Caregiver safety — practical tips for precarious times

Deborah MacFarlane, MD.

Violence in the workplace is a tragic, unfortunate reality in today’s world. Dermatologists are not immune to potential threats and must face the issue head on. At the AAD Summer Meeting 2019 last week, Deborah MacFarlane, MD, took on the difficult topic in her session “Physician Safety: Protecting the Caregiver in Violent Times (F008). DW Meeting News talked to Dr. MacFarlane about the impetus for the session, and she also provided a detailed list of practical tips for all dermatologists.

DW: Can you tell us about the experience that prompted the creation of this session?

Dr. MacFarlane: A year ago, my neighbor and friend Mark Hausknecht, MD, a cardiologist, was shot as he rode to work at Houston Methodist Hospital. It was later determined that the murderer was the son of a patient whom he had treated some 20 years prior. This affected me profoundly. I asked myself what could have happened to make someone this angry for so long? What was wrong with the killer? Had Mark contributed in any way? Our very vulnerability as physicians struck me. What could we do to protect ourselves? And what could the hospitals do to help us?

Violent events are hard to predict. And, although uncommon, potential violence must be considered in the dermatology care setting. Clinicians should be aware of the stages of violence and recognize early warning signs. Preventive measures are critical, plus verbal de-escalation techniques as well as the use of emergency services as needed. Individually and collectively we have resources to address and resolve the issues that lead to violence. We do not need to feel so vulnerable.

DW: What can be done to de-escalate a potentially violent or explosive situation?

Dr. MacFarlane: Harness your natural reactions. Have an open, nonaggressive physical presence. Be respectful in manner. Acknowledge the patient’s concerns: “I understand that you feel you have been treated unfairly.”

Don’t underestimate the importance of good communication skills. An awareness of your emotional baggage in the exam room will decrease the number and intensity of difficult encounters.

Acknowledge their expertise/goodness; you are seeking to empower them. Allow for some venting by the patient; you need to understand their world. Take the time to figure them out. Find areas of agreement, using phrases like “yes, and…” Avoid “you” statements and use “I” statements. Offer apologies, when appropriate. Ignore/deflect attacks. Instead, identify the patient’s needs and reframe their demands.

The patient should walk away with their dignity preserved.

While no physician can avoid a difficult clinical encounter, having tools to deal with these situations can make for a better experience for you and your patient.

Dr. MacFarlane offered these practical tips for safety in the workplace

  • Protection starts with your behavior. Some patients will rile you up; don’t let them see this. You can vent with colleagues but maintain your professional demeanor with patients at all times.
  • Put yourself in the patient’s place; they are allowed to be tired, scared, stressed, but you are not.
  • Monitor your stress levels and analyze external monitors (i.e.; use and apply Press Ganey results).
  • Staff should feel comfortable providing feedback on your behavior.
  • If you do lose your cool, call the patient once you’ve regained composure and smooth over any hurt feelings. But do not blow this off.
  • Be aware of patients with identified risk factors before you consider seeing them alone (history of violence or arrests, psychopathy or antisocial personality disorder, substance abuse, unemployment).
  • Don’t schedule new patients at the end of the day or with minimal staff support.
  • Have staff report any unusual patient behaviors to you prior to your patient visit.
  • Develop a good working relationship with building/ hospital security.
  • Interview in quiet settings. Keep the door slightly ajar for possibly problematic patients.
  • Have panic buttons/personal panic alarms for staff.
  • Use security cameras.
  • Beware of furniture that can potentially be used as a weapon.
  • Don’t walk in the hospital/clinic parking lots late at night — a high percentage of attacks on physicians occur in these areas.
  • Ask for escorts when leaving the building.
  • Avoid looking at your phone as you walk out of your office.
  • Pay close attention to cars parked around you as you’re coming and leaving office.
  • Lock car doors as soon as you get into your car.
  • Have separate entrances for staff and patients.
  • Use keychain alarms.
  • Don’t call patients from your personal cell phone; they can give your number to strangers. When and where it is possible, call from a hospital or office phone.
  • If there is a problem, be available.
  • Inform Risk Management early.
  • If a patient is upset, call them immediately, listen, explain things clearly, and involve patient advocacy. Don’t put this off as the next time you hear from the patient may be through a lawyer.

Editor’s note: Dr. MacFarlane also recommended this article for further reading on the topic.