Violence Against GPs

This article is a follow up to the article and survey sent out in the Northern Pulse on the 28th October 2009. Violence and aggression is underreported in general practice and little has been known about its severity until now.

Source: VicDoc, December 2009.

AMA Victoria Communications and Public Affairs Officer Francesca Jackson-Webb reports. Patients seeking urgent medical care can be at their worst - anxious, short tempered and in pain - and when they become violent it is often the healthcare workers trying to help them who bear the brunt of this aggression. The threat of violence in emergency departments is treated seriously, with research and planning to reduce the threat of harm to hospital staff. But violence in general practice is under reported and is often just seen as one of the shortcomings of the job.

Nearly two thirds of Australian GPs have experienced some form of violence in the past year, with staff commonly encountering aggressive patients who are verbally abusive, threatening, and who cause damage to property.

Preliminary findings from the Australian National University's (ANU) research on violence in general practice, released in October, found that violence was often triggered when patients were told they had to wait to see a doctor or when practices discontinued bulk billing or raised fees. The Commonwealth Department of Health and Ageing commissioned the Australian Primary Health Care Research Institute (APHCRI) at ANU to find out what was behind a largely unreported wave of violence in general practice.

"So far we have found that aggressive patients are part of their everyday working life." says research leader Associate Professor Rhian Parker. "General practice staff - particularly receptionists - are frequently abused by patients."

The researchers found that while aggression occurred at all times of the day, high-level violence, such as physical abuse, sexual harassment and stalking, was more likely to occur after hours.

"This obviously has implications for training staff, as some of them are being worn down by these experiences," says Assoc Prof Parker. "What we need to do now is find out the extent and impact of this aggression."

The preliminary findings were used to develop a national online survey for GPs and practice managers, which closed last month.

The ANU data follows 2005 research from Dr Parker Magin and his colleagues at the University of Newcastle, which showed that violence in general practice was significantly more likely to be directed at female GPs, less experienced doctors and those working after hours and in areas of social disadvantage. Dr Magin concluded that formal education programs in preventing and managing violence were needed for GPs and doctors in training.

Melbourne GP Dr Leanne Rowe, co-author of the doctors' health and wellbeing handbook 'First do no harm', says general practice needs to catch up to other professions' standards of violence management and prevention. "As doctors, we are very focused on patient care," says Dr Rowe, "often to the detriment of our own health and our own safety." She says GPs and their practice staff need to be trained to identify, manage, and prevent the threat of assault in private practice. Knowledge of de-escalation techniques, violence management plans, and safe environments are essential. Practice layouts need to be planned with violence minimisation in mind: barriers to prevent aggressive patients directly accessing consulting rooms, window and door locks, shatter-proof glass, bright outdoor lights, high fences and duress alarms.

Dr Rowe says doctors should consider seating themselves closest to the door of their consulting room so they can escape if a patient's aggression escalates, or inviting an observer into the room to help diffuse a potentially violent situation. There is a fine line between difficult behaviour and assault, Dr Rowe admits, but whenever a doctor or practice staff member "fears immediate or unlawful violence", this constitutes assault and should be treated seriously, with appropriate interventions.

"We must recognise the point at which strong emotion tips into threatening behaviour," says Dr Rowe. Four Australian GPs have been murdered at work in the past twelve years. One of those GPs was Dr Khulod Maarouf-Hassan, a close friend and colleague of Dr Rowe. Dr Marrouf-Hassan's attacker had developed a delusion that the medical profession was trying to kill him. He had sought help from several services in the months before he attacked Dr Marrouf- Hassan in her Noble Park clinic in June 2006.

Last year 25 year-old Samuel Benjamin was found not guilty of Dr Marrouf- Hassan's murder due to mental impairment and was sentenced to 25 years in a secure facility. "We should be learning lessons from all those deaths," says Dr Rowe. Managing patients at risk of violence can prevent these kinds of attacks. Patients at risk of violence should be reported to the police, and this sets the motions in train to secure specialist mental health care for the patient.

Dr Rowe argues that other practices should be warned about patients with a past history of violence but acknowledges patient confidentiality requirements make this difficult. For Rowe, the answer to reducing violence in general practice is empowering GPs and their staff by training them to deal with the threat of violence and aggression in their clinics. "The solutions are actually there. In any other area of medicine, that's what we do: we offer training and make sure people are skilled."

'First do no harm' is a guide to being a resilient doctor in the 21st century. This timely new book details the obligation of all doctors to their own well being, health and safety, which is vital for the competent care of their patients. GPs Leanne Rowe and Michael Kidd have created a comprehensive and practical handbook for doctors of all craft groups and career stages.

By drawing on their own experiences in medical practice, they delve into territory which is rarely explicitly explored in medicine: dealing with driven personalities, responding to personal criticism, coping with partner separation and reducing risky behaviours. 'First do no harm' is full of practical advice for achieving a satisfying work-life balance and responding to the challenges of being 21st century doctor. It also provides practical advice about preventing and managing patient-initiated violence. Visit www.mcgraw-hill.com.au or your local medical bookshop.

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