April 27th, 2016

The Dark Side of Medicine

Ahmad Yousaf, MD

Ahmad Yousaf, MD, is the 2015-16 Ambulatory Chief Resident in Internal Medicine at Rutgers New Jersey Medical School.

The following is paraphrased documentation, authored by a physician I know, regarding an intoxicated patient in the ER:

1AM: Patient is telling nurse, “Before I leave, I need everyone’s name for my lawsuit. Tell the phlebotomist that if he’s good, he’ll  get a cut.”

1:40AM: Patient is making inappropriate sexual comments and is verbally aggressive with medical staff. He is advised to stay in bed.

2:02AM: Patient (who had been sleeping comfortably) wakes up and begins screaming obscenities at everyone. When a nurse asks why he was angry, he says, “What do you think , mother f*****? I will wipe your a**.” Multiple attempts to calm patient fail.

depressed girlI will stop here, because the insulting language, obscene physical gestures, and eventual threats of physical abuse only become more vulgar and inappropriate. The attending recorded in the chart, word for word, the things that spewed from the patient’s mouth and, eventually, when he became physically aggressive, called the Crisis Team who came and restrained the patient.  The story was shared with me by one of the residents who had witnessed the entire discourse, and we laughed about the absurdity of some of the drunken babble. We also smiled in speaking about the state of mind of the doc who documented the conversation so meticulously in the chart. She must have just had it with the abuse and decided she was going to permanently record all the nonsense in the EMR.

As I sat by myself, thinking about the somewhat comical story, I realized that it really was not funny at all. This is the status quo. Healthcare professionals deal with patients like the one above every day. The verbal abuse and physical threats are so common that we have settled in to just trying to find some humor in them. This type of abuse is not unique to the healthcare field, but the difference is that you cannot just stop treating your abuser. You have to make sure he or she gets better… You cannot fire a patient in an ER who would die in the street if you kicked him out. Every doc or nurse has an anecdote in which they have been spit on, urinated on, cursed at, assaulted, or threatened.

In the medical world, we do not talk a lot about this aspect of our training and experience. Incoming residents have no idea that, along with their medical education, they will be getting a pedagogy in dealing with some seriously aggressive personalities. Whether it is a drunk patient in the ED, an angry family member, or the overtly psychotic patient on the psych ward, being on guard becomes second nature.

I remember one resident laughing hysterically as he described an enraged patient using the TV remote as weapon against his caretakers, swinging it in circles like a lasso. Or the time a family member broke into the medical lounge and attempted to physically intimidate a resident into changing a medical plan for a dying patient in the ICU. I have seen female trainees and attendings cat-called, harassed (both physically and verbally), and made to feel unsafe by the people they care for. It is tough to diagnose and treat someone when you cannot put your hands on them without fear of a violation of personal space.

This is medicine. There is so much beauty in the patient-doctor relationship and so much that I could say about the wonderful people whom I have learned from and loved while they were under my care. But, like anything else in life, medicine has a dark side that we rarely discuss with people outside of the field. With an increasing percentage of doctors feeling unappreciated, abused, and depressed, maybe it is time to share the whole story (N Engl J Med 2016 Apr 28; 374:1661).

Please share your experiences.

P.S. God bless nurses, who deal with this stuff even more often than docs do.

36 Responses to “The Dark Side of Medicine”

  1. M says:

    Patients that act criminally (e.g., commit what would be considered assault and battery in any other environment) and are not incompetent by means of their own doing should be prosecuted for criminal behavior.

    • Mohammed AlKhateeb says:

      Yes, indeed should be prosecuted for criminal act or behavior

    • Mayada says:

      Yes they should! Being angry, out of control , or if you deceided to get drunk is not these caring respectful Doctors or staff’s fault .

    • S.pai says:

      Patients abusive behaviour should be meticulously recorded without any editirial comments. After providing the appropriate treatment to assist his/her recovery the record should divulged to the local sheriff’s office and the hospital lawyer.
      There simply is no place for abusing the health care providers regardless of patients condition.

