Welcome, everybody. My name is Dr. David Kim. I'm a senior staff physician at Henry Ford Hospital practicing pain medicine and also helping run the fellowship here. I'm also a clinical associate professor at Wayne State University. I have a distinguished panel here with us to discuss this very important topic of violence toward physicians. I have Dr. Jonathan Glauser. He's an ER physician from Metro Health in Cleveland. Sarah Money is actually my colleague in PM&R and pain at Henry Ford. And Dr. Joseph Crow is a family practice physician through Henry Ford Health System as well. We were hoping to get Dr. Forrest, who's an anesthesiology colleague of mine, but hopefully he will join us a bit later. So without too much ado, we'll get started. So my topic is violence toward physicians, a hidden crisis. I really got an interest in this basically an incident that happened. I got frantic phone calls actually from one of my former residents of the incident that was happening live down in Baltimore at Johns Hopkins where a physician was shot while in the hospital at the patient's bedside by a relative. And this is the actual scene where they called in the SWAT teams. So this got me thinking about how far does this violence go? And apparently it goes a lot further than we thought. The most tragic and most recent one I've looked at is by Dr. Michael Davidson, a distinguished young cardiothoracic surgeon at Harvard Medical School who was actually shot by a patient's son who had called him out to the waiting room after he had, you know, after long ago when he treated his mother. So, you know, very tragic and really kind of shocking. Another thing that kind of brought this to attention is the fact that with even with COVID right now, we are seeing anecdotal reports of increasing violent behavior of patients toward healthcare staff, especially nurses and even physicians. And this one photo shows that this one hospital is actually equipping nurses with emergency buttons that they carry on person for emergency potentially violent patients. So I wanted to give a grand perspective of the numbers of what we're dealing with. This is actually from the Bureau of Labor Statistics going through up to 2013 showing that healthcare and social assistance as an industry has a marked higher cases per million employees of violence compared to say private industry, retail trade, construction, and manufacturing. So looking at the numbers, a large number of assaults occurred at healthcare facilities ranging from 13 to 36 per 10,000 workers. By comparison, the private sector was only three per 10,000 full-time workers. So the healthcare workers from 1993 to 2009, they found they had a 20% higher level of violence at the workplace than average. And that violence in the medical occupations represented 10.2% of all workplace violence incidents. But the main thing is that these numbers they think are vastly underreported and the numbers may be much higher. So let's look worldwide and see what other countries, is it a US phenomenon? Unfortunately, it's not, it seems very universal. Looking in the US alone, here's what's interesting is that Goodman, and what's the scary part, Goodman et al just kind of combed through some data. This is not even official data. And they found there were 26 physician homicides from 1980 to 1990, which is average about 2.6. I mean, two to three of us are going to be killed per year. One US study reported 86% of psychiatry residents were threatened, 25% were assaulted. The National Survey of ERs by Benman et al noted 78% of ER physicians were exposed to workplace violence at least once a year. Another survey of ERs by Cassandra reported 25% of the staff did not feel safe with a median of 11 attacks per facility in five years. Canadian Survey of Family Practice Physicians reported 75% experienced major abuse by patients. International experience, you know, the UK, because of its national healthcare system, is very cognizant of this, and they study this fairly extensively. 63% of family of doctors have reported violence within the last previous 12 months, 18% at least once a month. There were minor injuries in 3%, but 0.5%, a fairly same amount, reported serious injuries. In the hospital setting, one survey of large UK ERs noted 283 episodes of violence in 12 years. In Australia, in Australia, 58% of family doctors experienced verbal abuse, 18% reported property damage, 6% reported physical abuse. The same thing, seeing this again and again in New Zealand, where psychiatrists, 46% were verbally threatened, 39% were physically intimidated, and 10% were actually sexually harassed. So this is cross-cultural, but also even in Japan, one of the least violent societies have noted workplace aggression and violence instance of 0.2 per practice hour. But interestingly, they report the three specialties with the highest incidence of violence as being dermatology, psychiatry, or ophthalmology, which I don't understand, but yeah. So what is the violence toward, you know, a physical medicine rehab specialist in particular? Well, there was a paper which I published back at Pain Medicine back in 2015, which kind of addressed this. I'd sent the national, the introduction, basically I sent the national survey out to the American side of interventional pain physicians, which encompasses multiple different specialties. And I looked at basically, I want to collect demographics, rates, and types of violence, get a characteristic of it, characteristic of what the violence is all about, the injury, the risk mitigation techniques, and the context of violence. So the, we had two, I think 2,200 surveys were sent out. Actually, the response rate was actually fairly good considering it was 330 respondents. The average age is 44.3. Now the most were obviously MDs or DOs, and the most listed specialty was anesthesiology, 66% as their primary specialty. Others include PM&R, neurology, family practice being the next most numerous. Now under the question, the frequency of having to call police or security due to disruptive patients, the majority of the providers, 64.85% reported having to do so at some time. On the frequency of being threatened by a patient with bodily harm, over half the respondents were threatened at some time. So a fairly huge number. The characteristics of the threats, 91% were verbal, but 21.2% were actually physical assaults with punching fists. 