A Dangerous Game to Play in Turkey’s Health System: Medical Doctors vs. Patients and their Relatives?
Violence against medical doctors, including its physical, verbal and psychological forms, recently has become widespread in Turkey. Killing of Dr. Ersin Aslan, a thoracic surgeon, was the last horrendous example. Aslan’s death has become the last straw that broke the medical doctors’ back.
Unfortunately, violence against medical doctors has always been there not only in Turkey but also in other countries. For instance, Israeli medical doctors reported that they have been subjected to violence by the patients’ relatives due to reasons such as the postponement of a scheduled medical operation (Haaretz, 2008). More recently, it has been reported that Chinese medical doctors also have been facing threats against their personal safety at work (The Lancet, 2012).
In Turkey, increasing media coverage concerning the issue and contemporary studies (i.e. Aydın, 2009) suggest that violence against medical doctors has been substantially increased in last couple of years in Turkey. For instance, a research conducted in Gaziantep indicates that 36.5 per cent of the medical doctors participated in that research declared that they were exposed to violence within the last year (Gaziantep Medical Chamber 2008); a similar research in Antalya demonstrates that 44 per cent of the medical doctors were subjected to violence from patients and/or patients’ relatives at least once in last 5 years (Antalya Medical Chamber, 2012). Last but not least, in a recent research conducted in Izmir 40 per cent of all medical doctors stated that violence is the biggest problem they face in practicing their profession (İzmir Medical Chamber, 2012). The research findings illustrate that an overwhelming majority of perpetrators are patients’ relatives; while other medical doctors and health professionals commit crime or offence as well (Turkish Medical Association and İstanbul Medical chamber 2009).
The violent attacks against medical doctors have been more common worldwide in most stressful departments of hospitals such as the emergency care, psychiatry and first aid units. For instance, emergency care units are the main scenes for violence against medical doctors in Israel. In some cases, medical doctors working for specific departments are targeted. To exemplify, gynaecologists are subjected to politically motivated violence due to their engagement with abortion in the U.S. (Haaretz, 2008).
However, in the Turkish case, it is interesting to observe that violence is more widespread among different medical departments. Medical departments such as neurosurgery, neurology and thoracic surgery that are not commonly considered are also scenes for violence in Turkey.
Second factor that makes the Turkish case interesting is that medical doctors used to have a high reputation in Turkish society, had been standing at the top of the occupational status hierarchy and are still composed of top ranking students in university entrance examinations held nationwide. Previously, it has been a common cultural practice for patients and their relatives to show respect to the medical doctor. Medical doctors had been considered as “wise saviours” in the eyes of the public.
Here, at least two major questions need to be addressed: What are the factors behind the increasing violence against medical doctors in Turkey? What might be the political implications of this trend for Turkey’s health system?
No violence can be justified on any grounds. This article is in no way aims to make violence against medical doctors “understandable” or “justifiable”. Nevertheless, it is sociologically important to understand the root causes of violence directed towards members of this profession.
First of all, the starting point is that the increased violence against medical doctors today suggests that relatively peaceful yet hierarchical relationship between medical doctors and patients in Turkey does not work anymore. Why so?
One of the key areas to look at for explanation is health policy. Contemporary health care reform titled “Transformation in Health Programme”, initiated by the Justice and Development Party (Turkish acronym: AKP or AK Parti) government just after its rise to power in 2002 general elections, is definitely an important variable in the transformation of the public image of medical doctors.
This reform basically strengthened the insurance-based financing structure of Turkey’s health system, injected market incentives to the health care delivery structure, gave an end to the dual commitment of medical doctors to public hospitals and their private clinics and led to a substantial increase in the role of private sector in health care delivery structure.
Turkish Medical Association (Turkish acronym: TTB) and Health and Social Services Labourers Union (Turkish acronym: SES) hold the AKP’s health reform responsible for the increase in violence against medical doctors. Both headed by elected left-wing cadres and being ardent opponents of the contemporary health reform, TTB and SES argue that the implementation of pro-market approach in health care provision culminated into the acceleration of tension in doctor-patient relationship. One research, supporting TTB and SES’s critique of the current reform process, suggests that various problems of the current health system including long waiting times especially in emergency services, incompatibilities of the government’s promises and the realities in hospitals are among the important reasons why patients and their relatives turn to violence against medical doctors (Özyurt, 2009).
Another factor that possibly contributed to the increased tension between patients and medical doctors has been the use of anti-medical profession rhetoric by the government representatives as a part of the political tactics to increase the credibility of the reform in the eyes of the public. Since the launch of the reform, the government representatives attempted to discredit Turkish Medical Association by accusing it of being an interest group that is blind to the grievances of citizens about health care services and accuse dissenting medical doctors of being greedy for more money. Alternatively, the government presented itself as the only representative of the public interest fighting against the vested interests of prosperous medical doctors and their organization. Indeed, the rate of public satisfaction with health care services substantially increased throughout the reform process that supports the government’s thesis at least for the time being. Nevertheless, medical doctors suggest that not all patients are satisfied with the changes and they can see broader problems will arise in near future.
