Doctors have been stalked, shouted at, and had their lives threatened. Physician safety, burnout and five-star reviews are on a collision course.
On July 11, Dr. Benjamin Mauck, a respected hand surgeon, walked into an exam room in Collierville, TN to meet a patient. Within minutes, he was shot and killed and the patient was arrested shortly thereafter.
It’s an all-too-familiar story. Fortunately, few cases elevate to the level of violence of what happened in Tennessee, but local doctors have experienced their share of harrowing events. Some have been stalked, others have been shouted at, and while the offending patients may be banned from one health system or medical group, they often simply move on to the next one where their behavior may be repeated.
It’s a problem that SSVMS has recognized as a top concern among its members and one, studies show, that is increasingly contributing to burnout.
One local doctor, who asked not to be identified or even say where events occurred because “this guy’s still out there,” was stalked even to the point that the doctor thought the patient might have been staking out his parents’ house.
“He went all the way up to calling me and my wife and my parents on their landline and giving the impression he was going to come and shoot up our clinic," the physician said. "It was terrifying.”
Permanently discharging the patient, who had also been abusive to staff and had proclaimed a militia mentality, wasn’t easy. And that was frustrating.
“How severe and threatening does somebody have to be before we, as an organization, will take action?” he asked. “We’ve still got to get letters and sign off from so and so to make sure we can do this.”
To make the situation even more nerve-wracking, this episode was happening shortly after January 6, recent shootings in Colorado and Georgia, and in the pandemic when certain elements of society seemed emboldened to make threats.
A drive for top patient satisfaction reviews throughout the industry have made medicine look more like tech support, with promises of around-the-clock service. That creates unrealistic expectations for patients, who get upset if they don’t get an immediate response to their needs.
“That used to be a $2,000 a month retainer for the concierge doc in San Francisco for that level of service,” the same physician said. “Every Homo sapiens over the age of 12 has a cell phone now and can install the app and message their doc. Now we’re building billboards on Highway 80 saying message your doc anytime, and you know, great, right? But that’s not good and it’s burning people out.”
“The fact that we call patients ‘clients’ now is representative of the consumer mentality,” a Sacramento physician said. “It gives all the power to the patients — the clients — and it makes doctors disposable. A doctor’s choice of treatments shouldn’t be based on patient satisfaction, but the quality of care. If you give everyone Adderall, it might make the patients happy but it doesn’t mean it’s indicated and it can be dangerous.”
An atmosphere is created where when a patient doesn’t get what they want, even if it’s not best for their care, the reaction can go far beyond leaving a poor patient satisfaction review that can affect hospital revenues and physician bonuses. Patients feel increasingly entitled to send abusive emails and yell at staff.
According to the Bureau of Labor Statistics, violent attacks against medical professionals grew by 67% between 2011 and 2018, with health professionals five times more likely to experience workplace violence than workers in all industries. Health professionals were also about 50% more likely than other community members to have been harassed, bullied or hurt as a result of the COVID-19 pandemic.
Still, physicians still feel obligated to do what they can for patients until it gets to the point of no return. In the first physician’s case, he saw a pattern of how the patient — who was talking about weapons and was showing sympathies with the Proud Boys — reacted to frustrations with the health care system, lawyers, and others. There had been loud talk and threats, and a lot of unpleasant messages, but fortunately no sign of actual violence. But, the physician said, there was no way to be sure whether he would cross that line.
The physician tried to continue to help and said that he and his staff had a sense of how to handle the patient “and allow him some degree of back channel” to avoid some of the things that exacerbated his frustration.
“No one likes waiting on hold, no one likes repeating their birthday five times to the telephone before they finally speak to you,” the physician said. “These are universally irritating experiences.”
“The Mayo Clinic has a zero-tolerance policy with clearly laid out consequences for bad behavior, including patient dismissal,” said SSVMS Executive Director Aileen Wetzel. “We’re working on a policy similar to the Mayo Clinic’s, but we plan to include language letting the patient know that all hospitals and medical groups in the region uphold the same policy,
"However, we recognize the need for care, which is why we are also looking at a ‘walk back’ policy that goes beyond Mayo's. It could enable a patient to earn their way back into a practice through tools such as a signing an agreement that they must meet behavior standards or by completing anger management classes.”
“It’s a very interesting problem or paradigm because in pretty much every other aspect of the workforce — other than like working with prisoners where everybody knows that they're going to potentially attack you or treat you poorly — in most other places. somebody does something bad to you, you can just say, ‘You know what? You're out of here. We're not going to take care of you, you’re not our customer anymore,’” said Vanessa Walker, DO, a pulmonologist and the SSVMS president-elect. “In health care, you don't really have that luxury. No matter how poorly somebody's treating you or the things they're saying, sometimes you have to continue caring for them. It's a really tough position to be in as a health care provider and as a person.”
Many relationships between doctors and patients took a significant turn for the worse during the pandemic, when conspiracy theories and anti-science misinformation brought politics into the exam room.
“When COVID came, it was, like, every single day I was at war with my patient or their family member in one way, shape or form,” Dr. Walker said. “I was constantly having to explain to them why what I was doing was in their best interests.”
Dr. Walker said she was accused of falsifying death certificates and had people screaming over the phone a demand that the death certificate be changed. For political or other reasons, they did not want their loved one to be considered a victim of COVID.
