Aggressions by patients against medical doctors in Switzerland

Transcription

62
Aggressions by patients against
medical doctors in Switzerland
A comparison of two surveys among members
of the organization SGIM/SGAM and among
medical doctors working as consultants in insurance medicine.
Magdalena Guggenheim, Bruno Soltermann
Swiss Insurance Association, Conrad F. MeyerStrasse 14, POB 4288, CH-8022 Zürich
Alexander Hänsel
Department of General Internal Medicine, Division of Psychosomatic Medicine, University
Hospital, Inselspital Berne, Switzerland
Wolf A. Langewitz
Department of Psychosomatic Medicine, University Hospital Basel, Switzerland
Elisabeth Zemp Stutz4
Institute of Social und Preventive Medicine,
University of Basel, Switzerland, Department of
Women, Gender, and Health, Steinengraben 49,
4051 Basel
Corresponding author:
Magdalena Guggenheim MD
Schweizerischer Versicherungsverband
Conrad F. Meyer-Strasse 14
P.O. Box 4288, CH-8022 Zürich
Phone +41 44 208 28 28, Fax +41 44 208 28 00
[email protected]
ASA | SVV Medinfo 2009/2 Suchterkrankungen
Abstract
Background: Physical or non-physical
violence against medical doctors (MDs)
have been investigated in recent years
in several countries. To date, there has
been published one single study on the
occurrence of physical and non-physical violence against MDs in Switzerland, but none in the population of MDs
working in insurance medicine.
Purpose: Comparison of the frequency of reported aggression by patients
against General Practitioners (GPs) and
Specialists for Internal Diseases (Internists), with the frequency of reported physical and non-physical violence
by patients against MDs in insurance
medicine. We hypothesized that working in insurance medicine with its potential financial consequences for patients leads to a higher frequency of
physical and non-physical violence.
Samples and methods: In May 2005,
two independent studies on verbal
and/or physical aggression by patients
against MDs were conducted in Switzerland: An electronic inquiry among
GPs and Internists, and a questionnaire
sent by mail to MDs working in insurance medicine. The response rate from
GPs and Internists was 24% (n=675),
63
from insurance MDs 30.8% (n=708).
Results: Verbal aggression was reported by 42% of GPs/Internists and by 45%
of insurance MDs, physical agression
by 3.6 and 3.9% respectively. All differences were statistically insignificant.
The gender distribution of the two samples varied, with a significantly smaller
proportion of women among MDs in insurance medicine (p=0.004).
Conclusion: The hypothesis of more frequent aggression against MDs in insurance medicine could not be confirmed.
Methodologically more sound studies
are required to design protection measures for physicians.
Keywords: violence, aggression, transgression, violent patients
Introduction
The disregard of boundaries in the
doctor-patient relationship has mostly
been studied from the perspective of
the patients as victims, with a special
emphasis on sexual abuse [1].
Aggression against MDs by patients
have been investigated much less. The
subject merits attention, however, since
the effects of aggression and violence
at work as described by victims are
manifold: posttraumatic stress disorder
(PTSD), depression, sleeplessness, reliving experiences, fearfulness, having
to take time off work, decreased professional self-confidence, refusal of visits
in certain areas, house calls only in the
presence of the police, fear of patients,
or thoughts to give up the medical profession [2 – 6]. Reported prevalence of
verbal abuse or physical violence vary
from 42% – 83 %, or 2.7% – 51%0 [7 –
12], respectively. Some studies, however, surveyed only aggression within the
past 12 months, whereas others included all incidents throughout the subject’s professional life.
To our knowledge, the frequency of aggression against MDs has not yet been
reported, with the exception of the recent study among Swiss practitioners
from Hänsel et al [13]. We also are not
aware of any research, national or international, addressing aggression against
MDs in the highly sensitive framework
of physician consultants in insurance
issues.
The only Swiss study was conducted in
May 2005, among the German speaking
members of the Swiss Association of Internal Medicine (SGIM) and the German
64
speaking members of the Swiss Association of General Practitioners (SGAM)
[13]. Simultaneously, also in May 2005,
the Swiss syndicate for insurance medicine (SIM) conducted an inquiry among
consulting MDs in insurance medicine,
aiming to assess physical and/or nonphysical violence against MDs within
their specific activities as consultants
in insurance issues.