7% was blunt objects, and 2.6% were knives. The respondents reported physical assault at 2.7, physical injury at 2.73%. But however, I did leave one number out that didn't come out in the graph, that I think around close to like 2% to 1.8% were actually firearms related. So the most frequent risk mitigation technique reported was to discharge the patient. This was about 85.3% of doctors that were threatened. But there were more serious security things such as police checks at 27, 28%. Personal protective equipment, including body armor at about 17%. Restraining orders at about 7.5%. Hiring a security guard about 6%. Closing of practice, 1.7%. Among those who did carry protective equipment, the most frequent was guns. Physicians were arming themselves. Other responses included knives, 30% may stun guns, blunt objects, body armor at 2%, and the other was 26%. Not surprisingly, the biggest context for violence was in the context of opioid management with the highest response at 89.91%. The next highest response were workman's compensation at 11.4%, and disability claims at 10.53%. Among the specialties, PM&R was most likely, and anesthesiology least likely to report never being threatened. So at least PM&R relative to anesthesia pain were less likely to be threatened. You know, whether you practice urban, you know, there was this myth of urban versus rural practices that we didn't find that was much of a factor in terms of violence, except urban practices were less likely to move or close to practice, and the rural practices were more likely to use restraining orders. And surprisingly, rural practices had the highest violence in the context of non-opioid-based medication management. Females were more likely to report never being threatened, and age was a factor where the younger physicians were probably are less likely to carry weapons. And those with more experience, in other words, they're getting more exposed, more time in the firing line, are more likely to carry weapons. So, you know, the percentage of those who have been threatened with bodily harm, you know, it's roughly 50%. But in context, comparing to other specialties, I looked at other data from other studies, was that actually we were lower risk in terms of violence compared to psychiatry, emergency medicine, and family practice, which kind of surprised me. I knew about psychiatry in EM, but I didn't realize how high it was in family practice, which previously mentioned studies noted between 75 to 86% chance of being exposed to violence. So our rates were lower for some reason. But the one thing I have to give to that is that I did another study looking at, since opioids were a big driving factor in violence, there has been a trend of a decrease in the opioid prescribing by family practice in internal medicine, and there has been a subsequent increase in prescribing by physical medicine rehabilitation. And in that paper, what I thought was happening was that there was really what I call a transfer of risk. Well, family practice and primary care was getting really scared, and they were putting it on, and PM&R was kind of picking up the referrals for that. So our specialty may increase in risk as we go. The risk factors for violence, if you look at OSHA data, some of this stuff's obvious, like working around people with a history of violence, drug abuse, gang members, if you're transporting patients or clients, working alone, poor environmental design, blocking vision, poorly lit corridors, lack of means of emergency communication, prevalence of firearms or knives and weapons in the area among patient and family members, especially, and working in neighborhoods with high crime. Although, like I said, in our study, we did not see a big urban-rural divide. In OSHA, looking at organizational risk factors, they said it was basically like usual in anything that OSHA says, lack of training, very general, working understaffed, high worker turnover, inadequate security or mental health personnel, long waits, unrestricted access, perception of violence is tolerated. So it's a culture of tolerance. So I looked at other papers, and there was a recent one by Kumari. He divided risk factors into three things. One is patient-related, one being that demographically, males, lower education, or ones with higher social status may be more violent. Low impulse control, mental disorders, drugs and alcohol, personality types, style, controlling personalities, dominance, poor previous experience with providers, patient dissatisfaction, legal issues, and spouses getting involved. For physicians, he felt that being female was higher risk, lower education status, less experience, if you're a shift worker. Personality traits, low self-esteem, high neuroticism, low agreeability. And obviously, it's stuff like poor communication skills. And also feelings like being unprepared for what's going to happen, not expecting it. And the organizational factors were very similar, as mentioned by OSHA. But I reviewed, looking at our numbers, there weren't too many factors, but looking at patient risk factors, usually male, usually under 40, opioids were a big one, pre-morbid psychiatric disorder, especially schizoaffective disorder, personality disorder, bipolar