Pain Medicine 2015; 16: 1882–1896 Wiley Periodicals, Inc.
Violence Toward Chronic Pain Care Providers: A National Survey
Kim David, Daftari Anuj, and Sibai Nabil
Reprint requests to: David Daewhan Kim, Anesthesiology, Henry Ford Hospital, Detroit, MI, USA. Tel: 313 622 7107; Fax: 313 916 8023; E-mail: [email protected].
Key Words. Behavior; Chronic Pain; Narcotics; Opioids; Pain Management; Psychosocial Factors; Violence Introduction
Abstract Introduction. This study measured the following: violence rates against chronic pain care providers (CPCPs), character/context/risk factors for violence and CPCPs’ mitigation strategies. Method. An e-mail survey was sent to members of the American Society of Interventional Pain Physicians (ASIIP) to collect demographics, rates/type of violence, injury, risk mitigation, and context of violence. Correlation with demographic factors calculated using one-way ANOVA and v2 test (Fisher test). Results. Security was called by 64.85% of CPCPs and 51.52% received threats. The threats involved a gun 7.05% of the time. Injury was reported by 2.73% of CPCPs. The most common risk mitigation was discharging patient (85.33%). Others used protective equipment (16.89%) of which a significant percentage carried a gun (54%). Opioid management was the highest context for violence (89.9%; P < 0.0001). Those who practiced part-time were more likely to be harmed (P 5 0.0290). Females were less likely to be threatened (P 5 0.0507). Anesthesiology was the most threatened vs other specialties (P 5 0.0215). Urban practices were less likely to move or close the practice (P 5 0.0292). Conclusion. CPCPs were at high risk for violence. Risk factors were older age, male, working part time, and anesthesiology. Risk was highest in the
1882
According to the United States (US) Bureau of Labor Statistics violence toward health care workers occurred at a higher rate than any other industry [1]. The National Institute of Occupational Health and Safety (NIOSH) reported that the majority of the nonfatal assaults occurred in the service (64%) and retail (21%) sectors [2]. Distribution of assaults in the service sector by industry was as follows: 27% in nursing homes, 13% in social services, and 11% in hospitals [2]. This made healthcare workers, the highest percentage recipients of nonfatal violence [2]. Patients were responsible for the highest percentage of nonfatal workplace assaults at 45%. Unlike nonfatal assaults, workplace homicides occurred most frequently in the retail sector at 38% with services sector at 17% [2]. Among health care workers, physicians were victims of violence at high rates as demonstrated in multiple studies in both the United States and throughout the world [3–28]. Several studies illustrated the seriousness and prevalence of violence in the US/Canadian health care systems. Goodman et al. [3] reported 26 physician homicides in the United States from 1980 to 1990. One US study reported that 86% of psychiatry residents were threatened and 25% were assaulted [7]. A national survey of emergency rooms (ERs) in the US by Behnam et al. [27] noted that 78% of emergency medicine (EM) physicians were exposed to work place violence at least once a year. Another survey of US ERs by Kansagra et al. [28] reported that 25% of staff did not feel safe with a median of 11 attacks per facility in 5 years. A Canadian survey of family practice (FP) physicians reported that 75% experienced major abuse [20].
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Anesthesiology, Henry Ford Hospital
context of opioid management and disability. Discharging patient was the most common risk mitigation. A significant number of physicians carried firearms.
