"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.
David Cornbleet, MD, Dermatologist
Dr Cornbleet, aged 64, was killed on October 24, 2006, by a former patient, Hans Peterson, aged 29. According to police, Peterson saw Dr Cornbleet for only 1 visit in April 2002. Isotretinoin(Drug information on isotretinoin) (Accutane) was prescribed for acne.
Dr Cornbleet had been in private practice in Chicago for 30 years. He had a high-volume caseload and saw more than 100 patients a week. He, too, was very devoted to his patients. After his long-time receptionist died, Dr Cornbleet continued to practice without a receptionist.
Peterson waited until the building was almost empty. Surveillance video shows him entering the office building at 4:45 pm and exiting 45 minutes later. Peterson covered his face when leaving the building so that he could not be identified. He had previously surveyed the building and had determined where the security cameras were placed. Dr Cornbleet was brutally tortured, stabbed, and murdered. His mouth, hands, and feet were duct-taped. Peterson stated he murdered Dr Cornbleeet because the isotretinoin caused persistent adverse effects that made him impotent, although no evidence exists for such an association.
Devotion to one’s patients is commendable, but it should not create a potentially fatal denial of danger. A carefully thought-out safety management plan is necessary. Although most clinicians do not experience a violent patient attack during their professional career, consultation with a safety expert should be considered. The higher the practice volume, however, the more likely the practitioner will encounter disgruntled or deranged patients. Other risk factors for exposure to harm include years of practice, types of patients treated, and the clinician’s style of patient engagement. However, at the other end of the practice spectrum, especially during internship and residency, a lack of experience combined with treating very sick patients increases the risk of patient violence against the clinician.
One cannot assume that all patients are grateful. Some patients are angry and blame the clinician for their illness. As the case of Dr Cornbleet demonstrates, a single visit by a deranged patient can lead to unexpected violence against the clinician years later. In any safety management plan, the clinician also must consider his or her age and physical condition in determining the ability to escape or to fend off an assault. Patients’ violence toward clinicians has many expressions, not only physical (Table 1).
TABLE 1: Varieties of patient violence
■ Threats (also Internet)
■ Harassment (also Internet)
■ Stalking (also Internet)
■ False and scurrilous accusations (also Internet)
■ Frivolous lawsuits
■ Complaints to licensure boards
■ Abusive/excessive phone calls, letters (also by third parties)
■ Threatening or obscene mail (also Internet)
■ Drive-by and home visits
■ Displaying knowledge of clinician’s personal life; eg, names of spouse, children
Kathryn Faughey, PhD, Psychologist and Kent Shinbach, MD, Psychiatrist
Dr Faughey, aged 56, saw patients in the evening at her East 79th Street Manhattan office. Dr Shinbach occupied an adjoining office suite with a shared waiting area. At 8 pm on February 2, 2008, a surveillance camera spotted David Tarloff pulling 2 roller bags. Tarloff told the security guard he was seeing Dr Shinbach. The bags contained a meat cleaver, knives, rope, women’s clothing, slippers, tape, and adult diapers. The surveillance camera showed a security guard reading what appeared to be a newspaper. Another individual, talking on a cell phone, was emerging from the door immediately adjoining the reception desk.
Tarloff, aged 39, was a former patient of Dr Shinbach. Tarloff waited in the office reception area, chatting with a patient, while Dr Faughey was in session. When the patient concluded the session with Dr Faughey, Tarloff entered her office. Dr Faughey and Tarloff talked for about 20 minutes. What was discussed is not known.
Tarloff viciously attacked Dr Faughey with the meat cleaver. Screaming, she furiously tried to fight off Tarloff. Dr Shinbach, hearing her screams, tried to help but was seriously wounded by slashes across the face and neck. Dr Faughey was hacked to death. Tarloff bore a grudge against Dr Shinbach for giving him a diagnosis of schizophrenia and involuntarily hospitalizing him in 1991. Dr Shinbach was the originally intended victim.
Again, seeing patients while alone, especially at night, requires careful safety planning. Offices should have 2 doors, one leading to the receptionist’s area and a locked door that leads to the clinician’s office. The second door should have a peephole to see who is in the reception area. A separate exit door that allows the clinician to leave when a threatening individual is in the reception area is usually not available. Even if a receptionist is present, consider a panic alarm or buzzer system that alerts the building security or police. A silent alarm or warning light can also be used to alert the receptionist or security.
