Correspondence
I declare no competing interests.
Sadeer Al-Kindi [email protected] Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH 44106, USA 1 2
3
4
Nelson R. Tackling violence against health-care workers. Lancet 2014; 383: 1373–74. O’Hanlon ME, Campbell JH. Iraq Index, Oct 1, 2007. The Brookings Institution. http:// www.brookings.edu/fp/saban/iraq/index.pdf (accessed April 1, 2014). Burnham GM, Lafta R, Doocy S. Doctors leaving 12 tertiary hospitals in Iraq, 2004–2007. Soc Sci Med 2009; 69: 172–77. Donaldson RI, Shanovich P, Shetty P, et al. A survey of national physicians working in an active conflict zone: the challenges of emergency medical care in Iraq. Prehosp Disaster Med 2012; 27: 153–61.
www.thelancet.com Vol 384 September 13, 2014
5
6
Lafta M, Pandya A. Verbal and physical aggression against resident physicians in two general hospitals in Baghdad. J Musl Ment Hlth 2006; 1: 137–44. Doocy S, Malik S, Burnham G. Experiences of Iraqi doctors in Jordan during conflict and factors associated with migration. Am J Disaster Med 2010; 5: 41–47.
Tackling violence against health-care workers in Spain I read with interest Roxanne Nelson’s World Report (April 19, p 1373).1 In Spain, April 20 is National Day Against Aggression in Health-Care Facilities. This national day was created in reaction to the murder of a resident family doctor by a patient in 2009.2 Spanish health-care providers demanded the Ministry of Public Health to give special attention to this event.3 Since that event, things have changed in Spain, thanks to the actions taken by the Spanish General Medical Council and the establishment of this National Day, violence against health-care professionals has achieved awareness in the society Moreover, the government issued a law to penalise attacks against doctors as a criminal offense of undermining on the authority of a government agent. Several offenders have already been sentenced for up to 2 years in prison. These progresses should be credited to the Observatory for aggression of the Spanish General Council of Medical Colleges. This Observatory for aggression is responsible for collecting all data about attacks on doctors, characteristics of the attacks, and the final outcome of the legal processes, with the aim of generating legal strategies on the basis of judgments that have produced dissuasive effects. Such efforts may have influenced the 16% decrease in the number of assaults since 2012. The National Day Against Aggression in Health-Care facilities promotes social awareness, encourages professionals to fight against this scourge, and attempts
to get the attention of the general population through social media with initiatives like the creation of the “#stopagresiones” Twitter hashtag. We encourage all our colleagues to raise awareness against this scourge by promoting a cultural change in professional, social, and political circles, to eradicate this problem that affects not only our quality of life as health-care providers, but also the quality of care provided to populations. This year’s motto was “Against health workers aggression: zero tolerance”. We hope that next year the slogan will be “Attacks on health workers in Spain are over”.
Getty Images
consequences. 11 years have passed since the 2003 war in Iraq and the dreams to have a better life never came true. Iraqi doctors are getting assaulted, violated, and humiliated, and as a result, more physicians are leaving the country. More than 2000 doctors have been killed since 2003.2 According to Gilbert Burnham and colleagues’ study,3 a 22% decrease has occured in the number of medical specialists in the capital Baghdad between 2004 and 2007 due in part to violent deaths (1·65%), threats (3%), and kidnappings (0·67%). In a 2008 survey 4 of emergency department physicians in Iraq, 80% reported an assault by a patient or a family member, 38% of which involved a gun threat. Resident physicians were no exception, 87% reported assault and 86% reported that it is emotionally painful to talk about their experience.5 These violent assaults were a trigger for many physicians to leave the country.6 In war-torn Iraq, these assaults might result from bereavement, lack of security, internal political corruption, and inadequate repartition of physicians. If this phenomenon continues, more doctors will be forced to leave the country and the health of the population will continue to deteriorate. Here, I call for immediate action from the Iraqi Government and WHO to protect the remaining health-care workforce from humiliation and violence.
