Objective: Aggressions against health staff is a phenomenon that is not widely studied worldwide. To date, there is no national study analyzing this situation in Spain. Our objective is to describe and analyze aggressions to physicians of the whole Spanish territory in the period 2010–2015, through an observational analytical study by conglomerates (ecological) with all aggressions to physicians identified by the 52 official medical associations of Spain over 6 years of study. Results: There were 2419 aggressions on physicians, 51% on men. Primary care is the area that concentrates more incidents (54%) and the public sector is the most affected (89%). A third of the assaults were concentrated on profes- sionals aged 46–55 years old. Cumulative incidence decreased from 20 aggressions × 10,000 physicians in 2010 to 15 × 10,000 physicians in 2015. The importance and seriousness of the problem of aggressions against physicians is verified through notifications to the registry. The collection method is different from others based on surveys, and therefore the figures are significantly lower than other studies. The scant denunciation by attacked physicians in Spain makes deceiving the real dimensions of the phenomenon. Keywords: Aggression, Physician–patient relations, Workplace violence Introduction Our objective is to contribute to the current state of Aggressions against physicians is a problem of grow- knowledge of this problem in Spain and serve as a refer- ing interest in research, which has been poorly prior- ence in the European region. itized in healthcare systems. To date and knowledge Until 2015 there are very few published studies related of the authors, there is no regulated study in Spain that to this phenomenon in our society . In 2015 a survey analyzes this situation and its trend at national level in of physicians in Barcelona  described how 44% of the recent years. The number of related international stud - professionals surveyed stated that they had been vic- ies is limited, most of them are old, without evidence of tims of some form of verbal aggression. Another regional a prospective analysis of the phenomenon and with dis- survey, this time carried out in Aragon and Albacete to parate results, which may well be the indirect reflection 1845 health professionals concluded that up to 64% of the of the characteristics of different health care systems and sample had suffered aggressions of different magnitude, organizations, or of the particular situation of each coun- and 5% acknowledged having been attacked on multiple try . occasions . Main text Methodology *Correspondence: email@example.com The study has an observational design, and analyzes General Council of Official Medical Associations of Spain (CGCOM), Plaza de las Cortes, 11, 28014 Madrid, Spain both the set of cases accumulated in 6 years, and its Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. The National Observatory of Aggressions to Physicians (ONAM) Workgroup Page 2 of 6 and General Council of Official Medical Associations of Spain (CGCOM) BMC Res Notes (2018) 11:347 longitudinal evolution. It collects all the aggressions Statistical analysis on physicians registered by the National Observatory The descriptive analyses were based on frequency dis - of Aggressions to Physicians (ONAM) of the CGCOM tribution and were performed on the total of aggres- from 1st January 2010 to 31st December 2015. The sions observed in the study period. In the frequency population under study (N = 2419) is composed by of analysis of each variable, only have been excluded the all physicians whose aggressions were registered by the aggressions with lost data. For the accumulated inci- 52 Official Medical Associations of Spain during this dence of aggressions, we used the number of assaults period. Each Medical Association reports its aggres- recorded each year, among the total number of colle- sions to the ONAM in a grouped manner, describing giate doctors in the same period. P values were calcu- the scope of the professional practice in which they lated using Pearson Square Chi or Fisher’s Exact Test. occur and the sociodemographic and professional char- All statistical analyses were performed using Stata soft- acteristics of the physicians assaulted in each period. ware (version 11.1) . Considering that the general report of the ONAM is based on reports by clusters, the present study is eco- Results logical. The evaluation was anonymised. During the study period, there were 2419 aggres- sions on doctors in Spain, 50.8% on men and 49.2% on women. The great majority of the aggressions were Aggressions detected in the public exercise (88.7%). 