Violence Toward CPCP
The levels of violence in developing countries have been less studied but reports have noted concern for increased violence in multiple countries such as China, Saudi Arabia, India and Nigeria [10,14,19,31]. In Turkey, a high percentage psychiatrist reported verbal threat or physical violence (71%) although physical assaults appear to be less (2.7%) [8]. A Polish study noted aggression toward physicians at rates of 80% for inpatient services with the most common in surgery (48%), neurology (40%), and EM (33%) [23]. As can be seen in this literature, violence toward care providers was prevalent across countries and most reported in certain specialties such as EM, psychiatry, and FP. The literature, however, is limited for chronic pain care providers (CPCPs). Two papers by Fishbain et al. [4,5] studied violence in the context of chronic pain care. Both studies were limited in scope to case reports and focused on measuring self-reported violent ideation in acute and chronic pain patients. A survey of US pain physicians in 2013 by Gupta et al. [32] reported a 27% incidence of what they labeled as “definite risk of death/ bodily harm threats.” This survey was, however, limited in scope to academic training programs and only had 26 respondents (response rate 5.2%). This study attempted to measure the rates, character, and context of violence toward CPCPs in a larger national survey. It also attempted to see what risk mitigation techniques those CPCPs were using and to demonstrate if there were CPCP demographic risks factors for violence. Our current hypothesis is that given the psychosocial complexities of chronic pain patients, we would expect higher or at least
equal rates of violence when compared with other high risk specialties such as EM, psychiatry, and FP. Method Subjects Members of the American Society of Interventional Pain Physicians (ASIIP) were chosen for the study Instrumentation After internal review board approval through Henry Ford Hospital (Detroit MI), an e-mail survey was sent via Survey Monkey (Palo Alto, CA) to 2,000 members of ASIPP (Table 1). Data Collection Procedures The recipients were not allowed take the survey if they responded “no” to currently practicing pain medicine. The first part of the survey involved collection of demographic data such as level of training: physician (MD/ DO), physician assistant (PA), nurse practitioner (NP), and fellow. Other demographic data collected included percentage of practice in pain medicine, age, gender, location of practice (rural, suburb, urban), years in practice, specialty (anesthesiology, physical medicine and rehabilitation [PMR], neurology, internal medicine, palliative care, FP, pediatrics, and psychiatry). The second part asked the frequency of threats and if any injuries occurred. The respondents were asked to characterize the mechanism of the threat as well as the injury. They were asked what risk mitigation techniques were used and if weapons/personal protective equipment were used in the office. Lastly, the clinical context of the threats and violence was questioned. In the previous descriptive questions concerning violence, the participants were allowed to choose more than one option. Data Analysis Descriptive statistics were reported for each of survey questionnaire as well as demographics of respondents. Mean and standard deviation and proportion were summarized for continuous variables and categorical variables respectively. One-Way ANOVA and v2 test (Fisher test) were applied to comparisons of all violence related questions with each demographic characteristic. Results Response Rates There were a total of 372 responses to the survey. Residents (n 5 7), medical student (n 5 1), and nonpracticing pain management physicians (n 5 3) were removed from the dataset. In addition, respondents who did not answer the questionnaire at all were removed (n 5 9). There were 22 respondents who did not answer questions from 4 to 15, so they were removed from the 1883
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In the developed world outside of the United States and Canada, the United Kingdom (UK) with its National Health System (NHS) has studied this phenomenon most extensively. UK medical sites in one report by the Health Services Advisory Committee found that 73% of staff suffered verbal abuse and threats vs 63% in other service sectors such as transport and public administration [29]. The percentage of NHS staff that had been threatened with a weapon was reported to be 5% [29]. Among physicians, 63% of FP physicians reported some sort of abuse or violence in the previous 12 months and 18% at least once a month [29]. Minor injuries were reported by 3% of physicians in the prior 3 months and 0.5% reported serious injuries [30]. In the hospital setting, one survey of a large UK ER noted 283 episodes of violence in 12 years [13]. An Australian survey by Forrest et al. [11] reported that 58% of FP physicians experienced verbal abuse, 18% reported property damage, and 6% reported physical abuse. A New Zealand survey of psychiatrist found 46% were verbally threatened, 39% physically intimidated, 16% assaulted requiring medical attention, 14% harassed by formal complaint, and 10% sexually harassed [21]. A Japanese survey of physicians by Saeki et al. noted workplace aggression and violence incident rate of 0.2 per practice hour. Interestingly, they reported three specialties with the highest incidence of violence as being dermatology (3.8), psychiatry (2.7), and ophthalmology (1.9) [9].
David et al.
Survey questionnaire
Number
Question
Response Choices
Q1
What level of training / practice are you currently in?
Q2 Q3 Q4 Q5
Are you practicing pain management? What is your age? What is your gender? What is Your Primary Specialty?
