In 2020, as the COVID-19 pandemic progressed, the daily news began to report disturbing stories: family members becoming belligerent after being refused entry to their loved one’s hospital room, intensive care patients uttering verbal slurs at nurses trying to employ lifesaving oxygen equipment, and clinic personnel enduring physical attacks simply for enforcing a mask-wearing policy.
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November 2022For much of the public, this was a first glimpse of such egregious behavior in a healthcare setting. But for experienced physicians, nurses, and other healthcare professionals, these events represented an escalation in the ongoing pattern of difficult behavior exhibited by the people they are charged to serve.
According to the U.S. Bureau of Labor Statistics, the rate of injuries from violent attacks against medical professionals grew by 63% from 2011 to 2018. And, although emergency rooms and psychiatry practices are the settings people typically associate with unruly behavior from patients, the fact is that incidents of verbal and physical violence are increasing across the healthcare spectrum, including in otolaryngology offices.
A 2022 literature review, published in the Journal of Public Health, concluded that violence against physicians and nurses is a global health problem, citing growing incidents of verbal threats, physical assaults, sexual abuse, ethnic harassment, reputation smearing, mobbing behavior, bullying, intimidation, and racial harassment.
At a time when medical science is making tremendous breakthroughs that enable physicians to help more people than ever, why have abusive incidents against them and their teams seemingly skyrocketed? And, more pressingly, what can be done about it? Many otolaryngologists find themselves walking a tightrope as they seek safe and ethical solutions in today’s increasingly volatile landscape.
An Erosion of Trust
Doctors’ offices and hospitals are already emotionally charged settings for patients and families, and it isn’t unusual to see normally calm individuals become rattled and even disruptive out of frustration and fear. In such instances, a cocktail of empathy and validation, provided calmly and sincerely, often prevents emotional fuses from lighting. Sometimes, however, the distraught person is already in a heightened emotional state over other stressors, and the healthcare professional has no idea what their back story might be.
These aren’t easy economic times, and for consumers, healthcare has become one of the biggest hurdles to getting by. “The healthcare system in this country is broken and gets more frustrating every day,” said Eric Gantwerker, MD, MMSc, associate professor, department of otolaryngology, Zucker School of Medicine at Hofstra/Northwell in Hempstead, N.Y. “People see other entities making money from healthcare while their own costs continue to rise. They don’t necessarily see justice being done on their behalf. In response, some individuals empower themselves by taking matters in their own hands.”
Moreover, trust in physicians as a group has receded, along with faith in the system. “There’s currently a growing lack of trust for authority figures in general, and a growing degradation of the blanket of respect for healthcare professionals, especially as media outlets and social media highlight the small number of physicians, nurses, and other healthcare professionals being charged with crimes,” Dr. Gantwerker said.
G. Richard Holt, MD, D Bioethics, and professor emeritus and clinical professor in the Department of Otolaryngology–Head and Neck Surgery at the University of Texas Health Science Center in San Antonio, believes that the increase in poor patient behavior reflects a more general trend in our society away from interpersonal courtesies and into a more brusque and accusatory manner of interaction. “Perhaps this has been a negative outgrowth of the anonymity of social media, as well as the lingering broad frustrations incited by the pandemic,” he said. Dr. Holt acknowledges the need for healthcare reform to improve access and equity but emphasizes that the safety requirements of the healthcare setting “cannot excuse potentially dangerous behavior.”
The problem has started gaining attention on a national scale. In June 2022, citing the lack of a federal law to protect hospital employees from intimidation and assault, a bipartisan team of U.S. Representatives introduced the Safety from Violence for Healthcare Employees (SAVE) Act. Modeled after current protections enacted for aircraft and airport workers, the bill would criminalize violent behaviors against hospital employees. It would not, however, address the root of the problem, nor provide a roadmap for physicians and their staff to continue providing excellent care to patients while protecting themselves and others.
The Front Lines
Every day, doctors, nurses, and other medical providers willingly place themselves in the vulnerable position of interacting with the public, often with individuals they are meeting for the first time or know only slightly. Most often, these individuals aren’t feeling well; they might be in pain and may be nervous or worried. However, medical professionals are ready for this and, theoretically, have been trained to spot any potential behavioral problems early in the process.
“With experience in patient care, physicians develop a sense of the boundaries of appropriate and inappropriate behavior in the healthcare setting,” said Dr. Holt. “We learn to discern minor, benign behavioral actions from those that may pose a clear danger to others. However, as violent acts in our society appear to be an increasing occurrence, our level of concern must also increase.”
The first staff member a patient meets not only sets the tone for their visit and subsequent interactions but can also be trained to assess that patient and communicate any red flags to coworkers. “The initial intake impression of a patient or family can be very important to recognizing potential threats to the office personnel and other patients, as persons with pathological personalities often do treat staff differently than providers—at least at first. I consider this behavior to possibly be controlling and narcissistic,” said Dr. Holt, who added that the unpleasant behavior can either be professionally addressed with the patient or mentally filed for future interactions. “I have always requested that the intake and first clinical contact personnel apprise me of their concerns about any patient or family members before I enter the room so that I can plan an approach and potential series of responses should the interaction go awry.”
As a pediatric otolaryngologist, Dr. Gantwerker sometimes sees this phenomenon from the families of his patients. “If I learn that the family was out of line [with staff], I thank them for their patience but tell them that we are a team, and I would appreciate everyone getting the same respect that they give me,” he said.
