Dr Phil Hammond, GP and broadcaster

I've only been hit once in the line of duty. I didn't see it coming and it landed plum on the middle of my chin. It was in the middle of a busy ward and with plenty of witnesses, but they all laughed. And so did I. More out of surprise than humour.

The aggressor was 75 and female, and didn't quite pack enough power to floor me. She was the wife of a diabetic man who'd fallen over after an early morning hypo. I cut his evening insulin and his sugar went the other way, causing him to fall over again. All my fault, of course.

More recently I've had a few disturbed patients to deal with in the clap clinic, but as yet I've escaped the fate of my consultant, who bears an eight-inch facial scar from a machete attack.

Have I lead a charmed existence? A recent survey of 4000 GPs found that three-quarters had faced a violent patient at least once and more than half had been physically assaulted. Then there were the horror stories of weapons used: a Stanley knife, a crowbar, a brick, a crutch, an electric fire and even a beer glass. Just goes to show you shouldn't be drinking during surgery.

In dangerous times, doctors tend to seek desperate solutions. In 1994, a Stoke GP admitted carrying a replica Smith and Wesson revolver in his black bag, and more recently, 5ft 9in Birmingham GP Mark Payne employed 6ft 2in Ira Emelianove – a 14 stone Russian Sombo wrestling champion – to accompany him on visits where 'a white, middle-aged, middle-class doctor stands out like a walking cash-machine.'

I felt likewise on a recent visit to a sink estate in Preston, to make a film about violence towards GPs for BBC1's 4x4 series. The outside of the surgery serving the estate was indescribably depressing. Inside, there were three women serving 1700 very deprived patients. The level of racist abuse they have to put up with would shock Bernard Manning. And most of it comes from children.

Ironically, since New Labour introduced their 'zero tolerance' policy for aggression and violence to NHS staff, the incidence has increased by 20%.

All health authorities were told to create local plans and provide resources to tackle this problem, but to date only one has funded a secure surgery where the most violent patients can be seen safely. It's in Cardiff, and you have to have been violent at least once already to be referred there.

A policeman lets you in and pats you down for weapons, and the CCTV cameras extend into the surgery. True, the volume's turned down during consultations but there may be some reluctance to undress under the watchful gaze of PC Plod.

Another solution is for us all to go on an aggression management course, and I've just been on one. It starts by telling you how inadequate your surgery layout is (nearly always, the GP is trapped behind the desk with the patient blocking the exit) and the importance of keeping your desk clear (hot tea, china cups, letter openers and paperweights are asking for trouble – unless you nail them down).

Then it moves onto your consulting technique and – as someone who's been teaching communication skills for 10 years – you'll be pleased to hear I've got it completely wrong. If someone aggressive charges into your room, you don't sit down to defuse the anger and appear less threatening, you stand up and lean on the desk so you can make a sharp exit.

Also – contrary to popular belief – barriers between doctor and patient are a good thing. If you write your prescription on a bloody great sharp-edged clipboard, you're much less likely to be hit.

Alas, in my role-play, I was quickly trapped in my chair with my lapel being ripped to shreds. But never fear. I was taught a cunning holding technique which involved grabbing and twisting the arm, and then applying unnatural forward pressure over the elbow joint until the patient agreed to behave. As she was only 5ft 4in, I felt very unnatural pinning her down in a half-Nelson.

Has family medicine really come to this? Whatever would Michael Balint say? However many courses I go on, I doubt I'll ever learn to switch from 'doctor carey-pants' mode to 'I'm going to have to break your arm if you don't stop that' mode. I guess I'm just a sitting duck.

Guidelines in Practice, November 2001, Volume 4(11)
© 2000 MGP Ltd
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