Violence against doctors: Causes, effects and solutions with Ramin Davidoff, MD

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How to protect physicians and health care personnel from violence in the workplace. During the pandemic, physicians’ stories about threats and harassment from patients came to the forefront. However, the risk of workplace violence in health care has been on the rise since 2011. In this AMA Update episode, Ramin Davidoff, MD, co-CEO of the Permanente Federation, discusses the toll workplace violence is having on physicians and what we can do about it. AMA Chief Experience Officer Todd Unger hosts.

Speaker

Ramin Davidoff, MD, co-CEO, the Permanente Federation

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Transcript

Unger: Hello and welcome to the AMA Update video and podcast series. Today we're talking about an increase in workplace violence in health care. Here to discuss this important issue is Dr. Ramin Davidoff, co-CEO of the Permanente Federation in Oakland, California. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Davidoff, Thank you so much for being here today.

Dr. Davidoff: Thank you so much, Todd, for inviting me to talk about this really important and timely issue. It's really an honor for me to be here. Thank you.

Unger: Well, this particular issue seems to have really come to a new level with the pandemic. And today, workplace violence has become a top concern for physicians and health system leaders. Dr. Davidoff, what issues are we continuing to see?

Dr. Davidoff: Yeah, unfortunately, workplace violence in health care has been occurring for many, many years and decades. And yes, the pandemic has brought the issue to the forefront.

And I think it's really because many people delayed their care. And they're coming to see us now, even sicker than they were before. There is a lot more anxiety and frustration and aggression that is being displayed, now more than ever before.

And so the types of things that we're seeing are assaults, essentially, assaults against physicians and staff. And they take many different forms, including verbal abuse, threats, acts of intimidation, gun violence, knife attacks, physical assaults, gender based aggressions and sexual harassment, and also attacks via email and voicemail, and increasingly on social media, which is really troubling and problematic.

The Bureau of Labor statistics reports that 10.4 in 10,000 workers in health care experience some sort of workplace violence. And that's compared to 2.1 in 10,000 across all industries. So you can see a massive discrepancy in health care.

And also, in surveys, at least one quarter of all nurses say that they've been assaulted by a patient or a patient's family member during their career. There was also a survey of more than 500 physicians in the U.S. that was published in 2021, that found that 24% of women and 22% of men had been harassed on social media. And those are mainly with death threats. 16% of women and 1.5% of men had experienced some form of sexual harassment online as well.

So there are global studies as well that show similar trends across the world. So it's really a global issue. And all health care systems, including ours and Kaiser Permanente, are experiencing very, very similar trends.

Unger: And what's going through my mind as I listen to this first is just, statistics are horrifying and they're surprising. And I can't imagine that is already a high pressure situation, that kind of threat of violence must take a pretty serious mental and physical toll on your physicians and your health care teams. What impact are you seeing that this is having on well-being?

Dr. Davidoff: Absolutely, Todd. Very good point. And as physicians, as nurses, those of us who are in the health care field, our calling is to help our patients when they need us. We work to heal. We work to heal, both physically, emotionally and psychologically.

So when we experience, and health care providers experience this level of trauma, there is truly psychological injury that the clinicians experience as a result of the anxiety over the workplace verbal and physical abuse. And even, we see violence like gun violence and knife attacks.

So it's really difficult for doctors and nurses and other clinical staff to be able to provide high quality care. So quality of care is absolutely impacted when our people are worried about their own personal safety. And they are always easily distracted by disruptive patients or family members and having violent interactions.

And so there's no question that there is a link with workplace violence in health care, with deterioration of the quality of life for physicians, traumatic stress, which is also linked to physical and mental health problems. And these, in turn, affect the ability to provide high quality care.

So physicians experience psychological consequences, including burnout, post-traumatic stress disorder, depression, anxiety, and increasingly, a willingness for all health care providers to actually leave the profession. Recent surveys have shown that 25% of registered nurses in the emergency department and in the critical care settings have experienced job dissatisfaction due to violence. And 25% are willing to leave the field because of this particular issue.

And so the issue is really have a massive and profound, impacting care quality, demoralization and wanting to leave the profession which they entered, that we all entered, to help make a difference in the lives of the patients that we serve.

Unger: And we know from other AMA research, we've got all time high physician burnout, at about two-thirds. About one in five physicians considering leaving practice, so similar to the statistics that you mentioned there.

It sounds like we've got two big problems here. One is just dealing with the threats of that workplace violence. And the second is the mental health side of this.

Let's talk first about, how do you physically protect physicians and your staff from this kind of violence in the workplace?

Dr. Davidoff: Terrific. Our people are our most valuable assets and they look for us to take action as leaders, to help support and protect them. And if we send a signal that we're not there and we're not going to invest in this, that also is demoralizing to our people.

So we are very much on top of this. I believe my job as a leader is to continue to look for strategies to keep people safe. And we can do some of that through support groups, therapy, training, training them to address situations before they escalate.

In Southern California, also, we've taken many other steps to physically protect our people. For example, we launched a regional pilot program at four of our locations that use metal detectors at the emergency department entrances. And this prevents anyone from bringing objects that could be used as weapons into the emergency rooms.

