Patient Disrespect, Harassment, Bullying, and Potential Violence
One area that I believe is a blind spot in our training relates to what I call Patient Management (part of the broader topic of Clinic Management). How our patients treat us is a frequent area of concern, stress, burnout, and even frank fear. Patients too often engage in behaviors that are disrespectful and entitled on the one hand and intimidating, harassing, sexually provocative, and bullying on the other. A related behavior on the serious end of the spectrum is patients stalking clinicians (Because of the unique issues this topic raises, I’ll cover it in a later post.)
The blind spot in our collective failure to adequately address clinician concerns centered around disruptive patient behaviors may grow out of our profession’s desire to avoid demonizing persons with psychiatric disorders. It is true that psychiatric patients are not more violent on average than others. Having said this, even a demographic group (our patients) that is no more violent than the general population still includes some percentage of bullying and potentially violent individuals. During my years of running the psychiatry oral board prep course, I had two women psychiatrists share with me details of assaults they suffered at the hands of their patients that left one doctor with facial fractures and the other needing months of physical rehab. Both are lucky to be alive and both were suffering from long-term PTSD at the time of our discussion. Thus, this issue is a life-and-death matter and deserves more discussion and, more importantly, optimization of clinic (and inpatient) procedures to minimize such dangers that clinicians face.
Today I’m opening a conversation with you about these negative patient behaviors. He are my thoughts on approaches to manage these problems. Of course, I’m not an attorney or safety specialist. Treat them as raising issues and offering possible common-sense solutions for your consideration.
Work as a Group
If you are part of a training program, academic department, group practice, or medical institution, these issues of disruptive and possibly dangerous patient behaviors are of collective interest. Just because no else in your program/group/department has raised these issues does not mean they don’t harbor the same concerns in silence. The topics of maintaining safety and curbing disruptive behaviors are best solved through systemic and operational changes, and through working as a team of watchful individuals.
For example, one patient group that is more likely to engage in clinician intimidation or violence are individuals seeking psychoactive medication prescriptions. This recurrent and common problem can be addressed starting with the Treatment Contract the patient signs and the Clinic Policy Pamphlet the patient receives. These two documents should NOT be handed to patient with, “Here, sign this” but rather should be discussed in detail with patients by clinic staff. These documents can and should communicate that “verbally abusive, and verbally and physically intimidating behaviors are not acceptable and will likely lead to termination of care from the clinic.”
Establish Safety Procedures
The aspects to review include:
Safety concerns of the physical plant: Is lighting in clinic hallways, staircases, entrances, and parking areas adequate? Can patients gain access to restricted areas? For example, the patient restroom may allow the patient to walk unobserved into the staff lunchroom, supply room, or a stairwell and hide there.
Safety concerns in clinician offices: Is the clinician able to easily egress their office if the patient escalates? For example, a clinician may be positioned behind a desk at the far end of the office away from the door. The only way out is through the narrow passage between the desk and the wall, and then past the patient. In these cases, the office layout should be altered. Further, does the clinician have a panic alarm button unobtrusively available within hand reach? Note that these devices are now available as wearables, key fobs, and apps. Convenience and cost are no longer a concern.
Safety concerns related to staffing: Are clinicians ever alone in the clinic? For example, the front desk staff may leave before the clinician completes their session with the last patient of the day. Or perhaps the clinician is alone in the clinic on a weekend day without support staff.
Nip Problem Behaviors in the Bud
Inevitably, a patient will engage in behavior somewhere on the spectrum between disruptive to potentially violent. When the behavior occurs, it is best to address it immediately. If the patient behavior rises to what your policy defines as behavior leading to termination, then terminate the patient. A person who is once abusive, intimidating, and/ or potentially violent, is likely to repeat that behavior.
If the patient’s behavior is disruptive but does not pass the threshold for termination, then it should be addressed when it occurs. Obviously, our patients are often dealing with acute psychiatric issues and are in evident distress. We need to use judgment when deciding whether to continue to work with a patient despite their behavioral shortcomings.
Let’s take one example. You are running behind schedule in your clinic. You walk from your office to greet the patient who has been waiting for you. You hear the patient speaking loudly to front desk staff about what a “shit-show” this clinic is, and how his time is being disrespected. The patient is crude and rude but not making threatening statements. You decide to invite the patient into your office and make the following statement, “Mr. Adams. I couldn’t help hearing your comments to our front desk staff. I understand I am running late. I apologize to you for that. Having said that, I need you to stop engaging in such behavior. It is not acceptable to yell or curse at our staff. They deserve a safe and respectful work environment. Also, your loud words were upsetting to other patients who also deserve a safe and comfortable environment. I need to ask you right now to commit to not engaging in such behavior again. Once I have your commitment, we can speak how you and I can handle situations when I’m running late in the clinic.”
A second example. (And here, since I’m using an example of a woman clinician with a male patient, I ask your forbearance because I’m only guessing how best to handle it. Please send me your more informed take on this scenario.) You are conducting an intake evaluation in the clinic. You ask your male patient, “Do you have sex with men, women, or both?” The patient responds with, “Oh no. I only have sex with fine women such as yourself.” You respond with, “Mr. Adams, you and I are engaged in a serious professional relationship. I am your doctor. You may have meant your words to be a joke. However, they are disruptive to our working relationship and I must ask you to not speak that way to me or about me again. Can I have your commitment on that right now?”
Please let me know your thoughts. I’m excited by the possibility that we can learn from each other regarding both problem scenarios and possible solutions. I’ll follow up with additional aspects in future posts.
“Safety doesn’t happen by accident.”
“Safety is 30% common sense, 80% compliance, and the rest is good luck.”
“It will never happen to me.”
Captain EJ Smith (captain of the Titanic)