disorder. Chronic pain is a risk factor we found. If they're in litigation, workman's comp and disability claim. Physician risk factor, to us, male and female were equal. Some studies noted increase in younger physicians have less experience, emergency medicine, psych, family practice. And other studies have noted practice in lower socioeconomic areas. But like I said, in our study, we did not see that. So what can we do to prevent and mitigate violence? Are we going to arm ourselves? Is that where society is going to? Hopefully not. So I just have to quote OSHA, because that's the Bible. But unfortunately, OSHA doesn't really help you, in my opinion. If you go to the website, look at their guideline book, it reads like a bureaucratic, like a committee meeting. It's so vague that I'll just leave it up here for people to peruse and look on the internet. I want to get more in specifics. So you got to understand most risk mitigation strategies are not based on science. It's based on opinion, consensus, people give their experiences. Like Kumar, once again, in his paper, looked at individual organizational level and societal levels of handling violence. Training doctors, avoiding disagreements and miscommunication. This is pretty obvious stuff. Getting informed consent, improving personal skills, encouraging empathy. Organizationally installing high security systems, closed circuit cameras, metal detectors, alarm system, panic buttons, better lighting, restricting who has access to the clinic, management of that. Transparent billing and an active complaint readdressal system. Like most hospitals have ombudsman or someone they can complain to. Societal level, obviously, politicians are going to have to get involved in the media. But what I did was I kind of distilled some of the opinions of papers and distilled them into different categories of strategy. One is assessing patient risk strategy by Fishbane and Allen, Pay Medicine 2000. This is like basically opinion, but he recommended first recognizing risk factors for behavior, such as he recommended looking at young age, male, once again, substance abuse, antisocial behavior, intermittent explosive disorder, personality disorders are the biggest ones. And he recommended behavior interventions were recommended, including not arguing, avoiding provocation, but not showing fear. Not showing fear, he felt was very important. Not talking down to the patient. Do not touch the patient. Determining the source of anger, rectifying that source, and suggesting to patients that you wish to help to calm them down. The author suggested even using Ativan, Haldol, and Droparadol. It fails, call 911. You can look at the assessing the signs of violence when you have the patient in front of you. Done it out, recommend looking for signs such as complaining loudly, blaming others, threatening others, being paranoid, accusing staff of being out to get them, stating they're going to lose control. But one of the biggest things I've seen, in fact, it happened to one of my colleagues, one of the first signs was actually throwing a punch at an inanimate object, slamming on a desk, hitting the wall, and obviously trying to intimidate you, showing interest in owning guns, weapons, intoxication, romantic obsession, especially for female physicians. They recommended de-escalating verbal abuse because if you can't de-escalate that, that leads to physical abuse, and being a good listener and avoiding accusatory language. They recommended paying attention to body language, maintaining eye contact, standing at an angle from the patient, not directly in front of them, which can be perceived as being confrontational. And then always, if the situation escalates, obviously rapidly disengage and keep records of abuse. Now looking at environmental and administrative design strategies. Once again, done a look at this, and obviously posting a zero tolerance policy at your doorstep, closed circuit cameras, locking all unused doors, providing safe rooms for emergencies, ensuring good lighting, installing monitoring equipment, including panic buttons, and designing waiting rooms to accommodate patients who are delayed, almost separating them out a little bit. Under administrative controls, they suggested a written violence prevention plan to all employees, prohibiting weapons, obviously, ensuring no reprisals for employees who are reporting abuse, writing down all abuse, never having staff work alone. Obviously, when we see a patient we are a little uncomfortable with, it's always to have someone else there. Reducing waiting times, educating our staff, having an alarm system, flagging patient charts, especially in our electronic records, as someone who has potential bad behavior, and escorting patients to and from waiting rooms. And if violence occurs, obviously call 911. There should be a post-trauma counseling and debriefing session for all your employees and recommending calling OSHA within eight hours of any violent incident. There's another interesting strategy from, by Hodgson reported, the VA medical system, because the VA medical system is rather unique. In my understanding, they cannot discharge patients. So that becomes really problematic. So the VA has used what they call the Disruptive Behavior Committee at each facility to evaluate and manage violent patients. The DBC was composed of mental health, the top administrators, police, ethics person, all the VA stakeholders, nursing, PT, whatever, and a patient representative. Recommendations were flagged on the electronic medical records available to everybody, and they were tailored to specific patient circumstances, including identifying triggers, restricting gender-appropriate care providers, and mandates for police presence. Through this technique, they reported a decrease in assaulted behavior, but