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Review Article

Medical Violence (Yi Nao Phenomenon): Its Past, Present, and Future

Abstract Sudip Bhattacharya1,

Violence against doctors is on the rise worldwide. Doctors are no more considered demigods or Kanica Kaushal2,
authorities in their field; on the one hand, where there is a valid reason for it because of the dilution Amarjeet Singh2
in the field; however, on the other hand, the distrust is getting generalized to the whole community
Department of Hospital
1
of physicians. Violence against them in any form is reprehensible. However, acts of violence in a
Administration, 2Department of
hospital are the most extreme and should be dealt with an iron hand. Community Medicine, PGIMER,
Chandigarh, India
Keywords: Doctor–patient relationship, medical violence, psychological aspects

Introduction that the 50% violent incident took place in

India is witnessing “Yi Nao” phenomenon
which is common in China. The literal
meaning of “Yi Nao” is healthcare
disturbance. More precisely related to
violence against doctors. It is a type of
violence in hospitals to get repayment for
real or apparent medical negligence from
the hospital authority. This phenomenon
includes assault to the hospital personnel,
damage health facilities, and equipment
ultimately resulted in normal hospital
functioning. According to a study in China
in 2006, of 270 tertiary hospitals, 73%
reported the Yi Nao phenomenon.[1]
In India, there was a time when Indian doctors
were bestowed upon divine status. Doctors, in
India, were treated as gods and attracted vast
respect without people actually questioning
their treatment. They blindly trusted with the
lives of their dear and near ones. However,
now, the scenario has changed.
The practice of nonviolence of Mahatma
Gandhi inspired millions during the
preindependence era. However, the forces
of increasing economic aspirations, stress
levels, frustration due to urbanization,
high levels of competition, distorted and
disturbed religious, and cultural values
are adding to the intolerance among the
masses. This has also led to the sense of
distrust toward the medical fraternity. An
Indian study suggests that nearly 75%
of medical personnel have faced any
workplace violence. This study concluded
the Intensive Care Unit of hospitals, and in
70% of cases, the relatives of the patients
were actively involved.[2]
Violence is an outburst of anger mixed
with the frustration among the relatives of
the people. Whenever we face the demise
of any of our dear and near one, we go
through phasic alterations in our mind and
pass through five main stages of grief,
denial, anger, bargaining, depression, and
finally acceptance. People exhibit the
displacement of anger and denial to cope
with the situation, and it is the emotion
transfer from a situation or person to
another that is the main reason for violence
against doctors and other health staff.
Advanced medical care technology has
revolutionized medical care outcomes on
the one hand; however, it has led to high
expectations for 100% cure among patients
and relatives. The difference between these
high expectations and actual ground realities
is the main root cause of this curse. Other
incidents, including blaming the doctor
even when the relatives, have brought the
Address for correspondence:
patient at the end stage of the disease, to Dr. Sudip Bhattacharya,
avoid paying hefty medical bills. Further, Department of Hospital
contributing factor for increasing violence Administration, PGIMER,
is the poor image of medical professionals Chandigarh, India.
E‑mail: drsudip81@gmail.com
projected by media leading to the general
belief around that healthcare delivery has
become a business, and the patients are Access this article online
sort of consumers and are basically for
Website: www.cjhr.org
extorting money. Corporate hospitals try to
negotiate with the patient parties outside DOI: 10.4103/cjhr.cjhr_43_18

the institution of law to retain their social Quick Response Code:

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identical terms. past, present, and future. CHRISMED J Health Res
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Bhattacharya, et al.: Medical violence
status.[3] A literature search shows workplace violence as a
result of doctor–patient mistrust, changing dynamics of the
doctor–patient relationship although the other factors cannot
be ignored.[4]
History of Physician–Patient Bonding
For easy understanding, we have described it in five stages
as follows:
a. Ancient Egypt (approximately 4000–1000 B.C) –
Edelstein et  al. (1937) described the physician–patient
relationship evolved from the priest‑supplicant association.
The paternalistic approach was in vague. At that time,
healers used to play the dual role of magicians as well
as priests to dominate the helpless, sick, and moribund
people and their near ones. Egyptian medicine was
based on paternalistic type or activity and passivity type
relationship between the doctors and patients. Then, the
doctors directed and patients obeyed orders without any
queries or doubts.[5]
b. The era of Greek enlightenment in 5th century B.C. – At
that time, they believed in the empirical‑rational
approach. It meant that they depended more on
observation, trials, and mistakes. They abandoned the
magical and religious justifications and developed
the relationship of guidance, cooperation, and a lesser
degree of mutual relationship approach. They told the
patient what to do after proper counseling similar to
adult‑adolescent relationship. Hippocratic Oath raised
medical ethics all above self‑interest, irrespective of
class, and status at that time.[5,6]
c. Medieval Europe and the Inquisition
(1200–1600 A.D.) – After the death of Roman empire,
the religious and supernatural world beliefs were
restored. After the crusades and witch hunt, the doctor–
patient relationship was destroyed. Again, the doctor
regained the father such as figure; similar to the Egyptian
era, where the doctor dictated, and the patient obeyed.[5]
d. French revolution – the French revolution ended the
situation in which underprivileged populations were put
into the dungeons. Again, a change of the doctor–patient
relationship took place in the reverse direction[5]
e. Modern era (1700 onwards) – In the early 1700 s,
there were very few doctors and they dealt with
only upper‑class patients. This model was called
“symptom‑based model of illness,” and the doctor
played a dominant role.
In the late 18th century with the rapid development of
science, especially progresses in microbiological and
surgical skills, “biomedical model of illness” emerged
and it superseded the “symptom‑based model of
illness.” In this century, the paternalistic model was
persisted.
With the emergence of psychosocial theories (Breuer
and Freud) in 1955, the mutual participation relationship
were restored. The practice of medicine was renamed as
260 CHRISMED Journal of Health and Research | Volume 5 | Issue 4 | October-December 2018
patient‑centered medicine. Michael Blaint, in 1964, proposed
the idea of “doctor as a drug.” It was based on the dynamic
relationship between the doctor and the patient. According
to him, the doctor–patient relationship is a “mutual
investment.” He believed that by the time the doctor obtained
the patient’s details, it permitted the clinician to improve
his communication skills with his patients. It resulted in
efficient consultation, which eventually provided a better
understanding of the patient’s requirements. That was missing
in the previous era. From the above discussion, we can
conclude that the doctor–patient relationship goes through
ups and downs. Sometimes society sketched them as a god,
sometimes as evil according to the changing scenario.[5,6] It is
a macro/generic description of the doctor–patient relationship.
The change in dynamics described in era wise may be seen
in a single lifetime of a doctor [Table 1]. The same doctor
can behave differently when the situation changes. As an
example, a doctor may engage in a parent–infant relationship
when the patient is poor and illiterate. At that time, he thinks
he is more powerful than the patient he will dominate. As
it is seen in earlier times (Ancient Egypt model 4000–1000
BC), this kind of relationship is predecided by the doctor.
The same parent–infant relationship also gets developed in
the cases of emergency; however, at this time, it is by default
not by choice of the doctor. Here, the power relation naturally
shifts to the doctors’ side. The same doctor can establish
an adult–adolescent relationship in cases of acute nonfatal
diseases (such as malaria and diarrhea.) with literate patients.
Relationship of mutual participation is observed in chronic
diseases. Here, the adult‑adult transaction takes place.
Interestingly, the inverse relationship between adolescent
and adult is developed, when the patient is more powerful
(by knowledge, money, and insured). In this relationship, the
patient even dictates the doctor for his treatment. Usually,
it is seen in less severe diseases such as minor acidity,
leg cramp, or a headache. In corporate sector hospitals,
adult–child relationship is established. It is seen, when
an illiterate but poor patient visits a corporate hospital. In
this case, the doctor does not want the dominant role in
decision‑making still patient rely on doctors. Again, the
power shifts toward the doctor by default and not by choice.
Factors Affecting Doctor–Patient Relationship
[Figure 1]
1. Patient’s grievances – Unnecessary investigations, delay
in attending to the patient, and request for advance
payments or withholding a dead body after demise
under a final settlement of billing.
2. Doctor’s grievances  –  There is commercialization of
medical education with the rapid growth of private
medical colleges with inadequate infrastructure,
short of faculty staff as per the medical council of
India (MCI) standards.[7] Education in these private
medical colleges is so expensive that most doctors
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Bhattacharya, et al.: Medical violence

Table 1: Model of doctor–patient relationship

Model Doctors role Patients role Applied aspect with examples Transaction analysis
(doctor‑patient)
Paternalistic Does what he thinks Patient is inert, obeys It is seen in earlier Parent‑infant
approach right for the patient. what doctors think times (Ancient Egypt model
Father like figure best. (illiterate and poor) 4000-1000 BC)
Exception‑In emergency
situation, acute conditions,
in comatose patients… still
nowadays it is practiced
Guidance‑cooperation Tells the patient what Cooperation (obeys) from Acute infections such as Adult‑adolescent
or mutual to do after proper both side diarrhea, uncomplicated
relationship approach counseling malaria, dengue, etc.,
Mutual participation Helps patient himself to Participant in a mutual Mostly in chronic NCDs such Adult‑adult
find a solution partnership (patient need as DM and HTN
expert help)
Consumerist Doctors obey as they are Patient is influential, Prescribing minor ailments such Adolescent‑Adult
approach empaneled doctors or She/he dictates about as painkillers, multivitamins.
certificate doctors prescription (commonly (the drugs or procedures are
among highly educated harmless)
and insured patient)
Default relationship Tells patient what to do Patient cannot participate A rich patient come from Adult‑child
after proper counseling due to low knowledge or remote village to a corporate
willpower hospital, doctors give them
opportunity to participate, but
they refuse and stick to doctors
opinion (common nowadays)
NCDs: Noncommunicable diseases, HTN: Hypertension, DM: Diabetes mellitus

