Jeanette L Morrison, MD,1 John D Lantos, MD,2 and Wendy Levinson, MD3

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One of the most difficult situations that physicians face is being threatened, abused, or physically harmed by one of their patients. This is not an uncommon problem: Bureau of Labor Statistics (BLS) data for 1995 indicate that more workplace assaults and violent acts occur in health care and social services industries than in any other. Health care patients, the most common perpetrators of nonfatal workplace violence, were responsible for 45% of all nonfatal assaults in 1992. Although the majority of such incidents involve nursing staff, all health care workers are at risk, and physicians are no exception. From 1980 to 1989, 22 physicians were killed while at work. This represents almost one fourth of all workplace-related homicides among health care workers during this time period. Physicians may also experience nonfatal violence, verbal abuse or threats, destruction of property, or intimidation with a weapon.

Aggression and violence in the health care setting is costly on a number of levels. Financial losses to the institution as a result of medical expenditures, time away from the job, and psychological counseling have been estimated to be as high as $107,000 for a single incident; workers’ compensation claims may add to this amount significantly. The cost to the individual also extends beyond the immediacy of physical injury. Many of those who are attacked or threatened experience anger, fear, anxiety, self-blame, and loss of confidence. Furthermore, being threatened or harmed while providing care may be difficult to reconcile for a physician who strives to bring compassion and respect to each clinical encounter.

Among doctors, psychiatrists and emergency medicine physicians are believed to be at highest risk of aggression and violence. This is most likely explained by a combination of clinical and environmental factors. For example, physician inexperience, urban locale, and patient characteristics such as intoxication, acute psychosis or delirium, and drug-seeking behavior have all been described in the psychiatric and emergency medicine literature as risk factors for aggression and violence. Because these factors also exist in many internal medicine training and practice settings, physical safety is an important and valid concern. However, aggression and violence has not traditionally been a topic discussed by general internists.

The purpose of this article is to provide a general overview of aggression and violence in the health care setting and a more specific focus on violence directed toward physicians by their patients. We hope to make members of the internal medicine community aware of the magnitude and subtleties of violence and to present a framework for understanding and addressing such behavior.


We present three brief cases that demonstrate a variety of clinical examples of aggressive and violent behavior; we will use these cases to discuss some of the situations in which persons may become violent, offer basic strategies for handling dangerous persons, and suggest ways to educate ourselves, prevent harm, and conduct future research.

Case A

Mr. A is a 50-year-old man with a history of schizophrenia and posttraumatic stress disorder who presented with auditory and visual hallucinations to the acute care clinic at a large, busy, urban hospital. This clinic is staffed entirely by internal medicine residents and does not contain a separate waiting room for psychiatric patients. Mr. A was evaluated by the psychiatry team, and while arrangements for his admission were being processed, he was seated in the main hallway to wait. After waiting for more than 1 hour, Mr. A became agitated and began yelling at the staff in the clinic. When a third-year internal medicine resident approached him, Mr. A picked up a chair and threw it at him, breaking the resident’s right hand.

Case B

Mr. B is a 50-year-old man who was hospitalized on the general medicine service for treatment of cellulitis. On the day he was to be discharged, he became angry and argumentative with a nurse when the breakfast that was delivered to him was not what he had ordered. The nurse left the room, and the third-year medical student on the team went to see him in an “attempt to calm him down.” His anger escalated, and he threw his water pitcher at the resident. Mr. B’s primary physician later commented that he “had a hostile personality” and was often short-tempered with his wife.

Case C

Mr. C is a 43-year-old man with a past medical history of hypertension and cocaine use. He suffered a massive pontine hemorrhage with resultant Glasgow coma scale score of 3. Although his family members were told that the prognosis was dismal, they remained optimistic that he would recover completely. At times, they expressed distrust of the medical team. In addition, some members of his family made direct threats and intimidating gestures toward housestaff. For example, the patient’s cousin told an internal medicine resident, “If anything happens, you’re going to pay,” and “I know where to find you.”

Five months after his admission, Mr. C suffered cardiopulmonary arrest and could not be resuscitated. The chief resident and one of the interns delivered the news of his death to his family. In response, the patient’s mother and a cousin became hostile, accusatory, and verbally abusive. The cousin attempted to punch one of the physicians in the face. Hospital security and city police officers were required to subdue and restrain the family members.


Researchers and clinicians use a wide range of terminology when reporting and describing “violence.” As in other situations, such as child abuse or sexual harassment, what counts as “violence” to one person may be inconsequential or at least acceptable to another. Words such as abuse, threats, assault, battery, combative, and hostile are used interchangeably in the violence literature. Thus, it is important to clearly define what we consider to be “violence and aggression.” For the purposes of this discussion, we use the definitions of violence and aggression offered by Webster’s New World Dictionary:

violence—“…physical force used to injure, damage, or destroy…”

aggression—“…a forceful, attacking behavior…destructively hostile to others…”

Case A clearly fits the description of violence. Indeed, some data sources only collect information on “violence”—those acts that result in documentable physical injury such as fractures, lacerations, gunshot wounds, or homicide. Although these cases may be easier to quantify, actions that either do not result in physical injury (such as case B) or are limited to threats of violence (such as case C) can also be damaging, albeit in somewhat different ways. Verbal and physical aggression of this type can result in significant emotional and financial damage, and if mismanaged, it may result in physical harm or destruction of property.

Courtesy: NCBI/PMC


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