authors could not say this was the sole reason for the improvement. So I just ran through the quick topic on this. I actually wanted to dedicate this lecture, if the physiatrists on board have not heard this, but Dr. Todd Graham, one of our colleagues several years ago in Indiana, was actually shot by a patient's husband, and unfortunately died. And once again, it was in the context of refusing to give opioids to a new patient, his wife, that instigated this assault in the parking lot as he was leaving work. So without much to do, I will open this up to questions and comments from both the listeners to this lecture and our panel. Any comments? Thanks, Dave. I wanted to add just a couple of things. Your study was fantastic. I just had the same concern about discharging patients. The VA cannot discharge patients, but they're not unique in that lack of ability to do that. There are a lot of clinical scenarios where it's not possible to discharge the patient. And the second thing is, it's automatically considered felonious assault if it occurs against EMS, firefighters, police, but not healthcare workers. And that's also a consideration in this. There may be some comfort in taking advantage of that kind of situation. Absolutely. In fact, in my study, there was one very interesting comment, which I put in the study, where one physician said that he could not discharge a patient who was violent toward him because the hospital administration did not want to damage the reputation and the Preskeny scores of patient satisfaction. So as physicians become more and more employed, obviously, we have administrators to deal with in hospital policy. So I know a lot of hospitals, including our own, I'm not saying violent patients, obviously, but disruptive patients. And like I said, these are signs that we see that are not technically what I call, I should call the cops thing. There are more signs that this could be a potentially violent person, but he hasn't made actual threats to you. That's a scenario that I think most of us get into because we're afraid, our gut tells us something's not right. And then unfortunately, a lot of systems like ours will not discharge the patient, but they will have them, I think this may, I'll get the pins from everybody on this, I'm gonna call it behavior contract, where you actually talk to the patient about their behavior and that they sign a behavior contract. And if they violate the contract, the consequence is actually a full discharge. I just wanna go around to Dr. Crow and the primary care. Now, obviously, I geared this lecture to physical medicine rehab, but it seems like to me, at least by the data, that family practice, which kind of surprised me is really up there in terms of abuse for physicians and possible physical violence. And I was wondering what your take on that data was like for you. Well, I think with primary care, you have longer relationships. So once you kind of have your established relationships, I don't think you see it as much, it's the transitions. So when you're a new provider, you'll all of a sudden get the disgruntled patients from other providers, all trying to get attracted to you. So I do think it's the newer providers who are very vulnerable and might not have as much experience in handling it. Or when you have some physicians retiring, they might have a different practice style, were more liberal with how they gave out medicines. And then when they transitioned to a different provider, that's where you see there's no relationship. And that's where you see the initial intimidation or threats or being upset, my provider gave it, why aren't you? Yes, yes. Thanks for pointing that out I think all of us see it to some degree, especially even pain providers that we see like one pain provider doing something outrageous and then they get their insurance changes or they get dumped by them and they come to us and say, well, my other provider was giving, why can't you? And I tell them, I said, your provider was wrong. But I'm just curious about Dr. Glauser, from the ER perspective, since you are seeing patients at the most duress and you're literally open, it's all comers, gunshot wounds or whatever, how does the ER handle this kind of behavior? Are you seeing the same opioid seeking violent behavior in the ER? And then how is the ER, how does ERs do you think manage this violence? Well, you all know that Southern Ohio and West Virginia constitute the epicenter of the opioid crisis. The only one of the saving graces is that it's made so much publicity in recent years that it's given us some cover. That is, we only write prescriptions for three days, seven days maximum and our patient population know that we're being tracked, they're being tracked and nobody is expecting 30 day prescriptions. That said, my hat's off to practitioners like Dr. Crowe because if somebody, I only give prescriptions for controlled substances to two or 3% of our patients. There are people who advocate the opioid free emergency department, but let's say they have a legitimate problem, they've broken their humors and they get three days of supply. Well, that may not suffice, but they know, pretty much everybody knows that they're not gonna get their Norco or OxyContin refilled in emergency department now. It just isn't going to happen and that's filtered through to the public. So how is it that maybe one in six of the population that we start on narcotics are still taking them a year later? There's a tremendous amount of pressure from their practitioners, the orthopedic doctors, the primary care providers. We've given them a three day supply and they know they can't come back to the emergency department. We won't give them a refill. I won't tell you what that does to patient satisfaction scores, but you can imagine we have to deal with a