The existence of these two independently conducted studies offers the opportunity to analyse whether the activity in insurance medicine leads to more
frequent aggressions, as would be expected due to possible financial consequences of the medical assessment
of patients by consultants for insurance medicine. The present paper has
the objective to shed more light on this
issue. By comparing the two surveys,
we intended to answer the following
questions:
1.Is there any difference in the frequency and nature of aggressions
by patients on MDs between the two
surveys?
2.Is there any difference in the nature
and frequency of aggressions by patients on GPs and Internists occur-
ring in private practice or in hospitals
(collective of the respective study
SGIM/SGAM) as compared to aggressions occurring in the subcollective
of GPs and Internists within the SIMinquiry)?
3.Is there any difference in the nature
and frequency of aggressions by patients between male and female
MDs?
Samples and methods
In May 2005, 2781 German speaking
members of SGIM and SGAM (GPs and
Internists) were contacted by e-mail,
requesting their participation in an internet-based, anonymous survey. The
number corresponds with approx. 50
percent of German speaking members
of those two associations. Four weeks
after the first e-mail, addressees received one single reminder. The questionnaire was based on the validated
questionnaire used by Farber et al. [10]
and was adapted for an internet version. Apart from information concerning
age and gender, it comprised questions
relative to the number and nature of aggressions by patients during the last
12 months. The following criteria were
65
listed as aggressions by patients in relation to their MDs: overly affectionate
behaviour (embraces, touching), use
of sexually explicit language, attempting or engaging in sexual contact, attempting to socialize (invitations, parties etc.), use of the MDs first name,
attempting to give expensive gifts, inappropriate personal questions, verbal
abuse, physical abuse. 675 of the 2781
addressees sent an answer (24%). The
results of the SGIM/SGAM study have
been published in the meantime [13].
Equally in May 2005, 2303 MDs acting
as consultants in medical insurance issues received a questionnaire by mail.
The questionnaire was accompanied
by a letter requesting the addressees
to participate in an anonymous inquiry.
A stamped and addressed return envelope was included. The mailing list then
available to SIM, containing MDs who
acted as experts, had been researched
with different institutions (Santésuisse, the association of health insurers in Switzerland; the Swiss Insurance
Association; SUVA, the Swiss Accident
Insurance Fund; Swiss Association of
Medical Examiner SGV; Swiss Association of Insurance Psychiatry SGVP,
and the Swiss Association of Traumatology and Insurance Medicine SGTV).
This questionnaire was newly developed and comprised – apart from information on medical specialisation and
gender – specific questions relative to
verbal or physical attacks by patients
against MDs. Aggressions were defined
as threats/aggressions in verbal, written, or telephonic form or physical attack. The frequency was assessed by
5 categories (seldom, approx. 1x per
year, approx. 1x per semester, approx.
1x per month, and more frequently than
1x per month). The accompanying letter emphasized that the questionnaire
was solely relative to the activity of the
MDs as consultants in insurance related matters.
708 of the 2303 addressees responded
(30.8%).
The two surveys did not use the same
categories of answers relative to aggressions. While in the SGIM/SGAM survey,
the exact number of aggressions during
the last 12 months could be reported,
the SIM-study offered five categories
(as quoted above). For the comparison of the frequency of transgression,
the categories of the SGIM/SGAM sur-
66
of SGIM/SGAM doctors was compared
to the frequency in the subpopulation of GPs and Internists from the SIM
study population. The analysis was performed using SPSS 15.0 (Windows). The
significance testing was done by the χ2
test.
vey were adapted to the categories of
the SIM study by generalizing the data
given for the last 12 months. Specifically, the answer “1x in 12 months” was
set equal to “1x per year”, “2 – 5x in 12
months” to “1x per semester”, “6 – 11x
per year” to “1x per month”, and every
answer exceeding 11x per year to “more
frequently than 1x per month”.