[ ]Medical Student [ ]Nurse Practitioner (NP) [ ]Physician Assistant (PA) [ ]Residency/Fellowship [ ]Practicing Physician (MD or DO) [ ]Psychologist [ ]Other (please specify) [ ]Yes [ ]No
Q6
How many years have you been practicing pain (exclude residency)?
Q7 Q8
Location of Practice How often do you call security / police due to a disruptive or argumentative patient (Approximately)? How often are you threatened by a patient with bodily harm (approximately)? How have patients threatened you (check all that apply)?
Q9
Q10
Q11 Q12
Q13
Q14 Q15
Have you ever been physically harmed or injured by a patient? If you have been physically injured by a patient, what was the method of injury (check all that apply)? If you have been verbally or physically threatened with violence what risk mitigation have you taken (check all that apply)? Do you carry any weapons / protective equipment to work (check all that apply)? What was the clinical context of the threat (check all that apply)?
[ ] Anesthesiology [ ] Family Medicine(FP) [ ]Internal Medicine (IM) [ ]Pediatrics[ ]Neurology [ ]Palliative Care [ ]Physical Medicine and Rehabilitation(PMR) [ ]Psychiatry [ ]Psychology 10)Nurse Practitioner (NP) [ ]Physician Assistant (PA) [ ]Other (please specify) [ ]Currently in fellowship [ ] 0 – 5 years [ ]6 – 10 [ ]Years11 – 15 years [ ]16 – 20 years [ ]21 – 25 years [ ]261 years [ ] Rural [ ]Suburban [ ]Urban [ ]Never [ ]Weekly[ ])Monthly [ ]Every 2 – 3 months [ ]Every 6 months [ ] Once a year or greater [ ]Never [ ]Weekly [ ]Monthly [ ]Every 2 – 3 months [ ]Every 6 months [ ]Once a year or greater [ ]Never been threatened [ ]Gun shot [ ]Knife [ ]Physical violence (punch, slap, kick ) [ ]Use of a blunt object (brass knuckles, trash can, chair, . . .) [ ] Verbal [ ]Other (please specify) [ ]Yes [ ]No [ ]Never been physically injured [ ]Gun shot [ ]Knife wound [ ]Physical violence (punch, slap, kick, . . .) [ ]Use of a blunt object (brass knuckles, trash can, chair, . . .) [ ]Other (please specify) [ ]Never been threatened (verbally or physically) [ ]Carry personnel protective equipment (firearm, stun gun, mace, body armor) [ ]Discharge patient [ ]Hired security guard [ ]Moved or closed practice [ ]Request police check-in [ ] Restraining order [ ]Other (please specify) [ ]Don’t carry any weapons [ ]Blunt object [ ]Body armor (ex: bullet proof vest) [ ]Gun [ ]Knife [ ]Mace [ ]Stun Gun [ ]Other (please specify) [ ]Never been threatened [ ]Auto accident litigation [ ]Disability request [ ]Interventional treatment [ ]Non-opioid medication management [ ]Opioid management [ ]Workman’s compensation [ ]Other (please specify)
analysis as well. Therefore, 330 respondents were used for final analysis with a response rate of 16.5%. Demographics The average age of the 330 participants was 44.3 with a range of 27–77 (Table 2). Female physicians (43.8 6 10.2) were significantly younger than male physician (47.0 6 9.5; P 5 0.01). Male physicians were the majority with 78% of total participants. Physicians (MD or DO) made up over 90% of respondents. Most listed anesthesiology (66%) as their primary specialty. Other specialties included PMR (21.24%), neurology (2.42%), 1884
and FP (1.52%) being the next most numerous. Despite pain management being practiced by different specialties, the vast majority of physicians (90%) practiced pain management as their primary focus, >50% of the time. Half of the CPCPs had more than 10 years practice experience. Practice location was distributed as follows: suburbs (50%), urban (39%), and rural (10.3%). Frequency of Threats On the frequency of “having to call security/police due to disruptive patients,” the majority of CPCPs (64.85%) reported having to do so at some time (Table 3). “Once a
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Table 1
Violence Toward CPCP
Table 2
Demographics Frequency
Percent
Fellowship Nurse Practitioner (NP) Physician Assistant (PA) Practicing Physician (MD or DO) Percent of practice pain management 1– 25% 26–50% 51–75% 76–100% Gender Female Male Primary Specialty Anesthesiology Physical medicine and rehabilitation Neurology Family medicine Nurse practitioner Palliative care Physician Assistant Internal medicine Pediatrics Psychiatry Other Years of practice Currently in fellowship 0 –5 years 6 – 10 years 11 –15 years 16 – 20 years 21 – 25 years 261 years
21 6 2 301 Frequency