I declare no competing interests.
Manuel María Ortega Marlasca [email protected] Primary Care Medicine, Medical College of Cadiz, Jerez de la Frontera 11406, Spain 1 2
3
Nelson R. Tackling violence against health-care workers. Lancet 2014; 383: 1373–74. Anon. Fallece la doctora tiroteada por un paciente esta madrugada en Moratalla. March 11, 2009. http://www.murcia.com/ moratalla/noticias/2009/03-11-fallece-doctoratiroteada-paciente.asp (accessed May 4, 2014). Anon. Concedida la Medalla de Oro al Mérito del Trabajo a la doctora asesinada en Moratalla. http://www.laverdad.es/murcia/20101203/ local/region/murcia-consejo-ministrosconcede-201012031739.html (accessed May 4, 2014).
Violence against doctors in India I read with interest the Editorial1 about the deterioration of the doctor–patient relationship in China. I believe the situation in India is worse than it is in China. Studying in private medical colleges has become very expensive. Admission is based on entrance examination, not on vocation, aptitude, or attitude of the student. How can one expect ethics and humanity in the medical profession? Moreover, to settle in big cities, where life is expensive, doctors might unwillingly practise unethically, such as advising expensive unnecessary radiology, endoscopic, or laboratory investigations. 2 In government
For more on the Observatory for aggression see https://www. cgcom.es/documentacion_ agresiones
955
Correspondence
hospitals, doctors are overworked and under pressure from politicians who can interfere with medical admission, affecting doctors’ self-esteem. The main reasons for patients’ relatives to become violent are unnecessary investigations, delay in attending patient, request of advance payments, or withholding a deceased body until settlement of final billing. Ultimately the medical trade now involved in this noble profession has resulted in doctors, patients, and relatives’ unrest.3 Today, doctors are not recommending to their children to go to medical colleges, which is a real misery for the medical profession. Another important issue is the involvement of drug companies in unethical trade including sponsoring doctors’ tours abroad, conferences, and offering expensive gifts. 30 mg of tenectiplase, a thrombolytic drug used for acute myocardial infarction, costs 27 000 rupees (US$450) to patients (beneficiaries), which is the maximum retail price. However, the same drug costs only 21 000 rupees ($350) to the treating physician. Patients are used for research, but benefits are given to doctors.3 I declare no competing interests.
Himmatrao Saluba Bawaskar himmatbawaskar@rediffmail.com Bawaskar Hospital and Research Centre, Mahad, Dist-Raigad, Maharashtra 402301, India 1 2 3
The Lancet. Violence against doctors: why China? Why now? What next? Lancet 2014; 383: 1013. Sachan D. Tackling corruption in Indian medicine. Lancet 2013; 382: e23–24. Bawaskar HS. The medical trade. Indian J Med Ethics 2013; 10: 278.
Publication pressure on Chinese doctors— another view In China, the debate about doctors’ promotion and publications (through science index citation) has been ongoing for years.1–4 Many doctors, and espec ially young doctors, complain about the huge pressure 956
for publication. 1 However, others, including ourselves, hold the view that it is necessary for doctors to be engaged in research,2,5 and that “engaging in research is likely to develop analytical skills and promote critical thinking”.2 Scientific research is not a luxury but a necessity. China, as a country, provides a large number of disease cases, with important potentials for relevant research, and so, not only for China, but also for other countries worldwide. However, whether a doctor should be engaging in research or not is not the key point of the debate. In China, patients can choose their medical providers, and this can lead to excess. A patient with a cold is likely to go to a well-equipped hospital, and a doctor will have to spend some time on this patient who could or should have been treated in primary health-care facilities. Hence, many doctors who would do research are too often overloaded and do not have enough time for academic research. Therefore, the key point here is the conflict between the academic expectation laid on doctors and the time that they have. There are two problems involved here: the first one is how to guide patients’ rational use of different health-care providers. The second one is how to establish a reasonable standard for doctors’ promotion. Although, there is growing research on health-seeking behaviours, very few studies have looked at promotion mechanisms of doctors in China. In fact, in China, no requirement for publications is made at the national level, however lots of hospitals have brought the number of articles published and the research implemented by doctors into their promotion mechanisms. To determine whether this approach is reasonable or not, and how to improve it, will require more research. We acknowledge funding from the Natural Science Foundation of China (71203068), Health and Family Planning Commission of Wuhan Municipality, and Guiyang city health bureau. We declare no competing interests.