We're also deploying marked mobile patrol vehicles at multiple medical centers to enhance safety and security, and we've increased the number of security personnel and their visibility in all venues of care, including in the hospital setting, as well as in the ambulatory setting, which violence happens very frequently.

We've also installed some solar powered surveillance cameras at the medical centers, including in the parking structures. And we've done this across the Southern California region. And these are highly visible, and they deter trespassing unauthorized visitors and provide real time alerts to the security personnel if there is something going on that shouldn't be happening.

So there is a lot of training also that is occurring with our personnel, training in terms of identifying circumstances that can potentially escalate and also training that once escalation happens, how to manage it in a safe manner, before they have to call security personnel, or even the local law enforcement personnel.

So over the last two years, I would say that our organization, and I believe most health care organizations, have taken this extremely seriously, invested in a lot of research and resources, to make sure that our people can feel safe, so that they can come to work and be their authentic self, without fear for their own personal safety.

Unger: You hear a lot about this kind of new level of uncivil behavior across many different environments these days. I think folks out there would probably be surprised, unless you're a physician or a health care worker, about a level that you're saying has gone on for some period of time.

Obviously, there's something happening that's broader than the health care system and what health care system can do on its own. What do you think, in terms of broader changes that need to happen, let's say at a governmental or even societal level to address the root cause of the problem here?

Dr. Davidoff: Great question, Todd. And I want to maybe just take a step back and stress, and make it clear that a vast majority of our patients are very respectful, very well behaved and grateful for the care that is provided for them.

There is a small minority that's having a particularly harder time. And much of their aggressive behavior could stem from a sense of helplessness or disempowerment that they're feeling in life, in general.

The reasons can be varied. And they can include patients worrying about their medical conditions, which sometimes can be displaced by anger towards the people around them, including physicians and health care staff, and their loved ones, frankly.

Also, there can be group grief over the decline of a hospitalized loved one. There can be frustration while trying to get attention and care, such as prescriptions when there is a shortage of staff in the health care field. There can be a feeling of gender and race discrimination.

And there's also increasing amount of mental health disorders. And also, very importantly, I want to point out that there is political and social issues in play here.

There is increased polarization in our country, which I believe has led to more anxiety and feeling of helplessness. And for some, the methods with which they handle those feelings lead to more violent behavior.

It's very important for us to have a handle on why this is happening, and also making sure that our people are trained in terms of areas of potential de-escalation, as well as making sure that physically, the proper resources are put into place to make them feel better.

At a governmental level, I think it's super important for us to make sure that we advocate for additional resources and additional legislation that can provide the type of safety and security and respectfulness which our health care environments really need to be able to provide the type of safe care that we are capable of providing.

And there is—the Joint Commission, which accredits the hospitals, has put new workplace violence prevention standards into effect in January. And these focus on identifying security risks and training staff in violence prevention, which I think will be very helpful. And in general, legislation that protects health care workers is also very important. And each legislation really does need to be examined individually for their proposed effect, on a case by case basis.

And meanwhile, as health care leaders, we have to continue to take steps to protect our most valuable assets, which are our physicians, our nurses, our staff, with preventive measures, including employee training and action plans, and providing clear and safe ways for physicians and staff to report warning signs before they get to a point of escalation.

Unger: Dr. Davidoff, do you think that folks outside of the health care space understand how urgent this problem is, and do they understand what might happen if we don't act now?

Dr. Davidoff: I do believe that in many circles, there is better and better understanding. Of course, there are some highly publicized situations, such as what occurred in mid-Atlanta just last month. And then last June, there was another very violent incident that occurred in a health care setting.

I do feel, though, that these events are very prevalent in society. And so to some extent, people are becoming desensitized to it.

That's why programs such as this, as well as more discussion open discussion with the public in any venue possible is critically important, so that people, the public, the legislators, the governmental agencies and our politicians really understand that this is a really critical issue.

What's at stake here is the quality of care, ultimately, that is provided. If our people don't feel safe in the workplace, quality of work is affected. Quality of care is affected. And so, we do absolutely need to think about ways we can make sure that our physicians and staff feel safe for the public to understand the potential ramifications of continued violence in health care.

And the other potential ramifications is that health care needs to remain an attractive field for physicians and clinicians and nurses, pharmacists and everyone involved to enter the field. If there is continued violence and feeling of lack of security, then it's likely that less and less people will enter the field. And we already have a shortage of physicians and nurses in the United States.

So these are important things for our public, for people to understand, so that they can have an advocacy effort and an advocacy accountability with the governmental agencies, with the politicians, to assure appropriate legislation, appropriate resources are put into place to make sure that these sacred environments, where we work very hard to heal people, stay safe for everyone involved—physicians, nurses, staff, patients and their family members who come to these settings.

So there's a lot at stake and it's important to continue the discussion. And that's why I very much appreciate being able to speak with you about it today.

Unger: Dr. Davidoff, Thank you so much for being here today and talking about this extremely critical issue. That's it for today's episode. We'll be back with another AMA Update soon. In the meantime, you can catch all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.