lot of patients who leave without fulfilled expectations, but they don't come to us for refills, they know better. So Dr. Crow has to deal with that and not to blame people who are still taking controlled substances 12 months after we've prescribed a three day supply, but I can only imagine the pressure that you guys are under to refill. Feel free to respond, Dr. Crow. Yeah. Just in terms of how you handle violent patients or very disruptive patients in the ER, what mechanisms do you have in the ER that you use? Do you ever ban people from coming to your ER? No, you can't do that. Yeah, I know. In fact, as you all are well aware, EMTALA doesn't even allow you to post a sign saying we will not refill your Norco. Don't bother to come here, you can't do that. Yeah. But I feel protected. First of all, we have metal detectors. There are only a couple of ways of getting into any hospital at night and one of them is always the emergency department, but we have security. You're not going to get past security with a weapon. If somebody has a gun in a hospital, they didn't get it through a legitimate means of entering the emergency department. We have a very busy psychiatric population and we have on-site security. Our nurses, frankly, are at more, and every survey says that the nurses are actually at more risk than we are. Yes, absolutely. But I feel pretty safe within the emergency department. People don't come in with weapons and some of it is the psychology of, you leave your gun behind if you've been injured or you want to come to the hospital, you leave it in the trunk. We don't generally even have to deal with it. There are very few weapons confiscated by our security people. People know better. Now that's not to say that if multiple gang members come in, we can't shield them from one another if they happen to be injured or they happen to come at the same time, but we don't have to deal with weapons much. Okay. And we do have security on-site. Metro is the busiest emergency department in the city and we're well accustomed to it. See, I think that's the one advantage of ER is that you have that heightened security presence plus the metal detectors. And it sounds like to me that you have all the environmental structures built in to give you protection. This isn't anything new to us. Yeah, it's anything new. So you're kind of used to that. But just talking to my other colleagues here, just any comments that us working in area spaces that we expect to be safe, which are basically, most of us do outpatient clinics. These are community centers and that are by design supposed to be welcoming and to be open. And in fact, part of the thing at, well, part of what happened to us was that we have these large suburban clinics and we used to have actually uniform security that looked like cops who wore blue uniforms. They were armed and they would patrol the clinics. Now they've switched them to a less of a militarized or you can say less of a police presence, more of a security guard in which they are not armed. So, because the expectation is that we're open, we're welcoming, it's a safe place. But like I said, you go to a place in which there are a lot of heavy guards and things like that, that can be intimidating for patients. But on the other hand, you're kind of balancing that with the fact that if something bad does happen that and you got a security guard who basically all they can do is say harsh words to the gentleman who's armed with a gun, it doesn't make a lot of sense to me in some ways since I think I was reading somewhere that the majority of mass shootings are literally done in five minutes, it's over. And all you're doing right now is just doing the postmortem investigation. I mean, I think most of us feel safe in our settings, but do you feel, I mean, those of us who are in the outpatient clinical setting, do you think hospitals should have better security or should we have some security mechanism of contacting somebody that can come in and help us? What do you think? Just the ones who are doing outpatient, I know ER definitely you have the firepower, as they say. Well, I can speak to our clinic. Ours is, we just have about 10 providers in the suburbs. You wouldn't think of it as being dangerous, but it's actually our staff who I think feel it more. Sometimes by the time the patient gets back to see me, they might be acting nicer because they are trying to get something from me. But at the front desk or with the medical assistants is sometimes where they'll see the intimidation, the anger, the outbursts, if they're coming in, trying to get their refill without an appointment. And so we have had staff who don't feel safe, don't feel comfortable. Security come out to a couple of our all staff meetings to go over different action plans and how we should react, how we could just deescalate. We're open two late nights a week. And so we've put in extra lighting in our parking lot. We put in extra mirrors. We've actually made sure that we're, we don't have one doctor running way later who's gonna be there. So we cut our hours to make sure everyone's pretty much ending at the same time because there were concerns about people who might be staying late and just one or two walking out to the parking lot when it was dark and just for their safety. We even, I think the shrubs next to our building, I think they kind of thin those out because there was some concerns that people could hide in there. We haven't had any actual violence, but it is just interesting that the staff was concerned enough that we've done all those measures just in the last two or three years. Yeah, I would agree that I see this also that I have my staff and they will complain to me. And I frankly tell them, I'll talk to the patient, tell them, hey, that's really not necessary because usually they're