Family medicine physician Kenneth Cheng, DO, was on-call at a local hospital when a nurse told him that a patient needing evaluation hated Asians.
"I talked to him about whether he was okay seeing me and he said yes," Cheng said. "But I remained vigilant and conscious of what the patient was doing the whole time so he couldn't take advantage of the situation."
Cheng never turned his back to the patient and even backed out of the exam room. That encounter passed without incident. However, a urologist Cheng knew from residency wasn't so fortunate. Ronald Gilbert, MD, of Newport Beach, California, was shot and killed by a patient in his office. The patient blamed him for complications following prostate surgery 25 years earlier.
Last year, a gunman in Tulsa, Oklahoma, blamed his physician for pain from a recent back surgery and shot and killed him, another physician, and two others in a medical building before taking his own life.
Nearly 9 in 10 physicians reported in a recent Medscape poll that they had experienced one or more violent or potentially violent incidents in the past year. The most common patient behaviors were verbal abuse, getting angry and leaving, and behaving erratically.
About 1 in 3 respondents said that the patients threatened to harm them, and about 1 in 5 said that the patients became violent.
Experts say that many factors contribute to this potentially lethal situation: Healthcare services have become more impersonal, patients experience longer wait times, some abuse prescription drugs, mental health services are lacking, and security is poor or nonexistent at some healthcare facilities.
Violence against hospital workers has become so common that a bill was introduced last year in Congress to better protect them. The Safety From Violence for Healthcare Employees Act includes stiffer penalties for acts involving the use of a dangerous weapon or committed during a public emergency and would also provide $25 million in grants to hospitals for programs aimed at reducing violent incidents in healthcare settings, including de-escalation training. The American Hospital Association and American College of Emergency Physicians (ACEP) support the bill, which is now before the House Judiciary Subcommittee on Crime, Terrorism, and Homeland Security.
The Worst Day of Their Lives
"You have people who already are having the worst day of their lives and feeling on edge. If they already have a short fuse or substance abuse issues, that can translate into agitation, violence, or aggression," said Scott Zeller, MD, vice president of acute psychiatry at Vituity, a physician-owned multispecialty group that operates in several states.
Healthcare workers in psychiatric and substance abuse hospitals were 10 times more likely to experience nonfatal injuries by others in 2018 than were healthcare workers in ambulatory settings, according to an April 2020 Bureau of Labor Statistics report. In addition, healthcare workers were five times more likely to suffer a workplace violence injury than were workers overall in 2018.
Psychiatrists who responded to the poll were the specialists most likely to report that they encountered violent patients and potentially violent patients. "Historically, inpatient psychiatry, which requires more acute care and monitoring, is considered the most dangerous profession outside of the police," said Zeller.
Emergency physicians have reported an uptick in violence from patients; 85% said in a survey by ACEP last year that they believed the rate of violence in emergency departments has increased over the past 5 years, whereas 45% indicated that it has greatly increased.
Some doctors have been threatened with violence or actually killed by family members. Alex Skog, MD, president-elect of ACEP's Oregon chapter, told HealthCare Dive that "a patient's family member with a gun holster on his hip threatened to kill me and kill my entire family after I told his father that he needed to be admitted because he had coronavirus."
"I've been scared for my safety as well as the safety of my family," Skog said. "That was just not something that we were seeing 3, 4, or 5 years ago."
Many patients are already upset by the time they see doctors, according to the poll.
"The most common reason patients are upset is that they're already in a lot of pain, which can be expressed as anger, hostility, or aggression. They're very anxious and afraid of what's happening and may be thinking about the worst-case scenario — that a bump or lump is cancer," Zeller said.
Patients may also get upset if they disagree with their doctors' diagnosis or treatment plan or the doctor refuses to prescribe them the drugs or tests they want.
"One doctor commented recently, 'After over 30 years in this business, I can say patients are worse now than at any point in my career. Entitled, demanding, obnoxious. Any denial is met with outrage and indignity, whether it's an opioid request or a demand for MRI of something because they 'want to know.'"
An orthopedic surgeon in Indiana lost his life after he refused to prescribe opioids to a patient. Her angry husband shot and killed the doctor in the parking lot only 2 hours after confronting him in his office.
Decreased Physician-Patient Trust
"When doctors experience something frightening, they become more apprehensive in the future. There's no doubt that after the first violent experience, they think of things differently," said Zeller.
More than half of the doctors who reported experiencing at least one violent or potentially violent incident in the poll said they trusted patients less.
This diminished trust can negatively impact the physician-patient relationship, said the authors of a recent Health Affairs article.
"The more patients harm their health care providers, intentionally or unintentionally, the more difficult it will be for those providers to trust them, leading to yet another unfortunate pattern: physicians pulling back on some of the behaviors thought to be most trust-building, for example, talking about their personal lives, building rapport, displaying compassion, or giving out their personal cell phone numbers," the article stated.
What Doctors Can Do
Most doctors who experienced a violent or potentially violent incident said they had tried to defuse the situation and that they succeeded at least some of the time, the poll results show.
One of the best ways to defuse a situation is to be empathetic and show the person that you're on their side and not the enemy, said Cheng, the cofounder of Personal Concierge Physicians of Newport Beach.
"Rather than making general statements like 'I understand that you're upset,' it's better to be specific about the reason the person is upset. For example, 'I understand that you're upset that the pharmacy didn't fill your prescription' or 'I understand how you're feeling about Doctor So-and-so, who didn't treat you right,'" Cheng stated.
Zeller urges physicians to talk to patients about why they're upset and how they can help them. That approach worked with a patient who was having a psychotic episode.
"I told the staff, who wanted to forcibly restrain him and inject him with medication, that I would talk to him. I asked the patient, who was screaming 'ya ya ya ya,' whether he would take his medication if I gave it to him and he said yes. When he was calm, he explained that he was screaming to stop the voices telling him to kill his parents. He then got the help he needed," said Zeller.
Cheng was trained in de-escalation techniques as an Orange County reserve deputy sheriff. He and Zeller recommend that physicians and staff receive training in how to spot potentially violent behavior and defuse these situations before they escalate.
Cheng suggests looking at the person's body language for signs of increasing agitation or tension, such as clenched fists, tense posture, tight jaw, or fidgeting that may be accompanied by shouting and/or verbal abuse.
Physicians also need to consider where they are physically in relation to patients they see. "You don't want to be too close to the patient or stand in front of them, which can be seen as confrontational. Instead, stand or sit off to the side, and never block the door if the patient's upset," said Cheng.
He recommends that physician practices prepare for violent incidents by developing detailed plans, including how and when to escape, how to protect patients, and how to cooperate with law enforcement.
"If a violent incident is inescapable, physicians and staff must be ready to fight back with whatever tools they have available, which may include fire extinguishers, chairs, or scalpels," said Cheng.
Christine Lehmann, MA, is a senior editor and writer for Medscape Business of Medicine based in the D.C. area. She has been published in WebMD News, Psychiatric News, and The Washington Post. Contact Christine at clehmann@medscape or via Twitter @writing_health
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Cite this: Physicians Don't Feel Safe with Some Patients: Here's How to Reduce the Danger - Medscape - Feb 14, 2023.