Shanquan Chen, Yao Pan, Qiang Yao, Lan Yao, Zhiyong Liu, *Li Xiang [email protected] School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China 1 2 3
4
5
Ye B, Liu AHJ. Inadequate evaluation of medical doctors in China. Lancet 2013; 381: 1984. Hong JX, Xu JJ, Sun XH. Young doctors and the pressure of publication. Lancet 2013; 381: e10. Yuan HF, Xu WD, Hu HY. Young Chinese doctors and the pressure of publication. Lancet 2013; 381: e4. Yu NZ, Hassan KZ, Long X, Wang XJ. Young doctors and the pressure of publication. Lancet 2013; 381: e10. Holden J. The work and research of a single non-academic family physician. Family Practice 2009; 26: 75–78.
Department of Error Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 957–79—In this Article (published online on May 2), changes have been made to the author list and affiliations. These corrections have been made to the online version as of Sept 12, 2014, and the printed Article is correct. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 980–1004—In this Article (published online on May 2), changes have been made to the author list and affiliations, and the key of figure 5C has been corrected. These corrections have been made to the online version as of Sept 12, 2014, and the printed Article is correct. Murray CJL, Ortblad KF, Guinovart C, et al. Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990—2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 1005–70—In this Article (published online on July 22), changes have been made to the author list and affiliations, and to data in table 5. These corrections have been made to the online version as of Sept 12, 2014, and the printed Article is correct.
www.thelancet.com Vol 384 September 13, 2014
I declare no competing interests.
Sadeer Al-Kindi [email protected] Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH 44106, USA 1 2
3
4
Nelson R. Tackling violence against health-care workers. Lancet 2014; 383: 1373–74. O’Hanlon ME, Campbell JH. Iraq Index, Oct 1, 2007. The Brookings Institution. http:// www.brookings.edu/fp/saban/iraq/index.pdf (accessed April 1, 2014). Burnham GM, Lafta R, Doocy S. Doctors leaving 12 tertiary hospitals in Iraq, 2004–2007. Soc Sci Med 2009; 69: 172–77. Donaldson RI, Shanovich P, Shetty P, et al. A survey of national physicians working in an active conflict zone: the challenges of emergency medical care in Iraq. Prehosp Disaster Med 2012; 27: 153–61.
www.thelancet.com Vol 384 September 13, 2014
5
6
Lafta M, Pandya A. Verbal and physical aggression against resident physicians in two general hospitals in Baghdad. J Musl Ment Hlth 2006; 1: 137–44. Doocy S, Malik S, Burnham G. Experiences of Iraqi doctors in Jordan during conflict and factors associated with migration. Am J Disaster Med 2010; 5: 41–47.
