Shaukat Ali Jawaid

Patient satisfaction, patient safety and increasing violence against healthcare professionals

Increasing commercialization and corruption coupled with wide spread unethical practices by the medical profession has lead to increased violence against the healthcare professionals which has highlighted the importance of patients satisfaction and patient safety. A study by Hongzing Yu et al.1 being published in this issue from China has also highlighted numerous cases of violence against healthcare professionals leading to death of some doctors as well as nurses by patient’s relatives. The reasons for this violence according to the authors are poor quality of services, increased awareness of patients about their rights and their willingness to knock the doors of courts to seek justice. They have further reported that more than one million cases of violence against healthcare professionals are reported every year in China.2 Negative media reports about hospitals and doctors, out of pocket medical expenditures by the patients and lack of trust in doctors and hospitals have been reported to be some of the causative factors.3-5 Medical malpractice claims in courts in China is also reported to have increased by 7.6% from 2009 to 2010.2 This situation seems to be similar in most of the countries in this region including India, Bangladesh and Pakistan. Ali Khawaja and Hira Irfan6 reported that medical professionals are among the highly vulnerable professionals who are being increasingly subjected to violence by the patients and their relatives. According to them almost 77% of physicians have faced either verbal or physical abuse in Pakistan.7 Another study from Pakistan by Nazish Imran et al8 reported that 74% of respondents in a retrospective exploratory cross sectional study in a public sector healthcare facility in Lahore were victims of violence during the preceding twelve months with verbal abuse being the most common. Those exposed to violence experienced high level of psychological distress. Emergency Departments were the most common place where violence was witnessed and the sources of violence were patient’s relatives along with negative media reports besides irritating staff attitude. The potential reasons for violence in Emergency Departments include lack of confidence in the emergency staff, real or assumed lack of attention to the patient, death which brings out the worst behaviour in the relatives even though appropriate treatment might have been given in serious cases. Madhok from India has reported doctors being molested, thrashed and abused by lay public for a trivial fault. According to them the causes of violence were lack of communication between doctor and the patient, poor image of medical profession, lack of faith in judicial system and the police, besides insufficient security for doctors.9 A report from Bangladesh also throws light on the fact that violence in healthcare sector has been increasing at an alarming level throughout the country. Doctors become an easy target for the blame game by sensational media reports. Since a wide gap exists between the patient’s expectations and the reality, patients who feel they have not been looked after properly then take the matters in their own hands. These incidents have certainly decreased the self esteem of the doctors.10 Another report suggests that almost 70% of doctors won’t want their own children to go into the medical profession.11

Prevention and intervention strategies to check increasing violence against Healthcare Facilities and Healthcare Professionals.

International Committee of the Red Cross (ICRC) initiated a multicenter research study on violence against healthcare in Karachi some time ago and its report has now been published. Apart from ICRC, Jinnah Postgraduate Medical Center, Ziauddin University and Jinnah Sindh Medical University had participated in this study and the report was formally released at a meeting in Karachi on November 13th 2015 which was largely attended by the different stakeholders. Principal investigator Prof. Lubna Baig Dean, APPNA institute of Public Health who has now also been appointed Pro Vice Chancellor of JSMU and his team has done a commendable job in pointing out the reasons for violence against healthcare professionals (HCPs) and Healthcare facilities (HCFs). The most important reasons highlighted in this study include unreasonable expectations (56.1%), unexpected outcome (42.6%), communication failure (55%), and human error (53.7%) besides substandard care (35%). Poor quality of service provided by the healthcare facilities besides low capacity of healthcare professionals are also reported to have contributed to these violent incidents. The report has also pinpointed that a vast majority of the perpetrators of this violence were the patient’s attendants.1 They collected the data from hospitals, ambulance service and NonGovernmental Organizations. The report is based on eight hundred twenty two questionnaires which were received and analyzed. The report further highlights that majority of the violent incidents 41.8% occurred in Accidents and Emergency followed by 39.4% in emergency obstetrics, 13.6% in wards and majority of the violent incidents were reported from public hospitals.1 In fact increasing commercialization and corruption along with wide spread unethical practices by the medical profession has also lead to increased violent incidents.2 Numerous studies from China have also highlighted increasing incidents of violence against healthcare professionals which unfortunately lead to death of some doctors and nurses by the patient’s relatives. According to study by Hongzing Yu et al from China poor quality of services, increased awareness of the patients about their rights and their willingness to take legal action, negative media reports about hospitals and doctors, out of pocket medical expenditures by the patients, lack of trust in doctors and hospitals were reported to be some of the causative factors.3-6 Violent incidents against healthcare professionals have also been reported in other countries in this region i.e. India, Bangladesh and Pakistan by Ali Khawaja and Hira Irfan7 Nazish Imran et al,8 Mirza NM9 Madhok from India10 and HAM Nazmal Ahsan from Bangladesh.11 A critical analysis of these studies also reveals that most of the triggers for violence in all these studies are also common such as lack of communication between doctors and the patient, unexpected expectations and unexpected outcome, poor image of the medical profession, sub-standard quality of care besides insufficient security for doctors. A wide gap exists between the patients’ expectations and the reality and all this has certainly decreased self-esteem of the doctors as well. These studies have also similar findings as regards the place of occurrence of these incidents which most often has been in the Emergency and Accidents Departments. Editorial