then plan to get jobs in corporate sectors to get
equal or more returns than the money that they have
invested in their careers and corporate hospitals have
a set protocol of how to proceed with a patient of the
said disease.
Doctors are hesitant to file a complaint or the first
information report against the accused/angry relatives
as granting justice is a slow process in a country like
ours and further usually these assault cases are mob
driven; there is no conviction of anyone assaulting
a doctor because of inactivity of judicial system and
police officials, further MCI, state medical councils are
the bodies for registration, and record keeping which
has not intervened in either of the assault cases which
have surfaced in the past
Due to all these factors, doctors are hesitant to take
risky decisions which might have been better for the
patient in the first place.
3. Workplace factors – Workplace factors such as
communication barriers, physical barriers, political
pressure, the influence of relatives, and heavy workload
adversely affect the relationship.
4. Macrolevel factors which include:
a. Failure of the Government healthcare system:
Factors, such as Government health policy,
i.e., allocation of money on health, free
medicines, and fixed timings of the outpatient
department (OPD), are also an important
determinant. For example, in a Government primary
or secondary healthcare settings, the patients are
being provided with free medicines. However,
sometimes, due to inventory issues, the medicines
could not be dispensed for a period, patients have
the easiest access to the doctors to blame irrespective
of the political interplay of factors.
The public healthcare system in India follows the
welfare model as the majority of people is poor and
lack any health insurance. Due to subsidized medical
care, Indian healthcare institutions (government run)
are swamped with patients with their attendants. Some
of the medical officers are looking after an average
of 100 patients per day. It is obvious that quality of
care will get compromised if the doctor has to see a
100  patients in a fixed period. This pressure cooker
situation in the OPDs imparts a pseudoperception
of negligence to the patient and his relatives, which
leave them unsatisfied as doctor–patient interaction
time reduces. Due to long waiting time in queues,
inappropriate interaction or delay in attending patient
triggers anger. As most of the patients are uninsured,
sometimes diagnosis comes as a bolt from the blue
for them and this economic disaster pushes them into
emotional mayhem.
b. Doctor–patient or Google patient relationship:
Disease‑related information accessed through the
internet is often free, yet it is dubious. It provides

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Bhattacharya, et al.: Medical violence

Figure 1: Factors interplaying among patient–doctor relationship

quick access to the ordinary people for their
health‑related issues. It is supposed to empower
the patient and facilitate the mutual relationship
approach, i.e. adult–adult interaction. Relevant
health‑related information is available on social
media groups such as WhatsApp and Facebook,
nowadays. Patients and their family access the
information and have a lot of opinions before
consulting any doctor. This cannot be entirely
attributed to the mistrust for the treating physician;
however, they feel its better to have a beforehand
idea about the symptoms so that they can go fully
equipped with the medical knowledge and derive
answers from the doctor. It can be encouraged by the
doctors only if patients refer to authentic standard
sites for information; however, in reality, mostly,
the patients come up with a concoction of theories
about their symptoms. This irritates the physician
affecting doctor–patient relationship.[8]
Way Forward
Doctors are no more considered demigods or authorities in
their field; on the one hand, where there is a valid reason
262 CHRISMED Journal of Health and Research | Volume 5 | Issue 4 | October-December 2018
for it because of the dilution in the field; however, on the
other hand, the distrust is getting generalized to the whole
community of physicians. Medical decisions are being altered
by Wikipedia references on the related disease, untrusting
patient’s caregivers, practicing defensive medicine to be on
the safer side, and seeking jobs in corporate hospitals. People
blame doctors without thinking why anything which has
happened in the first place. Every alternate day, we find the
news of patients relatives assaulting doctors, inflicts grievous
injuries but then it’s just a piece of news in the corner of
the paper somewhere. It is high time someone takes the
responsibility of saving the saviors.
Solutions to reduce the incidents of violence against the
doctors include improved trust between the patient and the
doctor not to be isolated from various other socioeconomic
problems plaguing the market‑oriented society. Deteriorating
doctor–patient relationship is the symptom of social
degradation, increasing intolerance, and increasing distrust.
Hence, all these factors need to be addressed horizontally;
medical education strengthening, filling crucial gaps in
communication between doctors and patients, reducing
the number of patients per doctor which is the root cause
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Bhattacharya, et al.: Medical violence
of the majority of problems as doctors are overworked,
empathetic attitude toward patients, and tougher laws for
both medical negligence and violence against doctors. The
medical curriculum can definitely incorporate necessary
communication skills. Media can play a role in improving
the image of doctors and the medical profession projecting
role models more than the negligence cases, so that young
minds can replicate the ethical practices. Furthermore,
violence against the doctors should be made a nonbailable
offense so that the trust of physicians in the judicial system
continues. Failure to acknowledge the altruism of the doctors
will be the reason to discourage the next generation of
brilliant students from taking up this unforgiving profession.
Acknowledgement
We acknowledge Dr. Vijay Kumar Chattu for his valuable
inputs in this manuscript.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
CHRISMED Journal of Health and Research | Volume 5 | Issue 4 | October-December 2018
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