Refusing to Tolerate Patient Violence

Let me start today with some sad news many of you may have caught wind of last week. A Tennessee orthopedic surgeon was shot dead in his office by a patient.

Violence against healthcare workers is way too common. It can be the patient who spits at a nurse or punches a doctor – or, as in one recent incident at a hospital near me, a pregnant nurse being kicked in the abdomen. This resulted in a guilty court verdict for aggravated battery of a pregnant person.

And for some reason, in most cases, these violent acts are usually ignored, with excuses like claiming the patient was in distress, and that the staff should have de-escalated the confrontation. That is not acceptable. There is no excuse for violence. My personal view is that any acts of violence by patients should be reported to the police to let the legal system handle the determination of their responsibility for their actions and the consequences.

Every healthcare facility should also have an action plan for such circumstances. As Dr. John Zelem recently pointed out on Monitor Mondays, over the last three years we have seen an increased amount of distrust and confrontation in medical care, and I think the line has to be drawn. Violence is never acceptable.

Moving on, one of my responsibilities to this audience is to keep you informed of topics being raised in the medical literature and social media that may affect your work. Well, one such article appeared in the prestigious New England Journal of Medicine last week. This article was titled “Hospital Problems.” It was written by a rheumatologist who, during rounds at the hospital, was told that a patient with vasculitis and proteinuria was being discharged. The exact cause of the patient’s kidney disease was not yet clear, and the patient required a kidney biopsy, but she was medically stable for discharge, and as the doctor described, he was told that the biopsy was not “a hospital problem.”

The doctor agreed that the patient was medically stable and would need to have her aspirin held for three days prior to the biopsy, but also felt that she should be allowed to remain in the hospital for those three days because the biopsy was needed.

He then went on to assign blame for this, citing the introduction of the hospitalist as a specialty in the late 1990s, the ever-growing number of metrics used to measure care (including readmissions and length of stay), the increasing push for more throughput to increase hospital revenue, and of course, the “business majors” who run hospitals.

What he neglected to mention were the number of patients boarding in the ED whose health and safety would be improved by having access to an inpatient bed, the number of patients whose surgeries may be delayed due to lack of capacity for their in-hospital post-operative care, and the risks of continued hospitalization.

Does he have a solution? Well, he thinks physicians must embrace dual roles as both employee and patient advocate, and he hopes that value-based payment models may help break down barriers separating inpatient and outpatient medicine. Those hardly seem like new ideas to me.

Now, what will come of this?

Well, dialogue is always good. There are many flaws within our healthcare system. But I tend to think that hospitalists are already aware of their dual roles – and the many, many models to improve the system that have been tried. “Value” is so vague as to be, in my opinion, worthless as a term. Despite years of trying, we still do not know how to measure the quality of care provided to patients. And I truly think that every one of us is already doing our best to balance the priorities of not just one patient, but all patients.

For now, let’s keep on talking, continue to work together as a team, and perhaps one day, a solution will be found.

Programming note: Listen to Dr. Ronald Hirsch as he makes his Monday Rounds on Monitor Mondays, with Chuck Buck and sponsored by R1-RCM.