Preventing Violence in Medical Settings

(This article originally appeared in Sierra Sacramento Valley Medicine.)

Dr. Hayes was dazed, afraid, and outraged. His patient, Mr. Maxwell, a 45-year-old with chronic knee pain, had just punched him in the mouth in the exam room. He suppressed the urge to fight back, left the room, told his MA what had just happened, and went to the bathroom to collect himself. From the bathroom he heard the familiar PA announcement that had previously never been associated with him: “Code Grey, Room 4, Side B.”

Over the course of thirteen years working in a community medical center, I’ve heard these announcements with increasing frequency. This observation hews with SSVMS’s own internal member polling data, which found this year that 39% of respondents reported having experienced one or more of these types of on-the-job mistreatment: sexual harassment or abuse; verbal mistreatment or abuse (including racial slurs); and physical intimidation, violence, or abuse. Statistics are still taking time to catch up with the COViD-19 pandemic and its aftermath, but there is increasing evidence that patient violent behaviors are continuing to rise worldwide, leading to what some are calling an epidemic of patient violence. In 2019 about 7 in 10 emergency room physicians reported believing that ER violence was increasing. Emergency rooms, psychiatric units, and geriatric settings have long been identified as arenas where patient violence might be expected. Now there is real concern about an uptick in violence in outpatient primary care settings.

In my experience as a faculty in a family medicine residency program I was frequently met with requests by busy, stressed residents to “tell me what to do” about complicated patient scenarios. While I certainly understand an overworked physician’s desire for a simple solution, the complex origins of any violent patient encounter must be factored in. If we are to understand and respond to patient violence risk, we must understand context on multiple levels.

Many factors contribute to the moment that explodes in violence. A common denominator in many studies implicate long wait times and poor communication from staff about the wait time. Also, improper workplace design has been implicated in increasing patient stress. For example, crowded, hot waiting rooms with few amenities (restrooms, windows, or greenery) can contribute to a stressful wait. Poor professionalism and inappropriate comments from staff, and poor physician communication skills have also been implicated.

Within the patient, there are several possible factors that can contribute to a violent outburst. These include:

• Acute intoxication or withdrawal
• Life stressors (e.g., unemployment, financial stress, marital discord)
• Acute/chronic pain
• Acute/chronic mental illness causing acute agitation
• A history of trauma (medical or otherwise) that is activated within the medical setting.
• Certain medical conditions, particularly ones with neurologic complications (e.g., dementia, delirium, stroke)
• Prior experiences with racism, sexism, and/or any of the other “isms”
• Low health literacy and poor understanding of the healthcare system by the patient and their families.
• Discrepancy between patient expectations and services.
• High cost of services leading to financial stress
• Prior negative experiences in medical settings that predispose the patient to be hostile and expecting more mistreatment (“you doctors are all the same, you never listen”)

Mr. Maxwell has had chronic bilateral knee pain related to overuse in his carpet laying job. He has not worked and has been fighting for disability for two years. His previous physician (now recently retired) gave him hydrocodone monthly with escalating doses for his pain. Five years prior his teenaged son was in a car accident and was brought to the hospital adjacent to the clinic, where he died in surgery; coming to the outpatient clinic re-activates this trauma response in him. He feels deep shame from the financial stress of not working and providing for his family. Dr. Hayes is the third provider he has seen in the past two weeks to try to get his hydrocodone refilled.

Because any violent encounter involves at least two people, it is important to remember that physicians may be bringing something unintentional to the encounter that is contributing to the escalation. The training of physicians and the conditions of their work may increase the likelihood of patient violence. Physicians may come to patient encounters with any or any combination of the following:

• Lack of training on recognizing and managing violence
• Lack of awareness of body language (their own and the patient’s) that subtly communicate defensiveness and lack of treatment alliance.
• Poor medical and communication skills
• Poor time management
• Burnout, leading to defensiveness and a loss of empathy with patients.
• Physician’s own emotions and countertransference to the patient

Dr. Hayes was short on sleep and running late due to being double-booked per company policy. All of his patients were showing up this day. He was frustrated and stressed, as it was only 3:00 p.m. and he had eight more patients to see. Upon entrance to the room, he saw his new patient Mr. Maxwell, who was pacing the room. Mr. Maxwell irritably started the visit with “I need my pain medicine refill.” From some previous patient encounters, Dr. Hayes had assumptions about patients requesting opioids. Not tracking Mr. Maxwell’s body language and vocal tone, he flatly told him “I don’t prescribe opioids for chronic pain.” Mr. Maxwell’s frustrations boiled over and he punched Dr. Hayes.

Any violent encounter has a multi-factorial context. Recognizing the patient’s escalating agitation is the first and most crucial step indicating a need for physician intervention, closely followed by least some physician understanding of the context behind the patient’s escalating behavior. Without an understanding of the events leading up to the agitated presentation, two crucial pieces are missed: 1. An opportunity to address the patient’s concerns to satisfaction (or some modicum thereof), and 2. An ability to empathize with the patient’s experience that led to the strong emotion. I have always appreciated the subtly profound message found on those kindergarten facial feelings posters: “All feelings are okay, it’s what you do with them that counts.”