Tackling violence against health-care workers in Spain I read with interest Roxanne Nelson’s World Report (April 19, p 1373).1 In Spain, April 20 is National Day Against Aggression in Health-Care Facilities. This national day was created in reaction to the murder of a resident family doctor by a patient in 2009.2 Spanish health-care providers demanded the Ministry of Public Health to give special attention to this event.3 Since that event, things have changed in Spain, thanks to the actions taken by the Spanish General Medical Council and the establishment of this National Day, violence against health-care professionals has achieved awareness in the society Moreover, the government issued a law to penalise attacks against doctors as a criminal offense of undermining on the authority of a government agent. Several offenders have already been sentenced for up to 2 years in prison. These progresses should be credited to the Observatory for aggression of the Spanish General Council of Medical Colleges. This Observatory for aggression is responsible for collecting all data about attacks on doctors, characteristics of the attacks, and the final outcome of the legal processes, with the aim of generating legal strategies on the basis of judgments that have produced dissuasive effects. Such efforts may have influenced the 16% decrease in the number of assaults since 2012. The National Day Against Aggression in Health-Care facilities promotes social awareness, encourages professionals to fight against this scourge, and attempts
to get the attention of the general population through social media with initiatives like the creation of the “#stopagresiones” Twitter hashtag. We encourage all our colleagues to raise awareness against this scourge by promoting a cultural change in professional, social, and political circles, to eradicate this problem that affects not only our quality of life as health-care providers, but also the quality of care provided to populations. This year’s motto was “Against health workers aggression: zero tolerance”. We hope that next year the slogan will be “Attacks on health workers in Spain are over”.
Getty Images
consequences. 11 years have passed since the 2003 war in Iraq and the dreams to have a better life never came true. Iraqi doctors are getting assaulted, violated, and humiliated, and as a result, more physicians are leaving the country. More than 2000 doctors have been killed since 2003.2 According to Gilbert Burnham and colleagues’ study,3 a 22% decrease has occured in the number of medical specialists in the capital Baghdad between 2004 and 2007 due in part to violent deaths (1·65%), threats (3%), and kidnappings (0·67%). In a 2008 survey 4 of emergency department physicians in Iraq, 80% reported an assault by a patient or a family member, 38% of which involved a gun threat. Resident physicians were no exception, 87% reported assault and 86% reported that it is emotionally painful to talk about their experience.5 These violent assaults were a trigger for many physicians to leave the country.6 In war-torn Iraq, these assaults might result from bereavement, lack of security, internal political corruption, and inadequate repartition of physicians. If this phenomenon continues, more doctors will be forced to leave the country and the health of the population will continue to deteriorate. Here, I call for immediate action from the Iraqi Government and WHO to protect the remaining health-care workforce from humiliation and violence.
I declare no competing interests.
Manuel María Ortega Marlasca [email protected] Primary Care Medicine, Medical College of Cadiz, Jerez de la Frontera 11406, Spain 1 2
3
Nelson R. Tackling violence against health-care workers. Lancet 2014; 383: 1373–74. Anon. Fallece la doctora tiroteada por un paciente esta madrugada en Moratalla. March 11, 2009. http://www.murcia.com/ moratalla/noticias/2009/03-11-fallece-doctoratiroteada-paciente.asp (accessed May 4, 2014). Anon. Concedida la Medalla de Oro al Mérito del Trabajo a la doctora asesinada en Moratalla. http://www.laverdad.es/murcia/20101203/ local/region/murcia-consejo-ministrosconcede-201012031739.html (accessed May 4, 2014).
Violence against doctors in India I read with interest the Editorial1 about the deterioration of the doctor–patient relationship in China. I believe the situation in India is worse than it is in China. Studying in private medical colleges has become very expensive. Admission is based on entrance examination, not on vocation, aptitude, or attitude of the student. How can one expect ethics and humanity in the medical profession? Moreover, to settle in big cities, where life is expensive, doctors might unwillingly practise unethically, such as advising expensive unnecessary radiology, endoscopic, or laboratory investigations. 2 In government
For more on the Observatory for aggression see https://www. cgcom.es/documentacion_ agresiones
955
Correspondence
hospitals, doctors are overworked and under pressure from politicians who can interfere with medical admission, affecting doctors’ self-esteem. The main reasons for patients’ relatives to become violent are unnecessary investigations, delay in attending patient, request of advance payments, or withholding a deceased body until settlement of final billing. Ultimately the medical trade now involved in this noble profession has resulted in doctors, patients, and relatives’ unrest.3 Today, doctors are not recommending to their children to go to medical colleges, which is a real misery for the medical profession. Another important issue is the involvement of drug companies in unethical trade including sponsoring doctors’ tours abroad, conferences, and offering expensive gifts. 30 mg of tenectiplase, a thrombolytic drug used for acute myocardial infarction, costs 27 000 rupees (US$450) to patients (beneficiaries), which is the maximum retail price. However, the same drug costs only 21 000 rupees ($350) to the treating physician. Patients are used for research, but benefits are given to doctors.3 I declare no competing interests.
