AST MONTH , WHILE AT a mandatory conference at our hospital and idly checking my email , a note from my nurse caught my attention : “ Dr . Ma , can you call me now or let me know where you are ?” I replied , “ In a meeting – I ’ ll let you know when the session lets out .”
My nurse ’ s next message really caught my attention : “ Local law enforcement has been called .” I escaped from a group activity and called back my characteristically calm and unflappable nurse .
A series of phone calls from a long-term patient of the hemophilia center had raised the alarm . Brenda , the center ’ s highly experienced nurse , and Curtis , our well-trained social worker , filled me in : “ We just couldn ’ t get him calmed down , and we think he ’ s threatening to hurt you .” Okay . “ He ’ s in his car driving and isn ’ t answering our calls any more . We don ’ t think you should be alone , and we wanted to make sure you weren ’ t in clinic late and coming out to an abandoned parking lot .” Great .
The patient was upset about the copay for his monthly narcotics , the winter weather , the poor heat and insulation in his girlfriend ’ s apartment , his unemployment , and his lack of disability insurance – for which he apparently blames me . He also has an anger management issue , and depression , and he ’ s been fired from work for assaulting people who “ got in his face .”
As a child , he had a heart murmur and received disability benefits . He no longer has a heart murmur , and he blames me for documenting this . Because he equates his lack of a heart murmur with his lack of disability , he went from faulting me for cosigning a resident ’ s “ no M / R / G ” note to accusing me of writing the disabilities board to say his application should be denied .
Brenda and Curtis explained to him that this wasn ’ t true , and that no adult patients with hemophilia get approved for disability on their first application , and that he should reapply after keeping a log of his bleeds and joint pain . He could not be reasoned with . Curtis found it hard to keep up with the patient ’ s disorganized ranting , but several phrases stood out : “ Make an example of her . … Get people ’ s attention . … Mass shooting .” And , my personal favorite : “ If I could , I ’ d come and blow the b---- up .”
Apparently , he ’ s been angry with me for a decade . This was news to me , since I had arranged a monthly clinic visit schedule for him so we could track his bleeds and pain , thereby helping him with his disability documentation .
Luckily , that day it was threatening to snow . In North Carolina , not even a potential mass shooter wants to be out on the roads in bad weather . He turned around and went home .
A few hours later , I was driving to a previously arranged dinner while thoughts were scurrying around my head . What would I do if the patient pulled a gun in clinic ? What if he was by my car , or waiting at my home ? Golly , my colleagues would have to cover a bunch of calls and clinics for me if I were dead or wounded . … I found little solace when I told others about my experience . My mother – ever unsupportive – asked , “ Why do you always get yourself into these situations ?” Not helpful , Mom . The husband of a trainee offered to loan me a handgun . Gulp .
Should I think about getting a gun ?
I turned to the internet next . I looked up “ handgun classes The content of the Editor ’ s Corner is near me .” A facility located in the same shopping center as my
the opinion of the author and does nail salon offered handgun training . Their website proclaimed not represent the official position of the American Society of Hematology
“ Violence as a second language .” They offered classes titled unless so stated .
“ Defend Your Castle ” and “ Urban Warfare 1 .” I hesitated ; I ’ m not certain I want to be fluent in violence . Have a comment about this editorial ? Note to self : There ’ s a real opportunity to market handgun Let us know what you think ; we welcome your feedback . Email the editor at ACNEditor @ hematology . org . safety to academicians . Call it “ Handgun Training for Squeamish Liberals .” I ’ d have signed up for a class like that , but all I found was “ Boom : Introduction to Firearms .”
After careful consideration , I concluded that a handgun was NOT for me , since I really didn ’ t think I could shoot a hemophilic patient . And , firearms are forbidden in clinic , so even if I bought a of medicine in the Division of
Alice Ma , MD , is professor Hematology and Oncology at gun , I couldn ’ t bring it to work . I the University of North Carolina settled on ordering pepper spray School of Medicine in Chapel Hill . and a Taser from Amazon .
Now , what to do about the patient , his hemophilia , and his boiling rage ? On the one hand , he has specialized health-care needs that are best served at our center . Could we mandate that he be actively engaged with mental health care as a condition of treatment ? Could my partner see him in clinic when I ’ m not there ? Yet on the other hand , he might go off the rails and decide to follow through on his threat . How do we keep our other patients and health-care providers safe , while addressing the needs of this patient ?
Serendipitously , while I was wrestling with these questions , I ran into Arlene Davis , JD , a terrific colleague and co-chair of the University of North Carolina ( UNC ) Hospitals Ethics Committee . Yes ! I clearly needed an ethics consult . Soon , I was at a meeting with representatives from our ethics committee , legal department , and hospital police . I learned that we should have called the hospital police at the first threat so that officers could have patrolled our off-site clinic and that we could implement a behavioral contract mandating the patient undergo regular mental health care as a condition of receiving hemophilia care at UNC .