Results
Table 1 shows distribution both study
populations by gender and medical specialisation. A significantly higher proportion of women was seen in the sample of the SGIM/SGAM study (p=0.004).
Among the SIM population, there were
29% of GPs/Internists. (Table 1)
Analysis of the data
The frequencies of verbal and physical
violence of the two surveys were compared and also analysed by gender. In
a second step, the frequency of verbal
and physical violence in the population
Table 1
Study Population
total
Gender:
male
female
no declaration
Medical Specialist:
GP/Internist
Other
SIM
SGIM-SGAM
n
%
675
100
n
708
%
100
574
89
45
86.6
13.4
545
130
–
80.7
19.3
205
503
29
71
675
–
100
P (χ2)
0.004
67
The overall frequency of aggression is
practically and identical in both samples: 45% rsp. 45.4%, respectively report any kind of aggression (Fig. 1, p.
68). In both surveys, 42% report aggressions occurring seldom to 1x per
semester. The frequency of aggressions
against male MDs and female MDs
showed no differences in the SIM study
and non-significant differences in the
SGIM/SGAM survey (Fig.2, p. 68).
Also, the type of aggressions did not differ between the two study populations
(Table 2, p.69): 42% rsp. 45% verbal,
and 3.6% rsp. 3.9% physical violence.
Physical violence against women in the
SIM group were reported by 3.5%, as
compared to an apparently smaller frequency of 0.8% against women of the
SGIM/SGAM population. The sample,
however, is too small to show any statistically relevant difference.
Similar results are also seen when
comparing the subpopulation of GPs/
Internists in the SIM sample with the
SGIM/SGAM sample. Thus, we found no
evidence for our hypothesis that more
verbal and physical violence would occur in the subpopulation of medical
doctors in insurance medicine.
Moreover, the frequency of verbal at-
tacks against female GPs/Internists of
the SIM survey (52%) seems to be higher than verbal attacks against all women
of the SIM-sample (40.7%). This difference, however, did not reach statistical
significance neither (χ2 test p = 0.172).
Discussion
Main results
The major objective of our study was
to assess whether there are differences
in the frequency and nature of violence
by patients against GPs/Internists and
against MDs consulting for insurance
medicine. In both studies, the SIM and
SGIM/SGAM survey, the frequency of
verbal violence is somewhat higher
than 40%, whereas physical violence
remain between 3 – 4%. Statistically
significant differences are seen neither
between the two study populations
nor between the subsample of GPs/Internists of the SIM population and the
SGIM/SGAM sample. There were also
no significant gender differences. However, the percentage of women in the
SIM population is significantly smaller
than the percentage of women in the
SGIM/SGAM population.
68
Figure 1
Frequency of Aggression
60%
54.94%
54.52%
50%
40%
never
rarely
1x per year
1x per semester
1x per month
>monthly
no declaration
30%
25.00%
24.44%
20%
17.48%
9.46%
10%
7.34%
0.99%
0%
2.26%
1.93% 1.63%
0%
0%
SIM
0%
SGIM-SGAM
Figure 2
Type of Aggression according to Gender
100%
90%
80%
70%
317
292
51
79
60%
520
83
532
50%
129
40%
30%
20%
230
253
35
51
10%
verbal
25
3
15
0%
physical
m
verbal
physical
verbal
f
SIM (all)
physical
1
physical
verbal
m
f
SGIM-SGAM
–
+
69
Table 2
Verbal and Physical Aggression Overall and in the Subgroup of GPs/Internists
Overall
SIM
n
708
285
Total (n)
Verbal Aggression
(all)
Physical Aggression
24
(all)
According to Gender
Verbal Aggression:
m
230
f
35
Physical Aggression:
m
15
f
3
Subgroup of GPs/Internists
%
100
42.2
p=0.297
3.6
26
3.9
p=0.773
42.0%
40.7%
253
51
46.4%
39.2%
p=0.146
p=0.829
2.7%
3.5%
25
1
4.6%
0.8%
p=0.105
p=0.147
SIM
Total (n)
Verbal Aggression
Physical Aggression
According to Gender
Verbal Aggression:
m
f
Physical Aggression:
m
f
χ2
SGIM-SGAM
n
%
675
100
304
45.0
χ2
SGIM-SGAM
n
%
675
100
304
45.0
26
3.9
p=0.796
p=0.364
n
205
88
5
%
100
44
2.5
74
13
43.3%
52.0%*
253
51
46.4%
39.2%
p=0.471
p=0.235
1
2.3%
4.0%
25
1
4.6%
0.8%
p=0.193
p=0.190
70
Subgroup of GPs/Internists
SIM
n
Missing
%
Gender 45
Verbal 33
Physical 33
SGIM-SGAM
n
%
Gender 0
Verbal 0
Physical 0
χ2
* Difference between female doctors in total and female doctors among GPs/Internists is not significant (p [χ2]=0.172)
Comparison with literature
Compared to previously published international research, the frequency of
verbal and physical violence against
MDs in Switzerland matches well, falling
rather in the lower range. In contrast to
a Canadian study [14] but similar as Farber et al. [10] we have not found any significant differences relative to gender.
