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How to sail through the MRCGP orals without stress

MRCGP orals are looming, to test your decision-making skills and professional values. In two 20-minute exams you will be asked to talk about five topics, spending about four minutes on each.

Pulse has spoken to GP tutors and registrars who recently passed the orals about what hot topics could be fired at you. We've distilled their advice into simple points on the clinical and ethical dimensions in each subject, to help you pick up maximum marks with minimum stress.


mWe have a human right to security of person1

mSections 4 and 5 of the Public Order Act 1986 cover threatening behaviour

m50 per cent of UK doctors have experienced some degree of violence or abuse from patients2

mThe concept of violence as a public health problem3 uses the premise that it is both predictable and preventable

m47,000 increase in reported cases of violence since 19984

mIncidence figures were likely to be an underestimate because of confusion over definitions – 'any incident where staff are threatened, abused or assaulted'. Does not apply when patients are mentally unwell

The NHS zero tolerance campaign was launched in October 1999. It has two aims

– to make it clear to patients that violence to NHS staff is unacceptable (and a commitment has been made to stamp it out)

– to reassure health workers of the above

The implications of zero tolerance might be considered on three levels:


Consultations and individual practice management


Intervention of the PCT


National issues and Department of Health

Micro level

l Qualitative report5

l Verbal abuse and intimidation are common and not reported

l Receptionists receive most verbal abuse

l Some practices attempt to 'screen' those seeking to register for risk of violence

Responsibilities of GPs

l NHS Human Resources Performance Framework requires NHS employers to reduce incidents of violence to staff

l It is in our interests to act to reduce:

•time off work

•temporary staff costs

•legal costs and stress

•loss of staff if unable to continue in their job

l Violence is the commonest reason for patient to be removed from lists (59 per cent6)

•includes physical damage to premises, staff, or other patients

•includes verbal or racist violence or abuse

Areas for possible improvement7

l Communication

l Clear practice policy for abusive patients (set out in practice leaflet)

l National poster campaign (March 27, 2003)

l Use of internet to download posters and postcards8

l Liaison with local agencies, such as crime prevention officer

l Protocols for visits, with agreed actions if not back when expected

l Critical incident analysis at the practice level

l GP partner identified to co-ordinate policy for violent patients

l Use of 'yellow' or 'red' card systems may exacerbate the situation


l Receptionists to prevent or combat violence

•offer alternatives to the patient instead of refusing something outright

•refer aggressive patients early to senior team member

•avoid making judgments over patient needs

•two receptionists should be on duty at all times

• Violence awareness courses

• Personal safety courses

Surgery layout

l Wide desks to protect receptionists from being grabbed

l Formal screens may provoke more hostility

l Panic buttons and alarms connected to computer system

l Quiet area for aggressive patients away from the 'audience' of other patients, smoking perhaps tolerated in this area

l Security of premises

l CCTV discourages antisocial or violent behaviour

l Locking up at night should be done by two people

Meso level

l Formalise the reporting system

l Use adverse incident reporting guidelines

l Crown Prosecution Service evaluates the available evidence for prosecution

l PCT should have protocol for referral of violent patients

l Secure location should be provided for seeing patients who are persistently violent, paid for by Government local development fund

l Funding for local initiatives under National Improving Working Lives Standard9

l Out-of-hours arrangements need review as staff may be particularly vulnerable

l Provide a driver to home visits, in an anonymous car

l Train staff in conflict resolution, management of aggression

l Remove patients for violence or threatening behaviour both in the surgery or on visits10

l Carry out a practice risk assessment, which might include:

•flagging patient records (if possible)

•encourage patients to come to health centre, not request a visit

Rob Wheatley is a registrar at

Bulford Camp army barracks

in Salisbury, Wiltshire


11 Article 3 United Nations: Universal Declaration on Human Rights

12 Violence at Work: The Experience of UK Doctors BMA 2003

13 Iona Heath BMJ 2002;325:726-7

(October 5)

14 Department of Health figures up to 2002

15 Department of Social & Political Science Royal Holloway, University of London (2001)

16 Pickin et al BMJ 2001;322:1158-9

(May 12)

17 AMSPAR guidelines 1999

18 downloads/postcards.pdf

19 Improving Working Lives Standard October 2000

10 RCGP guidelines on removal of patients from GP lists 1997

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