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Second opinion: Patients getting physical?

'How to handle the aggressive patient' was the title of one of the sessions at a GP refresher course I recently attended, in the spirit of the commitment to life-long education and clinical excellence now expected by our political and professional leaders. The lecture, or 'workshop', was presented by an enterprising young man from the Centre for Action on Staff Safety, who is also the author of Handling Aggression and Violence in Health Services (an 80-page book 'written in collaboration with the British Medical Association') and Disengagement, Breakaway and Self-Defence (also 80 pages, but 'complete with diagrammatic instructions').

A glance at the GP press confirms the impression that violence in the surgery is a major and growing problem. A survey conducted by the British Medical Association (BMA) News Review in March revealed that 'more than four out of 10 GPs have been attacked in the course of their work' (13 March). Another survey in Walsall found that 24 out of 57 local GPs had been attacked or threatened in the past five years, though many were too frightened to report attacks to the police (10 April). These reports include lurid tales, such as that of a 'drug addict brandishing an eight-inch knife'.

In response to the perception of 'GPs under siege from violent patients', the police and private consultancies are providing advice and training for GPs and practice staff. The Centre for Action on Staff Safety offers a 'comprehensive approach', including staff skills, practice procedures and legal requirements. In Strathclyde the police provide advice on surgery layout and security arrangements (panic buttons, CCTV, etc) as well as training in self-defence and techniques for preventing and containing aggressive behaviour.

Perhaps the most striking feature of the wave of terror in the surgeries is the fact that it has only recently been recognised. Ten, even five, years ago this problem did not seem to exist. Not only does it appear that violence is now commonplace in general practice; it is seen as a more widespread problem. The BMA News Review survey notes in passing that 'violence in the workplace is also a real threat to hospital doctors'. Indeed, throughout public services, from schools and social security offices to buses and planes, staff are working in constant fear of assault. A senior social worker recently wrote to the journal Community Care to point out the hitherto unrecognised dangers of working with old people who have been known to use their Zimmer frames to attack care workers.

My first response to the spectre of violence in general practice was that this was simply a non-problem. Though I have occasionally read about assaults, even murders, committed by some of our patients in the court reports of the Hackney Gazette, I could not immediately recall a single violent incident in the surgery over the past decade. However, on reflection and talking over this matter with colleagues, we began to remember a few incidents. An irate patient spat at me on one occasion, a disgruntled man once grabbed a female doctor around the neck, other staff had experienced swearing and abusive language. Another angry man kicked in a glass window in a door on his way out (and immediately presented himself at the local police station to complain about his treatment!).

The one area that has undoubtedly contributed to some increase in violence in general practice is its expanding role in the containment of drug abuse, through the prescription of methadone to heroin users. Here GPs have taken on an essentially policing function of trying to reduce drug-related crime by providing a substitute drug on prescription. It is not surprising that addicts come to regard GPs as (rather soft) policemen, and treat them as such. The logical conclusion of this style of practice is to conduct surgeries in police stations: a pioneering project along these lines is due to open in the Bitterne police station in Southampton in September and another is planned in Walsall.

Apart from drug-related confrontations, I suspect that incidents of aggression and violence have occurred in general practice occasionally over the years and I doubt whether there has been much of a recent increase. In much the same way, there have been occasional tragic cases of health professionals (and members of the public) being attacked, even killed, by people with severe mental illness. Though such cases now attract much greater publicity, there is no evidence of any recent increase in numbers.

The key change in recent years is not so much in the scale of violent incidents, but in the way such incidents are perceived. In the past, these were regarded as unpleasant episodes, each to be dealt with according to its particular features, but were not seen as having any wider significance or consequences. Today, every expression of hostility or anger is treated as an event of great importance and regarded as symptomatic of a wider erosion of civility in society. Indeed, there is a marked tendency to efface the distinction between serious physical assault (rare) and abusive or threatening language (relatively common) to reinforce the impression that aggressive behaviour is a large and growing problem.

The real problem revealed by doctors' sudden preoccupation with the 'aggressive patient' is the breakdown of the traditional relationship of trust and respect between doctor and patient. As the medical profession has lost confidence in itself, it has come to regard patients as either potential litigants or assailants. The conclusion of Dr Chelliah Mahenthiralingham, who conducted the Walsall survey, is that 'patients need to be educated in what they can reasonably expect of their doctors'. I would suggest that if doctors stopped treating their patients as enemies against whom they need to defend themselves, or children who they need to teach, they might be able to cut back on panic buttons and karate classes.

Dr Michael Fitzpatrick

Reproduced from LM issue 120, May 1999

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