Various methodological approaches
have been used to assess patients’ aggressions against physician. The most
frequent form is the retrospective assessment, with recall periods ranging from 6 or 12 months (analogous to
the SGIM/SGAM survey) [3, 6, 8, 9, 11,
15] to the total professional life (analo-
gous to the SIM survey) [16]. One single
study chose a prospective assessment
with regularly written or telephonic reminders with a feedback quota of 56%
[18]. Remarkably, this survey from Ireland shows a very low frequency of verbal aggression (9.7%).
Limitations
A limitation in both studies is the low response rate of 24% in the SGIM/SGAM
sample, and of 31% in the SIM sample.
We therefore cannot rule out that the results are biased. These response rates
are below the rates obtained in international studies that vary between 40.6
and 88.5% [3, 6, 8, 9, 11, 15 - 18].
71
However, higher response rates may
have been due to special forms of reminding and/or the choice of specific
sample populations, e.g. the samples
within a hospital [3, 6], personally collecting the questionnaires [3], or the
regular reminder mailings in the framework of the prospective study [18]. These
approaches can be criticized due to the
fact that answers cannot be given anonymously, which may also lead to overor underreporting. Some studies with a
high response rate have unfortunately
not given details on their data assessment approaches [8, 9].
Due to the low response rate in the Swiss
studies, the frequency of aggression possibly is too low. It can, however, also not
be ruled out that the frequency of 42% is
an overestimation if physicians who have
experienced aggressions have overproportionally participated in the study.
The fact that the the result of the overall
SIM population, the subgroup of GPs/Internists of the SIM, as well as the SGIM/
SGAM population are in the same order
of magnitude speaks rather against this.
However, since the response rates of
both studies, are equally low, and when
considering that both surveys were conducted in the same month and the popu-
lations even partly overlap, it cannot be
excluded that similar biases exist in both
surveys. A new survey would necessarily
have to obtain a higher response rate.
The question remains open why the SIM
sample contained a significantly lower proportion of women. Unfortunately, there is no information on age in the
SIM survey; thus, we could not analyse
this difference more closely. It can be
assumed that MDs, both male and female, active in insurance medicine, who
are working independently, and with a
comparably broader professional experience, are on average an older population. Considering the gender distribution
of Swiss MDs in 2005, it is obvious that
the ratio of women among MDs above
45, especially in independent practice, is
considerably lower as in MDs below 45
[19]. This finding would be compatible
with the results.
The different forms of information assessment – electronically posted through
the internet (SGIM/SGAM study) versus posting by letter mail (SIM study)
– causes a further limitation. The electronic approach requires known e-mail
addresses. There are approx. 5275 German speaking SGIM/SGAM members,
but only 2781 (53%) could be addressed
72
by e-mail. It is possible that the population of male and female MDs with e-mail
addresses shows significant differences
from the non e-mail users, e.g. with regard to age, professional experience,
workplace, or others. These differences
could be reflected in the nature and frequency of violence.