“They would leave hateful messages on our answering machine demanding that we not lie {about the cause of death] and change the death certificate to not say that they died of COVID,” she said. “I would have family members just yell and scream at us for not providing things like Ivermectin, which is a big one.”
Dr. Walker had lost her father-in-law to COVID-19 earlier in the pandemic, and she says if there had been something that she could have done using Ivermectin or another treatment, she certainly would have done so.
“We're not trying to hide other reasons why people are dying,” she said. “And we're certainly not contributing to their death by withholding care that we think would help them simply because we're part of a government conspiracy or some conspiracy held by Big Pharma.”
Threats and abusive behavior by patients aren’t the only mistreatment physicians face.
“Remember, when we're talking about mistreatment, it's not just physical or psychological harm, but it's also sexual harassment,” Dr. Walker said. When she was a fellow at Duke University working at a VA facility, she was obviously pregnant and about to go on maternity leave when she saw a veteran for the first time in about six months.
“He goes, ‘Yeah, I thought you were pregnant.’ And then he said, ‘Man, I’m glad to see somebody’s hitting that,’” she remembered. “I felt so… I mean, it was just, I can’t even describe how gross I felt. Here I am, I’m pregnant, it’s my first baby, it’s supposed to be this really wonderful experience. And this gross man just turned it into something completely inappropriate and not the experience that I wanted.”
A recent study showed that preventing workplace mistreatment could improve physician well-being using the Mistreatment, Protection, and Respect (MPR) Measure. This measure was used to ask respondents about different forms of workplace mistreatment and violence from patients (and patients’ families), colleagues, nurses, leadership, and other staff. The forms of mistreatment and violence included sexual harassment or abuse, verbal mistreatment or abuse, and physical intimidation or violence. Verbal mistreatment or abuse is the most common: 37% of respondents reported experiencing it, and 28% said the abuse was from patients and their families. About 12% of respondents had been physically intimidated or abused by patients or patients’ families, and 39% of respondents overall reported some sort of sexual, verbal, or physical mistreatment from any source. About a third said the mistreatment came from patients or patients’ families, while a combined 16% report experiencing it from colleagues, nurses, leadership and other staff. It’s also important to note that 4% of respondents reported verbal mistreatment from their leadership teams.
Sometimes it can even come from colleagues. One physician was told by a senior physician that he “was going to picture me wearing that dress from then on when he encountered me at work when we were at a dressy social event.” Another said that as a woman in leadership, her positions are often questioned and need to be justified but her male colleagues don’t face the same scrutiny.
“I am told I am aggressive or need to be more friendly or smile more,” she said.
The pandemic created a quandary for physicians who saw the unprecedented rise of misinformation and wanted to do something about it. Many took to social media, as the U.S. Surgeon General and organizations such as CMA and SSVMS encouraged them to do, to support the need for vaccines and to reiterate that pop culture treatments not only weren’t effective, but that they could cost the life of someone with COVID. The result, of course, was a dramatic escalation of online threats — almost all anonymous — against those attempting to save lives.
A JAMA survey found that in 2019, 23% of physicians experienced online harassment based on their posts. Just two years later, that number had risen to 66%. Doctors have reported receiving death threats, numerous posts advocating for their rape, and posts telling them to commit suicide.
Through these heightened tensions, physicians responding to SSVMS inquiries have expressed frustration that patients who threaten doctors and staff or break protocols currently face few consequences, something the zero tolerance policy would finally address. However, hospitals and health systems can be more aggressive in preventing these patients from shuttling from one provider to another who, because records may not be shared, aren’t aware of the patient’s past behavior. They can also do more to listen to physician concerns about how they feel they are put at risk.
One physician responding to the SSVMS survey noted that there are no new protections in a local hospital emergency department, even after an active shooter event there. “Incidents are reported to risk management and we get no feedback about the results of the investigation,” the doctor wrote, adding that there has still not been active shooter training in the clinics.
SSVMS realizes that, in some cases, it will be up to doctors to ensure their own safety. Many have learned to position themselves so that there is an easy exit if the patient becomes threatening. It recommends that hospitals and practices structure rooms so that there is a clear path for escape and for security to intervene.
The most recent SSVMS Joy of Medicine: Physician Wellness and Workforce report confirmed that physical threats, verbal abuse and sexual harassment have become key contributors to burnout. COVID, and the surrounding issues such as abuse, also led to a 26% drop in the number of students applying to emergency medical programs in the U.S., according to the National Resident Matching Program.
The emphasis on patient satisfaction, the ability to practice medicine based on the best outcomes rather than generating ratings they can feature on billboards, and the safety of physicians are on a collision course that is increasing burnout.
“Nobody signed up for hours of unpaid labor, to be undervalued and unappreciated, or to fear for their life every day,” said SSVMS President J. Bianca Roberts, MD.
One doctor said it will take physicians strongly expressing their discontent to make a difference, and that hospitals, health systems and medical groups can start by involving doctors more deeply in the policies that affect them.
SSVMS is currently preparing an extensive plan for the board to consider that would address mistreatment and violence experienced by physicians. As several physicians expressed, an important first step is to make elected officials, health care leadership, and the public aware of the increasingly volatile atmosphere in exam rooms in order to lead to meaningful change.
By Ken Smith, SSV Medicine managing editor.
