Staying alive was the last thing on Dr. Richard Mansfield's mind when he went to see a patient in his clinic at the V.A. hospital in Vermont two years ago. A primary-care physician, he was scrambling to keep up with a schedule crammed with patients. As he glanced over his next patient's computerized record, he hastily clicked past the "behavior warning" that popped up on the screen. Then Mansfield walked into the room, closed the door, and saw a tall, burly, 50-year-old man. Just as the doctor sat down, his patient suddenly lunged at him, wrapped his hands around his neck, and began twisting.
It's hard for me, as a pediatrician, to fathom being harmed by any of my patients—a parent, a kicking toddler, a hulking teen. The possibility, in fact, never seriously crossed my mind until I read Mansfield's account (subscription required).
My ignorance was naive. According to 2005 data from Bureau of Labor Statistics, health care workers are twice as likely as those in other fields to experience an injury from a violent act at work, with nurses being the most common victims. Nobody in this country keeps consistent track of how much of that violence is directed at doctors. (The last report from the Department of Justice put the number of doctors assaulted at about 71,000 from 1993 to 1999.) Perhaps the most accurate data we have in the United States come from emergency rooms. In a 2005 survey of ER doctors, 75 percent reported at least one verbal threat in the previous 12 months; 30 percent indicated that they had been the victims of a physical assault; 12 percent had been confronted outside of the ER; and 3.5 percent had experienced a stalking event. Of reported physical assaults, 89 percent came at the hands of a patient, the remainder from a patient's family members or friends.
All the average doctor wants to do is heal his patients. What could make someone turn on us? And since both doctors and patients not only value but require privacy, how safe can we ever really be?
Mansfield's attacker wanted pain killers. "I need you to give me more Percocets, given the shape I'm in after what I've been through," the patient said in a soft but gravelly voice. What I've been through apparently referred to a grudge he held against an orthopedic surgeon whose rough examination exacerbated his neck pain. Mansfield says, "[H]e tried to reproduce the 'painful range of motion exam' on me, such that if I knew how painful it was—I would understand how much he needed the Percocet."
Drug seekers and patients suffering from mental illness are the profiles of most violent patients. (Psychiatry can be a high-risk career choice.) But there are many other reasons patients become verbally or physically threatening. Some, like Mansfield's attacker, have understandable difficulty coping with pain, making them more volatile. One group of researchers concluded that physicians represent illness and power; violence may be an attempt to gain control over chaotic, difficult-to-comprehend medical events. Or the trigger could be something more immediate, like the frustration of a long stay in the waiting room. If you erupt too long or too hard with a worker in any other situation—say, a waiter who hasn't refilled your water—you're going to get kicked out. But medicine is different: Refusing care to someone in need of help isn't really an option—even if that person is quite disruptive.
There is no shortage of by-the-book solutions on how to handle violent patients, but none seems terribly persuasive or effective. Hospital protocols to handle violent situations, like many other rules, frequently get buried in file cabinets crammed with other institutional mandates and regulations. Many hospitals rely on some token education, like classes to teach doctors and other workers how to handle threats. In addition to techniques to defuse tense situations, this advice includes things like keeping your phone number and other contact information unlisted and using soft lighting and muted colors to reduce tension. But studies show the effects of such training wane over time: When a group in Vancouver measured violent events before and after staff training, the number of reported violent interactions was 49 at base line and then 19 at three months post-training. Six months later, the number of events returned to pre-training levels.
Some clinics and emergency rooms turned to security systems, but the results fail to impress: A 2003 study by researchers at the University of California-San Francisco looked at the number of weapons confiscated from the emergency room before and after the introduction of a security system that included metal detectors, cameras, and a manned security booth. Sure, more weapons confiscated—but the actual number of assaults remained the same.
Richard Mansfield was lucky. Just as quickly as his patient attacked, he backed off, though he remained between Mansfield and the door. Then the doctor did what he had to do. "At this point, whether or not he was due for his colon cancer screening seemed irrelevant. What I knew … was that the fastest way to get him out of the room was to give him the prescription he'd wanted all along."
A 2006 study confirmed that doctors usually improvise when confronted with a violent patient. Their responses range from pragmatic—like writing the desired prescription—to Vaudevillian. One doctor admitted to carrying a fake gun; another suggested he would fake a heart attack, fall to the floor, and hope the patient would feel guilty for having caused it and just walk out. More disturbing: Forty percent of ER physicians, according to the aforementioned 2005 survey, admitted to carrying a gun, knife, or other weapon.
Some doctors take a more deliberate approach by vetting potential patients, such as declining to see patients believed to be drug seekers. One doctor told researchers that his office has "a list of people who under no circumstances will they be given appointments and no appointments will be given to their relatives." Others use money as a lever. "Our practice, too, has been very strongly discouraging druggies, basically by putting the price up … and since that's happened, we've had much less aggressive behavior," said another physician. Some docs or their groups don't provide care after-hours or at night, when they might be alone or have fewer staff members in the office.
What concerns me is that these measures directly reduce access to care, which goes against the oath we doctors swear: to help others under any circumstances. A would-be patient who can't get through the door may become angered—escalating the threat of violence. There is also no way to cherry-pick an undesirable patient out of health care. If you kick him out of your practice, you won't have to deal with him, but what about your partner or the doctor down the street?
Most doctors (and other health care workers) rarely report incidents of any kind of violence against them—physical, verbal, or otherwise—to police. Mansfield, for one, never pressed charges. Some fear retaliation; others prefer to avoid the accompanying headaches, like time in court and publicity. In certain realms of medicine where violence is particularly common, it just becomes part of the background. "Because emergency medicine physicians, nurses, and techs are exposed to relatively high levels of violent behavior, we have become somewhat accustomed to it. I expect we'll be grading things lower than other health care workers," said one doctor.
Perhaps the most striking reason why doctors fail to report threats or even acts of violence is that they believe their own lack of communication or clinical skills helped escalate a situation from everyday anger to a violent act. That includes Mansfield, who said. "I felt [that] somehow this was my fault, that if I were a better clinician, or a better counselor, I could have addressed his issues before things escalated to physical violence—and so I didn't call the police or press charges."
Not talking about what happened or reporting it can lead to its own set of problems. Some doctors admit that being assaulted has eroded their confidence; others have considered leaving where they work—usually in tough, poorer areas that need more doctors to begin with—or leaving medicine altogether.
Even though we recognize these problems, there simply are not easy solutions. We can put up barriers, profile our patients, hire security guards, and take classes full of tips and tricks. After Mansfield was attacked, his hospital installed a panic button icon on computer screens in all of its exam rooms. But we can't practice medicine like a bank teller behind a plate-glass window. It's just the doctor and the patient who are sitting in that room, and we need it to be that way so we can do our jobs properly. As one doctor said, "The buck stops with us as the practitioners. You can't get around that."