Shukun Yao, Qing Zeng, […], and Jiangjun Wang
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The incidence of patient-doctor disputes are alarmingly increasing in China, this article reviews the current status and causes of violence against medical workers in China, six strategies to tackle the daily worrying problems have been proposed and hopefully could improve the medical working environment in China.
Keywords: Violent attacks, threats, assaults, hospitals, medical workers in China
Threats and violence to medical workers is common in every country, but is more common in China (1). Since 2000, the incidence of violence against medical workers has been increasing at about 11% annually (2) (Figure 1). Only in 2012, seven medical workers were killed (3) (Figure 2), which is approximately half of the total number of deaths in the previous 9 years. In 2013, one Ear, Nose and Throat (ENT) doctor at Wenling Hospital in Zhejiang province was murdered, most medical workers in China were shocked and hundreds of medical staff gathered together to request a safe working environment (Figure 3). The government has been tried to stop the violence against medical workers (4-6), unfortunately, daily oral abusive to medical workers occurs in almost every hospital, the number of physical attack to medical workers is still alarmingly rising. Believe it or not, the following violent events were reported in newspapers from January to March 2014 in China, we afraid it continues going on without ending.
The annual number of violent events reported is increasing.
Medical workers murdered during medical violence.
Medical workers in Wenling Hospital of Zhejiang province gathered together automatically to request the right to work with security and mourn Dr. Yujie Wang who was murdered by a patient.
Recent ridiculous and unbelievable violence against medical workers
February 17, 2014, at BeiMan TeGang Hospital in Qiqihar city of Heilongjiang province, a perpetrator was not happy with the surgical outcome, and attacked the head of his ENT doctor with an iron pipe and murdered him (7,8);
February 18, 2014, at Yi County Hospital of Hebei province, while Dr. Li, a general surgeon, was consulting a patient, his throat was slashed suddenly by his former patient (8,9);
February 20, 2014, at 2nd Hospital of Zhejiang University Medical College, a female patient and her mother complained the slow process of a pregnant nurse, even they had learned the nurse was pregnant, they still beat the nurse crucially and caused her a mischarge;
February 25, 2014, at Nanjing Stomatological Hospital, a young female patient was not happy for her ward arranged by a nurse on duty, later her both parents, the government officials, beat the nurse up to paralysis (8);
March 4, 2014, in Chaozhou Central Hospital, a patient had acute alcoholic intoxication due to abuse alcohol and died after prompt treatment. The relatives of deceased patient considered the doctor’s treatment lead to a death and called up approximately one hundred people to humiliate the doctor in charge by forcing him to walk in hospital for half an hour until the police breaking it up (Figure 4);
The doctor on duty was humiliated by hundreds of people because he failed to rescue a severe alcoholic patient (left) and the consultant at 6th Hospital of Beijing University was assaulted by another patient (right).
March 4, 2014, in Beijing Union Medical Hospital, being refused of jumping the queue to see a doctor, a female patient and her mother furiously attacked a nurse and a nursing supervisor, caused the nurse an ocular fundus hemorrhage (10);
March 4, 2014, a doctor in Laizhou Municipal Hospital was battered to coma by two men with iron rods (11);
March 4, 2014, in the early morning, in Ningbo 1st People’s Hospital, Dr. Su, a female ENT doctor, was attacked by a patient’s relative for one minute and slapped on her face three times leading to facial bleeding (12);
March 6, 2014, at Beijing Anzhen Hospital, a patient had a ruptured aortic aneurysm and died after aggressive resuscitation; a dozen of patient’s family members blocked the ward, attacked the doctor on duty, and interrupted the normal medical service (13);
March 7, 2014, in an elevator of Wenling 1st Hospital in Zhejiang province, Dr. Shan, a thoracic surgeon, was assaulted by a patient’s relative. Later the perpetrator claimed, “I just like to attack any doctors who are on white working coat with no reasons (14)”.
