Angry, threatening, and violent encounters are a fact of life in the realm of medical practice. Recognition of the problem, open discussion among physicians and staff, and careful planning should be undertaken in order to develop common-sense policies and protocols to help protect medical professionals against violence in the workplace.
The following is intended to provide basic information to guide physicians in dealing with situations involving anger, threats, and violence in the workplace.
The shooting of Toronto physician Bernard Lau, September 23, 1997, provides vivid evidence of the reality of the threat of violence that physicians face in their work. Since that incident, there have been calls to the Ontario Medical Association indicating an increase in physician awareness of, and concern for, personal safety.
While physicians may feel they are prepared to deal with the range of human emotions in their day-to-day work, few have specific training to deal with potential or actual violence. Such preparation does exist, however, and perhaps it is time for physicians to give greater attention to this matter.
The goal should be to familiarize all office or departmental staff with the issue of violence, and to establish procedures to deal with an angry, threatening, or violent patient.
Although there appears to be no final word on the subject of violence in the medical practice, a good deal of literature exists on the issue of violence in the workplace. The common fundamental points expressed in most literature can be summarized under the following three broad headings:
1. Recognize and deal with upset and angry patients
The following should be kept in mind when faced with a threatening situation in the medical office:
2. Develop a policy to deal with violence or the threat of violence
Many hospitals and corporations have written policies regarding the management of violence or abuse against staff. Following is an example of one hospital's policy:
" Our hospital supports an attitude of mutual respect among and between health-care workers, the recipients of health services, and visitors to the hospital. The board of directors and senior management are committed to providing a safe environment, free from the threat of sexual, physical, verbal and psychological abuse, as is reasonably possible. Physical violence and verbal abuse by anyone who is not cognitively impaired is inappropriate behavior and will not be tolerated. The following steps will be taken in case of abuse by a family member or visitor:
The above clearly indicates the hospital's policy of zero tolerance toward verbal abuse or physical violence by anyone deemed to be responsible for his or her actions.
In essence, the procedure involves recognizing the individual's behavior as threatening, confronting the individual with this fact, demanding immediate modification of behavior, and taking action - up to an including contacting the police - if the threatening behavior continues.
It is important to note that a serious threat is illegal and can warrant a charge of assault by police.
3. Make preparations to deal with a potential violent situation
Like most hospitals and corporations, physicians, too, should have a written policy to deal with threats of violence. The policy should be discussed openly with staff. In fact, staff should be contributing toward the formation of the policy. Adopting the "KISS" (keep it simple, stupid!) principle for the major points of the policy can help to ensure that the policy will be followed when a high-stress situation develops. For example, a policy may consist of the following four points:
Consideration should also be given to office design and placement of personnel. Police departments and security firms can offer advice on this issue, but most of it is common sense. A few questions to consider are: Is there a barrier between the waiting room and reception? Is there a system for alerting staff and others of trouble? Can you escape or are you trapped if trouble develops?
It is very important for physicians and staff never to underestimate the strength and insensitivity of someone in a violent rage. Many people say it is comparable to the strength of a drowning victim. Remember, do not attempt to engage a threatening individual in violence - it is far better to simply escape a violent situation whenever possible.
Finally, a word needs to be said about overall prevention. The role and responsibilities of physicians should be clarified to patients in an office newsletter and through discussion. This is particularly important when physicians perform duties on behalf of third parties, such as insurance companies or the Workplace Safety and Insurance Board.
In principle, physicians have a responsibility to provide information regarding medical conditions to third parties when requested. In practice, physicians are often asked not only to provide medical information, but also to make arbitrary decisions regarding the eligibility of benefits. In all cases, the role of the physician should be openly discussed with the patient beforehand. Mandatory reporting is another difficult area where it helps to have a policy of frankness, fairness and firmness when explaining that a report must be and will be filed.
In summary, policies against violence in the workplace should be developed and regularly reviewed by physicians and office personnel. There is no final word or singular opinion on this subject, and all comments and suggestions are welcome.
Members are encouraged to forward their comments or questions to Dr. Michael Thoburn, Executive Director, OMA Professional Services Department, 525 University, Avenue, Toronto, Ontario, M5G 2K7.