Urology Clinics Must Lead Way in Preventing Workplace Violence

Irene Heinemeier,FACMPE

It took just a minute and a half for a disgruntled patient to leave his deadly mark on a Nevada urology clinic, irreversibly changing the lives of everyone inside.

In the time it would have taken staff members at the Reno office to copy a couple of insurance cards or set someone up in an exam room, the man left a doctor dead, two others injured, and employees and patients shouldering the weight of grief, shock, and fear.

That ordinary afternoon in December 2013 turned terrifying when the man entered Urology Nevada carrying a shotgun, passed through the waiting room with a warning that patients should leave, and marched into the practice’s clinical area, where he shot two physicians—one of them fatally—and accidentally wounded a patient.

Then, catching sight of the clinic’s office manager and mistaking her for a doctor, the man followed her to her office and pounded on her locked door with the butt of his gun, screaming. From under her desk, the manager called 911, and when sirens sounded outside the building, the gunman went back into the reception area and committed suicide.

It was all over in a moment, but for some, nothing would ever be the same. Charles Garo Gholdoian, MD, 46, was killed in the attack. Surgeon Christine Lajeunesse, MD, FACS, had a shattered right arm—her operating arm—that continues to require intensive physical therapy.

Yet the clinic was “eerily quiet,” with everyone hiding in place. The practice’s chief operating officer, Irene Heinemeier, FACMPE, recounted the tragedy during a recent talk to urologists, in which she urged the doctors to be aware of the recent shootings of several of their colleagues across the country, and to take precautions to protect themselves, their employees, and their patients against similar attacks while there’s still time to intervene. She gave the talk with Eugene Rhee, MD, chief of Urologic Surgery at Kaiser Permanente San Diego Medical Center during a Practice Management Conference at the Annual Meeting of the American Urological Association (AUA) in May.

The shootings at Heinemeier’s clinic were among four across the nation over the past 11 years that have targeted urologists, she and Rhee said, including one at a Newport Beach, California medical office, in which Ronald Franklin Gilbert, MD, was killed in January 2013, and one at Kaiser Permanente in which the doctor survived. Another Kaiser Permanente urologist was wounded by a patient in a shooting 20 years ago, a spokeswoman for the institution confirmed, and a urology clinic in Colorado Springs was the site of violence in 2012, when a gunman held three people hostage before being shot by police.¹

“I could go on for 4 hours about the aftereffects of an incident like this, and I hope you never have to go through it,” Heinemeier said. But in case it happens, she urged, urology practices should “please take this seriously and put [safety measures] in place.”

Violence in Health Care: Facts and Motivations

According to a paper released in 2010 by the US Bureau of Labor Statistics,² nearly 60% of the nonfatal workplace assaults and violent acts between 2003 and 2007 occurred in the health care and social assistance industry, with patients or residents of healthcare facilities responsible for the violence in nearly three-fourths of those cases.

Furthermore, according to the paper, a worker in health care or social assistance is nearly 5 times more likely to be the victim of a nonfatal assault or violent act by another person than the average worker in all industries combined.

As far as job-related fatalities within the industry, 22% of those in 2007 were the result of assaults or violent acts, the paper stated.

While there is no data on whether urology is more affected by workplace violence than other medical specialties, Rhee said, “The numbers are really compelling. So, we ask ourselves the question: Is there something that we really need to take a close look at? Are we in a specialty that requires us to be sensitive to the patient encounter more so than other specialties?”

Even short of a definitive answer, it makes sense for urology practices to lead the healthcare world in learning to protect against workplace violence—whether that takes the form of a shooter or a verbal assault, Rhee and Heinemeier agreed. Urology clinics not only need to have physical safeguards in place, but should train doctors and support staff in how to best handle such situations, the speakers said.

Ironically, Heinemeier’s practice had planned a training session on how to handle a shooting incident for mid-January of this year; the tragedy occurred a month before that.

“As an administrator, it’s one of those things we were doing to sort of check off a box, to be part of our compliance plan,” Heinemeier said. “I’ve changed my thoughts on that considerably. I think it’s imperative that all staff get trained appropriately.” The need for such training is a part of modern American life, and there are most likely a variety of explanations for that, Rhee said.

Violent encounters are happening more often these days in unexpected environments, like schools, Rhee pointed out. “I think it’s more a reflection of us as a society,” he said, “how people are adjusting to bad news or challenges in life, and how they try to move on.”

In some instances, patient encounters may have become less personal over the years, and patients have been handed more responsibility for their own healthcare decisions. In an era of health-insurance changes, virtual healthcare encounters, reimbursement and billing changes, and in some cases long appointment wait times, medical care for some Americans may feel more like shopping at a large warehouse store than visiting the corner hardware store, he said, and “the challenge is to develop personalized relationships with patients, to bond with them.”