37.3% of inci- We consider as an aggression each of the cases com- dents were concentrated in the age group 46–55 years. prising physical or psychic attacks, insults or threats, Table 1 shows the frequency distribution of the main which is communicated by the affected physicians to characteristics of the population. their respective Medical Association. We consider clus- ter, the report of aggressions of each Association to Cumulative incidence the ONAM. We have not excluded any of the detected The cumulative incidence of aggressions against physi - aggressions. cians in the period studied shows a significant tendency to decrease (P trend < 0.0001), observing a cumulative incidence of 20.2 assaults per 10,000 physicians in 2010 Other variables and 15 assaults per 10,000 physicians in 2015 (no sig- The information of the professionals assaulted on gen - nificant differences between men and women). der, age groups, type of professional exercise, presence of injuries, generation of (paid) sick leave (SL), recep- Aggressions by area tion of support/guidance by the company, presentation Primary care concentrated more than half of the cases of a complaint, presence of previous aggressions and (53.9%), followed by the hospital and Accident and presence of material damages, and the information of Emergency Services (23.6%). the aggressor on personal background and profile, were obtained from the Annual Reports of the ONAM. Age Severity of injuries variable was categorized into ranges (< 35, 36–45, 46–55, Almost a fifth of the assaults on professionals dur - 56–65, ≥ 66 years). ing the study period were associated with personal The type of professional practice was categorized as injuries. Up to 12% of all attacks resulted in a SL. In 1 public and private. The scope of the aggression was cat - out of every 10 cases, material damages occurred and egorized as primary care (GP practices), hospital, pri- almost 8% of the physicians attacked had suffered prior mary care emergencies (out of hours and domiciliary attacks (Table 1). In a gender-stratified analysis of the care), hospital accident-emergencies services, and oth- aggressions recorded in 2015, no statistically signifi - ers. The aggressor’s personal history was categorized as cant differences were found in the proportion of physi - drug addiction, psychiatric, organic disease and others. cal and psychological injuries among men and women The profile of the aggressor was categorized as a sched - (Table 2). uled patient, unscheduled patient, center user and family member. The other variables were dichotomized (yes/no) Aggressor profile according to their presence or absence: personal injury, Only 7 out of 10 aggressions are done by the patient; generation of temporary incapacity for work, reception of the others are generated by a relative or compan- support/guidance by the company towards the physician ion. Regarding the aggressor’s antecedents, we found attacked, presentation of a complaint, presence of previ- that 13% of aggressors had a history of psychiatric ous aggressions and presence of material damages. The National Observatory of Aggressions to Physicians (ONAM) Workgroup Page 3 of 6 and General Council of Official Medical Associations of Spain (CGCOM) BMC Res Notes (2018) 11:347 Table 1 Characteristics of the studied population 2010– pathology, 12% of organic pathology and 8% of drug abuse; however, in the remaining 67% their medical his- tory was unknown. It was significantly more frequent Characteristics Distribution to find aggressions among the scheduled patients than Gender (n = 2401), % among the non-programmed ones (32.5% vs 24.3%, Men 1219 (50.8) P < 0.0001). Women 1182 (49.2) Causes related to aggressions: A cause could be identi- Type of practice (n = 2342), % fied in 1883 cases (78%) of the total number of assaults Public 2078 (88.7) recorded in the period. The discrepancies of the aggres - Private 264 (11.3) sor with the medical care provided motivated one of Age groups (n = 1809), years (%) every three attacks and became the most frequent cause. ≤ 35 254 (14.0) Other aspects related to the medical act itself and the 36–45 494 (27.3) decision making by the professional, such as the prescrip- 46–55 675 (37.3) tion of medicines, the issuance of temporary in capacity, 56–65 353 (19.5) or the generation of reports (11.9, 5.8 and 5.5% respec- ≥ 66 33 (1.8) tively) accounted for almost a quarter of the reported Area (n = 1523), % aggressions. Organizational aspects (waiting time, inter- Primary care 1267 (53.9) nal functioning, etc.) accounted for 15.4% of attacks Hospital 341 (14.5) (Table 3). Out-of-hospital emergency rooms 225 (9.6) Hospital emergency room 215 (9.1) Procedures after aggressions Other areas 303 (12.9) In only one-third of the attacks, the doctor received some Aggressor background (n = 1385), % support or advice from his institution. However almost Toxicomany 108 (7.8) 73% filed a complaint with the competent authorities. Psychiatric 184 (13.3) Organic disease 169 (12.2) Discussion Unknown 924 (66.7) The phenomenon of aggressions against doctors dur - Aggressor profile (n = 1859), % ing their professional practice is a latent phenomenon in Scheduled patient 604 (32.5) many countries. However, in Spain, the number of pub- Non scheduled patient 451 (24.3) lished studies that analyze and quantify this situation is