The formulation of the questions has
been a further limitation of the comparison. The SIM survey used a non-validated questionnaire with several deficiencies. It can be assumed from the
evaluation of the data that certain questions have not been correctly understood and thus the answers flawed. Age
information was not even requested, as
were details pertaining to the amount
of active experience in the medical profession. Thus, for comparing the results,
the categories of the question on aggressions had to be adapted. The SIM study
asked for aggressions having occurred
ever during the subject’s professional
life, and gave five categories. The SGIM/
SGAM inquiry assessed only incidents
during the last 12 months, but requested
addressees, as opposed to the SIM survey, to mention the frequency for every
single form of aggression. Depending on
the adaptations of categories from the
SGIM/SGAM study to the SIM survey, as
described in the methods section, the results led to both statistically significant
and non significant results. According to
Fig. 1 it seems possible that the SGIM/
SGAM population is experiencing more
violence than the other group.
Not included in either survey is a description of the situation in which violence occurred. It is furthermore unknown whether the aggressions were
initiated directly by patients or by their
relatives. It would also have been important to know whether certain illnesses
(psychiatric conditions, addictions) or
substance abuse (alcohol, drugs) are
triggering aggressions more frequently,
as has been described in some studies
[15, 20, 21].
In order to elaborate measures for a better protection of MDs, the context of aggression should be explored more closely: whether aggressions occur more often
in the emergency room, during house
calls, or in the course of a regular consulting hour. This would be the only way
of offering custom-made help to MDs, as
has already been realized by the NHS in
the United Kingdom [22].
73
Since, to the best of our knowledge, data
on aggressions by patients against MDs
have not yet been published in Switzerland except the study by Hänsel et al [13]
and since both studies happened to be
conducted in the same month, we are
convinced that the publication of these
data makes sense despite some methodical deficiencies in both studies. They allow a sensibilisation of MDs and of the
general public to this issue and to show
methodological issues to be solved better (higher response rate; improvement
of questionnaire instrument). Despite
these limitations, the order of the frequency of aggression observed is such
that further studies are warranted.
Conclusions
The observed frequency of verbal and
physical violence ranges in the lower
range of previously published international data (42 to 52% rsp. 2.3 to 4%).
The rates of physical violence were particularly low when comparing earlier
studies. Male and female MDs plus as
well as the subpopulation of MDs in insurance medicine reported similar frequencies of aggressions. The population of the SGIM/SGAM study possibly
experience it more frequently (Fig. 2),
although this difference was statistically not significant. A new survey should
study this issue in more depth.
Despite the limitations of the study,
Swiss MDs may have to be protected
more efficiently from aggressions in the
future. A package of measures however requires a renewed study, preferably
with a prospective design, aiming at obtaining more precise information on the
circumstances in which aggressions occur, on the character of the consultation,
and on the morbidity of aggressors.
Acknowledgment
I am very grateful to Mr. Alois Tschopp
of ISPM, Zürich, Department of Biostatistics, for his invaluable help with the
statistical evaluation and analysis of
the data.
74
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76
Der praktische Fall
Christian Reiff / Anton Zumstein
Die gesundheitlichen und gesellschaftlichen Auswirkungen des Alkoholismus
sind erheblich. In der versicherungsmedizinischen Risikoeinschätzung ist
der Alkoholmissbrauch von zentraler
Bedeutung. Er führt meistens zu einer
Versicherungsannahme mit erschwerten Bedingungen oder sogar zu einer
Ablehnung. Nachstehend präsentieren
wir einen praktischen Fall. Es handelt
sich dabei um eine Person, die Versicherungsanträge im Oktober 2002 und
im März 2009 stellte.