March 7, 2014, in 6th Hospital of Beijing University, a doctor who was consulting with a patient was knocked on the back of his head by another patient with a hammer (Figure 4). This perpetrator also carried a knife while knocking the doctor;
March 8, 2014, in 1st Hospital of Hanzhou city, a sick child removed a blocked needle himself and subsequently caused a bleeding, his father blamed the nurse on duty and hit her head with a bottle, resulting in a cerebral concussion, delayed cerebral hemorrhage, and comminuted nasal bone fracture (15);
March 9, 2014, a physician in emergency room at People’s Hospital of Bianyang city in Sichuan province ordered CT scan test to exclude cerebrovascular accident for a 80-year old lady who had vomiting, loss of speech, headache, hypertension, diabetes, the CT scan returned as normal, because of normal brain CT imaging, the patient’ grandsons, two young relatives of deputy police chief of Bianyang city, considered the order of the CT scan as useless, and assaulted the physician with three punches and kicks, resulted in glasses broken and forehead scratched (16);
March 11, 2014, 20 family relatives rushed into Chengdu Municipal Women and Children Central Hospital with iron pipes and assaulted five hospital employees, resulted in head injuries, head hematoma, closed abdominal injuries, renal contusion and bloody urine. The reason was a pregnant woman delivered a dead baby 4 days earlier (17);
March 13, 2014, a 4-month-old female patient with congenital heart disease and pneumonia had sputum and required suction, after sputum suction, the baby choked with cyanotic mouth on breast feeding, thus, the baby’s mother and grandmother in law started to chase and assault the nurse on duty (18);
March 21, 2014, at Shanghai 5th People’s Hospital, Dr. Cai, a chief surgeon, was consulting with a patient, and was assaulted on the back of his head, his right index and middle fingers were fractured. In addition, another two nurses and one security guard were also injured (19);
March 23, 2014, In emergency room at Beijing University of Chinese Medicine Hospital, a patient’s male relative with height 1.8 meter beat a nurse to head injury due to her slow reaction (20).
A survey conducted by China hospital association included 8,000 patients and 8,000 medical workers in 316 hospitals at 30 provinces, municipalities, autonomous regions and cities, the results show that the incidence of oral abusive and threaten to medical workers increased from 90% in 2008 to 96% in 2012, whereas the incidence of physical injuries of medical workers escalated from 47.7% in 2008 to 63.7% in 2012. The annual average number of assaults on medical staff per hospital increased from 20.6 assaults in 2008 to 27.3 assaults in 2012.
Statistics results of Chinese hospital association show the number of violence against medical worker is 57 in 2010, 86 in 2011, 99 in 2012 and 130 in 2013. Report from Chinese National Health and Family Plan Commission (NHFPC), formerly the Ministry of Health shows 11 violent events occurred in hospitals in 8 provinces and cities in 2011, resulted in 7 death and 28 injuries including 16 medical workers, 11 patient escorts, and 1 security guard (21). We reviewed the authority reports from January 2011 to April 30, 2014, a total of 88 events of violence against medical workers occurred in 48 cities and 22 provinces, of which 10 medical workers (11.36%) were murdered. The emergency department had the highest incidence (20.5%, 18/88), followed by 120 emergency rescue team (5.7%, 5/88) and intensive care units (5.7%, 5/88). Fortunately, no violent event has been reported in military hospitals, which may reflect their effective restrict management.
Causes of violence
The recent severe violence to medical workers in China reflects the poor related managing systems and little respect to medical workers in current society. The cause of violence against medical worker is not unique. The related legal system and health system are the main roots of deteriorating doctor-patient relationship. In early 1980s, the health care in China has been commercialized. The rapid growing of the medical cost surpasses the patient’s affordable capability, and the medical cost is only partially re-imbursed for some people with health insurance. A severe disease may cost the lifetime earnings of patient’s family. Some patients and their family have been demanding greatly for a favorable outcome of any intervention, believe that the money they spent must translate into excellent or even full recovery of the health, even for untreatable advanced disorders. Once a patient died, the related family members will blame the doctors and try to fight for huge amount of compensation from the doctor as much as possible. They do not go legal process to sue the doctors, as it takes a long time and go through a very complicated process, and finally get a little compensation; in addition, they perceived that a legal channel has been in favor of medical establishment.
