Increasing violence in Australian general practice is a public health issue

The murder of Dr Khulod Maarouf-Hassan in her general practice in June 2006 (Box 1) has challenged the medical profession to consider the problem of violence in general practice. Debate has centred on protecting individual doctors with strategies such as secure physical practice environments, alarm systems, more intervention orders, and self-defence courses. Although such strategies are important, a systematic examination of the causes of increasing violence in general practice and the wider community is also needed, to identify a more effective long-term response.

Dr Maarouf-Hassan’s death is a sentinel event in the rise of violence both against general practitioners and within the wider community. The main Australian study on the prevalence of violence in general practice reported that 63% of GPs experienced some form of violence in the previous year.1 Most affected GPs were women or doctors working in lower socioeconomic areas1 and rural areas.2 There is some evidence from the United Kingdom3-5 and Australia6 regarding the precipitants and causes of episodes of violence in general practice. The adverse effects on the health and work performance of GPs who experience violence have been documented, and include difficulty working in an enclosed space in subsequent consultations.7

Although there are many gaps in our understanding, what can be observed is the significant increase in reports of assault in Australia over the past decade.8 There is congruence between increasing community violence and a perception of an increase in violence against GPs.3-6,9

Unfortunately, it is difficult to draw conclusions from national data on levels of reported assault because of differences in coding in each state and high levels of under-reporting.8 With these limitations aside, 184 671 physical and sexual assaults were reported to police in Australia in 2005.10 These figures contrast sharply with the National Personal Safety Survey in 2005, which reported the results of personal interviews on experiences of physical and sexual assault in a large representative sample of the population over 18 years of age and calculated that there were 808 300 assaults on men and 443 800 assaults on women in Australia in 2005.11

Increased awareness of family violence is responsible in part for the recent rise in reports of assault.10 In response, the Office for Women has worked to raise awareness in the community about the damaging effects of family violence in a campaign called “Australia says ‘no’ to violence against women”.12 However, much of the increase in assault appears to be related to violence against men by persons unknown. Increasing drug and alcohol use have also been implicated in the rise in violence.13

Mental illness associated with occupational violence in general practice has received little attention for a number of reasons. It is important to emphasise that most people who are violent are not mentally ill and most people who are mentally ill do not display violent behaviour.14 In fact, people with mental illness are more likely to be victims rather than perpetrators of violence.14 The long-term mental health effects of violence are well known, including post-traumatic stress disorder, anxiety, depression, suicide, and drug and alcohol misuse.7

There is a subgroup of people with serious mental illness and multiple risk factors who are at increased risk of being the perpetrators of violent behaviour:15 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. These people should be recognised and managed assertively with intensive, biopsychosocial intervention by a multidisciplinary mental health team. It is a paradox that such people are also at increased risk of being rejected by mental health and drug and alcohol services. In an environment of increasing burden of mental illness and substance use, coupled with medical workforce shortages and inadequate funding of mental health and drug and alcohol services, this is the group of people most likely to fall through the gaps of the health care system and end up in the criminal justice system.16

Violence in Australia is a major public health issue, and GPs have a role to play in seeking to prevent and deal with the complexities of violence.17,18 What is required is better training of all health professionals in recognising and managing people at risk of becoming perpetrators or victims of violence, and stronger advocacy for improved funding of state health services, including mental health services, drug and alcohol services, and family support services, particularly for disadvantaged groups.

Increasing violence in the community is a sign of disturbance in the social fabric of Australia. Violence against GPs and other health professionals should be considered in this wider context. To the Australian public, the death of Dr Maarouf-Hassan is another meaningless homicide statistic. To the medical profession, the tragedy of her loss should become a catalyst to begin a deeper public conversation about increasing violence and its long-term health effects on our individual patients and our communities. If GPs are to prevent another death of one of our own, doctors must do more than just protect themselves and inadvertently risk reducing access to health care for high-risk patients (Box 2).

In Victoria, the government has systematically addressed violence against nurses with a major taskforce,19 which has established mechanisms to promote consistent reporting and measurement of assault against nurses, and monitor, evaluate, prevent and reduce workplace violence. The Australian Government should develop a similar approach by establishing a national taskforce on violence in general practice to overcome current gaps in data and to promote a systematic approach.

A national summit of all medical groups on the expanding cycle of increasing violence in Australian society as a public health issue is recommended to address medical workplace violence in the context of increasing violence in the community.

What is needed most is a groundswell of concern by Australia’s GPs for children and adults at risk of becoming perpetrators or victims of violence, millions of whom visit GP consulting rooms around our country every year.