A comprehensive safety management plan preempts patient violence. For example, individuals entering the office building must identify themselves as well as their destination before they can proceed. The security person calls the clinician’s office to verify that the individual is known to the clinical or clinician’s staff and has a scheduled appointment. If such safety procedures were operative, Tarloff would not have had easy access to Dr Faughey and Dr Shinbach. This security arrangement may not be possible in other settings, eg, home offices, open clinics, and EDs.
The totally inadequate security at the entrance to Dr Faughey’s building, clearly caught on the surveillance camera, allowed Tarloff to proceed unimpeded on his homicidal mission. A vital lesson learned is that clinicians are responsible for their own safety management. Building security, even when adequate, is not enough. The clinician must do more to provide for personal safety.
In Dr Cornbleet’s case, the murder occurred 4 years after Peterson’s only appointment. Tarloff killed Dr Faughey and severely injured Dr Shinbach 17 years following his involuntary hospitalization for schizophrenia. For mentally ill patients with grievances toward clinicians, their paranoia and rage is timeless.
Clinicians often see thousands of patients over the course of their careers. No determination can be made about if or when a former patient will decide to harm the clinician. The clinician will not likely remember or recognize the patient many years later, especially if the patient was seen for a single visit or few visits. Thus, a safety management plan is required to protect against the contingency that violence could arise at any time from a violent patient long forgotten. While a violent attack against the clinician may not be foreseeable, it may be preventable by a comprehensive safety management plan.
Violence has a vector. It can be directed at the intended victim or redirected toward an unintended victim. Dr Faughey was not the intended victim of Tarloff. Thus, all clinicians who practice together must rehearse and adhere to a mutually agreed on safety management plan against potential patient violence. Although the patient’s grievance may be directed at a single clinician, all clinicians who practice together are at risk for violence.
Clinicians who work in EDs experience the highest level of patient violence (Table 2). High-risk violent patients are frequently evaluated and treated initially in the ED. The police often bring in violent patients who are handcuffed. Since the ED is open to the public, the patient population or accompanying third parties are usually not screened for potential violence. No therapeutic alliance is initially present to help mitigate a patient’s violent impulses. The patient may view the ED clinician as an enemy, not as a helper. Henry Ford Hospital in Detroit conducted a 6-month screening by magnetometer of ED patients.2 Thirty-three handguns, 1324 knives, and 97 mace-type sprays were discovered.
TABLE 2: Violent venues
■ Emergency departments
■ Psychiatric facilities
■ Home offices
■ Private outpatient offices
■ Forensic settings
■ Community mental health centers
■ Outpatient clinics
■ General hospitals
■ Wherever patients are seen
Patients with alcohol(Drug information on alcohol) and drug toxic syndromes with attendant violent behaviors are common. Individuals who accompany the patient may themselves be as or even more violent than the patient. Psychiatric patients frequently endure long waits in busy EDs, often on gurneys in noisy hallways, before being seen.3 Some psychiatric patients wait longer than 24 hours before being evaluated. Patients who already are angry can become enraged and violent.
The Joint Commission, in a Sentinel Event Alert issued June 3, 2010, reported increased numbers of homicides, rapes, and other assaults against patients or visitors by staff, by other visitors and patients, or by intruders at US health care facilities.4 Clinicians and hospital staff are also at increased risk for violence by both patients and visitors.
Psychodynamics of violence
As noted, violence is a function of the dynamic interaction between a specific individual and a specific situation for a given period. Violence is often a reaction to passivity, helplessness, fear, and humiliation. A violence prodrome provides the clinician with an opportunity to intervene before the outbreak of violence. Escalation of anxiety, verbal abuse, and agitation are components of the prodrome.1 Risk factors associated with violence can also alert the clinician to potential violence (Table 3).
TABLE 3: Risk factors associated with violence
■ Risk factors associated with violence
■ History of violence
■ Stated desire to harm or kill another
■ Alcohol and substance abuse
■ Psychosis, especially command hallucinations
■ Personality disorders, especially antisocial, borderline
■ Childhood physical or sexual abuse
■ Paranoid ideation, thought insertion or control
■ Fear of harm, humiliation
■ Organic brain disorder
Adapted from Simon RI, Shuman DW. Clinical Manual of Psychiatry and Law. 2007.8
Understanding the psychodynamics of violence informs intervention strategies. This may not be possible, however, for patients who are seen at an initial visit for examination or for consultation. Violence can occur suddenly, without warning. For example, Davydov, who saw Dr Fenton for an initial treatment consultation, responded with fear of a sexual assault in response to Dr Fenton’s recommendation of an intramuscular, long-acting antipsychotic medication. It is very difficult, often impossible, to discern when a patient will react violently to a simple encouragement to take an intramuscular medication. Drs Cornbleet and Faughey never had a chance to observe a prodromal escalation of risk factors before their murders.
