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In Practice: What to Do When Patients Become Violent

Avitzur, Orly, MD

doi: 10.1097/01.NT.0000391391.51340.39
DEPARTMENTS: IN PRACTICE

Years ago, a close colleague and friend of mine was murdered by a patient. Although the dispute that led to his death was not related to medical care, but rather to the confrontation that resulted from the neurologist's discovery that he had been swindled in a business deal, it was no less frightening nor tragic a loss to my community. According to 2005 data from the Bureau of Labor Statistics, health care workers are twice as likely as others to be victims of violence at work, and while it's not known exactly how much of that violence is inflicted upon doctors, stories are frequent enough to make regular headlines.

In September, a Johns Hopkins orthopedist was shot in the abdomen after informing his assailant that surgery to correct his mother's arthritis had gone poorly. In other high profile cases last year, a patient stabbed her Massachusetts General Hospital psychiatrist, and in Kentucky, a patient seeking prescription painkillers fatally shot his doctor.

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THE NEED FOR BETTER TRAINING

For neurologists and psychiatrists, the risk may be higher than for other physicians since our patients are more likely to have organic brain dysfunction and emotional problems. “But while every psychiatry resident is trained in the way to manage an aggressive or violent patient, neurologists are babes in the woods when it comes to having an ethically and medically responsible strategy to handle these situations, despite our high risk,” said Jeff Victoroff, MD, associate professor of clinical neurology and psychiatry at the University of Southern California Keck School of Medicine.

Lacking sufficient training, most of us tend to act on impulse with patients who cross the line of appropriate behavior. Leonard V. Cohen, MD, a neurologist who practices in Aventura, FL, where public transportation is poorly accessible, has had several encounters with hostile patients, mostly after forbidding them to drive. In one incident, a 70-year-old woman with early frontotemporal dementia and major behavioral problems began hitting him with her umbrella when she was told that she could not drive.

“She went completely berserk and accused her daughter of conspiring with me,” said Dr. Cohen, who had no choice but to invoke the Baker Act and send the patient for emergency mental health evaluation to the hospital across the road. (The Baker Act or Florida Mental Health Act of 1971 is a statute that allows for involuntary examination of a person suspected of mental illness or of being capable of harming himself or others; such laws vary from state to state).

Dr. Cohen also recalled seeing a lawyer in his fifties who refused to take medication for his frequent complex partial seizures. “I told him that no one can force him to take medication but I can insist that he not drive,” said Dr. Cohen. “With that he became extremely abusive and lashed out at his significant other who had tried to provide a history,” he said. When the patient began to use profanity, and to threaten him with lawsuits, he was also sent for an emergency involuntary psychiatric examination.

“The class of patients who are most likely to engage in a serious attack are those with severe frontal lobe impairment and those who are highly impulsive, paranoid, or delusional,” said Park Dietz, MD, PhD, a forensic psychiatrist and president of the Threat Assessment Group, a firm that specializes in workplace violence prevention.

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DEVELOP A PLAN FOR EMERGENCIES

“Attentive staff should be able to hear if a situation is escalating and call 911 immediately,” cautioned Dr. Dietz. “It's better to have false alarms than a tragedy.” Dr. Dietz pointed out that staff often become aware of angry patients before the doctor does. “There is frequently a series of escalating events that occur before violent acts; it's important that your staff not try to handle them themselves, but rather know to bring it to your attention,” he advised, warning that things can get even worse if staff is rude or hangs up on such patients.

Unfortunately, absent training and an emergency response plan, we often act chaotically in the face of a threatening situation. In an incident relayed to Dr. Victoroff by a colleague, one office employee ran for the fire extinguisher, another called the police, and the neurologist reached for her reflex hammer.

“Each one of us needs to have a plan and needs to rehearse it with staff so no one is confused about what to do,” Dr. Victoroff said. Planning should address three scenarios: emergent, urgent, and not urgent. “In an emergency situation — if you feel your life or the lives of your staff are at risk — get the hell out of there,” he advised. “If it's a criminal emergency, you are no longer in a doctor-patient relationship and you should behave like someone is breaking into your bedroom window.”

