Case Scenario

I have been the family physician for a middle-aged man for several years; we have had multiple visits over those years. During our encounters, he has always been polite, modest, and kind. Months ago, I discovered that he has been rude and demeaning to my medical assistant. This behavior has occurred on multiple occasions, on the phone and in person.

I feel guilty because when I see him, he is servile and mild-mannered. I want to ask him why he acts differently with other members of his care team, but I have not found the courage to confront him.

I am not sure whether it is professional or ethical for me to address his behavior with him, but I think I need to take action to ensure the well-being and safety of my staff. Because of his aggressive language and current news that is filled with acts of violence, I am concerned that his behavior might escalate.

Commentary

In July 2017, Dr. Todd Graham was fatally shot by his patient's husband when Dr. Graham denied his patient's request for opioids.¹ This case highlights that, according to the Bureau of Labor Statistics, health care professions are one of the most dangerous industries of employment in the United States.² Dr. Graham became a victim of the most common type of health care–associated violence: patients, or their families or friends, against health care professionals.³ Nurses, who comprise a field that is predominantly staffed by women, are most often the target of this violence.⁴ The acts of violence include verbal aggression, threats of bodily harm, and even death. In addition to physical injury, violence can cause psychological harm, including insomnia, depression, and posttraumatic stress disorder³; witnessing the aftermath of violence has the potential to provoke a variety of psychiatric conditions in first responders.⁵

Although violent tendencies are often present in patients with underlying risk factors (e.g., substance abuse, psychiatric illness, delirium, criminal history, delusions), individuals without this history commit the majority of violent acts.⁶

Physicians typically have little knowledge about or training in responding to potentially violent behavior. Because episodes of violence are becoming more common, with some episodes occurring in and around the health care setting,¹ physicians and staff must have basic preparedness skills. In particular, health care professionals should be aware of current recommendations to recognize and de-escalate potential violence.

Current methods to prevent violence against health care professionals are largely based on expert opinion. The U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) has issued a detailed guideline emphasizing management commitment, risk-factor identification, violence recognition, mitigation training, incident reporting, and root-cause analysis. OSHA recommends that health care professionals be able to recognize escalating behavior that may lead to assault and to defuse aggressive behavior and manage anger. For potentially violent situations, OSHA also advises a standardized response plan that includes trained personnel, alarm systems, or communication protocols. Similarly, other prevention methods include reducing the ability to commit violent acts (e.g., installing metal detectors, having nonmovable furniture), creating a calming and less frustrating environment, and reducing stress-provoking situations (e.g., long lines).^7,8 OSHA does not provide evidence-based techniques that are effective in conflict mitigation.

The Centers for Disease Control and Prevention (CDC) has published a free online training program for workplace violence prevention that offers insight about how to mitigate violence against health care professionals.⁹ The CDC⁹ and some physicians¹⁰ view the escalating forms of violence as a crisis continuum and advise training health care professionals to recognize the development of a crisis in stages that range from normal stress and anxiety levels to crisis and crisis resolution. These experts recommend using verbal and nonverbal communication skills as a way of defusing tensions in the early and middle stages of a developing crisis in which the patient can still cognitively respond. For instance, during the early and middle stages of crisis development, when anxiety and stress levels are moderate, these experts advise asking aggressors to express their concerns while empathizing with the situation and then seeking to resolve the issue with a shared problem-solving approach.^9,10

In this case, the question is not whether to intervene, but how. If the physician does not feel comfortable in de-escalation techniques and conflict management, then perhaps it is better not to directly confront the patient because the situation can potentially escalate into a crisis; however, the physician's institution can implement OSHA's recommendations to have a violence response plan with properly trained personnel to defuse the situation. The physician could then activate this plan. The health care community is still in the hypothesis and data-gathering stage; reporting and analyzing cases are essential to implementing institutional change to prevent further incidents. Physicians, such as the physician in this case scenario, should offer support to nursing staff and should share guidelines about preventing violence against health care professionals. Response strategies should be planned, and reporting and debriefing of an incident should be encouraged. Research still needs to be completed in violence mitigation strategies so that we can have evidence-based tools to combat this growing epidemic.