Being a health care provider has always come with personal risk. We care for all patients, which includes patients agitated due to psychiatric issues, dementia, acute medical illness, alcohol or drug intoxication or just anger. Patients can be extremely volatile and lash out unexpectedly causing physical injury to their doctor, nurse or another provider. Besides the physical risk, patients can be emotionally and verbally abusive as well- and both types of violence take their toll. Workplace violence is on the rise, and OSHA reports indicate that only 70 percent of violent encounters are ever reported upwards to a supervisor. The NEJM published a review article last year on workplace violence calling it a “problem that had been tolerated and largely ignored.”

Health care in America now has the highest incidence of workplace violence outside of law enforcement.

Recently the dangers of patients unhappy and dissatisfied with their care, particularly as it pertains to obtaining controlled substances, have been making the news. This danger has been increasingly apparent since we, as providers, have been scaling back on prescriptions of controlled substances, but reports of abusive opioid seeking patients were readily available years ago. A most extreme example recently occurred in Indiana where a patient’s husband shot and killed her doctor for not giving her an opiate prescription. This was the first time the patient had seen this physician, and this single patient encounter led to his death. Several years ago, another irate patient in Kentucky murdered his doctor for not prescribing him opiates- he was sentenced to 40 years in prison. Both of these physicians were killed for practicing good medicine, and this is a heartbreaking, frightening reality.

As we as a medical community continue to grapple with the risk of workplace violence, is there anything that we as individual providers can help to prevent protect ourselves? I would offer the following:

1. Be clear immediately and up front with the patient what his or her expectations should be. Many PCP offices have instituted policies where they never prescribe controlled substances, or at least never on the first visit. Knowing this information as soon as possible, ideally before the appointment, can help to diffuse the tension or lead the patient to seek care elsewhere.

2. In the hospital setting, there are on-call police and security teams and special codes to raise the alert for violent patients and trigger a response team — know what your policies are! In the outpatient world where this response team is usually not possible, have a clear safety plan in place with your staff and a pre-planned method to alert them to a dangerous patient.

3. Be alert to the risk of violence before you enter the room. Has the patient been violent in the past? Past violence is the single greatest predictor of future violence. Do they have mental health, addiction or chronic pain issues that place them at a higher risk for violent behavior? Consider flagging patients’ medical records to alert the staff of the risk for violence. If you know that risk is present, do not go into the patient’s room unattended.

4. Either in the hospital or office setting, when a patient starts to become agitated and violent, do the following: a. speak softly and do not raise your voice b. listen actively and maintain positive nonverbal communication with eye contact and nodding c. acknowledge that you can see the patient is frustrated and upset d. reassure the patient you are listening to his or her concerns e. let the patient talk without interrupting them f. ask what you can do to help resolve the issue.

5. If you sense the situation is going to escalate, and cannot be resolved, move slowly toward the exit. Keep as much physical distance between yourself and the patient as possible. Alert the surrounding staff and call the police as soon as is feasible.

6. Report any violent encounter according to your hospital or clinic protocol. Always report any incidence of violence, we cannot allow it to become an expected part of our workday.

7. Talk to your administrators about workplace violence policies that are in place or under development at your hospital or practice. Advocate for policy improvements where necessary to improve staff safety. Let your voice be heard.

Violence in our workplace is an ongoing issue. We can each help by reporting all violent incidents as they occur, and having firm policies and procedures in place. Always trust your intuition, if you are fearful of a patient take precautions before you enter the room to protect yourself.

Jenny Hartsock is a hospitalist.

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