Janet S. Richmond, MSW, an associate clinical professor of Psychiatry at Tufts University School of Medicine, in Boston, where she teaches a course on the doctor-patient relationship, agreed that fostering a bond of mutual respect and understanding between doctors and patients is key when it comes to preventing violence in healthcare settings.

Rather than practicing defensively, with the suspicion that any patient, on any day, could cause them physical harm or file suit, doctors need to notice when their patients are upset, when they don’t understand important medical information, or when they feel dissatisfied with the results of a procedure, and sit down for discussions, said Richmond, who is also on the staff at the Boston Veterans Administration Medical Center. It’s the patients who feel dismissed or vulnerable, and thus humiliated, who are likely to become angry—and they don’t need to be mentally ill to become violent, she said.

“I would also say that I think there is something unique about urology as a specialty,” Richmond added. “It is a specialty that can literally render someone impotent—the ultimate in vulnerability for some people.”

Identifying a Threat

So, did any of those factors lead to the shooting at Urology Nevada? Who was the man who ended a life, wounded two others, and terrorized an office full of people in Reno, leaving them to take what Heinemeier described as an “emotional nose dive” on the monthly anniversary of the shooting? And what can the healthcare community learn from the tragedy about how to protect itself?

According to the Associated Press,³ it was 51-year-old Alan Oliver Frazier, of a town near Lake Almanor—130 miles north of Reno—who stunned Urology Nevada and the surrounding community with his deadly acts of aggression. Frazier had not visited the clinic for a year and a half.

“He thought he’d had a botched vasectomy, but it was not botched,” she said of Frazier. “He’d convinced himself, through reading blogs [and other materials], that he had autoimmune disease as a result of having had a vasectomy. Laboratory tests showed no indication of that disease.” It wasn’t obvious to anyone on the staff that Frazier posed a threat, Heinemeier continued.

He “could be very belligerent on the phone, but when he was with the doctor, he was cordial,” she said. “He brought in stacks of research when he first came to see us post-op, but other than that he was just like your normal patient. Every doctor [in our practice] said, ‘I have at least 10 patients like the one that did the shooting,’ and I think most physicians in our community can say the same thing.”

Frazier’s violent outburst was a signal that staff members need to pay closer attention to potential signs that a patient may pose a threat—or redefine what characteristics or actions might spell danger—and a procedure for spotlighting such concerns has been added within the practice, Heinemeier said. Paying attention to behavior is especially important because some urologists can’t access the psychiatric histories of their patients, Rhee added.

“We now have workplace policies and procedures that are much more advanced. We have forms people can fill out if they feel threatened for any reason, and ways they can determine the level of threat,” Heinemeier said. “They can get that to a manager who, if the threat is at a low level, will try to talk to the patient. If not, we flag that patient in our computer system, so if he comes back to the office we are on high alert.”

A similar system has been implemented at Kaiser Permanente, where a patient’s computerized record may contain a color-coded assessment of his threat level. A warning that someone is “high risk” comes with a suggestion that his doctors should “contact security when having a patient encounter,” Rhee said. “You need to document, document, document, reporting every incident,” he suggested, “because that triggers the follow-up necessary for us as an organization.”

Rhee noted that employee morale has risen with the addition of the system. “It was frustrating for providers when they felt there was no process in place to document these patients with problems,” he said.

Defusing a Potentially Violent Encounter With an Agitated Patient⁶:

• Respect the patient’s personal space, remaining at least 2 arms’ lengths away.
• Demonstrate through body language that you will not harm the patient: Keep hands visible and not clenched, and knees slightly bent; avoid directly facing the patient; maintain a calm demeanor and facial expression; and make little direct eye contact.
• Designate one trained person to speak with the patient while others alert staff about the encounter.
• Do not insult or challenge the patient; be polite, and explain your intention to help protect his safety and that of others.
• Use short sentences and simple words, and repeat your message until the patient hears it.
• Ask the patient what he hopes to get out of the encounter.
• Listen actively, repeating what the patient has said to show that you understand. Try to imagine that what the patient is saying is true, or how it could be true from his perspective; this conveys interest and engages the patient. Find something about what the patient is saying that you can agree with; if that is not possible, agree to disagree.
• Lay out for the patient which behaviors are unacceptable, such as causing injury, and explain that arrest and prosecution may follow if he engages in those behaviors. Explain that you want to help but will not be abused. Once a relationship has been established, coach the patient in how to stay in control.
• Be optimistic, letting the patient know that things will improve for him.
• Give the patient choices by proposing alternatives to violence, and offer any comforts that are readily available, such as blankets, magazines, or food.
• If it is available, offer medication that will calm the patient yet allow him to remain alert.
• While an emergency-room doctor might use restraints or forcibly inject the patient with medication as a last resort, a urologist in a community setting may not have those options available. If not, a urologist should simply leave the room if he or she believes a patient has become physically dangerous.
• After a violent patient encounter, debrief staff and listen to feedback about what went well and what did not.

