Is enough done to deter violence in general practice?

Jolyon Attwooll

23/09/2022 10:18:39 AM

An encounter with an aggressive patient, and the fallout that ensued, was enough for one GP to consider moving away from the profession.

Dr Alvin Chua
Dr Alvin Chua has described a violent incident at his general practice as 'the final straw'.

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.’

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A.Prof Christopher David Hogan   23/09/2022 10:42:26 PM

Violence is never acceptable & should never be tolerated.
We are as frontline in the management of health as it gets. My limited experience bears that out
I once wrote a eulogy for a colleague murdered in her practice. I have been threatened with a loaded weapon while doing home visits. I my practice I was knocked to the floor & then picked up & thrown. One of my partners was knocked unconscious without warning.
Sometimes patients have bizarre expectations of GPs due to the very low community Health Literacy (It currently runs at 41%)

Dr Susanne Surabhi Davis   24/09/2022 9:06:52 AM

I wasn’t aware this happened to you Alvin. I’m so sorry to hear what you’ve been through. I have always admired what you have achieved in your career, not to mention that you are also a kind hearted and trustworthy human being. Keep fighting for yourself and all of us gps who need you to lead the way. If there’s anything I can do please let me know.

Dr Bradley Arthur Olsen   24/09/2022 12:14:03 PM

Thanks for bringing this to the spotlight, I suspect most of us have been threatened at some stage. I have been assaulted several times Averaged 1 death threat per year. But the most upsetting one was the new patient you quoted to me my home address and informed me if I didn't write a script for oxycontin he would kill me and rape my children. Naturally I protected my children, we have now moved house, have 2 guard German shepherds I carry a "object" at all times. The latest was one of my registrars being threatened with a firearm. all these reported to police with no action taken by them We are now leaving the Bundaberg altogether

Dr Shobha Balu   24/09/2022 4:42:31 PM

Saddened to read the above incidence of violence on Dr Chua. This should not happen to anyone in any clinical setting. Not getting the help that Dr Chua needed at the time from the Police was even more disappointing . Dealing with verbal aggression by patients is bad enough ; dealing with the aftermath of the physical aggression must be extremely difficult on one's psych and the physical injuries relating to the aggression of this kind.
Dr Shobha Balu

Dr Ruo Zhong Xie   24/09/2022 4:42:46 PM

It’s not coincident! I faced 2 violent aggressive pts last 2 days: one in Rockdale and another in Liverpool area. The one in Rockdale actually was the father of the pt who wanted me to see his son first though it was not his turn yet. The father shouted at me threatening to hit me when I trying to explain to them…the Liverpool case was a bit funny where the receptionist registered the pt with his son’s name. When I called the name, the pt (father) came in and I said to him: sorry, I am looking for a 6-yr-old boy , not you yet. He ran to the reception and shouted at the staff . I followed over trying to calm him down. He just turned at me trying to use his head to knock me.. these happened in 2 consecutive days: Thursday and Friday (22-23 sep 2022.

Dr Trevor David Hoffman   24/09/2022 6:59:45 PM

Dr Chua, this was a racist attack from beginning to its current tragic stage, and once again the farcical police inaction ("Dr Chua is also deeply disappointed with the police response to the general practice assault, with no charges pressed despite an affidavit") will ensure it recurs until the Asian Community rise up and expose it for what it was and is and ever will be without discipline