nice to us, but they really beat up our nurses and our front door staff. God bless them for their work. But I think it's important that we document this and also like for us at Ford, we have the radical logic or the RL system where we actually put in these untoward events. And I think there has to be some record keeping so the administration understands what's going on and get the pulse of the whole system. And then concerning the opioids, and I can toss this to Sarah as well. I have noticed a certain theme and I've been doing this for about close to 20, 30 years now that I get these patients that are on opioids or you think they've been on opioids and they're new patients or they're maybe old patients asking stuff. But I've noticed one thing, I would say 98% of them, if you talk to them and I actually just go over in detail what the regulations are, what the risks are, how this stuff doesn't work and the long-term risk to them, I'm really surprised that a lot of them said, no one ever told me, number one, that's one of the big things I hear. And number two is that I can talk the majority of them really out of it, okay? But I noticed with the ones that are real hardcore that you kind of knew our high opioid risk tool score would definitely have, this is really an addiction, that those are the ones that really, I just transfer them to get on Suboxone. I tell them, this is not for you. You know that if opioids is all you want, then the safest option for you is to go on Suboxone. And so then I will refer them to one of our Suboxone providers, which very interestingly, there are so many Suboxone providers now, it's amazing. I just type in a zip code to Suboxone. I'm not sure if I can give you the website or anything, but I type in 10 miles, I find literally 30 Suboxone providers. So the access is there, obviously. Well, let me speak to that because I have my Suboxone waiver myself. Oh, wow. But well, I did take a two-day course a couple of years ago, but we do have a controlled situation and I'd like you guys to talk about, a generation ago or so when I trained, it was just never acceptable for somebody with an appointment to an office-based practice to act out in ways that you have to deal with now. But we try, we have to be open to patients and welcoming and MTALA would force us to be even if we weren't. But could you speak to your option of firing patients? Oh, okay. Well, let's talk about that. Let's see how people do this. Well, basically in the old days, when I felt that the physician-patient relationship was broken, I would literally talk to them and say, listen, I think the physician-patient relationship is really broken. Obviously, you don't trust us, you don't want our treatment plan and then this is not gonna be good for you either way. It's just a bad relationship. And that I will no longer, I can no longer treat you. And then I will formally discharge them verbally and on chart. But now it's a little more complicated, more nuanced that unless they're really threatening you, I think our legal department told us that the best way to handle this is to put them on a behavior contract. That, and this contract can involve, I'll give you an example. I think it put a lot more people on behavior contracts for being disrespectful to one of our nurses or support staff, because I think it escalates from there. Because when that type of behavior is once again, tolerated at the junior level, it can escalate to us and even beyond. So I think having a zero-tolerance policy, which I think is pretty good for Ford, Henry Ford, we have a zero-tolerance policy. Although obviously everyone's gonna enforce it, have the guts to enforce it, is to give them a behavior contract and the physician has to talk with them. And then they have to sign the contract. If they don't sign the contract, then we can discharge them. If they sign the contract, they behave themselves, they know they're under the gun. They know certain behaviors cannot be done. If they violate the contract, I have, I tell them, you violate the contract, I can no longer see you, you signed this agreement. So that's kind of the way it's been handled. Obviously in our hospital, if someone is threatening violence they will be discharged immediately. It's just that gray zone where you have this escalation of behavior that you could, like I pointed to those signs of potential violence toward you, that's lethal. But on paper, it's not enough to discharge them, at least within our system. So that's the kind of the way it's been handled. And I think it's been vetted by our attorneys at the risk management level as well. What would you- I appreciate what you guys are doing. Any contract gives us cover. Yes. And we can always say you're under contract, you get your pain medication through this particular doctor or service. And I appreciate that. And I speak for everybody else in emergency medicine who appreciates that. Well, thanks a lot. I just want to comment from Sarah. What do you think about this whole concept of discharging patients as a- No, it becomes a very gray area, as you said. If the patient is exhibiting aggressive behavior but no overt threats, it becomes a very gray area to define the level of intimidation and danger to providers. The behavior contract, I haven't done any behavior contracts. I have threatened patients with the behavior contract but they have self-selected themselves out of the clinic and never signed it. So it has never come to that for me personally but the behavior contract, I'm not sure how effective it really ends up being because it's a fundamental characteristic of the patient to feel comfortable enough to be that aggressive towards their providers. So, I have encountered several patients where I've considered but not had enough evidence to initiate a discharge. Interesting. And