The World Report on Violence and Health (WRVH) prepared by the Violence Prevention Alliance (VPA), which is a group of many institutions such as the World Health Organization (WHO), the International Federation of Red Crescent and Red Cross (IFRC) and the United Nations Children's Fund (UNICEF), violence is defined as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation”.1

Currently, violence in the health field is a significant problem that is widespread, underreported and persistent. Based on the WHO data, approximately four out of every ten healthcare professionals (HCPs) are victims of physical violence at least once in their career.2 According to a meta-analysis, when verbal violence is also considered, 62% of HCPs are exposed to workplace violence.3

The triggers of violence in healthcare are multifactorial4–6 and shown in Table 1.

In most countries, physicians are seen as individuals of high economic status and are often thought to earn much more than they deserve. The influence of the media further increases this misperception. Accordingly, some resources consider violence against physicians a “class war”.7

For a better understanding of the causes and solutions of violence in health, it is also important to consider the perspective of patients. A study which aims to clarify patients’ thoughts about violence against HCPs and the relationship between these thoughts and aggressive behaviours was conducted with patients applying to family health centres (family doctor practices) in Turkey. According to the study, the most common reason for violence in health was reported as “patient attitude” (79.6%). The second most common reason was “lack of security” (27.6%). The risk of engaging in violent behaviour is 29 times higher among those who approve of violence, 8.8 times higher among those with psychiatric illness, and 8.2 times higher among those who do not attribute violence to illness. Although this research was not conducted with HCPs, 28.8% of the participants had witnessed violence in healthcare.8 According to physicians, the main reason behind the increasing violence is the changing health policies that frequently target physicians.5 In support of these findings, a study conducted with primary care physicians in Spain to determine the causes of violence against physicians showed that overcrowding in healthcare facilities and lack of communication between patients and physicians were the leading causes.9 In a Bulgarian study of patients and physicians, both groups reported that violence was a result of provoking behaviours.10

According to the World Medical Association, incidents of verbal and physical violence against physicians have increased significantly in recent years, regardless of the income and wealth levels of countries.6 Based on the Occupational Safety and Health Administration, the health and social service sector experienced 7.8 incidents of serious violence per 10,000 workers. In comparison, all other major industries experienced less than two incidents per 10,000 workers.11

During September 2023, depending on only the news reflected in the press, one general surgery specialist was forcibly detained by armed people, one pregnant dermatology specialist was beaten in the abdomen, four family physicians and one nurse were beaten, a security guard died of a heart attack after a brawl, armed clashes occurred in the emergency room of two different hospitals, three young physicians from various specialities took their own lives in Turkey.12Table 2 shows the prevalence of verbal or physical violence against physicians reported in some countries.10,13–18

In addition, in Canada, approximately 70% of emergency physicians reported an increase in violence in the last five years.19 Similarly, according to the American College of Emergency Physicians, almost half of emergency physicians have experienced physical violence, and 7 out of 10 physicians reported an increase in violence in the last five years.20 Along with the negative effects of this situation on physicians, violence affects the quality of patient care and causes financial losses in the health system.19

According to the “Report on Violence in Health” issued by the healthcare union with the most members in Turkey, there were 190 incidents of violence in 2021, which increased to 249 in 2022. Physicians are the most frequent victims of violence in the profession. Of the 494 aggressors who caused violent incidents during the year, 202 were not charged, and 141 were detained and released. Only 96 attackers were arrested, and legal proceedings were initiated against 53.21 However, these numbers are only the tip of the iceberg. It is known that physicians often do not report all incidents of violence against them because they believe that necessary measures will not be taken and reporting the cases will not change anything. There is also an acceptance that violence has become “part of the job”. A previous study found that only 50% of incidents of verbal abuse and less than 40% of physical assaults were reported.22 In a study conducted by the Turkish Medical Association, 69.7% of physicians stated that they did not report an incident of violence ‘because they knew reporting would not be effective’.23 According to the United States Department of Labour report, only 26% of physicians report an event of violence.24 Based on all this information, it is not accurately possible to reach real data, and physicians worldwide are violence victims more frequently than reported.6

One of the important reasons for violence is insufficient examination duration and dissatisfaction of patients due to this time slot.5 While the number of physicians per 100,000 inhabitants is 397 in European Union countries and 365 in OECD countries, this number is 217 in Turkey. While the number of applications per capita to primary care is 2.9, the number per capita to secondary and tertiary care is 5.1.25 What should be in the ideal system is the opposite of this situation. Patients who can be easily treated in primary care are being subjected to further tests and examinations in secondary and tertiary healthcare centres due to the nature of these centres and the effect of the defensive medicine approach, and this situation creates a vicious circle.