6.36 1.82 0.61 91.21 Percent
8 22 30 270 Frequency 71 259 Frequency 218 80
2.42 6.67 9.09 81.82 Percent 21.52 78.48 Percent 66.06 21.24
8 5 3 3 2 1 1 1 8 Frequency 20 79 64 56 41 46 24
2.42 1.52 0.91 0.91 0.61 0.30 0.30 0.30 2.42 Percent 6.06 23.94 19.39 16.97 12.42 13.94 7.27
year or greater “and “never” were the highest responses at 36.15% (n 5 122) and 35.15% (n 5 116) without significant difference in rates between the two responses (P 5 0.24). Among those who did call security,” once a year or greater “was the most frequent response (P < 0.0001). There were, however, CPCPs who called every 6 months (14.55%; n 5 48), every 2–3 months (9.39%; n 5 31), monthly (2.42%; n 5 8), and weekly (1.52%; n 5 5). On the frequency of “being threatened by a patient with bodily harm,” over half of the respondents (51.52%) were threatened at some time. The response “never” was significantly the most frequent response at 48.48% (n 5 160; P < 0.0001). The most frequent response by those who were threatened was “once a year or greater” at 37.27% (n 5 123) (P < 0.0001). Characteristics of Threat and Risk Mitigation Verbal threats were the most frequent type of threat at 90.75% (n 5 206; P < 0.0001; Table 4). There were
Correlation Between Demographics and Response Among specialties, PMR was most likely and anesthesiology least likely to report “never being threatened” (P 5 0.02; Table 5). Anesthesiology was also most likely to report verbal threats (P 5 0.02; Table 5). Practice location was not much of a factor in responses except urban practices were less likely to move or close the practice if threatened (P 5 0.0292) and rural practices were more likely to use restraining orders (P =.0023) (Table 5). Surprisingly rural practices had the highest violence in the context of nonopioid-based medication management (P 5 0.0046). NP/PA/fellows were consistently more likely to report never being threatened vs MD/DOs (P 5 0.0004–0.049; Table 6). MD/DOs reported higher rates of verbal threats (P 5 0.002), were more likely to discharge patients (P 5 0026), and request police check-in (P 5 0.0024; Table 6). They were more likely to carry weapons (P 5 0.0122) and more likely to have the threat being in the context of opioid management (P 5 0.0013; Table 6). Comparing percentage of practice in pain management to responses, those who practiced in the middle range (51–75%) were more likely to be physically injured (P 5 0.0290) and more likely to hire security guard (P 5 0.0342; Table 6). For gender, females were more likely to report “never been threatened” (P 5 0.0507; Table 7). Age was a factor only in that younger CPCPs were more likely to report never having been threatened (P 5 0.0039) and less likely to carry a weapon (P 5 0.0497; Table 7). More experienced CPCPs with >10 years’ experience were more likely to carry a weapon (P 5 0.0029) and in particular a gun (P 5 0.0212; Table 8). 1885
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Level of Training
more significant threats including gun shot at 7.05% (n 5 16), knife at 2.64% (n 5 6), physical violence such as punch or kick at 21.15% (n 5 48), blunt object at 7.49% (n 5 17), and other at 13.22% (n 5 30). A small number of respondents reported physical injury at 2.73% (n 5 9). The majority of those injured were injured by physical assault 77.78% (n 5 7) such as kick or punch with none by a weapon. The most frequent risk mitigation technique reported was to discharge patient at 85.33% (n 5 192; P < 0.0001). There were more serious security measures including requesting police check in at 27.56% (n 5 62), personal protective equipment at 16.89% (n 5 38), restraining order at 7.56% (n 5 17), hire security guard at 5.78% (n 5 13), moved or closed practice at 1.78% (n 5 4), and other at 16.44% (n 5 37). No protective equipment was carried by 84.85% (n 5 280) of the respondents. Among those who did carry protective equipment, the most frequent was a gun at 54% (n 5 27; P 5 0.0075). Other responses included knife 30% (n 5 15), mace 28% (n 5 14), stun gun 8% (n 5 4), blunt object 8% (n 5 4), body armor 2% (n 5 1), and other 26% (n 5 14). The most common clinical context for violence was opioid management with the highest response at 89.91% (n 5 205; P < 0.0001). The next highest responses were workman’s compensation at 11.4% (n 5 26) and disability request 10.53% (n 5 24).
