When faced with imminent life-threatening violence, physicians should:
- Leave the area and take steps to protect patients, staff, themselves, and their families.
- Call security or 9-1-1, as appropriate.
When faced with abusive behaviour, physicians should:
- Stay calm, professional, and non-confrontational.
- Take the lead by treating others with respect and compassion.
- Try to identify the root causes of the abusive behaviour.
- Focus on the issues rather than on personalities to reach a mutually acceptable resolution.
- Seek help from trusted colleagues or contact the CMPA for advice and assistance.
- Refer to policies governing the management of abusive behaviour in the workplace, when applicable.
- Document abusive encounters clearly and factually.
Life-threatening violence against a physician is a concern, yet exceedingly rare. However, the CMPA is often asked for help from physicians who report being bullied, intimidated, threatened, or harassed. The inappropriate behaviours that physicians may experience range from relatively minor (rudeness, yelling, verbal threats, personal insults), to major (physical aggression, destructive behaviour), to severe (assault, stalking).
Being the subject of bullying and other abusive behaviour affects the well-being of the targeted individual. In a healthcare setting, it may also affect patient safety and increase the risk of a patient safety incident. Physicians subjected to ongoing abuse may suffer mental health issues and sleep disturbances, fear for their or their family’s safety, and even decide to change workplaces. Knowing how to respond appropriately may promote safety, help defuse conflict situations, and prevent potential medical-legal difficulties for the physician.
Patients and their families
Physicians and their staff have the right to work in a safe environment. Many healthcare settings rightly post notices of policies indicating zero tolerance of abusive behaviour and enforce those policies to promote safe workplaces.
Nevertheless, when a patient's or the family's expectations are not met, they may resort to abusive behaviour, or threaten to launch a complaint or go to the news media. This may occur because of a multitude of scenarios, from being frustrated and stressed by uncertainty or long wait times to when a physician denies requests that the physician deems are unreasonable. Difficult as it may be, physicians should continue to follow the standard of care and not be intimidated into providing investigations or treatments they feel are not in the patient's best interest.
Case example: Abusive behaviour
A female comes into the office for elective care. The patient is told her provincial health card has expired and that she can either apply for a new card or pay for the visit and seek reimbursement once her new card arrives. The patient becomes verbally abusive toward the receptionist and begins throwing things. The office manager is able to get the patient to leave. The doctor discharges the patient from the practice, pointing out the posted zero-tolerance-to-violence sign.
The response to abusive behaviour should be calm, professional, non-confrontational, and preferably in private, away from other patients. Physicians should consider and address their security needs and that of their staff. Steps to consider when dealing with abusive behaviour from patients and families include the following:
When safety is not a concern
- Verbalize the specific behaviour, clearly tell the individual that it is unacceptable, and outline the consequences of continuing or repeating such behaviour. In hospital or large clinic settings, consider using other available resources such as security, social work, patient advocacy, and pastoral care.
- If the abusive behaviours are recurring, but minor, there may be insufficient trust in the relationship to provide continued quality care. This may lead to ending the doctor-patient relationship.
- If the abusive behaviours are major or severe, consider ending the doctor-patient relationship, in keeping with the applicable medical regulatory authority (College) guidelines. Contact the CMPA for case-specific advice where a patient is exhibiting aggressive behaviour or threatening your personal safety. There are certain legal measures that can be taken in these circumstances.
When behaviours escalate beyond abusive language and threats of complaints to assault, threats of harm, or disorderly conduct, the situation is different. Physicians in these circumstances must take steps to protect themselves and others around them.
Case example: Assault and threat of life-threatening violence
A male comes to the office seeking an exemption from work, which the physician feels is unjustified. The patient becomes verbally abusive, punches the physician, and as he leaves the office yells, “I know where you live and where your children go to school! You’ll be sorry when I’m done with you!”
The physician immediately calls the police to report the physical assault and a threat to his safety and that of his family.
The response to assault and threats to one’s personal safety should be decisive and designed to protect the threatened individuals. Despite the duty of confidentiality, physicians should not hesitate to contact the police if they feel their safety or the safety of others is at risk due to a patient’s aggressive or threatening behaviour.
When safety is a concern
- If there is a serious threat to safety, notify the police or if in a hospital, notify a security guard. A report to police should include only the information necessary for the police to address the threat, such as the name of the threatening individual and the nature of the incident. Divulging any further patient medical information should be avoided, if possible.
- Document the abusive behaviours clearly and factually.
Colleagues and other healthcare workers
Conflict with physician colleagues and other healthcare workers may result in abusive behaviour if the conflict is not well managed. While some of these conflicts arise from disagreements over patient care, many stem from power struggles, working conditions, substantive issues (compensation, office space, support), and personality differences. Physicians need to understand the environment in which they are practising and ensure their own behaviour does not contribute to the issue.
Case example: Workplace bullying
A physician contacts the CMPA because he feels he is being bullied by his section chief. At meetings, when the physician voices an opinion, the section chief denigrates him by repeating his statements in a mocking tone of voice and intimidates him by banging his fists on the table and telling him he has no time for his “nonsense.” The CMPA physician advisor is able to discern that the physician’s privileges are not under threat and works with him to identify appropriate channels to address his concerns. The physician raises his concerns with the department head, who thanks him for speaking up and tells him that his issue confirms a concerning pattern of behaviour that will be addressed.
In the workplace, behaviour that is perceived as abusive should be addressed in a calm, respectful, and non-confrontational manner. Steps to consider when dealing with workplace issues include the following:
- Identify the issues. Is it a new problem or recurring issue?
- Seek counsel from a respected peer who may assist the parties to find common ground.
- Refrain from speaking broadly about the grievance. Rather, you may want to discuss the issue with the appropriate individuals in the chain of command in a stepwise fashion (for example, service head, department chief, director of professional affairs). Document your discussions and share the documentation with the person you spoke to.
Lawyers, police officers, insurance company representatives, and others may request information about a patient. Even if there is no authorization for releasing such information, the requesting individuals may insist it is their right to obtain the information and may threaten the physician or staff with consequences if the physician does not comply.
Case example: Pressure from a third party
A distraught member calls the CMPA while in the midst of an encounter with a police officer who arrived at the clinic and is demanding information about a patient she had seen the day before. He is threatening her with obstruction of justice if she does not answer his questions. The CMPA physician advisor advises the physician to calmly tell the officer that she would be happy to assist, but requires consent from the patient or legal documentation such as a search warrant or court order. She is able to successfully defuse the situation.
In dealing with third parties seeking information, patient confidentiality is paramount.
- Be aware of situations that authorize sharing of information without patient consent (e.g. mandatory reporting).
- Share information only with your patient’s consent (unless mandated to do so by statute or court order).
- Voice your desire to be cooperative with third party requests and guide them to the necessary documents required to authorize the sharing of information.
The safety and wellness of physicians, staff, employees, and other patients should generally be given priority over concerns about patient confidentiality. While most threatening or bullying behaviours may be de-escalated with calm and tact, if a genuine threat is perceived or if an assault is perpetrated, physicians should call the police for help.
Members are encouraged to contact the CMPA for additional advice and assistance on dealing with concerns with disruptive behaviour and personal safety.