But what if a urologist wants to warn a colleague outside his own practice about a patient who might pose a threat?

Although there is talk about pushing for state laws allowing the circulation of lists of patients who could be dangerous, that is not legal now, Rhee said. However, he said, “Our compliance officers and lawyers told us that if you’re calling another physician about a particular patient and you are aware he is going to see that patient, that is absolutely legal.” He added that a physician has the right to put a note in a patient’s medical record to alert another physician that the patient might be dangerous.

Increasing Clinic Security

In addition to being more tuned in to patients’ behavior, clinic operators need to consider how to shore up security in their buildings, Heinemeier and Rhee said.

But administrators must keep in mind, Rhee cautioned, that “personal security is very personal.” That means the stakeholders in a clinic will need to gather to discuss what will surely be a variety of views on the ideal extent of physical protections.

At Kaiser Permanente, Rhee said, “We brought everybody together and took a survey of nurses, administrators, physicians, and internal and external security consultants.” The group took stock of patient complaints, high-risk areas, the footprint of clinics, and access to treatment areas. “We got an understanding of the feasibilities of panic buttons, video cameras, and metal detectors, and these are all open conversations,” Rhee continued. “We talked about doorknobs for doors that had access to [treatment areas], and decided what made sense was card readers, and this is being implemented in all our urology clinics in southern California as a first step.” Urology Nevada has made a similar change to its level of office security: The doors from the reception area to the clinic, previously always unlocked, now operate on a buzzer system.

“One thing we were really careful about was to not make our clinic into a fortress,” Heinemeier said. “People tried to use fear tactics to sell us the sun, the moon, and the stars, but our staff said, ‘I don’t want to feel like that, and patients will feel especially vulnerable if they are sitting there and the staff is safe but not them.’ These are the things you need to consider in deciding what is right for you.” Kaiser Permanente grappled with the same concerns, especially when it came to protecting receptionists, who are likely to be the first to encounter a threatening patient. “Our receptionists felt safe enough that a disgruntled patient really doesn’t start [his violent behavior] from the time he walks into the waiting room. It always seems to be after they go through a series of steps into the provider’s office,” Rhee said. “Some receptionists talked about plexiglass windows, which is an option we leave up to our local clinics. System-wide, the input was not consistent to say that we needed to put the windows up. The thought is that we don’t want to translate to patients that there’s a barrier between us and their care.”

The Occupational Safety and Health Administration (OSHA) recommends taking several steps when it comes to securing medical buildings.⁴ These include installing alarm systems, devices such as panic buttons, closed-circuit video of high-risk areas, and/or metal detectors; installing bright indoor and outdoor lighting; mounting curved mirrors at hallway intersections or "hidden" areas; arranging furniture to prevent entrapment of staff; and removing items with sharp edges or those that can be used as weapons.

An article that appeared in Monitor on Psychology,⁵ a publication of the American Psychological Association, added that it can be helpful to install a panic room—a secure space where employees can hide and phone for help—and to give patients lockers for all their belongings, making it less likely that they will bring weapons into exam rooms.

Heinemeier added that clinics can easily find local expert help in assessing the safety of their buildings and campuses. “You can have police go through,” she said. “The Reno Police Department has trainers who come in and assess your office. In addition, we are on the campus of a hospital, and their security department has come in.”

Finally, a Colorado urologist in the audience suggested that healthcare workers protect themselves by not mentioning where they work on social media outlets such as Facebook, so that they won’t be bothered or harassed in the office by people who may have disputes with them. That happened in a neighboring urology practice in 2012, the doctor explained, when a gunman had a confrontation with an employee there over a dispute that had begun on Facebook; after taking hostages, the gunman was shot by police, news reports said.¹

Setting Weapons Policies

Protecting the physical plant may also mean formulating policies that govern the presence of weapons in the workplace, Rhee and Heinemeier said.

The speakers and several members of their audience voiced questions, indicating that the issue still needs to be hashed out. Some supported physicians protecting themselves by getting licenses to carry concealed guns, while others asked what should be done if patients with concealed-carry licenses bring guns to their appointments. On the other hand, some asked, would it make more sense for clinics to prohibit any guns within their walls?