Individuals have difficulty finding an appointment due to the burden of secondary and tertiary care in Eastern European countries. Since the duration of the appointment they find with difficulty is limited, there is a general dissatisfaction among the patients even if the medical requirements are fulfilled during the examination. Similar problems are experienced in China. In a study conducted in China, 84% of physicians reported that patients were frequently referred to secondary and tertiary healthcare facilities for simple medical problems that could be solved in primary healthcare facilities.26 Also, in Bulgaria, only 5% of patients are satisfied with the healthcare system, mainly due to out-of-pocket payments and insufficient limits of the referral system.10 This challenge can be overcome by ensuring a referral system and strengthening the primary healthcare system. Primary healthcare is a cornerstone of the health system. Strong primary healthcare is the key to ensuring that society's health needs are met more effectively and everyone can receive healthcare services equally. More effective participation of primary care services in the health system will make health expenditures more cost-effective.27

The gender factor in exposure to violence has been frequently discussed in the literature, and the results vary according to the country where the study was conducted and the characteristics of the sample group, such as department. In a report on aggression against physicians in Spain, it was observed that gender was not a modifying factor in the incidence of aggressions.28 According to the results of a 20-year cohort study conducted by Noland et al. with Norwegian physicians, in the first years of the profession, male physicians were more likely to be exposed to violence, whereas no gender difference was observed after 15 years in the profession.29 In a study conducted by Tolhurst et al. with rural physicians in Australia, it was shown that men were more exposed to physical and verbal violence, while women were more exposed to harrasment.30

Healthcare studies indicate that emergency services and psychiatric units are the areas where violence is most prevalent. A comparative analysis examining violent events in primary and specialised care settings in one region of Spain over a year reported that one in four cases occurred in primary healthcare, with a higher rate of assault targeting doctors compared to other healthcare providers.31 A study in the Madrid region, analysing six years of records, similarly found that approximately one-third of the violent events occurred in primary healthcare settings. In both studies, verbal assaults were more common in primary care, while physical assaults were more frequent in specialised care settings.32

Most studies on violence against physicians have been conducted in Asian countries. In China and India, unlike Bulgaria and Turkey, a significant proportion of violence against physicians is not perpetrated by patients and their relatives. In China, intermediary groups called Yi Nao have emerged in health violence. The fact that people apply to these groups to receive compensation from physicians or hospitals has spread in many regions. In addition, these groups investigate possible malpractice cases and direct people.7

In a survey conducted by the Croatian Physicians’ Association, 97% of physicians stated that the physical security in health institutions was not optimal and safety was not fully ensured.10 In a research published by the Turkish Medical Association (TMA), almost all of the physicians (93.4%) stated they were worried about being subjected to violence.23 A physician who is afraid of doing their duty will have an increased stress level, and their work performance will be affected. The physician may experience a lack of concentration, dissatisfaction with their job, emotional stress and exhaustion. As a natural consequence, they may make medical mistakes.33

As a result of motivational problems, physicians are looking for different ways out. One of these way-outs is for physicians to migrate to countries where violence against physicians is not as common as in their current country. The immigration of doctors is increasingly mentioned in the national and international presses.34 In 2022, a cross-sectional study of 9881 final-year medical students from 39 medical faculties in Turkey was conducted. According to the study results, approximately 70.7% of the students stated that they would like to continue their career abroad, while approximately 60% stated that they would like to live abroad permanently. The main reasons for this situation were the intensive workload on physicians, violence against physicians and increasing economic difficulties in the current conditions.35 Similar studies with medical students were conducted in other European countries. 84.7% of students in Romania, 39% in Lithuania and 62% in Poland stated that they planned to work abroad after graduation in the hope of better working conditions.36–38

Violence is an important problem that should be condemned not only in the field of health but also in all fields. Unfortunately, violence against HCPs has become extreme today, and a multidisciplinary approach is required to prevent violence against physicians (Table 3). It is crucial to fully understand the extent and types of the problem to solve it. For this purpose, highly representative, multi-centre studies should be conducted by international institutions, associations or organisations using a standardised form.

Violence against physicians is a serious problem worldwide and is increasing day by day. For this reason, physicians have difficulty fulfilling their duties, are exhausted, migrate abroad or move to the private sector. As a result, it becomes challenging to maintain healthcare services in the public sector. Measures to prevent violence should be taken in a multidimensional manner, like improvement of regulations and law, focusing on communication skills of health professionals, working on health literacy of the populations, collaboration with patient organisations, good governance, a good role model government to the public in a sustainable way. Of course, the measures shall not be restricted to those mentioned only but search for other factors according to the regional needs by high-quality research. Given the long-term consequences, it should be considered by governments that not only physicians but the whole public will be harmed.

Not applicable.

The authors alone are responsible for the content and the writing of the manuscript. All authors read and approved the final manuscript.

This research did not receive any specific grant from funding agencies in the public, commercial, or nonprofit organisations.

The authors declare that they have no competing interests.