“People see other entities making money from healthcare while their own costs continue to rise. They don’t necessarily see justice being done on their behalf. In response, some individuals empower themselves by taking matters in their own hands. —Eric Gantwerker, MD, MMSc
Dr. Holt supports conflict resolution education for all patient care personnel, who also learn what to do if those tactics fail, and contends that medical students should be taught appropriate responses to this behavior as well. However, given the limited power that students have in the clinical setting, “the responsibility for their safety rests with the institution and their supervising physicians,” he concluded.
Indeed, an argument could be made for teaching conflict resolution in medical school. “It’s an invaluable skill,” agreed Dr. Gantwerker. “However, the problem with medical education is always that if you add something, you have to take something away. But I do think everyone should be taught de-escalation skills, because in these times, you cannot wait for security or the police. Brazen people are too apt to take matters into their own hands.”
When a situation does spiral out of control, any attempt at resolution must give way to decisive action. “The physician has a duty to protect other patients, their families, and clinic personnel,” said Dr. Holt. “Persistent unruly or threatening behavior may require a decision to contact hospital security or local law enforcement.”
Dr. Holt cited several instances with patients in which he, and even his family, were threatened with their lives. “The encounter that stands out most vividly in my mind is an adult patient who had a large osseous tumor of the face and who required a radical extirpation and a postoperative obturator,” he recalled. The patient had been diagnosed with paranoid schizophrenia and, unbeknownst to Dr. Holt, had stopped their medication after the surgery. “At one of the postoperative visits, this patient indicated to me that they had brought a gun to the appointment and planned to kill me and then my family,” he said. “Indeed, they did have a gun, and it required all of my persuasive capabilities to calm them down until security could arrive to secure the patient and the gun.” Dr. Holt continued to provide follow-up appointments to this patient, but these visits took place at the state institution to which they had been involuntarily committed.
Between Physician and Patient
The doctor–patient relationship requires a minimum level of mutual trust and respect to thrive. Understandably, much emphasis has been placed on the patient’s feelings toward the physician. Physicians, conversely, are meant to remain emotionally neutral, at least outwardly. At the same time, however, they care deeply about what they do, and when their efforts are met with disdain, insults, and even violence, they may find it challenging to maintain a professional mien.
“In situations like this, it’s difficult to have recourse,” said one practicing otolaryngologist who chose to remain anonymous for this article. “You can’t yell at patients; you can’t easily fight back at negative online reviews. There are things that patients say or do to us that we would never tolerate from someone else in our daily or professional life, but we just bite our cheeks and care for the person in front of us, even as we grow to resent them. And it doesn’t feel good.”
Physicians, therefore, are left to reconcile that conflict between their internal, normal human response and their professional ethics. To be clear, the ethics code of the American Medical Association states that, should a patient exhibit disrespectful, derogatory, or prejudiced behavior, it’s the responsibility of the physicians to “… identify, appreciate, and address potentially treatable clinical conditions or personal experiences that influence patient behavior.” But when behavior becomes a safety threat, “steps should be taken to de-escalate or remove the threat.” Complete termination of the relationship is advised only when the patient will not modify threatening behavior that’s within their control.
Jennifer L. Higgins, MSW, LCSW, is a healthcare manager who serves as special assistant for Healthcare Resolutions at Brooke Army Medical Center in San Antonio, Texas. Reporting to the hospital’s chief medical officer, Higgins addresses adverse events, unexpected outcomes, and any quality-of-care issues between provider and patient. “I work as a neutral party to try to make sure that we don’t abandon our patients, but at the same time, our staff knows that they have rights,” she explained. Given the large size of the facility, deferring an unhappy patient to a different provider is a frequently used solution.
Higgins noted that not every medical professional has the same level of conflict resolution/de-escalation skills, nor are they all able to exercise these skills 24/7, especially in the aftermath of an unpleasant or even threatening encounter with a patient. “I think with patients, empathy is the key, and really listening,” she said. “However, number one for a physician is figuring out where they themselves are emotionally. Ask yourself, ‘Am I in the headspace to have this conversation?’”
A hugely impactful yet often overlooked aspect to this issue is the shortand long-term effects on physicians, nurses, and other medical staff during or following abuse from a patient. Being the target of, witness to, or even close to an extreme event in which innocent people are seriously threatened, hurt, or killed is a recipe for psychological trauma. Prolonged harassment, in the form of ongoing online smears or other passive–aggressive actions, can affect a physician’s ability to perform their job optimally and may even discourage them from practicing clinical medicine.
Higgins recounted an incident in which a surgeon at Brooke was on the receiving end of hateful racial slurs made by a hostile patient. Understandably shaken and upset, the surgeon suffered a “lingering trauma” from the event, as “it reminded her of how hard she had to work because of people like that patient, and of the systemic racism that she deals with all of the time,” she explained. That physician took advantage of the Peer Support Program, co-chaired by Higgins and created to address the effects of adverse events on individual staff members and help them work through issues.
“Physicians are healers first, not police officers,” said Dr. Holt. “We are, by nature and training, compassionate and supportive professionals. Our first obligation is to understand the patient, why this attitude and behavior are taking place, and what can be done to alleviate any risk to the patient and others. Gathering the facts of the situation before seeing the patient is fair, as well as entering the room with a calm demeanor. If the patient is repentant and apologetic, it would be helpful to explain to them how their behavior was threatening and unacceptable, not conducive to a healthy medical environment, and that such conduct will not be tolerated in the future. Boundaries must be set, and it’s the physician’s duty to do so.”
Linda Kossoff is a freelance medical writer based in Woodland Hills, Calif.