Authors- the most dangerous pressure group.

Research scientists, academicians including faculty members in medical institutions under great pressure to publish papers to get promotions and higher grade indulge in all sort of scientific misconduct all over the world. Some of these include plagiarism, salami slicing, ghost authorship, falsification of data, fabrication of data and at times duplicate submissions etc. The revolution in information technology and tremendous developments which has taken place in the scientific publishing has though eased the job of editors of biomedical journals but it has not reduced their problems which in fact have further multiplied. The authors are so impatient that some of them want their manuscripts to be processed and published in the shortest possible time. Given below are some of the e mails which were received during the last few months from the authors which show their urgency: 1. I have been offered Residency in United States. I have got the Visa and also booked my seat but I urgently need one published paper in an Impact Factor journal. If you help me, I will be prepared to pay the Fee, as money is not a problem. 2. I have to defend my Ph.D Thesis and before the exam, I need one published paper in Impact Factor Journal. Willing to pay the desired fee if the paper is published in the next issue. 3. When is your next issue of the journal due as I wish to submit a paper for publication? 4. I have many research papers. I can submit five to six papers every month and if you enter into an agreement to publish two of my papers in every issue, we can negotiate the publication charges but would expect some discount keeping in view the large number of papers. 5. I forgot to get Ethics Committee approval but I need this paper to be published quickly to be considered for promotion by the university. Need your help and a sympathetic consideration. 6. I am submitting a research paper and it does not need any peer review as Prof…….. has already seen it and approved its publication. Please include it in the issue under printing and let me know the publication charges so that I can arrange it immediately. 7. My university accepts only those papers for academic credit which are published in journals covered by ISC, Web of Sciences with Impact Factor. I have three papers. If you …

Striving for improved visibility and increased citation through coverage by PubMed Central (PMC)

During the Year 2013 Pakistan Journal of Medical Sciences achieved yet another landmark when it managed to be covered by PubMed Central with the result that now all the manuscripts published in the journal effective January 2013 are now accessible through this important global database i.e. PubMed Central. It will ensure that the contributions by the authors have increased visibility and readership thereby improving the chances of citation as well. We had been planning for this for the last three years but financial constraints had been the major hindrance. However, now we have made arrangements with one of the commercial concerns overseas who prepares the XML files for submission to PubMed Central which is a pre requisite. We believe this investment is worth and will further improve the standard of the journal and its ranking in biomedical journals. In order to facilitate the authors in early publication of their accepted manuscripts reducing the waiting time, we also increased the frequency of publication from quarterly to bimonthly during 2013 while efforts are also being made to accelerate the Peer Review process and reduce the time but sometimes it is beyond our control since the Reviewers are all busy people and they perform these academic duties in honorary capacity, hence one cannot force them to convey their comments immediately, though many Reviewers are quite efficient and try to complete the review process meeting the deadlines. Earlier after an agreement with CrossRef we had started giving Digital Object Identifier (DOI) numbers to all the manuscripts. In order to protect the authors and ourselves from publication of plagiarized material, we also entered into an agreement with CrossCheck to use their software iThenticate for screening of manuscripts for plagiarism. This software though a bit expensive but has the advantage over other tools used for screening for plagiarism because this not only covers what is freely available on the internet but it also has access to journal publications that are not accessible free online. 1 During the last six months, after triage, only one hundred fifty manuscripts which are about 20% of all the submissions were accepted for further processing. Twelve were rejected because during screening similarity index score was more than 20% and in some cases it was as high as 40-60%. While screening for plagiarism, we remove the title as well as references from the manuscript. Three manuscripts which had similarity index score between …

