Practice measures not answer to violence against doctors

No-one could have failed to be moved by the tragic and brutal murder of Melbourne GP, Dr Khulod Maarouf-Hassan, in her surgery last year, and since her death at the hand of a patient there’s been much debate within the profession about violence in the medical workplace.
Yet as GPs Professor Michael Kidd and Associate Professor Leanne Rowe write in this week’s MJA, the discussion has been largely limited to measures individual doctors can take to protect themselves and their staff, such as ensuring secure physical practice environments, installing alarm systems and taking self-defence courses. While such strategies are important, tackling violence against health professionals is a bigger picture issue, they argue, and they’re right.
For a start, individual protection measures can only be so effective; an alarm wouldn’t have saved Dr Maarouf-Hassan from her frenzied attacker. Similarly, making sure the patient is never between you and the door is often unrealistic.
But apart from a lack of effectiveness of some individual practice measures, Professors Kidd and Rowe rightly say that violence against doctors isn’t just a personal threat, but a wider public health problem paralleling increasing community violence.
Moreover, there’s an identifiable subgroup of people more likely to be perpetrators of violence – “young men with active delusional psychosis, persecutory symptoms and disorganised thinking, who may be using substances, lacking insight, resistant to engagement, non-compliant with treatment and socially disadvantaged”, who paradoxically are also most likely to be rejected by mental health services and be denied help.
Of course, we in the medical profession must be careful not to get too carried away with the importance our own safety compared to other workers. All members of society deserve to return home alive from work each day, and just in the last week I’ve read about two rail workers, a construction worker and a truckdriver who weren’t so lucky.
But the ways to protect against violence, whether or not the victims are medically trained, are quite different to protecting against the physical accidents that claimed these workers’ lives.
According to the professors, we need a groundswell of concern by GPs for those at risk of becoming perpetrators or victims of violence. They’re right, but it’s a big ask to expect general practitioners to solve this problem on their own.
MJA 2007; 187; 118-9.

How to decide who's fit to drive.

I’m a bit of a Nazi about people who aren’t fit to drive but continue to get behind the wheel. While aware what a bummer it would be to lose your license, surely running over innocent people is even more of a bummer for all concerned.
Of course I might be particularly sensitive about the Mr Magoo types who struggle to park in our surgery carpark because I live in the same street. The idea of my children sharing a road with these incompetents is positively scary.
But a review in last week’s BMJ is a reminder against stereotyping the ability of older drivers. According to the article, the association between age and crashes per mile has been shown to be more related to low mileage than age and surveys reveal drivers over 80 to be consistently prudent behind the wheel.
Even people with early dementia are acceptably safe for around three years after diagnosis, the authors claim, by which time most have stopped driving. Which is lucky, because cognitive testing can’t discriminate well between early dementia patients who are safe on the road and those that aren’t.
One way to detect unsafe drivers is to ask family and friends about specific behaviours, such as driving the wrong way around roundabouts, getting lost in familiar areas, miscalculating speed and distances and poor judgement, the authors suggest. Sounds good in theory, but in my experience loyalty to the patient is often a barrier to honest disclosure about their driving ability. Similarly it seems doctors sometimes turn a blind eye out of concern about a patient’s loss of independence.
In short, recommending a patient lose their license is a balancing act between patient independence and population safety, and it’s probably among the harder decisions we have to make as doctors.
At least in our area there’s now a subsidised cab system for the elderly, and it’s this type of system that should be expanded so that independence and mobility isn’t totally dependent on being able to drive.

BMJ 2007; 334: 1365-69.

ACCC ruling divides doctors

The 6minutes story story on new rules to make details of every drug company do attended by doctors public has attracted a divided response from readers.
Some of you are outraged the ACCC ruling will force companies to divulge the professional status of attendees, hospitality provided, cost and educational content on a public website.
One concern is about an invasion of privacy when practice or hospital details are published. “I absolutely object to my privacy being stomped on by the ACCC”, wrote Dr Mason Stevenson.
I see his point but suspect patients have better things to do than trawl the net for examples of largesse bestowed upon their doctor. On the other hand, such info will probably make sexy copy for the lay media who always relish a “greedy doctor” story.
Other correspondents are enraged the medical profession has been singled out while other professionals are lavishly entertained ad nauseum.
“In any other industry entertainment of clients is an accepted part of customer relations…. Get off our backs”, wrote Dr John Lutz.
Again, he’s right, and I sheepishly admit traveling as a journalist to Paris courtesy of a drug company and Africa courtesy of a travel company, a vast contrast to the meager offerings I’ve received as female part-time GP.
And for the record if I sacrifice a home-cooked meal with my family to attend an educational function at night, I expect a hot meal not a sandwich. Who has sandwiches for dinner?
What’s different between the medical and other professions, according to ethicists, is the concept of information asymmetry, where a “knowledgeable” doctor chooses a drug for a patient who depends on them for drug info - quite a different process than a patient making their own informed decision about which car to buy.
Another major objection to the new ruling is the argument that hospitality and gifts don’t influence prescribing behaviour, and on this one there’s quite good evidence – they do.
In fact, it appears that the more gifts a doctor receives, the more firm their belief that seeing drug reps doesn’t affect their prescribing.
As they say, drug companies aren’t stupid. If it didn’t work, they wouldn’t do it.