The Occupational Safety and Health Act of 1970, which mandates that employers provide a workplace “free from recognized hazards that are causing or are likely to cause death or serious physical harm” protects workers from a broad array of hazards such as chemicals, machinery, and communicable disease. Assaults and violent acts also present a significant, and not uncommon, hazard to employees’ health.

Data on the incidence and characteristics of workplace violence are reported annually by the BLS and show consistent patterns between fatal and nonfatal events. Although most violent acts result in minor or temporary injury, aggression and violence account for a significant proportion of all workplace-related deaths. In 1996, for example, 19% of the 6,100 workplace-related deaths were due to violence, making this second only to transportation incidents as a cause of fatal occupational injury (and more likely to cause death than falls, contact with objects and equipment, or exposure to harmful substances). To better understand the epidemiology of fatal violence in the health care setting, Goodman and colleagues examined death certificates over a 10-year period (1980–1990). During this time, 522 health care workers died of work-related injuries, 106 of which were homicides. Twenty-six of those killed were physicians. Though this is certainly an unsettling statistic, the rate of workplace-related homicide for health care workers is far lower than the national average rate for all workers.

Health care workers, however, are among those at highest risk of nonfatal assaults or violence. Of the 22,000 workplace-related cases of violence reported in 1995, 70% occurred in the health care and social services industries. Numerous studies have shown that, of all clinical personnel, nursing staff are at the greatest risk of assault. The frequent and direct patient contact, predominance of women in the field, and highly accessible work sites have all been offered as explanations for this. At particularly high risk are those nurses employed in long-term-care facilities, emergency departments, psychiatric wards, or by home health care agencies. Although nursing personnel are at particularly high risk, pharmacists, therapists, and social workers are all known to be vulnerable as well.

Assessing the magnitude of violence and aggression directed toward physicians is difficult because there is little definitive information. Accurate data collection is hindered by inconsistencies in the definition and characterization of violence, methodologic limitations, and significant underreporting. Investigators have relied on physician recall, incident reports, or emergency room log books to quantify violent acts. These methods are likely to underestimate the actual rate of violence owing to nonresponse and underreporting.

To investigate the likelihood of underreporting, Brizer and colleagues placed a surveillance videocamera on an inpatient psychiatry ward and counted the number of violent acts over a 2-month period. Fewer than half of the 24 assaults (9 of which were considered “high hostility”) were reported. Clinicians may hesitate to discuss or report violence because they believe it represents an isolated incident of no further consequence or because they believe they provoked the attack. Some may feel ashamed, or think it is “part of the job” to deal with violent patients.

Despite these limitations, numerous investigators have studied violence in two specialized groups of physicians: those who work in the emergency department and psychiatrists. It has been estimated that 40% of psychiatrists will experience a nonfatal assault at some time during their career. Many of these events occur in residency training, during which violence is actually considered to be “common.” The rate of violence toward psychiatrists is highest in emergency departments, prisons, and the forensic units of state hospitals.

Violence is an area of increasing concern for emergency medicine physicians as well. Lavoie and colleagues surveyed 170 emergency department directors about violence; 32% of the respondents reported at least one verbal threat per day, and 18% noted that weapons were displayed in a threatening manner at least once per month. Residents who train in emergency medicine often worry about their safety and the adequacy of security measures at their institution.

In contrast to psychiatry and emergency medicine, there is a paucity of data on violent assaults in the internal medicine literature. In 1994, Paola, Malik, and Qureshi surveyed 100 residents and attending physicians in the Department of Medicine at the Nassau County Medical Center in East Meadow, New York. The authors used legal definitions of “assault” and “battery” to define and categorize violence. Of the 63 respondents, 41% reported being assaulted and 16% reported being battered at some time during their career by either a patient or a patient’s relative.


