When I took my first job as an attending emergency physician at Mount Sinai Hospital in New York, the man who hired me, the late, great Dr. Sheldon Jacobson, put it to me squarely: “Here’s the deal—I take good care of you, and you take good care of the patients.” One problem I never expected is that some patients don’t take care of us in turn.

A few years ago, I was working a night shift when a woman in her twenties presented for mild alcohol intoxication. She was alert and spoke clearly. We had a pleasant conversation, and I told her we would provide some Tylenol and IV fluids. She was appreciative. I sat down and began to type my note just a few feet away.

Just a few moments later, the nurse approached her to start the IV. The patient asked why she had taken so long and used a demeaning word. I overheard the exchange and was surprised at her sudden change in attitude. I walked over to deescalate the situation, and she responded with a racial epithet toward me. My nurse indicated that her behavior was inappropriate. The patient then punched her in the face. She then went on a verbal tirade and spat on me. We called the police, and she was arrested. Fortunately, neither my colleague nor I sustained any serious injuries.

How, I wondered, are we supposed to take care of our patients humanely if they fail to see the humanity in us? We do it because it’s our job and it is part of our moral code.

But that doesn’t make abusive behavior from patients OK.

Pervasive Violence Against Providers

Many health care workers will relate to these scenarios. Verbal assaults are so common that they are shrugged off as merely part of the job. We often even tolerate what should be unacceptable statements that are racist, sexist, homophobic—you name it. We often even try to let literal threats roll off our backs. But over the last few years, several studies have highlighted an epidemic of violence toward health care professionals. This we can never learn to tolerate.

Sadly, I fear, we have done just that. Back in the 1980s, workplace violence was first rigorously assessed in the emergency medicine literature. But by 2018, little progress had been made in addressing and reducing violence. Omar et al published data showing that the problem remained equally prevalent despite an increase in security measures over the previous decade.¹ (Just imagine if we didn’t have such measures in place!) 

According to one study, nearly 80 percent of emergency department physicians had either been the victims of workplace violence (which included threats, battery, outside work confrontations, and even stalking) or had witnessed it firsthand in the preceding 12 months.² In another study, 100 percent of emergency department nurses reported verbal threats, and 82 percent had been assaulted in the preceding year alone.³

Most of us—including myself—have been assaulted multiple times. The Occupational Safety and Health Administration (OSHA) tells us that health care workers are at higher risk of violence in the workplace than those in any other industry. The February issue of Annals of Emergency Medicine featured a frightening story by Amy Costigan, MD, of an ambush-type assault on an emergency physician.⁴ While awareness of violence against health care providers may be increasing, the issue is not being adequately addressed.

Currently, I am a freshman member of the Arizona House of Representatives. The focus of my campaign was to listen to people at a grassroots level, and to that end, I personally knocked on more than 8,000 doors. After being elected, I asked a few nurses during a shift about their biggest concerns. The very first thing they mentioned was workplace violence. Their stories were plentiful and frightening.

Specifically, my colleagues emphasized that we have developed a culture that discourages reporting. Many of us have the impression that reporting will not have any effect and the perpetrator will simply go free. These concerns are valid because currently in Arizona, as in many states, these crimes are often pleaded down to misdemeanors and the consequences are modest. But in the emergency department setting, we have the additional concern that some perpetrators will stalk us or retaliate since we are federally mandated to take all comers regardless of their past illegal behavior toward us.

Taking Action

To address their concerns, I authored a bill to protect all health care workers from assault. With the help of the Arizona Nurses Association and many other health care groups, our bill passed out of the House of Representatives with bipartisan support. Though it stalled in the Senate this term, we will continue to push forward again next year.

There are many potential ways to decrease this problem, from stiffer penalties to administrative reporting requirements. Even mandating signage that clearly communicates the law would be a step in the right direction. Since becoming involved with this issue, I have received countless emails from health care workers with their own harrowing stories and offers of support. And these letters of frustration and support keep on rolling in.

We are lucky to work in an amazing field with kind, caring, dedicated professionals, many of whom I consider personal friends. For all their sacrifices, they have the right to feel safe at work.

We as physicians are often viewed as captains of the team, so the burden is upon us to take the lead. If my experience here in my state can be of use elsewhere, please let me know by writing to me at amishforarizona@gmail.com .

Most of all, please join the effort to end violence in health care any way that you can. That may mean creating awareness at work, raising the issue with your state and local ACEP chapters, contacting your legislative representatives, or doing what I did and becoming one. The more our colleagues get involved, the better our chances are. 

Dr. Shah is an attending physician at Dignity Health and a member of the Arizona House of Representatives for Legislative District 24.

References

1. Omar H, Yue R, Amen AA, et al. 368 reassessment of violence against emergency physicians. Ann Emerg Med. 2018;72(4 Suppl):S144.
2. Behnam M, Tillotson RD, Davis SM, et al. Violence in the emergency department: a national survey of emergency medicine residents and attending physicians. J Emerg Med. 2011;40(5):565-579.
3. May DD, Grubbs LM. The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. J Emerg Nurs. 2002;28(1):11-17.
4. Costigan AD. My job: a courtroom victim impact statement. Ann Emerg Med. 2019;73(2):204-205.