DÄ internationalArchive10/2015Aggression and Violence Against Primary Care Physicians

Original article

Aggression and Violence Against Primary Care Physicians

a Nationwide Questionnaire Survey

Dtsch Arztebl Int 2015; 112(10): 159-65; DOI: 10.3238/arztebl.2015.0159

Vorderwülbecke, F; Feistle, M; Mehring, M; Schneider, A; Linde, K

Background: International studies show that aggressive behavior against primary care physicians is not an uncommon occurrence. There has been no systematic study to date of the nature and frequency of such occurrences in Germany.

Methods: A four-page questionnaire was sent to a nationwide random sample of 1500 primary care physicians. It contained questions about the type, frequency, severity, and site of aggressive behavior against the physician.

Results: 831 (59%) of 1408 correctly delivered questionnaires could be included in the analysis. 91% of the respondents (95% confidence interval [CI], 89%-93%) said they had been the object of aggressive behavior at some time in their career as a primary care physician, 73% (95% CI, 70%–76%) in the previous 12 months. Severe aggression or violence had been experienced by 23% (95% CI, 20%–25%) in their entire career and 11% (95% CI, 8%–13%) in the previous year. The vast majority of respondents said they felt safe in their offices. 66% of female and 34% of male respondents said they did not feel safe making house visits while on on-call duty.

Conclusion: The frequency and extent of aggression and violence against primary care physicians in Germany is comparable to those reported by international studies. Strategies for dealing with this problem should be developed. In particular, the issue of safety on emergency call needs to be addressed.

LNSLNS

The subject of aggression and violence against doctors has thus far hardly been given any attention in medical education and continuing medical education in Germany. Individual authors assume that the prevalence of violent acts against doctors has increased over the past decades (1, 2), but systematic investigations into the problem are lacking.

A striking finding in international studies is the fact that aggressive behavior towards doctors is obviously a usual occurrence. Four Australian studies from 2003 to 2007, for example, showed that 68–73% of the participating primary care physicians had already gathered experiences with aggression directed at them during their careers (36). In the 12 months preceding the surveys, incidence rates of aggression towards primary care physicians varied between 48% and 64% (36). A study from Canada from 2010 concluded that 29% of all participating primary care physicians had been exposed to aggressive behavior in the month preceding the survey. Of these affected doctors, almost each one had experienced milder aggressive events, for example, verbal insults and verbal abuse. 26% had experienced moderate aggression—for example, damage to property (criminal damage)—and 8% had been victims of serious physical violence and sexual assaults (7).

In order to contribute to, and thereby improve, the available data on the problems of aggression and violence against primary care physicians in Germany, we conducted a national survey on the subject. Our objective was:

  • To gauge the general sense of personal safety in primary care physicians in the surgery, on house visits and visits to homes, and during on-call duties (practice based or house visits);
  • To determine the proportions of primary care physicians who in the course of their professional duties had ever experienced different aggressive behaviors in rooms within their practices, during visits to patients’ houses or care/nursing homes, and during on-call duties (in the practice and during home visits), and to determine the frequency of these events in the 12 months preceding the survey;
  • To document the most serious aggressive incident for each respective participant, including the circumstances leading to the assault, characteristics of the perpetrator, and the consequences of the assault.

Methods

Study design

The study was designed as a once-only postal questionnaire sent to a random sample of 1500 primary care physicians; the evaluation was anonymized. The study was approved by the ethics committee at Technische Universität München (TUM, Technical University Munich). The total study population consisted of all resident primary care physicians who were active in Germany in October 2013. The sample was drawn from a national database of addresses held by the company Adressendiscount (www.adressendiscount.de), which includes data from 132 000 physicians in private practice (according to data from the German Medical Association, this is equivalent to 90% of all doctors in Germany who provide treatment on an outpatient basis), of which 36 400 were primary care physicians. The addresses were selected by using the “Select cases—random sample” function in the software package SPSS. All selected physicians received a letter in October 2013 that contained information about the study, a questionnaire, and a stamped and addressed envelope. Reminders were sent at the beginning and the end of November 2013.

Questionnaire

The four-page questionnaire was developed after an inspection of the original questionnaires from several international sources (39). A pilot version was tested qualitatively and quantitatively beforehand, in a continuing medical educational event for primary care physicians (n=30). Superfluous questions and the questionnaire’s quality and comprehensibility were discussed. On the basis of the evaluation of this test run, the final, four-page questionnaire was developed (eQuestionnaire). The questionnaire comprised six sections.