that's been a concern. Yes, unfortunately, I think administratively because like I said, if this is your private practice, okay, where you're the boss, and as long as you document what's going on, I think most private practitioners I've talked to in private practice will absolutely discharge a patient. Absolutely. Just drop a bat. But I think with large bureaucracies, they have these rules. Obviously they have other things they're worrying about including like bad reputation within the community, word of mouth, the prescany scores. Which everyone talks about, right? So, we're kind of caught in the middle. So, in some ways the behavior contract is somewhat of a compromise. I do like, frankly, that this idea of a safety committee that I think that should have all stakeholders, especially with patients you really feel uncomfortable with. I think that really should be instituted at every level in every hospital where you can identify potentially uncomfortable patients or patients who are even threatened by violence or whatever that I think at that level, it should come to a committee, including top administrators, legal, nursing staff, even the MAs. So, that's rule one. Rule number two is that I think it's important incumbent upon us to identify the signs of potential risky patients, number one. Number two is do not allow small slights even to your staff go unrecognized. I think this whole thing of tolerance of behavior causes self-escalation and allows patients to be violent. So, I think that's one lesson I think we have to learn. Because physicians naturally, we wanna be nice guys. We wanna be liked by our patients, but unfortunately that doesn't always happen. And a lot of times we have to put a pedal to the metal and do the right thing. But it was a little bit shocking to see physicians actually arming themselves. And that was the scary part that actually about like a good chunk of, I think most of these guys are probably private practice because obviously you can't carry a gun into a hospital or some kind of medical setting, but private practice, you can do what you want. You're allowed to arm yourself. In Texas, heck, everyone carries a gun in Texas, as they say, right? So, keeping tolerant, just looking for, tamp down even the smallest behaviors, nip it at the bud at the beginning. I think it's very important. Recognizing the risk factors, having the environmental controls, and then, and documenting correctly. I think it's important. So- I wanted to address one of the side questions. Oh, sure. How do you define, how do you manage to define disrespectful behavior in a diverse patient population? And that's a good question. You know, with different cultures, it is appropriate and normal to speak in a loud tone or in a more aggressive sounding way. And that becomes a very nuanced kind of perception. But I think the general feel of safety is what it comes down to. If you feel unsafe, then it is an inappropriate and threatening situation. I think if your sympathetic nervous system is going up, I think that's basically it. You know, I think what Justice Potter said when they were trying to find pornography, because I don't know what it is, but I know it when I see it. So I think the human experience of fear is universal. That I think we all know what fear feels like. So to escalate behavior to that level of fear, already, you know, that's an issue. Actually, as long as you're addressing chats, I see, is there any data to show that violent behavior toward physicians escalates from harassment and intimidation? I can produce some polls regarding violence against providers. And one of the reasons that people don't report it, besides the fact that they may think it's part of the job, is that they don't think that the hospital administration has their back. They're more into patient satisfaction and they don't want to antagonize patients who may be temporarily incapacitated anyway and intoxicated. And by the time anything comes to court, the healthcare provider thinks they've wasted their time. The administration's not going to back them, so it never gets reported. And that goes back to patient satisfaction as kind of a problem. Anybody who wants a paper out of UC Davis from about 2014, I'd be willing to provide that, that shows actually an inverse correlation between patient satisfaction and quality of medicine. I didn't like Dr. Kim because he didn't give me antibiotics for my cold. I didn't like Dr. Crowe because I had back pain for 23 years and he didn't do an emergency MRI. And I didn't like Dr. Mani because she didn't refill my Norco and I didn't like whatever. You can fill in the blanks. Patients' expectations are not met, but that doesn't mean we're providing substandard care. Yes, I absolutely agree. But I don't think there are... See, unfortunately, this whole area of violence toward professionals like ourselves is really understudied. And the problem is we're not just collecting enough data, but the problem also is there isn't a lot of inputted data because a lot of people don't report the data. That's another issue. A lot of times you get swept under the rug. You hear about whispers about something bad happening in the doctor's lounge, but then it's quickly forgot. So I think it's important to actually log any kind of these incidents in because I have a very low threshold of RL-ing incidents where my MA or my RN feels like they were disrespected, abused verbally, or whatever. I think it's important that we actually document this. I think that's the key thing to get the heads of the administration around this issue. And it's being documented more. Actually, there are a couple of publications up your way out of Oakland hospitals. I can cite them for anybody who's interested, but there's a movement called No Silence on ED Violence sponsored by the