Robert A. Fink, MD, a neurological surgeon practicing in Berkeley/Oakland, CA, had such emergencies in mind when he obtained a permit to wear a concealed firearm after he first started practice thirty years ago. In taking a headache patient's history one day, he became suspicious that one of the main reasons for her pain was daily physical abuse inflicted by the boyfriend, who insisted on being present throughout the entire history and examination. Dr. Fink was sufficiently concerned about the situation that before going into the exam room, he strapped a .45 caliber semi-automatic pistol onto his belt and covered it with his suit jacket.

“At one point, I said something which apparently displeased the boyfriend, who got out of his chair, screamed at me, grabbed me by my tie and forced me into the corner of the room, stating ‘I'm going to beat …you…’,” recalled Dr. Fink, who responded by staring his assailant directly in the eyes, and replying, “If you don't let me go by the count of three, I am going to kill you.”

Dr. Fink admitted that he couldn't have done so if he wasn't armed (legally so and military-trained). He's also grateful that his attacker believed him, immediately released his grip, and stalked out of the office. The patient then confessed that she had been mortally fearful of her boyfriend and agreed to call the authorities.

Although Dr. Victoroff agrees that if you're backed into a corner with a homicidal patient wielding a scalpel, for example, you must fight him with every weapon at hand as you're calling for help, he also warns that bringing a gun into a room with a violent person is extremely risky, regardless of training. “Over and over again, the person with the gun gets killed,” he observed.

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LEARN TO ASSESS RISK

While experts provide clear instruction on how to respond to threats that escalate into physical encounters — call for security and/or 911— most times it's not quite an emergency, it's somewhat ambiguous, Dr. Victoroff said. “You sense that there is a risk but you're not sure that it requires that you run away out the door of the building and calling the police.” In such urgent cases, you can try verbal de-escalation, he advised, but you must simultaneously get yourself into a position from which it is easy to flee and then call for help.

It was an instinctual reaction to threat that Dara G. Jamieson, MD, incoming president of the American Society of Neuroimaging, and associate professor of clinical neurology at Weill-Cornell Medical Center, experienced when she saw a patient two years ago after a bottle dropped out of a window onto her head, and the patient sued the building occupant. “I could tell that the patient didn't like me, a sentiment that was confirmed when she wrote a few very nasty (but amusing in their ridiculousness) letters that I handed over to my hospital,” recalled Dr. Jamieson, who upon Googling her, discovered that her patient had served a prison sentence for fatally shooting her lawyer boss. This was not at all reassuring when the patient requested her medical record be “corrected” to improve the evidence for her current litigation, said Dr. Jamieson.

When you are fearful of seeing a patient again, experts advise that you discharge the patient. “You have no ethical duty to see someone you are frightened of in an uncontrolled setting such as your private office,” Dr. Victoroff said. “Confidentiality sometimes takes second place in such cases, your first priority is to protect everyone against physical harm,” he concluded.

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HOW TO DE-ESCALATE A THREATENING SITUATION

Park Dietz, MD, PhD, president of the Threat Assessment Group, advises that in the event of an escalating situation, it's important that you don't become a threat to the patient:

  • Speak in a soft voice
  • Show your hands
  • Increase the distance by backing up
  • If you're big, get small (sit down and let them tower)
  • Give the patient space to be as verbal as he or she wants to be; allow the patient the opportunity to rant
  • Don't do anything that will provoke, humiliate or threaten

Dr. Avitzur, a neurologist in private practice in Tarrytown, NY, holds academic appointments at Yale University School of Medicine and New York Medical College. She is an associate editor of Neurology Today, as well as the editor-in-chief of the AAN Web site, AAN.com, and chair of the AAN Practice Management and Technology Subcommittee.

©2010 American Academy of Neurology