Author’s failure to read and follow instructions leads to increased trauma to their manuscripts

Authors under pressure to publish to meet some academic requirement are one of the most dangerous pressure group which the editors of good quality peer review biomedical journals have to face every day. Their failure to read and follow instructions for authors which are published on every journal website, lack of training facilities in research methodology, medical writing, and low computer literacy rate leads to increased trauma to their manuscripts. The authors must realize that from submission to final publication manuscripts go through various stages i.e. internal review, editor’s triage, similarity index check, formatting, external review, revision of the manuscripts in the light of reviewers comments and suggestions. It all takes time and there is no short cut. They must plan at least for six to eight months from the date of submission to acceptance and publication and avoid getting trapped by predatory journals which offer quick publication on payment.

Publish or Perish: Need to have another look?

Publish or Perish has been the driving force for the academicians, faculty members to publish and thus contribute to the medical literature besides promoting the research culture in their respective institutions. However, in view of some recent developments during the last couple of years, it has become essential to have another look on this. Number of publication has played a vital role in the selection, appointment, promotions and approval of research grants for the faculty members and research scientists. However, now increasing number of publications from medical institutions in India, Pakistan and many other developing countries are coming out of compulsion. The main objective of the authors seems to be for selection, increments, career advancement, assessments for seeking higher qualifications like M. Phil and PhD. Now there seems to be desperation to publish and temptation to explore short cuts and easy ways. In fact it should be the quality of research and publications rather than quantity of publications which should matter. 1 Pressure to publish is also leading to scientific fraud. Some scientists are willing to disregard scientific integrity in order to publish. For example leading publications like Nature, Science and Cell with high Impact Factors have amongst the highest rates of retraction. Peer reviewers can only study the present results but it is not always possible to detect fraudulent results. Moreover, peer reviewers can also be fooled by the fraudulent results.2 This Editorial

Pakistan’s Performance in Global Impact Factor Race

Research in science and social sciences play a vital role in education, planning, decisions, social and economic progress along with long-standing sustainable developments.1 The innovative research in science and technology contribute to improve the living standards and an excellence of life. Scientific publications reveal the academic and scientific advancement and science journals have significant impact in exchange of knowledge both at national and international levels.2-3 Pakistan is a home to more than 200 million people, 189 Higher Education Commission (HEC) chartered universities and degree awarding institutes4 including 29 medical universities, 157 medical schools5 125 engineering, 92 management sciences and 28 agricultural institutes.4 In Pakistan, there are 371 HEC indexed journals in various academic disciplines of science and social sciences4. In the last week of June 2018, Philadelphia USA based, a notable indexing institute, Thomson Reuters, Institute of Scientific Information (ISI) Web of Science, currently known as “Clarivate Analytics” released a global science and social science journals Impact Factor (IF) list of year 2017.6 Impact factor represents the total number of citations to a journal’s articles divided by the number of articles published during the previous two years. It is widely used in the academic world as a yardstick of a journal’s prestige. From Pakistan, out of 371 only 12 (3.24%) academic journals have achieved a place in ISI-Web of Science. Worldwide, 12271 science and social sciences journals are indexed in the ISI-Web of Science, their IF is ranging from 0.001 to 244.58.6 The Cancer Journal for Clinicians USA achieved a top position in the world with Impact Factor 244.58. The other top ranking journals are New England Journal of Medicine USA 79.25; Lancet USA 53.24; Nature UK 41.57; and Science USA 41.05.6 These journals are leading the world and have maintained their topmost positions in the global IF race. In our environs, China is leading the region with 203 academic journals achieved a remarkable position in ISI Web of science with IF 0.0045 to 15.393. India has 104 with IF 0.096 to 2.658; Iran 42 IF 0.280 to 2.667; Pakistan 12 IF 0.280 to 1.217; and Bangladesh has 4 with IF 0.214 to 1.532. Only one Journal from Pakistan, “Pakistani Veterinary Journal” exceeds the IF 1.217.6 While comparing the quartile factor of the journals, subject category in percentile rank, the top 25% of journals in a particular category are placed in Q1, next in Q2 and so on. 41 Chinese journals achieved a position in first quartile Q1, Q2: 63, Q3:57 and 62 journals in Q4. India has Q1: 0, Q2: 4, Q3: 26 and in Q4:74. Iran has 42 academic journals from them Q1: 1, Q2: 4, Q3: 12 and in Q4:25. However, Bangladesh has 4 ISI-Web of Science indexed journals only one journal placed a position in Q3 and 3 in Q4.6 The quartile ranking of Pakistani journals is: 2 journals in both Q2 and Q3 and the remaining Editorial