  • Section 1 included questions relating to the general feeling/perception of safety in the practice premises, during house and home visits, and during on-call work (practice based and during house/home visits).
  • Section 2 included questions relating to whether defined forms of aggression had been experienced in the practice premises at any point during their career as a primary care physician and in the preceding 12 months, and if so, how often. The individual forms of aggression are listed below; the predefined categorization as mild/slight, moderate, and serious/severe forms of aggression is given in square parentheses:

  – Verbal insult/abuse [mild/slight]

  – Threat/intimidation [moderate]

  – Mild physical violence (pushing, hassling, clinging) [moderate]

  – Pronounced physical violence (biting, hitting, kicking, suffocating/strangling) [serious/severe]

  – Threat using object or weapon [serious/severe]

  – Attack using object or weapon [serious/severe]

  – Sexual harassment (suggestive remarks and gestures; groping excluding breasts/genitals) [moderate]

  – Sexual abuse (groping of breasts and genitals; sexual coercion; rape) [serious/severe]

  – Criminal damage/theft [moderate].

  • Section 3 included the same questions as section 2, but relating to house/home visits and on-call duties.
  • Section 4 included questions relating to reputational damage, libel/slander, false statements on physician internet portals, and stalking.
  • In section 5, doctors were invited to provide further details about the incident that they themselves considered to be the most serious in their medical career. In addition to a free-text description of the incident, this section collected information on the perpetrator, the level of fear, location, timing, and consequences of the incident.
  • Section 6 included questions relating to the doctor’s person and practice.

Statistical evaluation

Previous experiences from a similarly conducted survey (10) prompted an expectation of a minimum return rate of 40% of the sample. The objective was the ability to estimate the prevalence of aggressive behavior directed at doctors with a 95% confidence interval of ± 4%. To this end, 600 evaluable responses were required for an assumed prevalence of 50% (calculated using EpiCalc 2000). In view of the expected response rate, we therefore wrote to 1500 doctors.

For the purposes of the descriptive evaluation, we calculated—depending on the type of data—means and standard deviations, medians, quartiles, minimum and maximum values or percentages and absolute frequencies, in total and separately for the sexes. 95% confidence intervals for frequencies for the most important prevalence estimates were produced by using the bootstrapping function in SPSS (1000 samples). Analyses for differences between female and male doctors were done according to the scale level by using Fisher’s exact test, the chi square test, the Mann-Whitney U test, or Student’s t test. Furthermore we calculated explorative logistic regression analyses (inclusion model) in order to study associations between:

  • Doctors’ characteristics (independent variables) and perceptions of safety (dependent variables)
  • Doctors’ characteristics and the experience of a serious incident (dependent) during the course of working as a primary care physician.

Lacking entries were not substituted (we report valid percentages). Significance tests and regression analyses (eSupplement and eTables 1–7) were undertaken exclusively for the purposes of exploration. We did not adjust for multiple testing.

P values for individual doctors’ characteristics from the multivariate ordinal regression analyses of associations between doctors’ characteristics and their sense of safety in the five settings
P values for individual doctors’ characteristics from the multivariate ordinal regression analyses of associations between doctors’ characteristics and their sense of safety in the five settings
eTable 1
P values for individual doctors’ characteristics from the multivariate ordinal regression analyses of associations between doctors’ characteristics and their sense of safety in the five settings
Ordinal regression for factors influencing the sense of safety in the practice
Ordinal regression for factors influencing the sense of safety in the practice
eTable 2
Ordinal regression for factors influencing the sense of safety in the practice
Ordinal regression for factors influencing the sense of safety during regular house visit
Ordinal regression for factors influencing the sense of safety during regular house visit
eTable 3
Ordinal regression for factors influencing the sense of safety during regular house visit
Ordinal regression for factors influencing the sense of safety during home visit
Ordinal regression for factors influencing the sense of safety during home visit
eTable 4
Ordinal regression for factors influencing the sense of safety during home visit
Ordinal regression for factors influencing the sense of safety during on-call shifts in the practice
Ordinal regression for factors influencing the sense of safety during on-call shifts in the practice
eTable 5
Ordinal regression for factors influencing the sense of safety during on-call shifts in the practice
Ordinal regression for factors influencing the sense of safety during house visits while on call
Ordinal regression for factors influencing the sense of safety during house visits while on call
eTable 6
Ordinal regression for factors influencing the sense of safety during house visits while on call
Multivariate logistic regression for association of doctors’ characteristics and report of at least one serious form of aggression
Multivariate logistic regression for association of doctors’ characteristics and report of at least one serious form of aggression
eTable 7
Multivariate logistic regression for association of doctors’ characteristics and report of at least one serious form of aggression
Overview of aggression/violence against general practitioners in the international literature
Overview of aggression/violence against general practitioners in the international literature
eTable 8
Overview of aggression/violence against general practitioners in the international literature

