How can doctors practice medicine safely without compromising on care?

Health and medicine explained.
March 18 2010 6:44 AM

When Patients Attack!

How can doctors practice medicine safely without compromising on care?

Illustration by Robert Neubecker.

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.

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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."

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