Antragsstellung im Oktober 2002
Antragsteller
40-jähriger Koch, verheiratet, beantragte folgende Versicherungen auf Endalter 65:
•Reine Todesfallversicherung: CHF
100‘000.–
•Prämienbefreiung bei Erwerbsunfähigkeit mit einer Wartefrist von 3
Monaten
Angaben gemäss Gesundheitserklärung des Antragstellers
Körpergrösse: 176 cm
Gewicht: 86 kg
Checkup im 09.2001: ohne Besonderheiten
Alle Fragen zum Gesundheitszustand
wurden mit «nein» beantwortet; also
keine Relevanz
Medizinische Auskunft (gemäss Angaben Hausarzt und behandelndem Arzt)
1987:Kreuzbandruptur am rechten
Knie mit Thrombose
1989:Kreuzbandruptur am rechten
Knie mit Reoperation
1994:Menisektomie am rechten
Knie, Lebersteatose
30.07.1996 bis 26.08.1996:
Hospitalisation für Entziehungskur (Alkohol)
Juli 1996 bis August 2002:
•Depression, soziale Phobie, dekompensiert durch Äthylismus, keine
Suizidgefährdung
•Antabus bis August 2002
•Erhöhte Leberwerte
•Berufliche Stabilität, verheiratet
1999:
2001:
2000:
Hyperurikämie
Prostatitis
Lumbago
77
Einschätzung
Wir haben hier typische, multifaktorielle Risiken, wie sie bei Alkoholabhängigkeit leider üblich sind. Es liegen sowohl
physische als auch psychische Störungen vor. Die Tätigkeit als Koch ist per
se in Verbindung mit der Alkoholproblematik ein ungünstiger Faktor. Hingegen wirkt sich die berufliche und private
Stabilität positiv aus. Die Gesundheitserklärung wurde sehr «summarisch»
ausgefüllt! Im Leistungsfall hätte der
Kunde u.U. mit einer Vertragskündigung wegen Verletzung der Anzeigepflicht rechnen müssen!
Aus versicherungsmedizinischer Sicht
haben wir folgende Einschätzung
vorgenommen:
•Todesfallversicherung: Risikozuschlag
entsprechend 50% Übersterblichkeit
•Prämienbefreiung: Ablehnung
Antragsstellung im März 2009
Antragsteller
46-jähriger Koch, verheiratet, beantragte folgende Versicherungen auf Endalter 65:
•Reine Todesfallversicherung: CHF
37‘000.–
•Prämienbefreiung bei Erwerbsunfähigkeit mit einer Wartefrist von 3
Monaten
Angaben gemäss Gesundheitserklärung des Antragstellers
Körpergrösse: 176 cm
Gewicht: 85 kg
Checkup im 06.2008: ohne Besonderheiten
Alle Fragen zum Gesundheitszustand
wurden mit «nein» beantwortet; also
keine Relevanz
Medizinische Auskunft (gemäss Angaben Hausarzt und behandelndem Arzt)
Zusätzlich zur ersten Antragsstellung:
2005: Diskushernie L4/L5
2007:Spannungskopfschmerzen
anhaltend
2008:Darmdivertikulose, Exzision
von 2 kleinen Polypen
2009: Bronchitis
2009: Leberwerte normalisiert
78
Einschätzung
Die Alkohol- und psychische Problematik scheint (im Moment) gelöst zu sein.
Die Leberwerte haben sich erfreulicherweise normalisiert, was bezüglich Todesfallrisiko zu einer günstigeren Einschätzung führte. Aufgrund der doch
langen und komplexen Krankengeschichte haben wir folgende Einschätzung vorgenommen:
•Todesfallversicherung:
Grenzfall,
normale Annahme (die Vorpolice
wurde zu normalen Bedingungen
weitergeführt)
•Prämienbefreiung: Ablehnung
Schlusskommentar
Alkoholabhängigkeit ist oft mit körperlichen Störungen und psychischen Beschwerden – wie es der vorliegende Fall
illustriert – korreliert. Die Beurteilung
ist sehr anspruchsvoll, da das Krankheitsbild komplex ist und eine langjährige therapeutische Begleitung erfordert. Für das Todesfallrisiko haben wir
eine eher milde Tarifierung vorgenommen (keine Suizidgefährdung wurde
als günstiger Faktor gewichtet). Beim
Erwerbsunfähigkeitsrisiko mussten wir
eine vorsichtige Risikoeinschätzung
vornehmen. In diesem Bereich führt
doch die Wahrscheinlichkeit eines Rezidivs oder das Auftreten von Spätfolgen
der durchgemachten Erkrankungen zu
einem überdurchschnittlich erhöhten
Risiko.

Aggressions by patients against medical doctors in Switzerland

Transcription

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