Proceedings of 4th National Conference of Pakistan Association of Medical Editors held at Khyber Medical University, Peshawar (March 3-4, 2018)

PESHAWAR: Pakistan Association of Medical Editors (PAME) organized its fourth National Conference at Khyber Medical University Peshawar from March 3-4th 2018. Prof. Arshad Javed Vice Chancellor of Khyber Medical University was the host and all this became possible due to his and his team’s keen interest. Prof. Arshad Javed, it may be mentioned here is himself member of PAME and as Chief Editor of Journal of Postgraduate Medical Institute for quite some time, has been the moving spirit for promoting the discipline of medical journalism in Khyber PK. Prof. Akhtar Sherin Chief Editor of Khyber Medical University Journal and Dr. M. Irfan were members of the organizing committee.

Proceedings of NADEP Diabetes Foot conference held at Lahore Pakistan (August 10-12, 2018)

LAHORE: National Association of Diabetes Educators of Pakistan in collaboration of Baqai Medical University, Baqai Institute of Diabetes and Endocrinology and Pakistan Working Group on Diabetic Foot organized its conference at Lahore from August 10-12, 2018. It was very well attended by Diabetologists, endocrinologists and family physicians interested in diabetic foot care. Saving Feet by implementation of guidelines in clinical practice was the theme of the conference. Prof. Khalid Masood Gondal Vice Chancellor of King Edward Medical University was the chief guest in the inaugural session. Speaking on this occasion he said that no surgeon is ever interested in doing amputation surgery for diabetic foot. Early diagnosis of diabetic foot, timely management including debridement and patient education is extremely important. College of Physicians & Surgeons Pakistan, he said, has now started postgraduate training programmes of Fellowship in Endocrinology. He suggested that each medical college and medical university should establish professorial unit of endocrinology. Proper diabetic foot care will save lot of amputations. Diabetes he further stated affects all organs of the body; hence we need to intensify our efforts for Conference Proceedings

Proceedings of National Medical Conference organized by Azra Naheed Medical College in collaboration with Pakistan Aspirin Foundation (April 28th 2018)

LAHORE: Azra Naheed Medical College affiliated with Superior University Lahore organized its National Medical Conference on April 28th 2018 in collaboration with Pakistan Aspirin Foundation. Harnessing the Cardiovascular Threat was the theme of the conference. Prof. Nizamuddin Chairman of Punjab Higher Education Commission was the chief guest at the inaugural session. Speaking at the occasion, he stated that we need to create medical institutions which promote research culture besides improving the quality of research. Doctors should improve documentation; maintain record of their patients which is extremely helpful in conducting research. We also need to promote preventive measures, use of low dose Aspirin for longer periods and change our lifestyle besides using healthy diet which will overcome numerous diseases. Continuing Prof. Nizamuddin said that we need to modify the known risk factors for cardiac diseases, control hypertension, diabetes mellitus, high cholesterol, obesity, physical inactivity, smoking, stress and unhealthy diet. Those with major risk factors are likely to suffer from various heart diseases. National Health Survey conducted in 2011 had shown that over 18% of our population above the age of eighteen years suffer from hypertension, Pakistan at present is at No. six as regards the prevalence of diabetes which is increasing and by 2020 we may be the No.4 country in the world with highest number of people with diabetes. At present about 25% of people over the age of forty five years suffer from diabetes mellitus and prevalence of smoking is reported to be between 14-21% in adolescents and adults. Healthy diet, active life style, staying positive all-day can go a long way in reducing the risk factors for cardiac diseases and diet also helps in attaining a healthy lifestyle. Obesity is caused when we consume more calories than our body burns and abdominal obesity is a major risk factor. He laid emphasis on the fact that exercise alone will