As patients turn violent, doctors and nurses try to protect themselves

Dr. Ronald Wyatt, an internist in Madison, Ala., entered an exam room to meet a new patient and his wife several years ago. When he walked in, the woman immediately pulled a framed photo from a large grocery bag.

It was the couple’s daughter, and Wyatt recognized her as his patient — one who had died two years earlier.

“I really can’t speak with you about this,” Wyatt recalled saying, his anxiety rising.

The father blocked the door, instructing the doctor: “You are not leaving this room.”

There were no alarms to set off, so Wyatt relented. Eventually, he opened his computer and showed, through patient records, how hard his team had worked to prevent their daughter’s death; he said he, too, had loved her. The father started weeping, then left peacefully. But it could have gone another way.

“Either one of them could’ve pulled a gun and shot me,” Wyatt said. “I had no way out of that room.”

It was a unique experience in Wyatt’s career. But at its essence, it was also a moment — filled with tension and seemingly ripe to explode in violence — that is disturbingly common in American clinics and hospitals. Those moments frequently lead to physical assaults when patients or family members suspect a medical error has taken place.

Conflicts between clinicians and patients and their family members have leapt onto the radar of health care administrators and policy makers this year. That’s partly the result of a traumatic episode in January in which a beloved Boston cardiac surgeon was killed by the son of a deceased patient. But it’s also because patient-on-clinician violence is on the rise, according to federal statistics.

Among the 26,000 significant injuries due to workplace assault in 2013, nearly 75 percent were reported in the health care and social services sectors, according to the Bureau of Labor Statistics.

Injuries caused by violence nearly doubled among nurses and nurse assistants from 2012 to 2014, and increased by smaller margins among doctors and other medical professionals over the same period, according to an April report by the Centers for Disease Control and Prevention.

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Hospitals with a history of violence have responded by hiring more security officers and even buying technology to track the whereabouts of patients and personnel. But hospitals are by their nature open environments meant to convey an atmosphere of healing, not defensiveness, so they’re pursuing other strategies, as well.

Wyatt, for one, is helping to identify ways to stop the violence before it happens. As medical director of the health care improvement division at the Joint Commission, an independent organization that accredits health care institutions, he has been studying innovative ways in which institutions are tackling the issue.

They range from a massive and ongoing antiviolence program conducted by the Veterans Health Administration to more recent initiatives from the CDC and the Occupational Safety and Health Administration, which is involved in its own effort to study antiviolence programs in the health care system.

“There’s an acute effort here to come up with something robust around workplace violence prevention, and hold organizations more accountable,” Wyatt said.

Read more: Choked, punched, bitten: Nurses recount attacks by patients

Emergency room doctors and nurses, who are among the most frequent victims of patient attacks, said perpetrators are often mentally ill or under the influence of drugs or alcohol. But in other cases, otherwise perfectly reasonable individuals turn violent when being informed of a family member’s death or being refused narcotics.

Perpetrators typically fall into two categories — “affective,” or spontaneous, offenders, who are spurred by their immediate circumstances, and “predatory” offenders, who plan attacks methodically.

That’s an important distinction, conflict-resolution specialists said. While clinicians may be able to defuse the anger of affective perpetrators, they might endanger themselves trying to reason with predatory offenders.

The Veterans Health Administration initiative prepares for a full range of threats, said Kathleen McPhaul, who supervises the Department of Veterans Affairs’ Prevention and Management of Disruptive Behavior program.

The program offers four levels of behavioral-management training, starting with a basic program required of virtually every VA health care employee. A more specialized level of communication training is offered to those who are more likely to encounter verbal conflicts with patients.

Those who are more likely to encounter physically combative patients, meanwhile, learn how to escape a patient’s grip without hurting the patient or themselves, for instance. Others learn how to work in teams to contain a patient safely.

For the communication training, McPhaul said, staff members participate in role-playing exercises. “We’ve insisted the training be face-to-face,” she said, “because it’s very difficult to be good at this if you don’t do it in front of somebody.”

Outside the VA system, safety concerns have grown so pervasive that some communication training programs that never dealt with the issue of violence have been forced to do so. Such is the case at Brigham and Women’s Hospital in Boston, where Dr. Michael Davidson, the cardiac surgeon, was fatally shot earlier this year.

Dr. Jo Shapiro, who directs the hospital’s Center for Professionalism and Peer Support, guides clinicians on how to conduct one of the most fraught conversations a doctor will have with a patient: one in which a clinician discusses an unexpected outcome or discloses a medical error and offers an apology.

Shapiro said these conversations represent “a moment of vulnerability for patients and families, and for clinicians the vulnerability was around shame and guilt and fear.”

“Clinicians may face fear of reputation, fear of punishment, and, now, a fear of harm.”

In her coaching sessions, Shapiro says she stops clinicians frequently to point out the importance of pausing and soliciting questions, and avoiding phrases shaded with defensive connotations, for instance, or complicated medical terminology that might signal obfuscation.

Such lapses can make it more difficult for a patient to deal with the emotional impact of learning difficult news, and they can spark a patient’s anger, Shapiro said.

“These situations are all about bearing the weight of the patient’s or family’s pain, no matter how horrible that might be for the clinician,” Shapiro said. “A lot of empathy training misses that self-regulation element, and that’s a building block that’s absolutely teachable.”

By the same token, Shapiro said she teaches clinicians that they shouldn’t tolerate aggressive behavior. “If anybody is acting in a threatening way, you have to leave or get help.”

Victims of medical errors say they understand the impulse to rage, if not violence.

In 1999, Linda Kenney, who at the time worked in the hospitality industry, entered Brigham and Women’s for ankle surgery. The anesthesiologist administered a nerve block that reached Kenney’s blood stream instead of the nerve, and she went into cardiac arrest.

By chance, surgeons were preparing for cardiac surgery in a nearby operating room and had a cardiopulmonary bypass machine ready. The heart surgery team bumped the scheduled patient, opened Kenney’s chest, and saved her life.

Kenney’s husband was waiting upstairs when her orthopedist and the anesthesiologist opened the door. “My husband physically and verbally went after him,” Kenney said. “We joke that if it hadn’t been for the orthopedic surgeon, he’d have been in the ICU with me.”

The anesthesiologst tried to see her several times while she was in the hospital, but he was blocked by her medical team, who felt his presence might traumatize her. Her husband later made amends with the doctor. And a week after she was discharged, he sent Kenney a letter apologizing and encouraging her to contact him.

Six months passed before she arranged to meet him for coffee.

The conversation went well, Kenney said, because the anesthesiologst approached it with empathy and contrition. “When you have those conversations you can’t add insult to injury,” she said.

With the anesthesiologst’s support, Kenney went on to establish Medically Induced Trauma Support Services, a Boston-based organization to support patients and clinicians who have experienced “adverse medical events.”

Through her own experience and similar ones from other patients, Kenney said she learned that most victims of medical errors don’t resort to violence. “But you have to be aware that anger is part of the process,” she said.

For many clinicians in Boston, a painful irony hovers over Davidson’s killing. He was widely known for his compassion. Not only had he treated the mother of the man who attacked him with error-free care, on the day of the shooting he had interrupted his scheduled appointments to speak to the assailant at length before the shooting.

Wyatt, of the Joint Commission, said his own survival was a matter of luck as much as empathic communication.

Once he sat down with the aggrieved parents, he knew he would get out of the room alive.

“I also remember thinking they deserve to know what happened,” Wyatt said. “And I also thought about the pain these people had been in, and as painful as it was for them and me, we needed to have this conversation.”

After the couple left the room — a “near miss,” Wyatt said — he let the matter sit.

He never heard from them again.