The vast majority of violence in the health care setting is perpetrated by patients. Sudden, unexpected attacks are rare; most incidents are preceded by mounting tension, frustration, or escalating threats. Anticipating and defusing violence is therefore an important clinical skill for physicians to acquire. Although it is impossible to identify reliably all those who might be dangerous, aggression and violence toward health care workers most commonly involves gang members, narcotic seekers, prisoners, persons with borderline or antisocial personalities, and patients who are acutely psychotic, manic, or intoxicated. Some consider a history of violence to be the best predictor of future violent behavior. Other patient factors, including gender, ethnicity, education level, and employment status are not useful in predicting violence.

Though less common, acts of aggression and violence can also be initiated by nonpatients. In a 1-year retrospective review of a California emergency department, nonpatients were responsible for nearly one fourth of all violent episodes. One important group of nonpatients with whom physicians have significant contact is a patient’s family members, caretakers, or other acquaintances. Aggression directed toward physicians by this group is exemplified by case C.

Finally, workplace violence has been associated with personal theft, disgruntled former employees, abusive supervisors, and personal or domestic disputes. These actions may occur in all workplaces and are not unique to the health care setting. In addition, workers can be victimized by politically motivated acts of violence or terrorism, such as the bombings at a Massachusetts Planned Parenthood clinic and at the Alfred E. Murrah Federal Building in Oklahoma City.

The different ways in which patients regard physicians may explain some of the reasons why aggression and violence occur. For some, violence is a style of communication and conflict resolution; physicians are treated no different from anybody else. Dissatisfaction with one’s care, displeasure with the physician’s inability to cure, and misdirected anger toward self or family can all be motivating factors for violence. Patients may believe that physicians, like parents, will not abandon them when they behave inappropriately or in socially unacceptable ways. Physicians also represent illness and power; violence may signify attempts to gain some control over unexpected and incomprehensible medical events.

Young physicians and those still in training are most at risk of being assaulted or threatened. These physicians tend to practice in urban environments and may have more exposure to “high-risk” patients. The relation between gender of the physician and violence is unknown. One might also wonder if racial or ethnic discordance between patient and physician is a predictor of violence. These are interesting questions. Unfortunately, data collected by the BLS do not include information on gender, race, or ethnicity, and to our knowledge, no formal independent studies to investigate these areas have been performed.

The cases we presented above nicely illustrate some of the risk factors and dynamics involved in violent assaults. Recall the case of Mr. A, who was an acutely psychotic patient being cared for by an internal medicine resident in an urban, acute care clinic. When he was left unattended in this loud, busy, unfamiliar environment, his agitation and potential for violence increased and culminated in his throwing a chair at the resident.

In the second case, Mr. B, who was known by his primary care physician to have “a hostile personality,” was dissatisfied with his meal and reacted by throwing a water pitcher. Observed interactions between Mr. B and his wife indicated that this is likely how he dealt with conflict in his own home. It is also possible that there were other aspects of his condition, hospital care, or impending discharge that frightened or frustrated him. Though we in no way condone Mr. B’s behavior, this act of aggression may have represented a useful window of opportunity to explore some of these other issues.

Nonpatient violence is demonstrated in the case of Mr. C, whose cousin and mother made repeated threats to his physicians. We do not know if either of them had a history of violent behavior, psychiatric illness, or substance abuse. What is clear, however, is that over the course of Mr. C’s hospitalization, they became increasingly frustrated and angry. We suspect that his family members felt guilt (toward themselves) and anger (toward him) for Mr. C’s long history of substance abuse that preceded, and most likely contributed to, his fatal stroke. In addition, Mr. C’s family did not trust the physicians involved in his care. Although the development of trust is a complex process and the reasons why it failed in this case are not completely known, some of the physicians suspected that race or ethnic discordance between the physicians and the family did play a role. As the family’s distrust manifested itself in threats and intimidation, the physicians responded by only engaging in limited, brief conversations. The inability to establish a relationship with the family made it difficult, and ultimately dangerous, to convey necessary information about Mr. C’s daily progress, his overall prognosis, and eventually, his death.

Courtesy: NCBI/PMC


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