Violence against urologists: Data, communication needed

In the last 11 years, four urologists have been shot by patients, two fatally. A fifth urologist was shot in 1994 and a Colorado urology clinic was the site of violence in 2012, when a gunman held three people hostage before being shot by police. In this interview, Eugene Y. Rhee, MD, MBA, discusses several of these incidents, the challenges of collecting and sharing data on potentially dangerous patients, and what some institutions are doing to protect their practices. Dr. Rhee is chief of urologic surgery at Kaiser Permanente San Diego. Dr. Rhee was interviewed by Urology Times Editorial Consultant Philip M. Hanno, MD, MPH, professor of urology at the University of Pennsylvania, Philadelphia.

A 2010 report from the U.S. Bureau of Labor Statistics showed that nearly 60% of assaults between 2003 and 2007 occurred in the health care and social assistance setting, and nearly three-fourths of those assaults were perpetrated by patients or health facility residents. When we think of potentially dangerous patients, we tend to jump to the field of psychiatry. What makes the field of urology particularly at risk for the dangerous patient?

That’s a good question. There isn’t a good reporting mechanism that shows the true incidence of this problem. There have been a disturbing number of gun violence incidents committed against urologists. However, in looking at statistics from the Occupational Safety and Health Administration and the Bureau of Labor Statistics, there’s no specialty-specific data on violent incidents.

There has been a lot of discussion as to why these acts have occurred. In the four recent cases in which urologists have been shot, the commonalities shared are that the perpetrators were male patients over the age of 60 years who had a pelvis-related issue that led them to violence. They were dealing with quality of life issues: pain, incontinence, or erectile dysfunction. These men had adjustment challenges that led them to ultimately violent acts.

Let’s discuss several of the high-profile examples of urologists who have been victims of violence. I know you’re familiar with Drs. Reynaldo Hernandez, Ronald Gilbert, and Charles Gholdoian. Can you comment on these cases?

These particular individuals have sacrificed immensely, and some of them are not with us today. One of my good friends is a Seal team executive officer and I asked him how many members of his executive team have been lost or injured in the line of fire, and he said one over the last 10 years. I asked him, “What if I told you four urologists I know have been shot?” He replied, “You should really look at the scope of this.”

Rey Hernandez was shot by a prostate cancer patient and survived. The gentleman had thought this out and planned it. It was a premeditated act.

Ron Gilbert didn’t even know the patient who killed him. The shooter suspected that Ron had operated on him as a resident, which, it turns out, may not have been the case.

In the incident involving the fatal shooting of Garo Gholdoian, another urologist, Dr. Christine Lajeunesse, was also shot and injured, as was a patient in the hallway of the clinic. The shooter in that case passed through the waiting room with a warning that patients should leave, and marched into the practice’s clinical area and started shooting. As in the other incidents, this was a premeditated event. It was not a spontaneous response to something.

In discussing these cases, the point is not to sensationalize; it is to understand that we all have an obligation to create a safe environment. We are all leaders in our own practices, we all have employees, and we also have our own personal safety to worry about. Personal safety is a very personal decision. Everybody has their own mindset about what they should do to secure their office. I urge everyone to think very diligently about this, because steps can be taken to improve personal safety with not as many resources as you think you need.

Next: "We must manage patient expectations."

Urologic surgery can have numerous expected and unexpected side effects and complications, including the obvious ones of erectile dysfunction and incontinence. How can we be proactive in preventing patients from reacting badly to these conditions?

We must manage patient expectations. We must discuss hard outcomes and how these patients could adjust to these outcomes. Identifying high-risk patients is critical to mitigate violent responses. There are ways to do this, such as observing body language and interacting with them (West J Emerg Med 2012; 13:17-25).

The challenge comes from the health care environment of today and our limited time in patient encounters. When I was a kid, I used to go to the hardware store. I learned how to build a birdhouse from the man who owned the store. Today, if you want to build a birdhouse, you go to a large warehouse type of store. You really have nobody to help you; you are in charge of understanding how to build your birdhouse.

In medicine, we are heading in the same direction, where patients don’t really feel a kinsmanship with the physician. Part of this comes from patients switching insurance and thus physicians. Also, we’re struggling to explain to patients about having prostate cancer and what it’s like to have the prostate removed. Shortened visits can blunt your ability to bond with patients.

We have to ask ourselves: Is this really an appropriate patient for a given treatment? Is this patient educated enough to deal with the possible side effects? You can’t argue about the side effects. They will happen; the complications of radical prostatectomy are well known in the literature, but you can make sure that the patient has adequate understanding before they give consent to proceed with treatment.

Please discuss the California Urological Association survey about workplace safety that was conducted last spring.

A couple of weeks after Ron Gilbert was killed, the California Urological Association (CUA) emailed a three-question survey to our members. The survey showed that 63% of doctors had a patient or knew a patient in their practice that made them fearful for their personal safety during the patient encounter.

We also asked whether respondents would support a reporting system for high-risk patients, if it were legal. The response was overwhelming; 89% of doctors said yes.