One woman recalled a patient coming into her clinic carrying a gun in his pocket.

“He was irritated when we told him he should not bring it into the office,” the doctor recalled. “He said he was a retired police or sheriff’s officer and had a right to carry an unholstered gun. After the patient left, we reported him to our insurance and the physician liaison at the local practice that had referred him to us. [In response], he reported us to the medical board and the office of civil rights, saying we had no reason to tell anyone. Now, we had to get our malpractice insurer involved.” While the doctor said the patient was unwilling to hear the clinic’s point of view, Rhee suggested that having a frank discussion with such a patient is normally a reasonable first step.

“There’s a law to protect individuals if they have a right to concealed carry; however, in your practice, it’s a good idea to follow up by…having a conversation with a patient about the sensitivities of bringing a firearm into the healthcare environment,” Rhee said. “Your next step is to notify staff and doctors that he has the right to carry a gun and he’s a retired police officer. It’s about patient communication and then communicating with staff about the policy you have in place.”

The AUA’s director of Practice Management, Rick Rutherford, CMPE, CHA, who introduced Rhee and Heinemeier at the beginning of the session, noted that the AUA “has not developed a public policy about gun control, either from patients being armed or AUA members being armed, and I am not aware of any discussions at the high levels. I think the AUA’s employee policy is zero tolerance. You can’t keep a firearm in your car in the parking lot; it would result in immediate termination. It’s something that needs conversation.”

Rhee put the discussion into context by noting that crimes with weapons are far outnumbered by less severe assaults, such as slaps, in the healthcare setting.

Training Staff to Handle Violent Encounters

Even with potentially threatening patients identified and buildings secured, safety plans are only as good as the people executing them, Rhee said. Staff must be trained to recognize and defuse potentially violent patient situations, and should always be present in adequate levels to respond to a threat, according to OSHA.

In the aftermath of the shootings at Urology Nevada, Heinemeier found that many staff members had protected themselves well in the face of the gunman’s threat.

“The staff are the heroes,” she said. “They went and literally hid in place, ran, and saved people’s lives. They were out there doing what they needed to do.”

But in some cases, staff members didn’t react swiftly enough, or failed to protect themselves as well as possible, she said. “In the case of the physician who did get killed, a patient said, ‘I think that was a gunshot,’ and the doctor said, ‘Oh, I think it was just an oxygen tank that fell over,’” Heinemeier recounted. “He opens the door and then makes himself a victim. He didn’t know what a gunshot sounded like, because who would? And also, gunshots can sound different from different types of guns.” Another physician, in an exam room with a patient, heard a gunshot and started searching for a concealed weapon he knew was in another employee’s backpack. “He was in the direct line [of fire] and, in fact, saw the shooter, and the patient pulled him back into the room, barred the door and said, ‘You can’t go out there. Any hero now would be a dead hero,’" Heinemeier said. “This [patient] was a retired special-unit Marine; thankfully, he was there. When the physician argued, the patient said, ‘I’m your patient, and you’re staying here.’ They together pushed a table up against the door and hid in place.”

“I’m amazed the staff did as well as they did,” Heinemeier continued. “I believe, after some investigation, that many of them, being young people, had learned this in school, because they’re doing these things now, having drills.”

But that kind of background isn’t enough; on-the-job training on how to handle violent situations is essential for healthcare personnel, Heinemeier and Rhee agreed. “Proper training means efficient resources that make sense,” Rhee said, “training personnel and staff to recognize when certain encounters have the potential for escalating, and when they do escalate, finding ways to de-escalate things before they get to a certain condition.” In a 2012 paper published in the Western Journal of Emergency Medicine,⁶ Richmond and colleagues outlined a “practical, non-coercive approach to de-escalating agitated patients.”

“De-escalation frequently takes the form of a verbal loop in which the clinician listens to the patient, finds a way to respond that agrees with or validates the patient's position, and then states what he wants the patient to do, eg, accept medication, sit down, etc,” the authors wrote. “The loop repeats as the clinician listens again to the patient's response. The clinician may have to repeat his message a dozen or more times before it is heard by the patient. Yet, beginning residents, and other inexperienced clinicians, tend to give up after a brief attempt to engage the patient, reporting that the patient won't listen or won't cooperate.

“The amount of time permitted for verbal de-escalation may vary depending on the setting and other constraints. However…verbal de-escalation frequently can be successful in less than 5 minutes. Its potential advantages in safety, outcome, and patient satisfaction indicate it should be attempted in the vast majority of agitation situations.” If a situation escalates anyway and violence ensues, staff members must be prepared to protect themselves, Heinemeier stressed.