Results

Response rate and participants’ characteristics

74 of 1500 sent letters were not delivered because they carried incorrect addresses. Furthermore, 14 doctors informed us that they had been wrongly contacted: 9 reported that they were not working as primary care physicians, and 5 were already retired. Four were deceased. Consequently, 1408 doctors had been contacted successfully. 835 study participants returned completed questionnaires. Since the protocol stipulated that a doctor’s sex was to be included in the analysis, four questionnaires were excluded from the evaluation as they did not contain this information. Our results are therefore based on data from 831 participants (59% of 1408).

40% of respondents were women and 60% men. Female doctors had been primary care physicians for a mean of 19 years, male doctors for 22 years. Female doctors worked slightly more often in large cities and conducted fewer house visits than their male colleagues (Table 1).

Sociodemographic and practice characteristics
Sociodemographic and practice characteristics
Table 1
Sociodemographic and practice characteristics

Sense of safety

The majority of respondents felt safe or very safe in their own practices and during house visits (Figure). Fewer female doctors, however, felt very safe than male doctors (58% vs 70% in practices and 63% vs 73% during visits to homes). Regarding house visits or on-call service in surgeries, the proportion of participants who ticked “partly-partly,” “less likely to feel safe,” or “not at all safe” was larger: 16% of female doctors (house visit) and 31% (on-call duty in the surgery), and 9% and 20% of male doctors. Regarding the perception of safety during house visits when on call, the responses increased to 66% in women and 34% in men.

General sense of safety in the practice, on home visits, on house visits, and during on-call service
General sense of safety in the practice, on home visits, on house visits, and during on-call service
Figure
General sense of safety in the practice, on home visits, on house visits, and during on-call service

Personal experience of aggression

9% (95% CI 7% to 11%) of participants had never experienced aggressive behaviors during their career, and 27% (95% CI 24% to 40%) not during the preceding 12 months (Table 2). 91% (95% CI 89% to 93%) of participants reported that at some point during their career as a primary care physician they had been confronted with aggressive behavior in some form, and 73% (95% CI 70% to 76%) reported that this had been the case in the preceding 12 months. Mildly/slightly aggressive incidents had been experienced by 79% (95% CI 77% to 82%) of participants at some point and by 54% (95% CI 51% to 58%) in the preceding 12 months. More female doctors had been affected than male doctors (60% vs 51%, p=0.01). For moderate incidents, the proportions were 81% (ever experienced aggressive behavior, 95% CI 78% to 83%) and 58% (experienced aggressive behavior in the preceding 12 months, 95% CI 55% to 62%). For serious incidents, the proportions were 23% (ever, 95% CI 20% to 25%) and 11% (in preceding 12 months, 95% CI 8% to 13%; differences between the sexes did not reach significance).

Proportion of respondents who were at some point during their medical careers or during the preceding 12 months exposed to the listed forms of aggression at least once in the respective setting
Proportion of respondents who were at some point during their medical careers or during the preceding 12 months exposed to the listed forms of aggression at least once in the respective setting
Table 2
Proportion of respondents who were at some point during their medical careers or during the preceding 12 months exposed to the listed forms of aggression at least once in the respective setting

In absolute terms (without considering the amount of working time spent in the respective location), incidents of aggression are particularly common in doctors’ practices (85% ever and 63% in the preceding 12 months). They were notably less common during house visits (33% and 14%), during home visits (23% and 9%), during on-call work in practices (30% and 16%) or during house visits while on call (39% and 19%).

Verbal insults and abuse were by far the most often reported incidents (Table 2). 73% of participants reported having been subjected to verbal insults or abuse in their practices at some point during their careers, and 48% reported this for the preceding 12 months. Criminal damage or theft (54% and 34%) and reputational damage or libel/slander on the Internet (48% and 31%) were also mentioned often. Sexual harassment was committed particularly towards female doctors (25% and 15%).

