Monday, October 12, 2009

Defensive tactics.

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ETHICS: Whether it's martial arts training or practice design, GPs are seeking a safer working environment - but at what cost to patient trust?

DR John Jory is not just a GP in St Kilda. He also runs a martial arts school and is secretary of Judo Victoria.

It makes Dr Jory better prepared than most GPs to defend himself if he is threatened. Not that he has had to call on his martial arts skills very often while practising.

The most memorable event was back in 1985 in country NSW. At the time he already had a black belt in judo. He was called to a house where a 45-year-old man with diabetes was agitated as a result of a hypoglycaemic attack.

'I tried to calm him, explaining that I needed to give him [a glucose] injection, when suddenly he ran towards me, fists flying,' Dr Jory says.

Dr Jory expertly deflected the man's arms, swiftly manoeuvred the lunging body past him and, before the patient could fall to the floor, grasped him and gently lowered him down.

'I then held him forcefully on the floor while I quickly injected him and rapidly his agitation subsided,' he says.

But while Dr Jory agrees that self-defence skills can be useful for GPs concerned about personal safety, he recommends that doctors should only decide to learn martial arts for their own sake with any self-defence benefit seen as a bonus.

He says doctors who do self-defence training should avoid overestimating what they can do with their skills.

'It takes a minimum of twice-a-week training for one year to reach a level when you can handle a physically capable person intent on doing you damage, but if the assailant is affected by amphetamines, you'd need up to three years of training,'Dr Jory says.

'There are martial arts students I have come across who have been hurt because they thought they were better trained than they really were and chose confrontation in situations when running away would have been the correct option.'

Debate about how GPs can ensure their personal safety at work has intensified since the killing of Dr Khulod Maarouf-Hassan in Melbourne in June last year.

It has raised ethical issues surrounding the implementation of some security measures, particularly overt measures such as glass panelling at reception desks, closed circuit television monitors in waiting rooms and doctors taking self-defence training.

Ms May Hassan, sister-in-law of Dr Maarouf-Hassan, told Australian Doctor in March: 'I don't think that Khulod would ever want to have been practising in a surgery with bars on the windows. The idea would have horrified her ... safety in general practice is about finding that difficult balance between looking after yourself and looking after your patient.'

Professor Paul Komesaroff, director of Melbourne's Monash Centre for the Study of Ethics in Medicine and Society and a general physician, says overt security measures can lead to a reduced level of trust in the doctor-patient relationship because, in effect, doctors regard all patients as potentially violent.

'The doctor-patient relationship needs to be built on mutual trust for it to be effective,' Professor Komesaroff says.

'Doctors can do technical things without trust, like sew stitches and give an injection, but with other things, such as helping a patient come to terms with a disease or managing psychological illness, they are powerless without trust.

'Certainly no one is blaming doctors for implementing security measures, yet if there are patients who feel they are less trusted because of [security measures] then there is potential damage to the doctor-patient relationship and this should be acknow-ledged.'

Dr John Meaney, a GP in Dandenong, Victoria, near to where Dr Maarouf-Hassan was killed, says this concern for the doctor-patient relationship is excessive.

'If you were to broadly apply the principle that preventive measures treat everyone as a potential threat, then should we abandon all law and order because that means we don't trust every civilian?' he asks rhetorically.

'For all the lovely patients who come to our practice there are a very small number who are not. So if out of a million patient visits you have one that ends up in a murder, then obviously it is better that there is security in place that can prevent it.'

However, Dr Meaney remains conscious of the need to maintain an environment that is as friendly as possible for his patients.

Seven years ago his practice moved into a new building that includes glass panelling with small apertures at the reception desk, similar to those used in banks, and doors leading to the doctors' rooms that only open one-way. These structural security measures were architecturally designed to be subtle.

'We were determined not to allow the practice to look like Belfast,' says Dr Meaney, who owns the practice with six other GPs.

'With all the additional security we still had an open-plan waiting room that was continuous with the adjacent pharmacy and had a playroom area.'

Dr Meaney says if the security measures result in a reduced level of trust he is confident such feelings are temporary. Once the patient is in the doctor's room, his experience is that trust levels do not remain diminished.

Dr Rosanna Capolingua, a WA GP and chairwoman of the AMA ethics and medicolegal committee, says there is no point in debating the doctor-patient relationship if doctors are too scared to go to work or work in an environment where they feel fearful.

'Of course we should always be willing to go the extra mile to provide care to patients whenever and wherever possible. However, our safety and health should always have the highest priority,' Dr Capolingua says.

'Taking risks may be justified where there is a demonstrable gain, for example, during a flu epidemic, but there is little or no gain if doctors increase the risk of experiencing threats or violence by not implementing security measures.'

There has already been an impact on the public as doctors are reluctant to do house calls and even avoid nursing home visits in suburbs where crime rates are high.

Dr Meaney says the situation in his area has got so bad that the practice has reduced substantially the number of house calls at night and won't send young female GPs to visit a nursing home even in daylight.

'I know that is to the detriment of our community, but that's not the fault of doctors. It is society's responsibility to deal with the root causes of violence,' he says.

Security personnel have long been present in hospital emergency departments to restrain violent patients, and consideration may need to be given to having this level of security available in general practice in some circumstances.

In the meantime, there is evidence that more GPs are learning self-defence skills. An unpublished survey, conducted by Dr Jan Coles, a lecturer at MonashUniversity's department of general practice, of GPs, social workers and nurses all aged under 34 years found several had learned self-defence skills as a response to work-related violence.

Dr Capolingua says she has several GP friends who have trained in martial arts, although most did it for lifestyle reasons. However, one friend told Dr Capolingua that having self-defence skills meant he was less likely to respond inappropriately in a threatening or violent situation.

'He has the skills to disarm or restrain an aggressor, whereas someone like me is more likely to freak out and hurt the aggressor or get myself hurt,' she says.


SECURITY measures are not the only consideration when implementing personal safety improvements in general practice, says Associate Professor Leanne Rowe, a rural GP and deputy chancellor of Melbourne's MonashUniversity.

And as with most things in medicine, good evidence of efficacy should be available before implementing specific measures. "For example, what is the proof that CCTV actually does provide a benefit?" Dr Rowe says.

"These measures also need to be assessed in terms of the ethical issues that they raise and what impact they may have on the doctor-patient relationship.

"A systematic approach is required that would assess the overall security needs of general practices. Measures may include the installation of structural changes and learning self-defence, but they are only one part of the puzzle.

"Other measures may range from education for doctors on identifying potentially violent patients and advocating for better access for them into mental health, drug and alcohol or welfare and family support services.

"Sadly it is nearly a year since [Dr Khulod Maarouf-Hassan's] killing. Many GPs are in denial and we, as a profession, have failed to make real progress on safety compared with other professional groups.

"I think GPs are now tired of hearing about the problem of violence. We want our medical organisations to unite to debate the solutions."

Source Citation:"Defensive tactics." Australian Doctor 00.00 (June 1, 2007): 39. Academic OneFile. Gale. BROWARD COUNTY LIBRARY. 13 Oct. 2009

Gale Document Number:A164867535

Disclaimer:This information is not a tool for self-diagnosis or a substitute for professional care.

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