"No physician, however conscientious or careful, can tell what day or hour he may not be the object of some undeserved attack, malicious accusation, blackmail or suit for damages . . ."
Assaults Upon Medical Men. JAMA. 1892;18:399-400.
It is contrary to clinical experience that a patient would want to harm a physician or allied professional who is trying to help. Nonetheless, clinicians inevitably encounter disgruntled, angry, and deranged patients. The reasons for violence inflicted against clinicians are many and varied. Violence is a function of the dynamic interaction between a specific individual and a specific situation for a given period. Patients who feel they have been physically and/or psychologically injured are at increased risk for committing violence against clinicians, especially if their complaints are dismissed. Fear and helplessness are risk factors for patient violence, especially when painful intrusive procedures are used.
Every case of patient violence against clinicians provides lessons to be learned in safety management.
The annual rate of nonfatal violent crime for all occupations between 1993 and 1999 was 12.6 per 1000 workers.1 For physicians, the rate was 16.2. The rate for nurses was 21.9 (80% of nurses were subject to violent crime during their career). For psychiatrists, the rate was 68.2 per 1000. For custodial staff, the rate was 69 per 1000. The rate for other mental health workers was 40.7. Of psychiatrists responding to surveys, the average rate during their careers was 40%.
Surveys of psychiatric residents found an assault rate ranging from 19% to 64%; rates of repeated assaults ranged from 10% to 31%. The assault rate was 20% among surgical residents, and 16% to 40% among internal medicine residents. Compared with the nonfatal crime rate for all workers, health care professionals—especially mental health workers—are at heightened risk for becoming victims of violence.
The following cases are instructional. No blame is intended or implied. The facts in each case were obtained by Google search.
At age 53, Wayne S. Fenton, MD, was a nationally recognized expert on the treatment of schizophrenia. He was an associate director at the NIMH. In addition, he maintained a private practice and treated patients with severe mental illness on weekday evenings and on weekends. Dr Fenton was totally devoted to his patients.
On Saturday, September 2, 2006 (Labor Day weekend), Dr Fenton saw Vitali Davydov, aged 19, in consultation for treatment of severe psychosis. The father was present. On conclusion of the consultation, an appointment for treatment was made for later in the week.
On Sunday, September 3, the patient’s father called Dr Fenton, pleading with him to see his son immediately. The son was agitated and angry about taking medications. At 4 pm, Dr Fenton saw the patient in a small, private office behind a locked door. The father left to run an errand.
Dr Fenton encouraged the patient to take an intramuscular long-acting antipsychotic. Upon the father’s return, he found his son wandering about with blood on his hands. Dr Fenton was discovered beaten to death. The patient told police that he feared a sexual assault, among other fears.
Before accepting a patient for consultation or referral for treatment, an inquiry should be made regarding the nature and severity of illness, a history of violence, drug abuse, and treatment adherence. The clinician can usually make a reasoned judgment whether the individual can be evaluated or treated as an outpatient. Severely ill patients may require referral to an emergency department (ED). The risk of violence to the clinician increases when severely ill, psychotic patients are evaluated or treated while alone, especially during evenings or on weekends.
“No physician, however conscientious or careful, can tell what day or hour he may not be the object of some undeserved attack, malicious accusation, blackmail or suit for damages . . .”
–Assaults Upon Medical Men. JAMA. 1892;18:399-400.
Safety management requires recognition of a patient’s escalating violence, such as agitation, threats, and the crossing of the practitioner’s personal space. Therapeutic zeal and the “First Do No Harm” ethic can lull the practitioner into a false sense of security. As the Fenton case illustrates, the clinician should require the presence of a reliable third party for the initial evaluation of an unknown patient with severe mental illness. The clinician needs to be reasonably cognizant, but not overly cautious, about the ever-present potential for patient violence against health care professionals.
1. Dubin WR, Ning A. Violence toward mental health professionals. In: Simon RI, Tardiff K, eds. Textbook of Violence Assessment and Management. Arlington, VA: American Psychiatric Publishing, Inc; 2008.
2. Thompson BM, Nunn J, Kramer I, et al. Disarming the department: weapon screening and improved security to create a safer ED environment. Ann Emerg Med. 1988;17:419.
3. Slade EP, Dixon LB, Semmel S. Trends in the duration of emergency department visits, 2001-2006. http://psychservices.psychiatryonline.org/cgi/content/abstract/61/9/8784. Accessed December 9, 2010.
5. Scheck J. Stalkers exploit cell phone GPS. Wall Street Journal. August 6, 2010:A1, A4
6. Simon RI. Bad men do what good men dream. Arlington, VA: American Psychiatric Publishing, Inc; 2008.
7. Benitez CT, McNiel DE, Binder RL. Do protection orders protect? J Am Acad Psychiatry Law. 2010;38:376-385.
8. Simon RI, Shuman DW. Clinical Manual of Psychiatry and Law. Arlington, VA: American Psychiatry Publishing; 2007.