The third question was: Are you taking any measures in your practice to create a safe workplace environment? One-third said yes, one-third said they are thinking about it, and one-third said no. To those who said no or that they were thinking about it, I urge them to consider the issues of safety in the workplace and understand liability risk.

Next: When you get bad vibes about a patient, what do you do?

When is it reasonable to refuse treatment for a patient or discourage treatment because of fear he may not be able to cope with a bad result? When you get bad vibes about a patient, what do you do?

This is a problem that happens every day for every health care provider, regardless if they are a urologist, nurse practitioner, or nurse. At some point, you have to determine whether or not a patient is too high a risk, and if you should stop seeing the patient. One must be careful how this is handled legally and there are privacy laws that must be taken into consideration.

It’s not legal to create a list right now of “disruptive patients.” This is where health policy advocacy can influence state legislation if it makes common sense.

When you talk to people who have survived these events, the common thread is that something was really “off” with the patient that the doctor had never felt before. I don’t mean an argument; I mean something happened that made the doctor think, “something is really off about this patient, and now I am worried about my personal safety.” As doctors, we take an oath that says we’ll treat anybody, and not seeing a patient goes against that. I think that’s why this issue is such a challenge in health care today.

Do you know of any urologist who routinely carries a firearm?

I gave a talk at the 2014 AUA Practice Management Conference on workplace safety, and it was very clear based on audience questions that there are urologists who carry a gun for personal protection. Every state is different in terms of what you’re allowed to carry and what you’re not. It’s very complicated because even though you may be able to carry a concealed weapon under federal law, you may be in a state or employer group that has laws or policies strictly prohibiting guns in hospitals and/or other public places.

I must add that this is not a conversation about gun control; this is about what we are going to do as an organized urology community to enhance safety for all of us as best we can.

There is a high incidence of posttraumatic stress disorder now among some patients at VA hospitals and other institutions. Can you describe what kind of a threat management system the VA is using and how that could be applied in other places?

The VA has a very robust threat management system in place just for these situations, and it has led to other large institutions implementing similar systems. It’s essential that grassroots urologists learn from these big systems in terms of what works.

The VA’s system is very similar to what we have at Kaiser Permanente. We have a very structured threat management plan that has escalation parameters. There are protocols in place for how to respond to those alerts. Kaiser Permanente and the VA are proactive in making sure that there is continual education for all employees and providers.

Beyond this, some urologists are now taking personal security classes. Urology practices are seeking out security consultants. At the 2014 AUA Western Section meeting in Maui, HI, the CUA sponsored a threat awareness course. The CUA survey clearly identifies this as an unmet need.

I worked at a hospital where after a murder in the lobby, metal detectors were placed in the hospital entrance. The University of Pennsylvania has a patient screening apparatus in the ER. Do you think weapon screening should be standard coming into a hospital?

As I mentioned earlier, security is very personal. A comprehensive security system can be very difficult to implement. It takes a lot of personnel, resources, and training. There are legal issues to consider. Implementing an expensive system that has cameras, metal detectors, and armed guards is not a sustainable plan, and it’s not feasible in a typical urology practice.

A lot of studies have shown that metal detectors don’t work. Earlier this year, at Olive View-UCLA Medical Center, a mentally disturbed patient with a knife ran through the metal detector, got into an elevator, and stabbed a nurse multiple times in the elevator. Did the metal detector prevent this incident from happening? The point is that a transparent look at operations within practices is vital before impulsively assuming certain safeguards need to be implemented.

Next: Who is collecting data on these incidents?

Who is collecting data on these incidents?

This is where the state societies and groups like the AACU and AUA can work together. We discussed this issue at the AUA Health Policy Council meeting. Additionally, the AUA’s Office of Practice Management is starting to look at this closely. I really don’t think the federal government is going to be able to give us pertinent specialty-specific data. We are going to have to gather data ourselves from within our urologic community; however, we are looking to have state urology societies work with state-level OSHA and government to help us with collecting the data. We are seeing an interest in doing this.

You intimated that HIPAA prevents doctors from warning other doctors about potentially violent patients. I would guess that addressing this should be another high priority.

There have been plenty of incidents in urology to justify considering bills that may help providers in the health care workplace that make sense on the state and perhaps federal level. In general, data show health care violence is becoming a big problem. The interesting thing about health care reform is that it’s causing a lot of angst between the provider and the patient, and because of that, whether it’s because we’re running late or because insurance keeps dropping providers or patients, or there’s a bill collection that needs to happen, there are challenging factors that influence our encounters with patients. That’s very important to understand in terms of mitigating the risk of these encounters.

Do you have anything else that you would like to add?

What is interesting is that it is legal for a urologist in the state of California to call another urologist and document that a patient is noncompliant to the physician’s care. Documenting a patient as noncompliant to your care and that you had some difficult encounters is essential, but a phone call to another provider to discuss this noncompliance may be quite helpful on many different fronts.

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