Analysis of incidents experienced as the most serious

449 participants provided further details on the incident that they themselves had experienced as the most serious in their careers. 310 participants described events in a free text field in greater or lesser detail. 67 descriptions were of verbal insults, 54 of threats, 74 of physical violence or running rampage, 45 of violence with weapons or objects, and 70 of different other incidents. Example reports (case descriptions) are shown in the eBox.

Incident descriptions
Incident descriptions
eBox
Incident descriptions

From doctors’ perspectives’, 38% of the 449 incidents were regarded as slight/mild, 41% as moderate, 16% (73 incidents) as serious, and 4% (19 incidents) as very serious. In 13% the affected doctors were afraid and in 6%, very afraid (Table 3). 58% of incidents occurred in the surgeries/practices, 19% during house visits while on call, and 12% during normal house visits.

Characteristic of the most serious incident by severity
Characteristic of the most serious incident by severity
Table 3
Characteristic of the most serious incident by severity

In four out of five incidents the perpetrators were male (Table 4). They hailed from diverse age groups. Alcohol, drugs, mental illness, or a combination of two or all three of these factors had a role in about half of these incidents (51%) and could not be excluded in another 15%. In 90 cases (20% of the total), the incident resulted in a report or complaint to the police, in 12 cases (3%), it triggered psychological damage, and in 2 cases (<1%) it led to physical injury. 81 affected doctors (18%) modified their behavior towards patients as a result of the incident.

Characteristics of perpetrators in the most serious incident by severity
Characteristics of perpetrators in the most serious incident by severity
Table 4
Characteristics of perpetrators in the most serious incident by severity

Factors influencing the experience of violence and subjective sense of safety

The multivariate regression analyses (eSupplement and eTables 1–7) found no association between doctors’ characteristics sex, age, migration background, or ty8pe and location of practice and the report of a serious incident of aggression. Only a financially weaker practice clientele was slightly associated with such experiences. A lowered sense of safety was, independently of individual work locations, clearly associated with the doctors‘ characteristics female sex and the experience of a serious incident of aggression in the past. Older age and a city location had a significant association with three or two work settings respectively.

Discussion

Almost every doctor in the survey had experienced some kind of aggression at some point in their career. Slightly more than half of participating doctors had been exposed to slight or moderate aggression in the 12 months preceding the survey. More than one in 10 primary care physicians had been confronted with serious aggression or violence during this time period. Although the extent of safety within practice premises was generally perceived to be high, only one in three female doctors felt safe during house visits while on call.

The response rate of 59% in the current study is high for a survey among doctors that did not offer any special incentives (7, 1015). The composition of participants seems largely representative in terms of the personal characteristics and the characteristics of practices of primary care physicians. Specialists in internal medicine working in general practice were not included, as the database we used did not differentiate between these and those working in hospitals for every federal state.

It seems entirely possible that doctors who had never encountered aggression and violence in the course of their work were less likely to participate in our survey, even though the process of filling in the questionnaire would have been much simpler for them. For this reason, the results presented here may somewhat overestimate the actual prevalence of aggression and violence. In milder forms of aggression, such as verbal insults, the subjective perception and memory has an important role, which can lead to overestimates but also underestimates of the actual prevalence. However, subjective perceptions are likely to have a much smaller role in the ultimately more relevant pronounced acts of aggression or for violence in the narrower sense.

To date in Germany in the preclinical setting, the only data on aggression and violence that have been available were those for rescue workers in North Rhine–Westphalia (8). In the 12 months preceding the survey, almost all participants in that study had experienced verbal aggression (98%), and more than half (59%) at least one violent assault. However, comparisons between the rescue services and primary care physicians would obviously make sense to a very limited degree only (perhaps in the setting of visits during on-call duties). Compared with other professional groups, the annual prevalence of non-physical and physical aggression against primary care physicians is lower than in police officers (80%/54%) (16) but much higher than in teachers (47%/2%) (17).

The data from the present survey are roughly consistent with the results from other, international, studies in terms of the experience of aggression (37, 9, 1820) (eTable 8). However, because of the in some cases very different healthcare systems and primary care systems, as well as data collection methods, any comparisons should be treated with utmost caution.