Center user 274 (14.7) limited. A systematic review by Vidal-Marti et al. in 2014 Relative or companion 530 (28.5)  found only 16 articles on assaults in Spain published Personal injuries (n = 2346), % since 2000. And of these, only 6 analyze with quality the Yes 465 (19.8) frequency of these events. At the international level, a No 1881 (80.2) systematic review by Nelsen et al. , finds only 12 stud - Sick leave (n = 2154), % ies published until 2013 that describe the prevalence of Yes 263 (12.2) aggressions against physicians, but with results with a No 1891 (87.8) wide range (1.5–68.5%). Company support (n = 1697), % Our results allow us to see incidences of aggressions Yes 544 (32.1) against physicians, ranging from 15 to 20 assaults per No 1153 (67.9) 10,000 doctors in the period studied. These numbers Formal complaint (n = 2283), % are significantly lower than those described by different Yes 1655 (72.5) authors. No 628 (27.5) The area in which we found more aggressions was pri - Previous aggressions (n = 2179), % mary care with 54% of incidents, a frequency very close Yes 168 (7.7) to 58% described in other Spanish studies [7–9] and to No 2011 (92.3) 63% described in Anglo-Saxon studies . Although Material damage (n = 2043), % we have not standardized the incidence rates of each of Yes 213 (10.4) the areas studied, the greater proportion of professionals No 1830 (89.6) specialized in Family Medicine and the greater number Values are expressed as absolute numbers and weighted percentages for of activities performed annually in primary care, we con- categorical variables sider that explain the greater proportion of aggressions in this area. The National Observatory of Aggressions to Physicians (ONAM) Workgroup Page 4 of 6 and General Council of Official Medical Associations of Spain (CGCOM) BMC Res Notes (2018) 11:347 Table 2 Comparison of the aggressions to physicians Low level aggressions (insults, threats) are not valued by area and gender 2015 as serious by doctors in many cases, which is why they do not ask for help from the Medical Association and only Area Men Women P value Total communicate it to the contracting institution. Therefore a d PC (%) 90 (50.3) 103 (56.6) NS 193 (58.3) the aggressions reported to the Medical Association may Hospital (%) 34 (19.0) 32 (17.0) NS 66 (18.3) have a greater severity (Berkson selection bias): one out b d PUCC (%) 15 (8.4) 20 (11.0) NS 35 (9.7) of every five aggressions had personal injuries and one c d HER (%) 19 (10.6) 9 (4.9) NS 28 (7.8) out of every ten generated a SL and presented material Other areas (%) 21 (11.7) 18 (9.9) NS 39 (10.8) damages. In fact, in other Spanish studies, the reported Values are expressed as absolute numbers and weighted percentages for prevalence of physical damage is lower [3, 8, 9, 18, 19, 22]. categorical variables Concerning the aggressor, it has been possible to iden- Primary Care tify his antecedents in a third of the cases, being the Urgent Care Centers antecedents psychiatric and of drug addiction the most Hospital Emergency Rooms frequent, findings that coincide with those described by No significance other authors [23–25]. In our data, gender was not a differentiating factor in Conclusions the incidence of aggressions, as described by multiple Aggressions against health professionals are a severe studies [11–16]. However, in the analysis of differences problem with important consequences for any health by gender and type of aggression, there are studies such system. The real magnitude has been silenced by the low as that by Miedema et al. describe a higher frequency of claims of assaulted physicians. It is a global phenomenon, sexual harassment-related aggressions among women which is present not only in other European countries than among men (60.7% vs 30.5%, P < 0.01) . (Germany, France, Great Britain, Norway), but also in Although it has not been possible to calculate the rates other continents. Although it is a multicausal situation, of aggression by age group due to the absence of records, the loss of respect for the doctor, especially in primary as it would have been necessary, it may be useful to make care and in the emergency rooms has favored an increase some comments on the distribution of age frequencies in violent attitudes. Although the studies show that a among the aggressed physicians. The age group with the large proportion of physicians have suffered from some highest proportion of recorded attacks was between 46 aggression in their professional practice, only a small and 55 years old, a range higher than that described in proportion formalizes the complaint to the competent other Spanish studies (30–43 years) [14–16, 18, 19]; but authorities. closer to the most affected ages described in international It is decisive, within the clinical management, to take studies: Canada (44 years) , Australia (45–54 years measures aimed at the prevention of aggressions and the old)  and Germany (55 years old) . That is, our attention to injured