Yinao, a patient-doctor dispute, is an illegal interruption of normal activity at hospital conducted by a patient, relatives of patient or those who aimed for money. Yinao gangs have been walking around the hospital, and find the way to provide illegal support for patients such as intimidation, threats, and violence to medical staff. It is common to find the scattered small cards advertising and providing illegal support for any patients who are unhappy with a doctor, saying call me if you are not satisfying with any medical services and need help.
Once a severe violence occurs, the reaction of police to the request of help from hospital is notoriously slow. They arrive in delay or just stand by observing the dispute or violence, and explain that this kind of issue belongs to doctor-patient relationship rather than the criminal issue and therefore they could do nothing but watching and waiting the order from their supervisor (22). For the media, it usually focuses on reporting the severity of medical worker, and ignores how the perpetrators were punished. The hospital administrators usually try to negotiate with perpetrator and to spent money for the settlement of dispute. Some injured medical staffs usually do not know how to protect themselves, and in fact, no effective avenue to protect medical staff is available. Therefore, they hesitate to report the assaulted events but just suffering emotionally and physically with heart in tears. Otherwise, unfortunately, the situation may get worse, the injured medical staff may be unfairly criticized or punished by the hospital governors. All these factors cultivate the growth of the violence in hospitals. As a proverb says, gaining big money after a big violence, winning small money after a small violence, and having no money for no violence. The medical workers have no sense of security in practice medicine and 86% medical staff do not expect their children to study medicine any more in the future (23). Nearly 40 percent of surveyed medical staff plan to give up the profession due to medical violence (23). Recent survey from Dxy.cn including 3,360 medical workers and 565 medical students shows 90% medical workers experienced or witnessed medical disputes, 50% had depression and 40% suffered from anxiety (21).
Six strategies for violence
Six solutions should be emphasized in order to ensure the security of medical care environment. First, the law must be reformed to tackle the violence in hospital as that in public area. Currently, the hospital is considered a special place rather than a public area, and therefore, the procedure in control the violence in hospital is rather slower and less effective than in public area. The perpetrator in hospital is punished much less than outside hospital, even outside the door of hospital. The slow response and delayed arrival of police to any urgent request from the medical workers and no reaction of police for the violence in hospital are a well-known phenomenon and should be solved. Second, any biased report, unfair or even false report from media must be stopped and punished seriously and severely. Free speech and free report on medical issue do not mean false or unfair report. Some reporters have little knowledge of medicine, but interested in reporting medical dispute or controversial events incorrectly for gaining public attention and generating the best-selling of the newspapers, they completely ignored the negative impact on the society and medical workers (7). Third, a neutral and fair judicial system to evaluate the medical dispute must be established, which should process independently and promptly, and should not be controlled by medical administrator or government. Fourth, the government should raise the salary of medical workers and encourage them to work with no worries about their living conditions. The aim of the hospital should be focused on the health of patients rather than hospital financial performance. The government should not evaluate the hospital by the index of financial income. Only in this way can the president of hospital, the director of department and medical workers concentrate on the quality of medical care. The medical workers should be guided to strive and compare the medical achievement of health care. Fifth, the suspected violent patients should be listed in the computer system and warned the medical workers to treat them cautiously. Sixth and finally, the medical workers should improve communication ability besides the medicine and know how to communicate with potential violent patients. And more importantly, the medical workers, especially the surgeons have to observe the guidelines of medical practice and evidenced medicine, and should always ask yourself in mind when practice medicine, “could I do it in this way if the patient in front were myself, my mom or my dad?”
Overall, the dream of medical workers in China is to deliver medical care in a safety working environment without assault. We expect that the six strategies above could be performed successfully, a friendly mutually trusted patient-doctor relationship can be rebuilt up and the quality of medical care will be improved further in China. In the end, hopefully, the dream of medical worker in China will become true.