When interpreting the prevalence rates by work location, it needs to be borne in mind that doctors spend much more time in their practices than on house visits while on call. If we assume that survey participants spent one-tenth of their working time doing on-call shifts, aggressive incidents are relatively most common during those shifts.

When the result that serious forms of aggression are more common during on-call shifts/house visits is put together with the descriptions of a poor sense of safety (especially in participating female doctors), the conclusion has to be that this constitutes a problematic area of primary care physicians’ working activities.

Conclusions

Primary care physicians in Germany should prepare for the fact that they are highly likely in the course of their work to be confronted with forms of aggression. In Australia, a safety program for primary care physicians was introduced by the Royal Australian College of General Practitioners (RACGP) in 2009 (General Practice—a safe place) (21), in Germany the problem does not seem to have been perceived as such in the (specialist) public to date. On the basis of the data collected, however, it does seem advisable to introduce the subject matter into medical education and continuing medical education and to devise strategies for the professional handling of aggression.

In large parts of Germany it is common practice to send out doctors on call, alone and without any safety structure (for example, feedback/reporting systems after a completed visit, service telephones with an alarm function), to mostly unfamiliar patients. On the basis of our data, the conclusion is that this practice requires critical reflection. The use of medically trained drivers, who also accompany the visits, seems sensible from the perspective of safety, but often falls at the hurdle of financial affordability. Especially in view of the large proportion of female doctors entering primary care, solutions will have to be identified that guarantee better safety for doctors at work. Furthermore, additional scientific debate of the subject is desirable, in order to research, for example, triggers of aggression in the context of treatment provided by primary care physicians.

Study funding

The data collection was undertaken in the context of the MD project of Maximilian Feistle at the medical faculty at the Technische Universität München (TUM, Munich Technical University). The study was funded exclusively from financial resources of the Institute of General Practice, University Hospital Klinikum rechts der Isar, TUM.

Conflict of interest statement

The authors declare that no conflict of interest exists.

Manuscript received on 15 October 2014, revised version accepted on
23 December 2014.

Translated from the original German by Birte Twisselmann, PhD.

Corresponding author
Dr. med. Florian Vorderwülbecke
Institut für Allgemeinmedizin, Klinikum rechts der Isar
Technische Universität München
Orleansstr. 47, 81667 München, Germany
florian.vorderwuelbecke@tum.de

@eSupplement, eTables, eBox, eQuestionaire:
www.aerzteblatt-international.de/15m0159