  2. Federico says:

    Dear Yousaf,
    Once again, your article depicts a reality that hits as hard everywhere. In Argentina thats also a reality in many hospitals, with acts of violence against the health team ocurrying almost daily. You can check some more info on that here http://www.intramed.net/contenidover.asp?contenidoID=86302.
    Is there any solution? I don´t know. But I do know that it should be our duty or fear to handle this type of situation.
    Hoping this will improve over time,

  3. Sakul says:

    I have seen relatives happy after a patient’s death just because they got to physically assault the doctor on duty. What else needs to be said.

  4. Ernesto Orozco says:

    There is indeed a dark side and a darker one. In the past few years physical violence against physicians-in-training in Mexico has escalated, leading up to some being killed. This situation is critical, particularly during the 6th year of medical school -the social service year- where young doctors are sent to impoverish, isolated rural areas to spend 1 year serving the community.
    This issue deserves an article in the journal.

    • c s says:

      the criminals who killed the doctors. are they arrested? what happen to the murderers? anything government takes to help protect doctors?

  5. Dr.m tariq says:

    This is a good suggestion. Those relatives and patients who act criminally should be prosecuted if they are doing this if they are competent

  6. Rom. Redman says:

    Your post script is gold.

    Thank you

  7. ajena says:

    I am doctor and I was patient too under situation post surgery I discharged and sever pain come after I eeach home then take me to ER nurse was relactant to give me analgesia I was frustrated I lost my temper as patient and doctor I will not accept crimanaliz patient act but should be controled

    • Jinpa Heyer says:

      I’m sorry for your bad experience, Ajena. But I’m having trouble understanding you. It would help me a lot if you could use punctuation marks. Again, I’m sorry for your troubles and I hope that you have better times.

    • Ahmad says:

      Ajena I am not sure you are a doctor Every ER has protocol for dispensing medications and nurses are not the one to decide that so getting angry with the nurse was not right you should have asked to see the ER physician.You are wrong you know so don’t justify your anger and loss of control

  8. Jinpa Heyer says:

    There definitely needs to be some kind of middle ground on this. Suffering patients can be abusive and impatient, antisocial patients can be abusive regardless of what you do to help. as a patient, I know that a positive attitude is generally rewarded.

    Caregivers need protection. Patients need safety and care. I hope to see more on this topic in the future.

  9. H Honeycutt says:

    In my experience the majority of nastiness on the streets and in Emergency Rooms is due to alcohol abuse. The old joke is, as a cop when was the last time he had trouble from a person on marijuana, he’ll look at his calendar. Ask him the last time he had trouble from a drunk, he’ll look at his watch.

    Of course alcohol abuse side effects are hardly limited to Emergency Rooms. Long ago I was, for a time, military police and then a bartender. The real offenders are not the habitual drinkers (who have (mostly) learned to act “normal”) but what we used to call the “amateurs” — people who do not get drunk more than, say, four times a week.

    While it may be little comfort, you can reflect on the fact that while your obstreperous and inebriated ER patient is making your shift miserable, at least he’s not beating his wife or his kids, or wetting himself in the back of some blameless cop’s patrol car.

    The real difference that I saw between the people on the streets and the people you see in an ER was not the drunks, who are everywhere, but the other people who don’t have a compelling medical reason to be in the ER — the people who are looking for the other things an ER offers — empathy, attention, human contact.

    My mother was an ER nurse for part of her career, and I have yet to meet anyone who is a better judge of character than she was. She said she learned it on the job.

    So I agree. The last thing I tell anyone on their way to the hospital, whatever the reason, is “Be nice to the nurses.”

    • Mrs.walkley says:

      Careful with that assumption now, with today’s marijuana THC content almost 30%.
      As a physician in Colorado, this is no longer our experience.

      And the worst are the opiate addicted patients using this cannabis.

  10. may says:

    This entire story is not about having to put up with a drunk, beligerant patient …it’s really about nurses and doctors inability to effectively manage patients with mental health and drug abuse issues.