professionals, always starting from results support the hypothesis that the profile of the phy an individualized analysis of the work environment and sician attacked is not necessarily a young physician with the factors that can favor such situations. For this, it is little experience as other authors have suggested [15, 21]. Table 3 Identified causes of aggressions to physicians in Spain 2010–1015 Cause related to the aggression 2010 N (%) 2011 N (%) 2012 N (%) 2013 N (%) 2014 N (%) 2015 N (%) Total N (%) Discrepancies with healthcare 99 (31.3) 166 (39.3) 113 (35.5) 93 (32.1) 81 (30.8) 98 (35.8) 650 (34.5) No prescription of desired medicine 38 (12.0) 56 (13.3) 44 (13.8) 33 (11.4) 25 (9.5) 29 (10.6) 225 (11.9) Waiting time 36 (11.4) 37 (8.89 35 (11.0) 34 (11.7) 34 (12.9) 37 (13.5) 213 (11.3) Personal discrepancies 31 (9.8) 25 (5.9) 34 (10.7) 25 (8.6) 30 (11.4) 42 (15.3) 187 (9.9) Related to work incapacity 21 (6.6) 24 (5.7) 19 (6.0) 22 (7.6) 15 (5.7) 8 (2.9) 109 (5.8) Medical reports that are not in accordance with 23 (7.3) 17 (4.0) 11 (3.5) 25 (8.6) 13 (4.9) 15 (5.5) 104 (5.5) the patient’s requests Disagreement with the functioning of the centre 13 (4.1) 16 (3.8) 13 (4.1) 11 (3.8) 12 (4.6) 12 (4.4) 77 (4.1) Other causes 55 (17.4) 81 (19.2) 49 (15.4) 47 (16.2) 53 (20.2) 33 (12.0) 318 (16.9) Total 316 422 318 290 263 274 1883 (100) We describe the sample size in each period. Values are expressed as absolute numbers and weighted percentages for categorical variables The National Observatory of Aggressions to Physicians (ONAM) Workgroup Page 5 of 6 and General Council of Official Medical Associations of Spain (CGCOM) BMC Res Notes (2018) 11:347 Secretary General, Official Medical Association of Ciudad Real; secretario@ important to maintain and develop research on this comciudadreal.org phenomenon. Garrote-Cuevas G, M.D. Achieving the intervention of legislative and execu- Secretary General, Official Medical Association of Cádiz; ggarrotesemer - firstname.lastname@example.org tive authorities, as it is already happening in Spain, for Muñoz-García M, M.D. the recognition of the health professional as an authority Presidency, Official Medical Association of Ávila; email@example.com [25, 26], can be the long way to go through other environ- Marín-Montero R, M.D. Secretary General, Official Medical Association of Córdoba; rmmarmon@ ments where the frequency of these events is increasing. telefonica.net Perez-Gallego L, M.D. Secretary General, Official Medical Association of Zamora; secretariogen- firstname.lastname@example.org Limitations Gutierrez-Bejarano D, M.D., M.P.H. • Although the ONAM reports have a national charac- email@example.com ter, as authors we are aware that the cases of aggres- Repullo JR, M.D. Foundation for Training of the Spanish Medical Association, jrepullo@ sions reported to medical associations usually coin- omc ff .org cide with cases of greater severity, so that there may be an important under-registration of aggressions Competing interests of less severity that never get to be reported by the The authors declare that they have no competing interests, since it is professionals involved, being that the main limita- promoted from the Medical Colleges with their own resources, to identify tion of our work. For our analysis, this can lead us the magnitude of a problem, such as aggressions at work, which affects its members. to underestimate the real magnitude of the problem, justifying the low incidences found, lower than those Availability of data and materials described by other authors. That fact therefore limits The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. the validity of the data provided and invites cautious interpretations of the results. Consent for publication • As authors, we would like to point out that this is the Not applicable. first analytical study to explore ONAM consolidated Ethics approval and consent to participate information throughout Spain, and although its The data come from registered records of incidents of aggressions produced results are not directly comparable with other stud- to doctors during a period of time. ONAM is a technical body of the General Council of Medical Associations, ies related to methodological differences, the analy - whose General Secretariat has sponsored the study and provided the neces- sis provides relevant data on the characteristics and sary records for its realization. typology of the aggressions to physicians, and con- stitutes a Spanish and European referent for future Funding investigations. The research has been carried out with the resources of the Medical Colleges, and it has not been necessary to obtain or assign additional specific funding. Abbreviations Publisher’s Note ONAM: Observatorio Nacional de Agresiones a Médicos (National Observatory Springer Nature remains neutral with regard to jurisdictional claims in pub- of Aggressions to Physicians); SL: sick leave. lished maps and institutional affiliations. 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