1.
Mäulen B: Vorsicht Patient! Immer mehr schwere Gewaltdelikte gegen Ärzte. MMW Fortschr Med 2013; 155: 14–20. CrossRef
2.
Püschel K, Cordes O: Tödliche Bedrohung als Berufsrisiko. Dtsch Arztebl 2001; 98: A153–7. VOLLTEXT
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Tolhurst H, Baker L, Murray G, Bell P, Sutton A, Dean S: Rural general practitioner experience of work-related violence in Australia. Aust J Rural Health 2003; 11: 231–6. CrossRef CrossRef
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healthcare setting: implications for managers. J Healthc Manag 2004; 49: 377–90. MEDLINE
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Institute of General Practice, Klinikum rechts der Isar, Technische Universität München: Dr. med. Vorderwülbecke, Feistle, Dr. med. Mehring, Prof. Dr. med. Schneider, Prof. Dr. med. Linde
General sense of safety in the practice, on home visits, on house visits, and during on-call service
General sense of safety in the practice, on home visits, on house visits, and during on-call service
Figure
General sense of safety in the practice, on home visits, on house visits, and during on-call service
Key messages
Sociodemographic and practice characteristics
Sociodemographic and practice characteristics
Table 1
Sociodemographic and practice characteristics
Proportion of respondents who were at some point during their medical careers or during the preceding 12 months exposed to the listed forms of aggression at least once in the respective setting
Proportion of respondents who were at some point during their medical careers or during the preceding 12 months exposed to the listed forms of aggression at least once in the respective setting
Table 2
Proportion of respondents who were at some point during their medical careers or during the preceding 12 months exposed to the listed forms of aggression at least once in the respective setting
Characteristic of the most serious incident by severity
Characteristic of the most serious incident by severity
Table 3
Characteristic of the most serious incident by severity
Characteristics of perpetrators in the most serious incident by severity
Characteristics of perpetrators in the most serious incident by severity
Table 4
Characteristics of perpetrators in the most serious incident by severity
Incident descriptions
Incident descriptions
eBox
Incident descriptions
P values for individual doctors’ characteristics from the multivariate ordinal regression analyses of associations between doctors’ characteristics and their sense of safety in the five settings
P values for individual doctors’ characteristics from the multivariate ordinal regression analyses of associations between doctors’ characteristics and their sense of safety in the five settings
eTable 1
P values for individual doctors’ characteristics from the multivariate ordinal regression analyses of associations between doctors’ characteristics and their sense of safety in the five settings
Ordinal regression for factors influencing the sense of safety in the practice
Ordinal regression for factors influencing the sense of safety in the practice
eTable 2
Ordinal regression for factors influencing the sense of safety in the practice
Ordinal regression for factors influencing the sense of safety during regular house visit
Ordinal regression for factors influencing the sense of safety during regular house visit
eTable 3
Ordinal regression for factors influencing the sense of safety during regular house visit
Ordinal regression for factors influencing the sense of safety during home visit
Ordinal regression for factors influencing the sense of safety during home visit
eTable 4
Ordinal regression for factors influencing the sense of safety during home visit
Ordinal regression for factors influencing the sense of safety during on-call shifts in the practice
Ordinal regression for factors influencing the sense of safety during on-call shifts in the practice
eTable 5
Ordinal regression for factors influencing the sense of safety during on-call shifts in the practice
Ordinal regression for factors influencing the sense of safety during house visits while on call
Ordinal regression for factors influencing the sense of safety during house visits while on call
eTable 6
Ordinal regression for factors influencing the sense of safety during house visits while on call
Multivariate logistic regression for association of doctors’ characteristics and report of at least one serious form of aggression
Multivariate logistic regression for association of doctors’ characteristics and report of at least one serious form of aggression
eTable 7
Multivariate logistic regression for association of doctors’ characteristics and report of at least one serious form of aggression
Overview of aggression/violence against general practitioners in the international literature
Overview of aggression/violence against general practitioners in the international literature
eTable 8
Overview of aggression/violence against general practitioners in the international literature
1.Mäulen B: Vorsicht Patient! Immer mehr schwere Gewaltdelikte gegen Ärzte. MMW Fortschr Med 2013; 155: 14–20. CrossRef
2.Püschel K, Cordes O: Tödliche Bedrohung als Berufsrisiko. Dtsch Arztebl 2001; 98: A153–7. VOLLTEXT
3.Tolhurst H, Baker L, Murray G, Bell P, Sutton A, Dean S: Rural general practitioner experience of work-related violence in Australia. Aust J Rural Health 2003; 11: 231–6. CrossRef CrossRef
4.Alexander C, Fraser J: Occupational violence in an Australian
healthcare setting: implications for managers. J Healthc Manag 2004; 49: 377–90. MEDLINE
5.Magin PJ, Adams J, Sibbritt DW, Joy E, Ireland MC: Experiences of occupational violence in Australian urban general practice: a cross-sectional study of GPs. Med J Aust 2005: 183: 352–6. MEDLINE
6.Koritsas S, Coles J, Boyle M, Stanley J: Prevalence and predictors of occupational violence and aggression towards GPs: a cross-sectional study. Br J Gen Pract 2007: 57: 967–70. CrossRef MEDLINE PubMed Central
7.Miedema B, Hamilton R, Tatemichi SR, et al: Monthly incidence
rates of abusive encounters for Canadian family physicians by
patients and their families. Int J Family Med 2010: 387202 (epub). MEDLINE
8.Schmidt J, Feltes T: Gewalt gegen Rettungskräfte – Bestandsaufnahme zur Gewalt gegen Rettungskräfte in Nordrhein-Westfalen. 2012. www.unfallkasse-nrw.de/fileadmin/server/download/PDF_2012/Gewalt_gegen_Rettungskraefte.pdf (last accessed on 11 December 2014).
9.Forrest L, Parker R, Hegarty K, Tuschke H. Patient initiated aggression and violence in Australian general practice. Australian Family Physician 2010; 39: 323–6. MEDLINE
10.Linde K, Friedrichs C, Alscher A, Wagenpfeil S, Meissner K, Schneider A: The use of placebo and non-specific therapies and their relation to basic professional attitudes and the use of complementary therapies among German physicians—a cross-sectional survey. PLoS One 2014; 9: e92938. CrossRef MEDLINE PubMed Central
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