AS EVIDENCE that violent incidents and patient bad behavior are ticking up in his hospital, hospitalist Bryan Harris, MD, chief medical officer of the St. Charles Redmond campus in Redmond, Ore., notes that his hospital last year added two new line items to its monthly quality reports: “caregiver physical attacks” and “caregiver harm.”
“We had one event recently where multiple caregivers were assaulted,” says Dr. Harris. “One had a concussion and was out a few months.” Over the past year, he estimates that patients have injured at least a dozen employees who have needed prolonged time off. The types of violent or threatening incidents that once took place in his hospital every several years started happening every few weeks.
But for every actual assault, Dr. Harris says that he and the clinical staff contend with dozens of confrontations with patients that don’t become physical but devolve into—or start out with—name-calling, abusive language, questioning their credentials or refusing their care. What he calls “a huge breakdown in the relationship between physicians and patients” first erupted during the pandemic, when angry covid patients demanded ivermectin, hydroxychloroquine or any number of unproven therapies. While the pandemic has subsided, “the distrust between physicians and patients isn’t going away. It may be only a very small fraction of patients who cause problems, but it’s happening enough that we all think about it every day.”
“We now have camps of people who really second-guess what a physician may be proposing.”
Joshua Lenchus, DO
As a result, hospitals are beefing up security, installing metal detectors and enhancing programs on violence prevention and de-escalation techniques. As for how to mend the breakdown in trust between some patients and their clinicians, the way forward is less clear.
Mental health and substance use
In Florida, hospitalist Joshua Lenchus, DO, is chief medical officer for Broward Health, a health system based in Fort Lauderdale. According to Dr. Lenchus, any additional cases of violence that he and his colleagues may be seeing are often related to what hospitals have come to traditionally expect: behavioral health issues.
At the same time, “it’s very difficult to tease out the denominator for that,” Dr. Lenchus says. “I don’t know if the violence is predicated on a patient’s untreated or undiagnosed mental health condition or if some verbal altercation between the patient and a health care worker incites it.”
Two of the four hospitals in his system have psychiatric EDs as well as psychiatric inpatient units. “We’ve dispatched additional security personnel to those areas,” he points out. “Their physical presence is to potentially dissuade something from occurring.”
In Boone, N.C., Lisa Kaufmann, MD, director of hospital medicine for Appalachian Regional Health Care, says that patient emotions on the floors now are running less high “because we’re not having to talk about covid.”
At the same time, she and her colleagues are seeing an uptick in confrontations related to substance abuse disorders. “People become angry and mostly verbally abusive,” says Dr. Kaufmann. “The people getting hit the most, of course, are nurses.” While ED personnel bear the brunt, it’s also a reality on the wards. “There are some patients, but mostly it’s family members or friends.”
“Better that the patient be unhappy than staff members be injured.”
–Lisa Kaufman, MD
Appalachian Regional Health Care
Is substance use with street drugs just more apparent now that covid has subsided? Or is substance use getting worse?
“I think it’s getting worse,” she says.
According to Dr. Kaufmann, her hospital installed metal detectors in the ED in 2022. Even before the pandemic, the hospital added a list of patient responsibilities to the list of patient rights that every patient receives. And signs throughout the hospital stress that violence and abuse are not tolerated.
The four hospitals in Dr. Harris’s health system in Oregon have also put up similar signage and are “increasing our number of security personnel.”
The hospital system is also providing updated training with a program designed to help people prevent and defend against workplace violence. “We’ve always had some education on workplace safety, but we’re definitely enhancing that.”
And patients arriving at his ED are now wanded. As he explains, the patient populations his hospital serves come from both urban centers and very rural communities. “We have an active gun culture, and there’s a lot of accidental carry where people forget they have a gun on them.”
As Dr. Harris points out, many of the confrontations he’s having with patients don’t stem from substance use but are driven instead by the kind of political polarization that erupted during the pandemic. After practicing more than 25 years, he’s now fielding questions from patients he’s never heard before.
“Patients in the hospital have always been anxious to hear what I have to say,” Dr. Harris says. “But now, I walk in and they want to know, ‘Are you sure you’re a doctor? Do you have a copy of your diploma? Where did you go to medical school?’ ”
“Nobody wants to go to work and be called names.”
Or they insist on picking and choosing among therapies or tests they will agree to receive. Dr. Harris recalls a pneumonia patient with a cough and fever who refused to allow anyone to swab his nose for a combined covid-flu test.
“He insisted that he had the right to pick and choose what care he received in the hospital,” he recalls. “But we can’t allow patients to railroad their care, particularly to their detriment.”
Distrust on both sides?
Dr. Lenchus in Florida points out that physicians for years have had to deal with what he calls “Dr. Google and Dr. Wikipedia.”
“But most of the treatments people used to ask about were easily discounted through explanation and shared decision-making,” he says. “Health care was once a protected bastion, but we now have camps of people who really second-guess what a physician may be proposing, and that distrust persists.”
At the same time, Dr. Lenchus believes that the bitter confrontations doctors were drawn into around covid have “left an indelible mark of stress and frustration on some health care professionals. We may not have the same environment as during the pandemic, but it’s going to take time for some to get back to not being so overwhelmed.”
