Is Being a Victim Part of the Job?
Rosalind Kaplan, MD
On June 1, two doctors, a medical receptionist and a patient were gunned down in the doctors' outpatient office in Tulsa Oklahoma. Investigation revealed that one of the doctors
was the intended target; a patient, angry because his pain was not yet relieved a few weeks after a spinal surgery, decided that the doctor who performed the surgery deserved to die.
The other victims were collateral damage.
This event is shocking and horrible. It is frightening to know that a place where people go looking for care and healing, a place where we should feel safe, became a place of danger and killing. But violence against healthcare workers is by no means a new phenomenon. In fact, healthcare workers have been the target of violence, aggression and abuse for many years, with up to 70% of nurses and doctors reporting verbal abuse by patients or families and up to 45% of emergency room doctors reporting physical assaults. And while assaults are most common in emergency settings, where mental health and substance abuse issues are likely to be encountered acutely, the incidence of violence against healthcare staff in a variety of medical settings has been rising steadily and has increased significantly since 2021, presumably related to the pandemic. While most hospitals and healthcare systems have security guards and, in some buildings, metal detectors, the issue of violence against healthcare workers has not been addressed in any other comprehensive way.
So the shooting in Tulsa last week was shocking, but not that surprising. It is entirely predictable that unaddressed systemic problems will worsen over time, particularly in an environment of fractured hope, political unrest, economic and healthcare disparities, and easy gun access--i.e. the current environment of the United States of America.
Sadly, many healthcare workers- doctors, nurses, technicians, and others- have come to view being the victim of physical and/or verbal assault as 'just part of the job.' There are a variety of reasons for this.
First, when we encounter patients who are unable to behave appropriately because of intoxication, delirium, or psychosis, we certainly don't want to punish them or worsen their situation. We must do the best we can to help those patients, to keep them, ourselves, and others around us safe. As compassionate professionals, many of us want to preserve the dignity of such patients to the extent that it is possible. In fact, preserving safety and dignity in these situations is, truly, part of our job. The trick here is having the right tools to do that job: training in de-escalation, access to safety equipment, a panic button, other people to help restrain a physically violent person... AND immediate access to care and counseling for the involved healthcare workers, to mitigate physical and emotional trauma. The unfortunate truth is that we rarely have all those tools. Often, we don't have any of them.
Unfortunately, many episodes of violence, aggression and abuse are perpetrated by patients and families who are physiologically able to control themselves, but are just very stressed. They are frustrated and angry at long wait times, insurance issues, and burdensome administrative procedures. They are scared and stressed and in pain. They feel dehumanized by the medical system, powerless to get their needs met. Lashing out may seem like the only way to cope.
When we are at our best, healthcare workers have empathy for all of this. We get it. We are trained to alleviate distress. But we are also human. And frankly, we are not at our best these days. Even if we have the empathy to understand it, we often don't have the bandwidth, the energy, the reserve needed to handle it in the best way, and that can lead to escalation. Sometimes, even if we do handle it well, aggression escalates anyway. Either way, it exhausts us further to have to manage anger, aggression and abuse along with the other aspects of our jobs.
Besides, just because we have empathy for someone's plight doesn't mean we need to tolerate all the hate that's thrown our way. Does dealing with angry, frustrated patients need to be part of our jobs? Or should there be a 'no tolerance' policy for abuse in medical settings, like schools have 'no tolerance policies' for drugs? Should aggressive, abusive patients and families be thrown out of these settings, or not allowed to return?
I recognize that we need to give life or health-saving treatment, regardless of patient attitude, but could we then disallow future visits?
I think I, personally, came to feel that violence and abuse is part of the job because my training program and the institutions I worked for early in my career gave me that message.
As an intern, I was bitten by an intoxicated patient in the ER. Nobody could have foreseen this, but it was laughed off by those around me, and by my supervisors; the only thing I could do was act nonchalant about the whole thing. I was berated, verbally harassed, and threatened by ER or hospitalized patients more times than I can recount during training. Later, as an attending working for a healthcare system, I was not allowed to dismiss patients from my practice, even with a referral to another doctor, for verbally abusing me or other staff unless or until it became a persistent problem. I had to see threatening patients for emergencies for 90 days, even after they'd received a dismissal letter. The message was clear: my safety and sanity was less important than 'customer satisfaction' or concerns of 'abandonment' lawsuits. And I was never offered education regarding management of violent or abusive patients. It was assumed that I would know.
By necessity, I learned these skills on my own. When a psychotic patient, someone I'd never met before, placed himself between me and the door of my exam room and threatened to set off a nuclear bomb, I asked him what he needed, and he told me. He'd been given a prescription for penicillin by another doctor, but the doctor had written it in medical abbreviations, which the patient believed was secret code, and intended to harm him. I was able to solve the problem by re-writing the script in English, and he left (he also showed me the inside of the bag he was carrying- no bomb). When a patient wielded a knife at me and my resident in medical clinic, I was able to talk him down. He was angry at his landlord and was confused about who we were. He agreed to an emergency psychiatric evaluation. When a heavily intoxicated patient smeared feces on the walls of my practice waiting room, I locked my staff and myself in an office and called 911 (I know when nothing I do or say is going to make a difference).
I consider myself lucky- I've walked away from violent and threatening episodes physically unscathed. Still, each one is exhausting. Despite the fact that these incidents were reported to my employers, I was never been offered any kind of debriefing or counseling. Again, I had to seek out help on my own when I needed it. It makes me question my decision to continue working in medicine. Recently, in a job I've now left, I had a patient throw a mask at me and lunge at me. I encountered several patients who were verbally abusive to staff in the clinic; one used racial and ethnic slurs. Another made a gun threat on the phone. Even in my current position, a lot of patients seem on edge, and I find myself wary at work. We have panic buttons and in some sites we have security guards, but we can't be prepared for everything.
We need to acknowledge that abuse of healthcare workers is one of the many factors leading to burnout. Already, burnout is responsible for one out of five doctors planning to leave the profession in the next two years. Already, burnout is responsible for a serious nursing shortage and an impending serious physician shortage.
I wish healthcare had taken a harder stance on aggressive behavior long ago. I wish we didn't have to see it as 'part of the job.' I think we ought to, as a profession, make a clear statement that it will not be tolerated, and that we will not allow abusive patients to return to our places of work. We also need to consistently teach de-escalation techniques and provide debriefing when healthcare workers are victimized. I fear that we will lose more doctors and nurses to burnout from violence and, tragically, to death from violence. We can't afford that loss.