“How do you train for that? The main thing is that you need to have drills,” she said. “Somebody comes in and says, ‘I am threatening.’ Where do you go, what do you do, where can you hide in place, where are your exits? Every office should go through that. Have drills with your staff and the physicians. Everybody needs to know what to do, so if something should happen, you are able to at least react or have thought through the process, so it’s not hitting you like a ton of bricks and you have no idea what to do.”

According to the article in the Monitor on Psychology, the goal of that kind of drill should be removing everyone to safety and calling for help.

Other tips for doctors, according to the article, include staying close to the door in case a quick exit is required; keeping office doors open slightly so that any violent interaction will be overheard; inviting colleagues to drop in during visits with patients who seem agitated, since an additional person in the room can have a calming effect; making an excuse to leave the room if a patient is becoming violent; avoiding working alone at night; and learning self-defense techniques in preparation for any physical encounters.

As with the issue of securing the physical plant, it can be helpful to get in touch with local police for recommendations about how staff should act during a violent incident, Heinemeier said. During that discussion, she said, it’s worth asking police to explain how they would respond if called in such an instance, especially if a clinic is a standalone facility that is far from other businesses. Clinic operators can also ask police when, and to whom, to report any threats made by patients, she said. “In [Los Angeles], the LA Sheriff’s Department is the first step,” Rhee noted. “We’ve talked with them about restraining orders, too. There have been multiple instances where urologists have had difficult patients stalk them, and there is a clear stalking law in California that allows you, as a physician, to tell a patient you’re going into a legal avenue.”

Doctors are also welcome to contact the American Association for Emergency Psychiatry (www.emergencypsychiatry.org) to seek a consultation about how to manage difficult patients in an effort to avoid violence in the clinic, said Richmond, who is past vice president of the organization.

Finally, clinics should check their insurance policies to make sure they are covered for the lawsuits that are likely to arise following a violent workplace incident, Heinemeier said.

Working as a Team

A short film Rhee showed before his talk underscored the need to train staff to handle violent situations.

The film featured Reynaldo Hernandez, MD, a urologist at Kaiser Permanente Baldwin Park Medical Center, discussing an incident in which he was shot three times by a patient in September 2003. The doctor recalled seeing the patient, whom he was treating for advanced prostate cancer, standing near his office, and deciding to invite him in. But before a word could be exchanged, the patient pointed a gun at the doctor and fired.

Hernandez awoke on his office floor, surrounded by bullet casings, trying to figure out what had happened.

“When I saw him in the hallway, he was just sending a signal that something was wrong—there was something about his posture, the way he was dressed, that scared me,” the doctor recalled. “I’d never been scared before like that, and I didn’t understand it, so I ignored it. I know now not to ignore those feelings.

Richmond Offers Counsel in Preventing Workplace Violence

“Unfortunately, violence is part of our human experience, and it can happen anywhere. Awareness and communication can help us deal with the risks. It takes a team. Homicide is an irrational act, a senseless act, and as long as you think it’s a rational act, you will not take appropriate precautions to avoid being shot.”If you ask Richmond, there is one simple key to preventing violence in the healthcare workplace: verbal de-escalation.

It is crucial that doctors and other staff members not only recognize when a patient is upset, but also engage in de-escalation techniques until they work, without giving up due to frustration, said Richmond, who feels so strongly about the importance of this strategy that she has volunteered to share her expertise with the healthcare professionals who compose OncLive’s audience.

Richmond is available to give talks on verbal de-escalation, and will also provide consultations by phone.

“I think verbal de-escalation is essential, and has the potential to really make a huge impact on patient care,” she said. “I’d like to be part of that mission.”

To contact Richmond, email her at janetrichmond@att.net.

References

1. The Denver Post. Armed Colorado Springs hostage-taker shot by police tonight dies. Denver Post website. http://www.denverpost.com/ci_20064367. Posted February 28, 2012. Accessed July 21, 2014.
2. Janocha JA, Smith RT. Workplace Safety and Health in the Health Care and Social Assistance Industry, 2003-07. Bureau of Labor Statistics website. http://tinyurl.com/ mgu74nc. Published August 30, 2010. Accessed June 30, 2014.
3. Griffith M, Sonner S. Botched Vasectomy Might Have Prompted Shooting In Nevada Urologist's Office. Huffington Post. http://tinyurl.com/md8bs2u. Published December 20, 2013. Accessed July 1, 2014.
4. Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. US Department of Labor website. https://www.osha.gov/Publications/OSHA3148/osha3148.html. Accessed July 1, 2014.
5. Munsey, C. Stay safe in practice. Monitor on Psychology. 2008;39(4):36.
6. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25.