The shooting of a doctor and two patients at Johns Hopkins Hospital in Baltimore in September sent a shudder of fear through all physicians, but for those who knew the late otolaryngologist John Kemink, MD, it was particularly saddening.
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December 2010Dr. Kemink, a nationally acclaimed ear specialist who directed the Cochlear Implant Program at the University of Michigan Medical School, was shot to death by an angered, mentally ill patient in June 1992 during an examination at an otolaryngology clinic in Ann Arbor, Mich. Police said he was shot four times and died less than an hour later. His 70-year-old killer pleaded insanity but was found guilty.
Carol Bradford, MD, ACS, professor and chair of otolaryngology-head and neck surgery at the University of Michigan Health System, was in the hospital’s hallways that day, watching physicians, staff and patients fleeing from gunshots.
“If you ever go through anything like that, you will be changed for life,” Dr. Bradford said. “You’re never the same.”
Violence in the health care setting often draws the most attention in the wake of tragedies like the murder of Dr. Kemink or the shooting this fall at Johns Hopkins. But as a Joint Commission report from June notes, violence is always a reality in medical care. And while physicians once associated most violent acts with emergency departments situated in crime-filled urban pockets, the Joint Commission’s so-called “Sentinel Event Alert” points out that incident rates are rising, and that means all physicians need to take precautions.
“While the alert does not specifically mention otolaryngologists, the principles and guidelines can apply to caregivers across different care settings,” Kenneth Powers, a commission spokesman, wrote in an e-mail to ENT Today.
A Systemic Problem
Paul Schyve, MD, senior vice president of healthcare improvement at the Joint Commission, said the summer missive served to raise awareness of the potential dangers of violent incidents, whether they involve patients or staff. The commission’s Sentinel Event Database includes a combined category of assault, rape, and homicide with 256 reports since 1995, a number the organization suggests is under-reported. The report found that since 2004, hospitals have reported “significant increases in reports of assault, rape, and homicide.” According to the commission’s website, there were 6, 4, 24, 25 and 20 incidents each year in 2002, 2003, 2004, 2005 and 2006. In comparison, there were 36 reported incidents in 2007, 41 in 2008 and 33 in 2009.
Further, the report recommends that physicians learn techniques to identify potentially violent patients, implement violence de-escalation approaches and conduct violence audits to help determine safety protocols.
The alert wasn’t a new take; violence prevention has drawn attention in the past. The U.S. Occupational Safety and Health Administration (OSHA) issued a 47-page report in 2004 titled “Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers,” a playbook still in use today. Both the Joint Commission alert and the OSHA report were often referred to in the wake of the Johns Hopkins shooting, in which two people died, as institutions and doctors answered questions about how well their offices, staff and patients were protected.
“This is occurring, and it is a systemic problem,” Dr. Schyve said. “Some organizations may have ignored it, and we’re saying you need to think about it in a systemic way…create a culture of remembering things can go wrong.”
Practical Approaches
But when it comes to violence prevention, terms like “systemic” and “culture” can often sound a bit amorphous to physicians looking for practical advice. Dr. Bradford said otolaryngologists should think about the issue in more narrow terms, such as installing security systems and drafting safety protocols for different situations.
She noted that while physicians often feel a medical and almost societal obligation to help their patients, otolaryngologists would do well to remember they do not have to put up with violent or otherwise inappropriate behavior. “You can fire a patient,” Dr. Bradford said. “We will do that if somebody is disruptive or abusive.”
The process is rare, she cautioned, and should almost always be handled in concert with legal advice, but the overall point she hopes people take away from the idea is that the physician can and should drive the process of creating a safe environment.
Dr. Schyve agreed that physicians need to push the conversation but says it can be difficult to find the right balance between creating an inviting office atmosphere and maintaining unseen security measures. Because many otolaryngologists work in private clinic settings outside the more regimented structure of hospitals and academic institutions, that balance is often something that must be tailored, he said. “In some settings in which controlled drugs are stored, an entrance that is opened only with a buzzer may be necessary,” Dr. Schyve explained, “whereas, in another setting, an unlocked entrance door may be appropriate.”
He added that the mindset of wanting to help patients is the same perspective that often leads physicians to envision rosier outcomes, both about a patient’s prognosis and the likelihood that a patient may be a violent actor. “We have a tendency to be optimistic,” he said. “That optimism…sometimes means we’re not paying attention to the fact that something could go wrong.”
Dr. Bradford takes a sober approach to violence prevention, given her personal history. She recalls one time when an elderly cancer patient of hers sent her a poem that ended with the phrase, “I opened the drawer, pulled out a gun and shot the little snot.” Dr. Bradford was so unnerved she committed the phrase to memory. She called security personnel to investigate, but it turned out to be “just sick humor.”
While she has butted against both the threat of violence and actual incidents, Dr. Bradford said she still believes violence is a rare event, and it’s not something she focuses on daily. “I would just call it a heightened awareness,” she added.
Clinic Safety
Cynthia Gregg, MD, FACS, was completing a five-year otolaryngology-head and neck surgery residency at the University of Michigan when Dr. Kemink was shot, and the experience helped shape the private facial and plastic reconstruction clinic she runs in Cary, N.C. It also helped to motivate her in researching and publishing “Violence in the Health Care Environment,” which reported that management of a violent incident includes “early recognition, de-escalation techniques, and a collaborative effort with security personnel” (Arch Otolaryngol Head Neck Surg. 1996;122(1):11-16).
“We used to think of our schools, our hospitals, our libraries as a safe haven,” she says. “That’s not true anymore.”
Dr. Gregg takes a holistic approach to violence prevention, starting with details as seemingly innocuous as a table or chair in the waiting room. Those objects, if they are sharp enough, can be used as a projectile in a violent incident. Her office also has a security system complete with a panic button and silent alarm.
She has instituted code words that her staff can use to alert each other to potential situations and puts yearly reviews in place to keep procedures fresh. All of the techniques and approaches have been implemented as part of basic office operations. “I thought about it when I built the office, and our staff review protocols on an annual basis,” she says. “I don’t think about it on a daily basis.”
In the end, Dr. Schyve preaches vigilance to the dangers of violence but not so much that it overtakes the role of a physician.
Put another way by Dr. Gregg: “There is nothing you can do to completely prevent somebody from entering your office. That’s the nature of our society.”