A combination of education, training, and policies can reduce the frequency and severity of incidents. Reforms from leaders with political will are required to stop this silent epidemic. It is crucial to recognize the vital role that doctors play and take concrete steps to protect them, ensuring quality healthcare for all. Healthcare organizations, law enforcement agencies, and policymakers must work together to create a safe and supportive environment for healthcare professionals. The increasing prevalence of such incidents highlights the urgent need for awareness, prevention, and response measures to address this multifaceted public health issue. This review lists some incidents of violence against healthcare professionals in India since 2021. While these are taken from various news media reports available online, they do not include every single incident that occurred. Adequate documentation of such incidents is the need of the hour to stop WPV against doctors and determine and address its root cause.

Appendices
This supplementary appendix includes Tables 1-3 featuring the date, place, state, and a brief summary of WPV against healthcare professionals reported (scroll down for links on reportage) in India between 2021 and 2023. Table 4 lists the rate of incidence of WPV against medical professionals in different Indian states while Figure 5 is a graphical representation of it.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.