American College of Emergency Physicians and the Emergency Nurses Association. So it's coming more to the fore, not enough. I would advocate a zero tolerance policy, but until then, I think we're coming along. Yeah, I agree with you. I think it's being more recognized. I think the more we get the message out there and we move toward a zero tolerance policy of violence and abuse of our staff, I think it's pretty important. And any other comments from any other interesting questions or comments? There's a question on training, comments on the value of self-defense training. I don't have any training in self-defense. Because under other of what people did, actually, that was one of the things they did. They actually took self-defense training. And I gotta tell you, self-defense training, someone comes at me with a fist, I can probably, even without self-defense training, I can probably at least blunt that. But against a gun, that's a whole different issue. And unfortunately, guns are so prevalent out there that... And here's the weird part. I've actually had a patient come in, into the clinic, sat in a clinic room, and she forgot that she had her gun on her. People actually forget because they have concealed gun permits, and they just forget that they can't bring it into a hospital or clinic. So people just bring it in just accidentally. We have a big advantage there. We know our patients are not armed, you don't. Absolutely, and what was the other thing? I've had comments during the study that one patient actually, one of the respondents actually just showed him the gun. Didn't threaten him, but just showed him the gun. So he didn't say a word, just showed him the gun. And that was it, and that was enough. So it's rather interesting. Any comments, Dr. Crow? Any final comments or anything you can think of to? No, I think it probably is dependent on the clinic. We've had really good administrative support. So we have been able to discharge patients when they have a threat of physical violence. Usually we're doing the behavioral contracts when they're threatening or intimidating the staff. And the staff really appreciates that. A lot of times, like I said, by the time they get to me, I don't necessarily see it. The patients are more cordial with me, but we take it seriously. If the staff says it, we'll write it up and we'll have a contract and I'll go over it with the patients. I kind of am in charge of two clinics. So I see a lot of it at the different clinics. What we found more lately the last couple of years is with MyChart. People view their MyChart messages like it's social media. And so that's where we're discharging some of the patients because they just will just go off on MyChart when they're not in front of you. And if they're threatening violence in their messages to the physicians, we'll be like, we've got zero tolerance for that. Oh, wow. Wow, I totally forgot about that. That actually because of all these electronic messaging tools they have with patients now that they can threaten you. But that's good because they're actually documenting it for themselves and the cops. That's fantastic. Wow, I totally forgot about that, that you can be actually threatened through the MyChart patient now. Yeah, great. If you can tolerate one last comment. Sure. And I'll give you one because I've given talks to emergency physicians on alternatives to narcotics, sub-dissociative ketamine and gabapentin and Lyrica and Tegretol and all the other stuff and topical lidoderm and capsaicin and topical Voltaren and so on. But I'd like to hear your comments when medical letter or other publications come out with reviews of analgesics. They really only talk about NSAIDs, Tylenol and narcotics. That's not a great choice. People can get Tylenol over the counter. NSAIDs are not terribly safe and narcotics are addictive. And I can only conclude that from a pharmacologic point of view, we really don't do pain very well. Any comments? Yeah, actually, there are quite a lot of different alternatives to alternative medications that we use in the pain clinic, a lot of different modalities. So I tell patients, you got a lot of options. So why do you want to go with something that early man was using when he crawled out of the cave and was sucking on the poppy plant? We have more advanced medications that don't screw up your brain, make you grow breasts, increase your risk of heart attack, opioids. And also what's interesting is opioids can actually suppress your immune system, at least theoretically in the animal model, increase your risk of cancer infection. So there is a lot of data out there for these non-opioid pain medication. You know, the membrane stabilizers are tricyclics, intravenous ketamine, you mentioned, topicals. So, you know, I'm optimistic that we can get patients, at least most patients out of opioids. Right, unfortunately, not all of them work well acute. No, and unfortunately not everybody can take any of them, especially our elderly, because unfortunately a lot of them are on blood thinners, they can't take an NSAID. So, you know, I think where opioids are probably gonna go, basically as acute pain, is more toward the end of life or elderly care where patients don't have kidneys, they're too sensitive to a lot of the tricyclics or the gout and things like that, and they're on blood thinners. So that's a large part of my population that they're on opioids, are the more senior patients who really failed everything. I think we have reached our time period of nine o'clock, and that was a great discussion. All I can say is stay safe out there. Thank you. Thank you. Thanks for having me. Thanks.

violence towards physicians

prevalence of violence

types of violence

underreporting

prevention strategies

training

security measures

zero tolerance policy

safer environment