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Re: Holding families to account

I have a policy, although as yet I do not have enough experience of using it to know whether it is effective. Trainee pediatricians or nurses may well tell me that family members of an in-patient have been verbally abusive to them. I then ask to see the family members and tell them that I may/will lodge a complaint against them with the Trust management. Basically, I simply try to use the same complaints procedure in holding families to account for the standards of their behaviour as they are entitled to use against professional staff to hold us to account for our standards of care. The outcome of the procedure should be an official letter of complaint from the Trust inviting their comments - but it has never yet come to that.

Although I have not accumulated enough experience to judge the effectiveness of this pro-active policy in nipping abuse in the bud before the violence stage, the early trend is for family members to be taken aback and to show some humility. Needless to say I keep anger and provocation out of my voice and body language, although I keep my words plain and straight. It may be that sometimes the concept that they owe some duty to a standard - that they can be the "them" in the them-and-us consumer world - is somewhat novel.

Send letter to journal:
Re: Close encounters in medicine

Dr Mackin’s article encompasses most of the issues relating to the causes of violence against paediatricians and has even suggested a specific action plan to tackle incidents in the future. He mentions that the child’s condition can cause the parents to display uncharacteristic or highly stressed behaviour. But he has not touched upon issues about whether the doctors themselves have aggravated the situation.

A similar study in a paediatric intensive care unit (PICU) in Mumbai, India looked at incidents of violence over a period of six months. During this period there were 671 admissions. The doctors working in the unit recorded incidents of violence, with details of the precipitating factors. More than half of the 28 incidents recorded were verbal threats. Actual physical assaults constituted just 7% of the total incidents. Deaths in the unit were associated with 68% of the violent episodes. But the other 32% were sparked off due to inebriated relatives, decisions to wean patients off the ventilator and transferring the patient to the general ward. Language and communication problems were considered to contribute to 71% of the incidents. Of the 6 doctors working in PICU, 4 were from Southern States of India and could not speak the local language well. This was compared with a 12-month period in the PICU, Belfast (359 admissions) and there were no incidents of violence. No parent of a child admitted to the Belfast PICU required an interpreter.

We agree with Dr Mackin that a good training programme covering all practical issues needs to be implemented, but also wish to highlight that the inability to communicate with the relatives in a language they understood was a major factor contributing to a culmination in violence. Doctors from Southern States of India are unable to speak the local language in Mumbai and hence prone to create confusion regarding queries from the relatives, unlike in the United Kingdom where a single language is spoken all over the country. Inaptitude to answer queries with expertise added to the problems. All this reasserts the need for a master plan to tackle violence with region specific modifications. We believe that courses in language and communication skills should form part of the core curriculum to enable doctors to deal rationally with aggressive situations.

Dr SV Kamath
Departments of Child Health & Clinical Biochemistry, The Queen's University of Belfast

Dr MD Shields
Department of Child Health, The Queen's University of Belfast
Consultant Paediatrician, Royal Belfast Hospital for Sick Children