The clinician is frequently an object of powerful feelings—both positive and negative. The patient may view the clinician as a savior, a god, a magician, or the devil. The presence or absence of a therapeutic alliance with the patient is a powerful, but not absolute, protective factor. Patients who are disgruntled, angry, treatment-demanding but treatment-rejecting are prone to filing lawsuits against clinicians. Lawsuits, however onerous and frivolous, provide a socially acceptable means for channeling a patient’s aggression. Although some will disagree, it is better to be sued than to be killed.
The patient who wants to stalk and harm the clinician no longer needs to leave home. He or she can do it via the Internet. Cybersnooping is facilitated by Web sites such as search engines, online forums, bulletin and discussion boards, and chat rooms. Social networking sites, such as MySpace, Facebook, Twitter, and LinkedIn, are sources of personal information. Placing personal information on Internet sites exposes the clinician to a variety of psychological and physical harms (Table 4). For example, one angry patient ordered over-the-Internet pornographic magazines and sex toys in the name of the clinician and sent it to his mother-in-law.
TABLE 4: Cyberstalking: psychological assault on the clinician
■ False accusations, derogatory statements (blogs)
■ Gathering personal information
■ Harassment (also by third parties)
■ False victimization
■ Sending viruses, e-mails, repeated instant messages
■ Ordering goods and services in your name; eg, pornography, sex toys
■ Arranging to meet
Opportunities to obtain personal information on the Internet are seemingly endless. Smart phones with GPS (Global Positioning Satellite) capability can be used to track the exact location of the person being stalked. More than 25,000 individuals in the United States are victims of GPS stalking annually, including by cell phones.5 Tracking can be stopped by turning off the phone. The cell phone company will deactivate the tracking function, if law enforcement officials report that it is being used for stalking.5
Consumers who search the Internet give up personal information that they may want kept secret from marketing firms, which use invisible tracking technology to monitor online purchases and other activities.5 Other sources of personal information include commonly occurring activities—for example, wish lists and posted wedding registries. Webcams can be hacked, allowing the stalker to watch the victim at will. For clinicians who use the Internet, anonym-ity is impossible.
A variety of safety measures can be employed against cyberstalkers.6 The stalker must be taken seriously. Never make contact with the stalker. The stalker craves personal contact with the clinician. To meet and to try to persuade the stalker to cease is futile and will only inflame the situation. Inform family and friends of the stalking. The police should also be called. Restraining orders can serve a useful purpose in threat management.7 If the stalker violates the restraining order, pressing criminal charges may be easier. Federal and state laws should be consulted. Also consider seeking legal advice.
Threat intervention strategy
A basic principle of threat intervention is to verbally engage the patient’s threat (Table 5). Clinician passivity can increase the threat of violence. It is essential to actively respond to escalating threat behaviors. The patient must be encouraged to respond verbally and to explain the reasons for the threats. If verbal engagement and response fail, the clinician needs to summon assistance (eg, panic button, silent alarm, or other similar measures). The clinician must locate a viable escape route if the risk for violence becomes acute. If not prearranged, an escape route may not be available. Self-defense will be necessary. Pepper spray and other immobilizing agents usually require some training for their effective use. Safety management techniques should also consider the armed patient and the armed clinician.1
TABLE 5: Threat intervention strategy: general principles
■ Observe prodromal escalation of threat (verbal)
■ Verbally engage patient’s threat
■ Strongly encourage patient to explain reasons for threat
■ Actively respond to escalating threat behavior; passivity is the clinician’s enemy
■ Summon assistance if active response fails
■ Locate viable escape route if threat of violence becomes acute
■ If escape route is not possible, prepare for self-defense
Key points to minimize the risk of violence
• Recognize that every health care professional is a potential target of rare but ever-present risk of patient violence
• Make safety measures against patient violence an integral part of clinical practice—akin to defensive driving
• Beware of the psychological defense of denial, a major impediment to successful safety management
• Identify the prodrome of violence
• Acknowledge and confront threats of potential patient violence
• Acquire threat management techniques
• Consider consulting with security experts