Is enough done to deter violence in general practice?
An encounter with an aggressive patient, and the fallout that ensued, was enough for one GP to consider moving away from the profession.
The pandemic has thrown a harsh light on many societal issues, including the potential for violence directed towards health practitioners.
General practice teams, particularly in clinics offering COVID-19 vaccinations, ‘were often the target of patient frustrations and at times aggressive behaviour’, an RACGP submission to the Australian National Audit Office reported last year.
But the issue has certainly not been restricted to those taking part in the rollout – as Adelaide-based GP Dr Alvin Chua knows only too well.
A violent encounter at his general practice, during the early stages of the pandemic, pushed him away from the profession.
He says the incident occurred after he intervened when a man entered the surgery and started using racial slurs against a receptionist. Dr Chua describes being pushed backwards by the man, losing his footing and jarring his back.
It set off a deeply upsetting chain of events for Dr Chua, including the discovery of pre-existing spinal stenosis and ossification of posterior longitudinal ligaments.
A cadaver bone graft was carried out, which subsequently crumbled, and another operation followed, with two rods and 10 screws put into his spine. Dr Chua said he felt pain like nothing he has ever experienced before.
Following a thoracic laminectomy, myelomalacia of his spine at the thoracic level was also discovered and he remains in severe discomfort.
‘Maybe he did me a favour, maybe he didn’t, but at the end of the day, it was the straw that broke this camel’s back,’ he told newsGP.
The increase in violence against healthcare professionals is by no means confined to Australia.
In May 2020, the World Medical Association described it as ‘an international emergency’, saying the issue had surged in the past decade then ‘expanded dramatically’ as COVID-19 spread.
Research based on meta-analysis and systemic reviews that took place before the pandemic found 61.9% of healthcare worker participants had been exposed to some form of workplace violence, including non-physical abuse.
More specifically relating to general practice, a study published in the British Medical Journal in April reported a steep increase in incidents compared to previous years, including physical violence.
Using Freedom of Information requests sent to police forces around the country, investigators found 1068 incidents of violence at UK health centres and GP surgeries in 2021–22 – including 182 that resulted in injury.
The figures were described by one British GP as ‘the tip of a much, much bigger iceberg’.
But it was not just the violence that Dr Chua found disheartening.
Dr Chua is also deeply disappointed with the police response to the general practice assault, with no charges pressed despite an affidavit.
At the same time, he had to contend with an Australian Health Practitioner Regulation Authority (AHPRA) notification, triggered by the man who assaulted him, that he found out about on the day of his first operation. It was only dismissed without prejudice on the day he went into surgery for the second time.
‘It has it made me want out of the profession,’ Dr Chua said.
Dr Cameron Loy, a former RACGP Victoria Chair and recipient of the RACGP’s Rose-Hunt Award, is another GP who has been assaulted in the line of duty – once in general practice, and once while working in a hospital.
He understands Dr Chua’s anger.
‘What happened to Alvin is awful,’ he told newsGP. ‘It should never have happened. His grievance that the system hasn’t protected him is absolutely valid.’
Dr Loy says most of the time GPs carry out their work without any issues – but that violence in general practice is ‘not new’.
‘The data suggests it’s very common and violence isn’t just physical,’ he said. ‘There’s verbal and other forms of violence that occur in general practices.’
Dr Loy believes there is a case for reform, with many healthcare workers – as occurred with Dr Chua – finding that incidents do not get heard by the courts.
‘I know that’s been true in my cases,’ he said.
‘The appetite for that to occur and how you affect that change is a much, much harder question.’
He believes part of the answer lies in how the courts, police and community perceive aggression towards doctors and other healthcare workers.
‘I want Mrs Smith down the road to be as angry that Alvin Chua got assaulted as I am,’ he said. ‘But I don’t know if she even knows about it.’
The legal background
Unpicking the different legislative approaches can be tricky with criminal laws specific to each state.
A further complication is that general practices are categorised as a small business, while in some instances government-employed healthcare workers can be offered more protection – in the letter of the law at least – in the face of assault.
Dr Chua is acutely conscious of the disparities, and points with anger to a bill recently tabled in NSW which would offer stiffer mandatory sentences for assaults on hospital workers and pharmacists but not GPs.
As highlighted recently in The Medical Republic, a NSW Sentencing Council report in 2020 looking into violent offences against emergency workers, agreed with the case for punishing assaults on hospital workers more severely. The report did not have the same view for general practice.
‘We have not received evidence that assaults against healthcare workers in other healthcare settings, such as general practitioner clinics or community health clinics, are a particular problem,’ the report stated.
‘We do not have the evidence to justify extending the new offences to these locations.’
While that report did not reference pharmacists under the definition of frontline health workers, the bill tabled to NSW parliament does – as well as omitting GPs.
Submissions from other organisations to the sentencing council also reflect some of the nuances and complexities raised by Dr Loy.
The NSW Young Lawyers argued the definition of health workers should be broader, while the Law Society of NSW contends that ‘an appropriate range of offences and penalties’ already exists, and that there would be ‘limited gains’ to amending maximum penalties.
AMA NSW contended that mandatory sentencing would limit a ‘judge’s discretionary power to take mitigating factors into account’. It could also ‘disproportionately affect those who are already over-represented in the prison system, such as Aboriginal and Torres Strait Islander people,’ their submission argues.
Meanwhile, an article published the Frontiers in Public Health journal in 2020 says the evidence surrounding the efficacy of such interventions is ‘still lacking’.
‘[Healthcare workers] worldwide generally advocate for more severe laws, but harsher penalties alone are unlikely to solve the problem,’ the report states.
Its authors, however, recommend for a fierce stance against acceptance.
‘The idea that violence is inherent to doctors and nurses’ work, especially in certain departments, needs to be fought,’ they wrote.
‘Urgent measures must be implemented to ensure the safety of all healthcare workers in their environment, and the needed resources must be allocated.
‘Failure to do so will worsen the care that they are employed to deliver and will ultimately negatively affect the whole healthcare system worldwide.’
Dr Loy is also adamant the sort of incidents he has experienced, along with Dr Chua and so many others, should never be viewed as ‘just part of the job’.
‘Is violence a characteristic of our society? Yes. Humans are a violent species. I think we have an entire evolution that demonstrates that,’ he said.
‘Should it just be part and parcel of working in medicine? No, it shouldn’t.
‘I don’t go to work to be the subject of verbal or physical aggression from patients or their families.
‘We should never accept it, there should be absolutely no tolerance to it occurring.’
The RACGP has the following resource available for members on dealing with patient aggression.
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Source: Ross Arrowsmith