The intimidation factor

I had planned on continuing the ramblings on GP visits.

However recent events made me ponder a more unpleasant issue.

I don’t think anyone in this country has been oblivious of the riots from the other week. In a short space of time, the country was gripped in fear, defiance, national pride and horror all at the same time. Gangs of people roamed the street at night causing damage to properties, businesses, discord and harm. People lost their lives, a nation lost its faith in those designed not only to protect, but also to guide us.

There have been shinning lights in those dark days. Riot clean ups via twitter, the broom army, local communities banding together to support and protect each other, Mr Tariq Johan, that father of the murdered young men in Birmingham (this man should be nominated for some award, or at least an Olympic future flame), and the various public services especially our hard working beat cops.

I am lucky, in that the area I work and live in was relatively untouched by the chaos that gripped the country (Yorkshire practicality I believe) . I cant even begin to imagine the emotions of an individual caught up in the riots or even working in them (however if you wish to, I recommend reading this excellent and poignant article by @mellojonny : ).

However the intimidation that the riots have instilled upon the population can not be doubted. It is unsettling at best, terrifying at worst. And what is worse, is that intimidation is not something restricted to the streets.

Working as a GP, we deal with all forms of presentations of conditions, problems, and general issues in our patient’s lives.  While primary care is working towards patient centeredness and shared care, there will always be time where doctor and patient do not agree. Hopefully this will be an amicable disagreement (a paradox I know), and any issues subsequently resolved.  Sometimes the disagreement will be justified and complaints issued etc. However sometimes patients can show an ugly side of the human condition, and try and intimidate a GP or clinician to get what they want.

I will be clear, I am not talking about assault or actual physical harm, but more the intimation of threats, the presence of harm, or as once colleague called it, ‘the threat of harm without an specific threat’.

I have been on the receiving end of this on multiple occasions.

Simple examples are the threats on your clinical standing, the classic ‘give me what I want or I am going to complain against you’. This can be very intimidating when unexpected, or more likely by inexperienced clinicians. Sitting down and talking about the motives behind such actions, or simple explanations can normally prevent further breakdown in the doctor-patient relationship, which is normally the reason us GPs will concede to demands by patients.  However sometimes you just need to accept a complaint is inevitable, bite the bullet and await the outcome.

More sinister examples are those where anger, frustration and aggression become involved. At this point I would ask (if you are still reading this) to think back to an encounter where you have actually felt intimidation from a patient. Where you have made a furtive look at the door, or for the panic button, or had that fleeting thought of: can I shout loud enough for the other staff to hear me.

I may be wrong and it could just be me being a wuss, but when I am trying to negotiate codeine use in a patient I feel to be addicted, but where he/she feels it is their right to have such medications as they feel they need and on the NHS, and they are hovering over me, blocking the exit and raising their voice to show that they want what they want; then I will feel a little bit intimidated.

This is one example, and there are others where this occurs, my the top three are:

  • sign me off as sick for X
  • give me medication Y
  • refer me for Z

In handling these situations, well to be honest I am still learning. At present, I have made it through this far without a physical assault (so far so good), but there have been several times where patients have left me either shaken from the ordeal, or angry that I let them intimidate me in such a manner. It is wrong and it should not be allowed. I do find being patient, calm and not rising to the growing tensions works, but ultimately if the spiral begins to coil around you, then to recues oneself from the consultation sometimes is the only way out, and at the very least means you will get out of there in one safe piece.

Roger Neighbour talks about housekeeping, taking that time after every consultation to sort out the paperwork, and to make sure you are good to go after each one, I know that after my codeine patient, I spent a good minute stretching and consoling myself. This was followed by eagerly finding a colleague at the end of clinic for a well needed vent. It is how I cope.  I guess in my rambling kind of way what I am trying to say is that no matter how you handle being intimidated, just make sure you look after yourself not only during, but also after the event, as that is where we as care providers tend to feel the angst and the frustrations more.

Reflecting on it, I know when a colleague of mine recently had a case of X with a patient that truly seemed to intimidated her; that my offer to see her next patient so she could catch a breather was met with warm appreciation, and actually made me realise how negative such experiences can make you feel.

The intimidation factor is present in primary care, and after the recent riots, has really made me ponder the situations I have been in. I would ask anyone reading this to feel free to comment on their experiences and handling of such situations.  Ultimately though I still will probably be reaching for my breather and venting, just hope my colleagues still put up with it.

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