One of the main issues that constituted the backbone of this contestation between the government and dissenting medical doctors has been the launch of patients’ rights call centre, a toll free number (named as SABIM) that collects complaints from patients and patients’ relatives about medical doctors. On the one hand, the introduction of a complaint procedure for patients and patients’ relatives is clearly a positive step forwards as it requires medical doctors to be accountable in their actions. This is clearly welcomed by the public. However, medical doctors argue that this complaints procedure might be (and some argue that it has already been) abused as a disciplinary tool against them. In addition, for medical doctors, SABIM promotes the idea that Turkey’s health system does not have any structural problems (such as the inadequacy of sufficient number of health professionals, insufficient supply of hospital beds etc.), but all problems originates from the practitioners, thus medical doctors. Dissenting medical doctors emphasize that this free number serves the populist tendencies of the government well without providing actual solutions to the problems raised by the patients. In the end, medical doctors increasingly believe that SABIM works in line with the government’s alleged intention to shift the blame of the actual and prospective problems of the health system from itself to medical doctors.
The key positions of medical doctors as gatekeepers in distributing entitlements of various cash benefits in Turkey’s welfare system might be another explanation for the increased tension between medical doctors and patients. Two examples can illustrate the gatekeeping role of medical doctors. One is that medical doctors, as members of a committee in accredited hospitals, are authorised to issue disability reports that determines the eligibility of the applicant to disability benefits. Secondly, medical doctors as a part of their daily responsibilities, issue medical death reports to people died in hospitals. These reports, once being issued, are being automatically uploaded to the web-based social security registers and leads to the stoppage of welfare payments to that person and his/her household.
Even though these roles of medical doctors are common to almost all welfare systems, the difference in Turkish context is that patients and patients’ relatives in Turkey expects the medical doctor to “do them a favour” and issue a disability report indicating a more serious disability (that means better rates of disability payments) or not to issue the medical death report (that means the continuation of the retirement pension). Medical doctors, unless defies the official procedures, might be punished by a violent act. In this case, medical doctors are again forced to face with the ills of the welfare system that transcends their professional boundaries.
Various solutions have been proposed to counteract violence against medical doctors. Turkish Parliament agreed to establish a Parliamentary Investigation Commission on Violence against Medical Doctors that may be influential in inspiring novel solutions. Minister of Health, Mr. Recep Akdağ, also declared that he would not tolerate violent attacks against medical doctors and backed solutions proposed so far (Hürriyet, 2012).
Most of the proposed solutions from the government’s side seem to be centred upon increasing security in hospitals and organizing public awareness campaigns. These are well-intentioned solutions but it is highly likely that they will fail to address the complexity of the issue at stake in the end.
Turkish Medical Association, alternatively, works for a better organisation of medical doctors against the reform by emphasizing that the government contributes to the increased violence against their colleagues by using anti-medical doctor rhetoric. In doing so, TTB called for a one-day strike on April 19th all around the country. On the day, medical doctors protested silently against the rising violence against them all around Turkey. Following these protests, unfortunately, TTB initiated a campaign among medical doctors, the major aim of which seems to be the restriction of patients’ access to toll free number and complaints procedure.
An interesting stage seems to be in play. On the one hand, patients and their relatives increasingly execute violence against medical doctors in public hospitals. These phenomena may strengthen the motivation of medical doctors not to engage in medically risky interventions. On the other hand, medical doctors started to ask for a less responsive health system that will have restricted access to complaints procedure for patients. This stance of TTB may contribute to worsening of relationship between medical doctors and patients.
Undoubtedly, all measures have to be taken in order to provide a secure working environment for medical doctors. However, these measures have to be built upon the complexity of the factors that feeds into the increased violence against medical doctors and should not be positioned against the patients’ demands and rights.
By complexity of the factors, I mainly refer to the fact that violence against medical doctors is closely related to the broader problems of Turkey’s health system and the welfare system. Increased violence against medical doctors should not be reduced into singular exceptional crimes. There are systematic links between how medical doctors have been used as scapegoats of the ills of the health system, how they have been expected to function as gatekeepers to the welfare benefits and why increasing number of people feel hatred against medical doctors.
Being two potential major allies for a better, overwhelmingly public and egalitarian health system, patients and medical doctors seem to be at odds with each other today. Politically speaking, this may have devastating implications for the direction of change in Turkey’s health system in near future. This is because, the current signals that both sides send to one another do nothing but harm the trust relationship between patients and medical doctors that is the moral basis of public health system.
Volkan Yılmaz, Ph.D. Candidate, the School of Politics and International Studies, University of Leeds, and Research Assistant, Department of Political Science and Public Administration, Istanbul Kemerburgaz University
Please cite this article as follows:
Yılmaz, Volkan (June, 2012), “A Dangerous Game to Play in Turkey’s Health System: Medical Doctors vs. Patients and their Relatives?”, Vol. I, Issue 4, pp. 28-33, Centre for Policy and Research on Turkey (ResearchTurkey), London: ResearchTurkey (http://researchturkey.org/?p=1356)
Antalya Medical Chamber. 2012. Hekim Eğilimlerini Değerlendirme Anketi.
Gaziantep Medical Chamber. 2008. Sağlık Sektöründe Şiddet ve Hekimlerin Şiddet Algısı Anketi.
Haaretz. 2008. Too much violence against medical doctors. June 3rd, 2008.
Hürriyet. 2012. “O eli bükmek boynumun borcu.” May 10th, 2012.
Izmir Medical Chamber. 2012. Hekimlik Alarm Veriyor.
The Lancet. 2012. Vol. 329 Issue 9828. Ending Violence against Doctors in China.
Turkish Medical Association and İstanbul Medical Chamber. 2009. Hekime Yönelik Şiddet Çalıştayı Raporu.