Himmatrao Saluba Bawaskar himmatbawaskar@rediffmail.com Bawaskar Hospital and Research Centre, Mahad, Dist-Raigad, Maharashtra 402301, India 1 2 3
The Lancet. Violence against doctors: why China? Why now? What next? Lancet 2014; 383: 1013. Sachan D. Tackling corruption in Indian medicine. Lancet 2013; 382: e23–24. Bawaskar HS. The medical trade. Indian J Med Ethics 2013; 10: 278.
Publication pressure on Chinese doctors— another view In China, the debate about doctors’ promotion and publications (through science index citation) has been ongoing for years.1–4 Many doctors, and espec ially young doctors, complain about the huge pressure 956
for publication. 1 However, others, including ourselves, hold the view that it is necessary for doctors to be engaged in research,2,5 and that “engaging in research is likely to develop analytical skills and promote critical thinking”.2 Scientific research is not a luxury but a necessity. China, as a country, provides a large number of disease cases, with important potentials for relevant research, and so, not only for China, but also for other countries worldwide. However, whether a doctor should be engaging in research or not is not the key point of the debate. In China, patients can choose their medical providers, and this can lead to excess. A patient with a cold is likely to go to a well-equipped hospital, and a doctor will have to spend some time on this patient who could or should have been treated in primary health-care facilities. Hence, many doctors who would do research are too often overloaded and do not have enough time for academic research. Therefore, the key point here is the conflict between the academic expectation laid on doctors and the time that they have. There are two problems involved here: the first one is how to guide patients’ rational use of different health-care providers. The second one is how to establish a reasonable standard for doctors’ promotion. Although, there is growing research on health-seeking behaviours, very few studies have looked at promotion mechanisms of doctors in China. In fact, in China, no requirement for publications is made at the national level, however lots of hospitals have brought the number of articles published and the research implemented by doctors into their promotion mechanisms. To determine whether this approach is reasonable or not, and how to improve it, will require more research. We acknowledge funding from the Natural Science Foundation of China (71203068), Health and Family Planning Commission of Wuhan Municipality, and Guiyang city health bureau. We declare no competing interests.
Shanquan Chen, Yao Pan, Qiang Yao, Lan Yao, Zhiyong Liu, *Li Xiang [email protected] School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China 1 2 3
4
5
Ye B, Liu AHJ. Inadequate evaluation of medical doctors in China. Lancet 2013; 381: 1984. Hong JX, Xu JJ, Sun XH. Young doctors and the pressure of publication. Lancet 2013; 381: e10. Yuan HF, Xu WD, Hu HY. Young Chinese doctors and the pressure of publication. Lancet 2013; 381: e4. Yu NZ, Hassan KZ, Long X, Wang XJ. Young doctors and the pressure of publication. Lancet 2013; 381: e10. Holden J. The work and research of a single non-academic family physician. Family Practice 2009; 26: 75–78.
Department of Error Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 957–79—In this Article (published online on May 2), changes have been made to the author list and affiliations. These corrections have been made to the online version as of Sept 12, 2014, and the printed Article is correct. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 980–1004—In this Article (published online on May 2), changes have been made to the author list and affiliations, and the key of figure 5C has been corrected. These corrections have been made to the online version as of Sept 12, 2014, and the printed Article is correct. Murray CJL, Ortblad KF, Guinovart C, et al. Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990—2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 1005–70—In this Article (published online on July 22), changes have been made to the author list and affiliations, and to data in table 5. These corrections have been made to the online version as of Sept 12, 2014, and the printed Article is correct.
www.thelancet.com Vol 384 September 13, 2014
