"I walked into the circle, took the patient by the hand, walked him across a lawn and up 2 flights of stairs. I got him into the locked men's ward, and I said 'I'm going to have to take away your ground privileges.' He picked up a water fountain—pulled out the pipes—and threw it through the nurses' station window. I thought, 'That was stupid. It could have been me.'"
Fink's personal experience reflects the findings of researchers of violence against physicians. David Fink, MD, surveyed psychiatric residents at several institutions in Pennsylvania and found that 41% said they had been assaulted and 48% had been threatened during their training. In an essay included in the APA's clinical practice publication Patient Violence and the Clinician, he noted that "Available studies confirm that a substantial percentage, approximately 40 percent, of psychiatric residents will be assaulted at least once during the course of a 4-year residence. . . . Violence against residents cannot be considered as an occasional and acceptable risk of training."1
Citing an earlier study, David Fink quoted S. I. Hallack as pointing out a possible reason for the increased risks during residencies: "Psychiatric training programs traditionally place their least experienced doctors in the most difficult treatment situations."
The effort to predict which patients may present a threat is still in its infancy. A study reported in BMC Psychiatry by Abderhalden and colleagues2 noted that the BrØset Violence Checklist has been effective when used with patients in the hospital: "The [checklist] assesses the presence of six observable patient behaviors namely whether the patient is confused, irritable, boisterous, verbally threatening, physically threatening, and attacking objects. The reported discriminatory ability is good with a correct prediction rate around 85%."
Paul Jay Fink suggested that practitioners dealing with unstable or unknown patients might improve their safety by redesigning their offices. "Place your chair closest to the door so you don't paint yourself into a corner. . . . There are times when you may . . . have to leave the door of the office open so that you have vocal access to somebody who will hear you. But that's when you know a patient is threatening.
"Most offices are not organized in the way I'm talking about," he added. "I don't have a single schizophrenia patient in my practice. I'm an analyst; I see patients on the couch. If I had Fenton's practice, which was almost all schizophrenia, I might have a panic button. If I thought a patient was extremely dangerous, I might ask a family member or a colleague to sit in with me. But you can't do that frequently. You've got to know the customer."