I would argue that, except in cases of neurological dysfunction, violent episodes are at base the result of an empathic breakdown between patient and provider. This breakdown has its roots in one or more of the systems issues, from the healthcare entity to the patient experience to the provider experience leading up to the patient encounter. Having limited agency to impact systems- and patient-specific experiences, the physician must look to each patient encounter for clues on how to prevent violence.
A great challenge to understanding the patient perspective is physician burnout, which according to the AMA was at 63% as of 2021. One of the key components of the Maslach Burnout Inventory is “depersonalization,” where the physician starts to have an unfeeling and impersonal response to their patients. At a time when the systemic stresses on physicians are as bad as they’ve ever been, it seems unfair to suggest that the physicians must be the ones to mitigate the burnout through their personal change. However, because complex medical systems take time to change, physicians who want to have increased safety (and overall well-being) must also adopt certain personal practices, including self-care, that may lessen their sense of burnout.
One means of lessening burnout is to attain and maintain a good working relationship with one’s patient, otherwise known as a treatment alliance. It is easy to feel when one has lost (or never had established) a treatment alliance with one’s patient. Of course, this may happen several times per day, even for a few moments. Even so, it is imperative that the alliance is established for the patient encounter to move forward productively without violence.
Patient interaction research has demonstrated that certain practices work well to develop and maintain a treatment alliance: greeting the patient and everyone else the patient brought with them, a little small talk, sitting down, good eye contact, open-ended questions to start the clinical portion, and giving the patient the first 90 seconds to explain before interrupting. Reflecting back and summarizing the patient concerns helps them to feel heard and understood.
One evidence-based technique that encapsulates most of these patient interaction skills is motivational interviewing (MI). A key component of the ethos of MI is that it is patient-centered and collaborative. When a treatment alliance has been severed, MI can be a very effective means of defusing conflict and re-establishing trust in the physician. “Rolling with” the patient’s resistance by reflecting it back to them rather than getting defensive is akin to dropping the tug-of-war rope. The vulnerable core behind many patients’ aggression and hostility is a fear of not being heard and understood. When one connects to that vulnerability by becoming inquisitive instead of defensive, patients are much more likely to de-escalate.

Meta-analyses of patient violence scenarios identifies several key strategies likely to mitigate violence risk. Understanding body language and personal space is a key element to defusing a tense situation. Many patients who have a history of trauma may literally be in “fight or flight” while in the room with you, and you or they may not know what has triggered them. If a patient seems unduly agitated, you need to respond with calm, open body language and soft verbal tones. Ideally make sure that you give your patient and yourself an escape route from the room, so no one feels or is “cornered.” Make sure you are giving at least two arms’ length of space to decrease their sense of physical danger and to give you time to respond should they lash out at you. If the patient tells you to get out of the way you should immediately do so. If you at all feel unsafe, make an excuse to leave the room for a few minutes (“I need to go check on your labs, I’ll be right back”). Often this intervention alone can de-escalate someone who’s activated. With no opponent to battle, the heart rate slows, and rationality can kick back in.

If the patient is well into the agitation phase (tense body language, flushed, pacing, raised voice), make sure to use short sentences and simple vocabulary. Recognize that the person may need more time to process and respond to what you are saying, and you should repeat as often as necessary until it appears that the patient has heard and processed the information. If the patient needs redirecting, it may help to set a clear limit but in a neutral tone such as “it is okay for you to be upset but you may not yell or threaten me or the other staff,” or “I really can’t hear you when you are pacing, and I feel unsafe. I really want you to sit down and calmly tell me your concerns so that I can help you.”

Finding areas to agree with the patient can help them to feel heard and understood. For example, if the patient complains about having been made to wait, you might say “Yes, I agree that waiting an hour to see me is too long. If it were me, I would be very upset too.” If one can’t agree, it is okay to agree to disagree. It may have helped if Dr. Hayes said to Mr. Maxwell “you clearly need help with managing your pain, but I disagree with your previous physician that hydrocodone is the best route to that. I understand that you think it is the only method that has worked for you. I think we will have to agree to disagree on hydrocodone and work to find another solution.”

Following a violent situation, even if it didn’t escalate into physical violence, it is important to debrief the episode with the patient both to set limits on this type of behavior re-occurring in the future and to try to re-establish the treatment alliance for future visits. In addition, personal debriefing with any of the parties involved and with a colleague, supervisor, and/or therapist can help to let go of lingering painful feelings from the episode.

Patient violence always has a context and antecedents. If physicians become adept at identifying the risk factors that the patient brings with them, then they can minimize the risk of violence and help re-establish a treatment alliance. Looking for signs of increased agitation, monitoring one’s own tone and body language, protecting oneself by leaving the room if necessary, engaging in reflective listening, and setting clear limits when the patient is calm enough are all tools that every physician should have available to themselves.