Mitigate potential workplace violence

In May of this year, while Atlanta police searched for a man who had shot five people in a medical practice waiting room, Earl Stewart Jr., MD, FACP, an Atlanta-based primary care physician, kept seeing patients. But he locked the practice's front door.

“It was extremely nerve-racking,” he said. “We really didn't know what direction he was going in other than what was provided on the news.”

While such fatalities are rare, physicians may still want to take another look at violence prevention measures that they can adopt to further protect their medical staffs, as well as patients and other practice visitors, according to experts in patient communication and workplace safety. Among some potential steps they suggest are regular training in de-escalation techniques, more routine documentation of worrisome encounters, and seeking guidance from law enforcement or a threat assessment consultant to improve a practice's protocols and physical layout.

Since 2017, the UConn Health primary care practice where Rebecca Andrews, MD, FACP, treats patients has continued to improve and formalize approaches to preventing and managing situations involving angry or disruptive patients.

They've increased de-escalation and active shooter training for medical staffers, which UConn police provides onsite. They use a formal notification process to alert patients if they're engaging in inappropriate behavior, a process that starts with providing a rights and responsibilities form to all patients, detailing their responsibility to be “considerate and respectful, in language and conduct,” and stating that any discriminatory harassment won't be tolerated.

A staff member already trained in de-escalation techniques may be standing by or may sit in on the appointment if a patient with a prior pattern of poor behavior requires medical care, said Dr. Andrews, a professor of medicine and director of primary care at UConn Health in Farmington, Conn. Or the physician may leave the door ajar and alert another staffer, such as a medical assistant, to periodically walk by to ensure nothing is amiss regarding safety. “We also teach them to sit in a chair that's closer to the door than the patient is, just in case,” she said.

Workplace violence and mistreatment are not a new phenomenon for physicians and their medical staff. Health care workers are five times more likely to suffer a nonfatal workplace injury than workers overall, according to a U.S. Bureau of Labor Statistics analysis published in 2018. But it's difficult not to be a bit more on edge in recent years, given the emotions and strained resiliency following years of a pandemic and heightened political tensions, some physicians say.

“I do find it disheartening that we have to consider options such as active shooter training because of how high risk we (health care workers) are for workplace violence events,” said Dr. Andrews, who was speaking the same July week that a Tennessee surgeon was killed by one of his patients.

Outpatient medical practices can be more vulnerable to violence than hospitals, which are more likely to have security guards, behavioral health professionals, and other experts on site, said Sue Bornstein, MD, MACP, Immediate Past Chair of ACP's Board of Regents. Along with providing de-escalation training, practices may consider stressing absolute zero tolerance for verbal or physical aggression, including signs and other postings to that effect, she said.

“It seems like a negative thing to do. Here we are, trying to establish these trusting relationships with our patients,” Dr. Bornstein said. “But unfortunately, it's reality. We live in a world where health care workplace violence is reality. And it's very clear that the pandemic really accelerated this problem significantly.”

Reducing communication breakdowns

Nearly one-fourth of physicians have reported mistreatment on the job during the prior 12 months, most frequently verbal abuse, according to one analysis, published May 6, 2022, in JAMA Network Open. Patients and visitors were the most frequent culprits, followed by other physicians.

One study, involving ED clinicians and staffers at an academic medical center, indicates that workplace violence became more common amid the pandemic. As of April 2020, 34.7% of emergency staffers recalled experiencing a physical assault within the prior six months, according to the findings, published in March 2022 in the American Journal of Emergency Medicine. By December 2020, 45.7% reported such a violent encounter.

Dr. Andrews recently conducted an informal poll with physician colleagues, asking about verbal abuse. “There were a lot of comments made,” she said. “But the one that stuck out to me was someone who just turned to me and said, ‘You mean like every day?’”

The physician also commented that “There is rising frustration and burnout to be found everywhere in health care right now: physicians, staff, and patients too; this leads to heightened emotions and sometimes workplace violence,” Dr. Andrews recounted.

Receptionists also reap significant patient abuse, as the front-line target of shouting, cursing, accusations of malicious behavior, and racist or sexist insults, according to a systematic review of 20 studies published in July in BMJ Family Medicine and Community Health. In the three studies that assessed frequency, between 68% and 90% of receptionists recalled verbal abuse from a patient during the prior 12 months.

Patient frustrations with their medical care can bubble below the surface for some time before flaring, said Thomas Gallagher, MD, MACP, a professor and associate chair of the department of medicine at the University of Washington School of Medicine in Seattle, who studies ways to improve the patient- physician relationship. “As physicians we think we know when patients are unhappy with their care, because we're familiar with patients who complain,” said Dr. Gallagher, an internal medicine physician. “But they are really just the tip of the iceberg.”

In his research, Dr. Gallagher has found that 35% to 40% of patients believe that something has gone significantly wrong with their medical care. But only one out of every 10 of those patients will share their concerns with their physician or another member of their treatment team. They hold back, he said, in part because they worry that their care might be impacted moving forward. “They largely are suffering in silence.”

These patients' concerns aren't trivial, such as parking headaches, but instead range from a delay in diagnosis to a perceived lack of concern about medication-related side effects, Dr. Gallagher said. In one of his studies, published in 2012 in the Journal of Clinical Oncology, patients described problematic events that involved medical care, such as complications from treatment, as well as other problems rooted more in communication.

For instance, cancer patients reported not being informed about treatment options or the clinician not listening. “In patients' minds, communication breakdowns are just as harmful as any other error or adverse event in health care,” Dr. Gallagher said.