The hospital police contacted the patient to inform him that threats against his providers would not be tolerated . He denied making threats , while simultaneously making more threats , and then he called the hemophilia center to make even more threats . We are in the process of dismissing him from our care ; he will be given a list of other hemophilia providers and two months of prescriptions during the transition period .
Violence against health-care workers is rising , though suffered most by nurses , and mostly in emergency-room or psychiatric settings , according to a Scientific American investigation . In 2015 , a surgeon was murdered by the son of a patient at Brigham and Women ’ s hospital . In 2017 , an Indiana man murdered his wife ’ s doctor after he refused to prescribe her opioids . Our health system is experiencing an uptick in the number of patients threatening harm to providers . Many come from drug-seeking patients ; most come from patients with untreated or undertreated mental health disorders .
I have no answers for this problem , but I know that my interaction with a potentially violent patient has taken a toll on my sleep , my interactions with other patients , and my feelings of personal safety .
I wonder how many others have had a similar experience ?
Alice Ma , MD
6 ASH Clinical News March 2018
Letters to the Editor
Workplace Violence
Editor ’ s Corner
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Not What I Signed up For
March 2018 Editor ’ s Corner
In our March 2018 issue , ASH Clinical News Associate Editor Alice Ma , MD , recounted an unnerving experience with a threatening patient in “ Not What I Signed up For .” Unfortunately , as Dr . Ma noted in her editorial , the occurrence of violence against health-care workers is rising , and it can be challenging to keep patients and providers safe while addressing the concerns of those with specialized health-care needs . Below , two readers react to the editorial and share their own experiences treating potentially violent patients .
HELP HEMATOLOGY PATIENTS FIND YOU ! i read dr . ma ’ s editorial and , having worked in North Carolina for 15 years , my first thought was , “ Is Dr . Ma now treating sickle cell disease and some of my past patients ?”
I have had similar experiences with a couple of congenitally and chronically ill patients who – after years of being in my care and even more years of dealing with psychosocial issues – decided to find a scapegoat in their longitudinal medical team . I want to highlight the psychosocial components of these patients ’ lives , because I believe that these factors greatly impact their clinical care . Each patient is dealing with poverty , depression , poor coping mechanisms , lack of social support , perpetual stigmatization , and undiagnosed or mismanaged neurocognitive deficits .
I agree that ethics , safety , and patient representatives all need to be involved and taken into consideration to ensure the safety of other patients and staff during these situations . At the same time , what really keeps me up at night is the reality that , while we are providing the best and most comprehensive medical care for these unfortunate patients , some people feel that their needs are unmet , even when multidisciplinary teams are available at most outpatient clinics . We the providers ( including the care managers , social workers , pain specialists , and psychiatrists on these teams ) can sometimes feel impotent to help them .
Laura M . De Castro , MD , MHSc University of Pittsburgh Medical Center
Pittsburgh , PA
In our particular practices , where we encounter difficult medical situations – sometimes resulting in the death of a patient despite what we believe to be our best efforts – it is imperative to act with honesty and to serve as fervent advocates for our most fragile patients and their families .
While I , too , have experienced a small share of threatening situations from patient families , I have found that , in most instances , the best defense is not a strong offense . Rather , true engagement with the individual and a show of sincerity have gone further than defensive tactics .
Of course , doing so might require us to cross an emotional boundary that we raise to keep ourselves both objective and removed from the trying situation ( perhaps that ’ s another defense mechanism ?).
I learned this while working with two families during my fellowship , one with a child who had Langerhans cell histiocytosis and one with a child with systemic lupus erythematosus . The former succumbed to her condition , while the latter is a high school student interested in robotics and dance . I have kept close ties with both families and speak to them every few months . While working with these families , there were many moments of angry outbursts , disillusionment , and blame that I chose to try to resolve or redirect .
I ’ m not saying this formula will work in every instance . However , I do know that we practice in an electronic health record – based world , where reimbursements are contingent on work Relative Value Units . The art of medicine and the healing touch of a physician ’ s mere presence are diluted by our scarce time and the cursory nature of our interactions .
I wonder if the problem arises from a perception of a lack of investment ? Thus , does the solution lie in trying to maximize the value of our short interactions ?
The editorial was a good read that didn ’ t simply raise questions about the safety of health-care providers in the current political climate , but also triggered introspection into what a valuable interaction should feel like both to the patient and the physician .
Sidharth Mahapatra , MD , PhD University of Nebraska Medical Center
Omaha , NE
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