When patients question treatment decisions, for instance, clinicians’ response “may be exaggerated,” he suggests. “We’re certainly attuned to these situations, and we’re paying attention to them more than we did before.” Dr. Harris agrees. “I think we became defensive,” he says, “because we saw a pattern, so maybe we deserve some of the blame in stereotyping patients.” Still, “when patients make some politically divisive statement within the first two or three sentences we exchange, they are the ones drawing these lines to begin with.”
In situations where patients push back against a physician’s decisions or want a different doctor, Dr. Lenchus says the escalation process typically involves the
medical staff office, the chief medical officer or a guest services associate. “First you have to make sure patients are given all the information they need to make an informed decision.”
But “when there’s obstruction or resistance to following doctors’ orders, I think we frequently lose sight of asking patients ‘why,’ ” he says. Before he became chief medical officer of the entire health system, he served as CMO at one of the Broward hospitals.
“There were many instances where I intervened to try to mitigate a situation,” Dr. Lenchus says. “A lot of times, you can get to the root cause of a misunderstanding, or perhaps a patient didn’t hear what you said or interpreted it in a different way than how it was intended. Or patients will say, ‘I don’t like how she or he is speaking to me,’ or ‘They haven’t paid attention to me,’ or ‘I’m asking these questions and they’re being dismissive.’ ”
Listening, he adds, can help. “Spending a few extra minutes can tamp down the entire situation, and I always followed up with the individual physician to try to provide feedback. Many times, doctors are completely unaware of what patients are complaining about.”
At the same time, Dr. Lenchus says, “When patients are very resistant to what is proposed to them, they still have autonomy. They can choose to leave even if that’s a poor choice.”
Dr. Kaufmann also steps in when colleagues have altercations and listens to patients’ concerns. “We may not agree, but I think patients come away with the idea that I have an open mind. They feel respected even if they’re not agreed with.”
It also helps that “we try to start with a census of 13 or 14 patients, so people don’t see more than 18, even on a bad day,” she points out. “That means actually having time to talk to patients and listen in a way that you just can’t if you start with 18 patients and balloon up to 25. I think one of the biggest factors in violence prevention is making sure your staff has time to listen to patients.”
Dr. Kaufmann’s health system has also looked at common patient triggers. “One is patients sitting around and not knowing what’s going on,” she says. The ED in her hospital has adapted its workflow to give waiting or boarded patients more frequent updates.
And in a new inpatient bed tower that opened earlier this year, a “whiteboard” that is actually a computer screen in patients’ rooms lists that patient’s schedule of any upcoming procedures. It also flashes the credentials of anyone who walks into the room, as long as they have on their locator badge.
Like many health systems around the country, “we will be increasing staff training around de-escalation of potentially dangerous situations,” Dr. Kaufmann adds, noting that her hospital system now has a shared services agreement with the University of North Carolina for resources, including violence prevention programs. “I think de-escalation is good, but I have my concerns. Sometimes people come away feeling that you’re supposed to always be able to de-escalate, and I don’t think that’s possible. If you feel you’re in danger, you probably are.”
She also sees hospital personnel undergoing a culture shift. “Staff members shouldn’t put up with this any more than they should bad physician behavior. We’ve often held that ‘the patient is always right,’ but the patient doesn’t have the right to put you at risk. Better that the patient be unhappy than staff members be injured.”
The debate over trespass policies
Dr. Kaufmann chalks the fact that people have become more verbally abusive up to the Internet.
“My theory is that people get used to all the trolling comments and then carry those over into actual physical situations,” she says. “They see people being insulting or threatening and having no consequences—but that’s not the case in health care. We ban verbally abusive or violent families and visitors from the hospital.” Anyone who screams or threatens violence or brings drugs onto the hospital campus “may be banned during a hospitalization. Or if there’s a pattern, we ban them permanently unless they have an emergency.”
But in many hospitals, clinicians and administrators are debating which security measures and policies may be called for and which may go too far. Some EDs have moved, for instance, to bring in teams of dogs to keep staff safer; other hospitals, pointing to a long history of dogs being used against people of color, feel that’s inappropriate.
And trespass policies like the ones that Dr. Kaufmann refers to—banning individuals from hospitals—as well as involuntary discharge policies are also coming under fire. Some clinicians and administrators worry that such policies could abandon patients dealing with mental illness or substance use.
But others feel such policies are needed for staff safety. “I can’t afford to have another nurse get hurt,” says Dr. Harris in Oregon. “That’s four rooms I can’t put patients in. We’ve asked people to put up with this for years, but now we have to put the importance on caregivers and caregiver burnout. Nobody wants to go to work and be called names.”
In the meantime, he adds, “there’s definitely a lack of respect for science, for scientific method and for people in the field,” he says. “And that chasm isn’t going away. I worry that it will always be there and that we’re never going to get back to 2018.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Focusing on patient satisfaction: A collection of articles from Today’s Hospitalist.
Published in the May/June 2023 issue of Today’s Hospitalist