When patients do become angry or emotional, their feelings may appear out of proportion with the medical concern at hand, but they likely reflect an accumulation of long-simmering frustrations, Dr. Gallagher said. Physicians shouldn't worry that asking about medical concerns will open a Pandora's box of lengthy feedback, he said. Instead, he suggests establishing a receptive environment from the start.

When Dr. Gallagher meets with a new patient, “I'll just say at the outset something like, ‘Health care is very complicated today, and sometimes things don't go as we expect. If you ever have concerns that there's a problem in your care, please let me know right away so that we can talk about it and address it.’”

Defusing risky situations

Some patient characteristics, such as having a mood disorder or living with chronic pain, may boost the likelihood of a difficult interaction, said Andrea Porrovecchio, MD, FACP, chief of the division of internal medicine at Westchester Medical Center in Valhalla, N.Y. She presented at ACP's Internal Medicine Meeting 2023 in April about turning potential volatile interactions into successful patient encounters. Other patient discontent may be related to the situation, such as lengthy wait times or prior negative experiences with the medical system.

Patients can also become stressed by a seeming turnstile of physicians coming into their hospital room, each focused on their own expertise, said Dr. Porrovecchio, a hospitalist. “That can cause a lot of anxiety when they talk to five different doctors, but they still don't really know what's going on,” she said, adding that it's up to the hospitalist to knit together the bigger patient care picture.

In some instances, body language can be illuminating. A patient may be sitting up in bed with their arms crossed, or primarily looking at the phone. Or they may only curtly respond to a greeting or questions, Dr. Porrovecchio said.

In those situations, she said, “I try to sit down. Eye contact is really important. I just ask the question: ‘Something seems to be bothering you. Is there something I can help you with?’ Or I will ask a more open-ended question. Sometimes people will tell me, and sometimes they won't.”

Physicians should strive not to be defensive, Dr. Porrovecchio said. “It can happen easily when you're tired and hungry yourself.” Try to avoid shifting the blame to someone else, such as criticizing a nurse for not giving the medication, which isn't productive, she added.

And don't underestimate the defusing power of an apology, said ACP Member Kimberly Fisher, MD, an associate professor of medicine at UMass Chan Medical School in Worcester, who has researched communication with patients about breakdowns in care.

Sometimes the patient's concern doesn't involve the physician, such as a delay in lab testing, Dr. Fisher said. But the physician still can express a full apology, she said, such as, “I'm so sorry to hear that.”

Avoid a more limited apology, which calls the patient's concern into question, Dr. Fisher said. For instance, “If that happened, I'm sorry,” is not a good approach, she said. “People want to feel understood and validated about what they went through.”

Discharging, other considerations

Despite a physician's best efforts, not every acrimonious conversation will get back on track, and the physician may decide to step out of the room if the patient continues to yell or becomes very agitated, Dr. Porrovecchio said. “It's a judgment call,” she said. “It's going to be different for every patient. But there comes a point when it's not going to become productive, you're no longer going to move anything forward.”

Documenting any concerning behaviors, even those that may begin as a few unsolicited patient emails, is a crucial protective step, said Ronald Schouten, MD, JD, director of the forensic psychiatry fellowship program at Saint Elizabeths Hospital in Washington, D.C. “I see this with so many professionals, that people do not attend to potential threats, and they don't take those threats seriously,” said Dr. Schouten, a psychiatrist with expertise in behavioral threat assessment and management.

Dr. Bornstein agreed that documentation should become more routine. “That's just not necessarily done,” she said. “If it seems that a patient has a pattern, then at some point you might consider discharging that patient. And that can be challenging too. That is not something that a practice does in a cavalier manner,” she said, noting related potential issues, including patient abandonment.

When physicians have decided to discharge a patient, Dr. Schouten suggests that they seek guidance first from a threat assessment consultant or local law enforcement. But once they take that step, he said, they should be upfront that the patient's behavior is involved, rather than manufacture another explanation. Such avoidance only risks more volatility, if the patient learns later that they have been misled, he said. “Because nothing ticks people off more than being lied to—it's the ultimate sign of disrespect.”

Physicians also can hire a consultant to assess any security-related changes that would benefit the practice, including physical design, Dr. Schouten said. For example, the exam room's furniture should ideally be positioned so that both the clinician and patient can easily exit without going through the other person, he said. (On the advocacy side, physicians can also press for more protection under state law from threats and violence in the workplace for all health care workers. An advocacy toolkit from ACP is online.

In his Atlanta practice, Dr. Stewart said that he's not preoccupied by the recent headlines about fatal health care violence. But as a physician married to another physician, they are difficult to completely ignore, he said. He argues that it's past time that the vulnerability of physicians and medical practices garners more attention.

“We are a soft target. I think we're a softer target, certain medical offices, than schools,” Dr. Stewart said, adding that even some schools have security guards. “We are a soft target because our doors are always unlocked during business hours. We're almost akin to churches.”

Even so, an individual physician's risk remains low, though every shooting undoubtedly resonates, Dr. Schouten said. “The way we define risk is frequency times impact,” he said. “The frequency is very low, but the impact is devastating.”

The best strategies are rooted in ongoing prevention, Dr. Schouten said, including practicing situational awareness, paying attention to relationships with patients and colleagues, and consulting with experts when needed: “Whatever you need to do to make yourself feel comfortable, so you can continue to treat patients the way you want to,” he said.