    • Eleanor RN says:

      I disagree. That does occur (especially with nurses not getting the support they need from hospital administrations), but to place the entire responsibility on the health care team denies the patient agency and autonomy. As RNs and physicians (and others), we have duty to the patient, which includes protecting the patient from themselves at times. But the HCP/pt relationship is just that: a relationship. The patient has his or her part to play and needs to cooperate with their plan of care as best they can. Thing is, we can accept the dangers posed by a patient who cannot help themselves (the mentally ill); it’s not as easy to accept the risks with someone who can. We understand that people are very frightened when they’re sick and that can lead to acting out. But it must be understood that we are people too, with our own fears and vulnerabilities and no one should be treated as we often are. \
      Calling the police works in situations of actual physical assault (and yes, charges should be filed, IMO), but the verbal abuse and threats are a gray area. Stating limits and telling the pt that s/he is not to speak in that language or use those terms often, but not always, works. It’s a tough call, but the responsibility does not lie solely with the healthcare team. To do so infantilizes the patient and it also does not allow for any feasible solution.

    • Mrs.walkley says:

      You must be a psychiatry PA or FNP. Many of them say this without much knowledge of what the internal medicine service deals with. Come on down to the medicine clinic or wards almost any day, and spend a little time.

      AND FRANKLY, I don’t have time to deal with dependent or narcissistic or borderline personality disorders when I’m trying to save someone’s life.

  11. Dr. Yousaf,
    Thanks for sharing your experience with workplace violence and contributing to the conversation. I’m the author of the Workplace Violence against Healthcare Workers review article that was published in NEJM this week, and your post augments the sentiments I tried to raise. We have all been victims in one way or another. I have had a patient convicted of battery, and another spit Hep C+ blood in my eyes, intentionally, when I was a resident. I had no idea there was any recourse or that it was even illegal back then.
    Sharing these experiences, especially in a high profile way, only helps if we take the frustration (and amazement) we feel from such violence and work to institute changes in our hospitals and clinics. I encourage you and others reading this to go to the next WPV committee meeting at your facility and tell your story. Demand answers. If you don’t get them, join the committee and make them.
    Keep fighting the good fight, and protect yourself and your coworkers while continuing to provide the best care you can. Thank you again for sharing.
    James Phillips MD


    • Ahmad Yousaf, MD says:

      I appreciate the comment and will take your advice to hear. Phenomenal article on WPV!


  12. Ghun Felix Mburi says:

    This is a disturbing situation. How do you treat the patient you can’t lay hands on for fear of being assaulted? Violent patients should be made to bell the cat so deterr would be violent patients. Deterrence is still part of a social engineering.

  13. Jim says:

    When I was a neuro resident I was called to do an evaluation of an alcoholic patient. As I was checking eye grounds out of the blue he took a swing and hit me with a close fist on my left zygomatic. Thankfully only a bone bruise… Nothing happened to him other than admit to medicine.

    • Mrs.walkley says:

      I was groped incessantly at the VA. And another recently threatened to choke me to death if I didn’t give him Percocet, but this is INSANE.

      Couldn’t you file criminal charges?

  14. n says:

    as long as a patient is not of psych they have no excuse to abuse doctors

  15. Kim NP says:

    Call the police – every time,

    People who are abusive and would cause trouble in a hospital setting, usually have prior problems with the law and often have outstanding warrants.

    Especially family members – who aren’t ill, just abusive – they’re gone – you can treat the patients.


  16. Punit malhotra says:

    Patients have a right to be treated with dignity and empathy. But so do the medics. The laws should be made against the violence and general populace made aware of it.
    Then the law be implemented to protect both parties from abuse.

  17. Maxine says:

    Its great to hear things like this aired. There is so much abuse in medicine that we are inured to to the extent that we don’t even recognise it as abuse. As has been said above, report the abuse, we would if we were on the street, why accept abuse in the medical context? We are there to assist people, for sure, but that does not mean that we are there to accept being abused. Understanding does not mean that criminal and socially unacceptable acts do not go being held unaccountable. If we do not take a stand against abuse in the profession, people will consider it their right to abuse us, knowing that they can ‘get away’ with it in the relative/patient role. There needs to be equal accountability for bad behaviour in society, both patients and doctors.

  18. Faith says:

    Call security and patient advocacy at the first sign of abuse or threat.

  19. Swira Naham says:

    What about people in their homes who have to deal with family members like this. In the hospital you have coworkers and security to protect you. At home we have no one.

  20. c says:

    Today, a Chinese doctor(oral surgeon/dentist) lost his life after more than 40 hours of efforts to bring him back. He was killed brutally by is patient who was treated by him 25 years ago, because this patient thought the artificial teeth becomes yellow and not in good shape after 25 years.

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