David et al.
Table 3
Frequency of threats
Responses
Frequency of Calling Security Due to Argumentative /Distruptive Patient Frequency of Threats
Never Weekly Monthly Every 2 – 3 months Every 6 months Once a year or greater Never Threatened Weekly Monthly Every 3 months Every 6 months Once a year or >
116 5 8 31 48 122 160 2 4 12 29 123
Percent
P-Value
35.15 1.52 2.42 9.39 14.55 36.97 48.48 0.61 1.21 3.64 8.79 37.27
0.24*
Percent Excluding “Never”
P Value Excluding “Never”
2.34 3.74 14.49 22.43 57.01
(< 0.0001)
1.18 2.35 7.06 17.06 72.35
(
Violence Toward Chronic Pain Care Providers: A National Survey
Kim David, Daftari Anuj, and Sibai Nabil
Reprint requests to: David Daewhan Kim, Anesthesiology, Henry Ford Hospital, Detroit, MI, USA. Tel: 313 622 7107; Fax: 313 916 8023; E-mail: [email protected].
Key Words. Behavior; Chronic Pain; Narcotics; Opioids; Pain Management; Psychosocial Factors; Violence Introduction
Abstract Introduction. This study measured the following: violence rates against chronic pain care providers (CPCPs), character/context/risk factors for violence and CPCPs’ mitigation strategies. Method. An e-mail survey was sent to members of the American Society of Interventional Pain Physicians (ASIIP) to collect demographics, rates/type of violence, injury, risk mitigation, and context of violence. Correlation with demographic factors calculated using one-way ANOVA and v2 test (Fisher test). Results. Security was called by 64.85% of CPCPs and 51.52% received threats. The threats involved a gun 7.05% of the time. Injury was reported by 2.73% of CPCPs. The most common risk mitigation was discharging patient (85.33%). Others used protective equipment (16.89%) of which a significant percentage carried a gun (54%). Opioid management was the highest context for violence (89.9%; P < 0.0001). Those who practiced part-time were more likely to be harmed (P 5 0.0290). Females were less likely to be threatened (P 5 0.0507). Anesthesiology was the most threatened vs other specialties (P 5 0.0215). Urban practices were less likely to move or close the practice (P 5 0.0292). Conclusion. CPCPs were at high risk for violence. Risk factors were older age, male, working part time, and anesthesiology. Risk was highest in the
1882
According to the United States (US) Bureau of Labor Statistics violence toward health care workers occurred at a higher rate than any other industry [1]. The National Institute of Occupational Health and Safety (NIOSH) reported that the majority of the nonfatal assaults occurred in the service (64%) and retail (21%) sectors [2]. Distribution of assaults in the service sector by industry was as follows: 27% in nursing homes, 13% in social services, and 11% in hospitals [2]. This made healthcare workers, the highest percentage recipients of nonfatal violence [2]. Patients were responsible for the highest percentage of nonfatal workplace assaults at 45%. Unlike nonfatal assaults, workplace homicides occurred most frequently in the retail sector at 38% with services sector at 17% [2]. Among health care workers, physicians were victims of violence at high rates as demonstrated in multiple studies in both the United States and throughout the world [3–28]. Several studies illustrated the seriousness and prevalence of violence in the US/Canadian health care systems. Goodman et al. [3] reported 26 physician homicides in the United States from 1980 to 1990. One US study reported that 86% of psychiatry residents were threatened and 25% were assaulted [7]. A national survey of emergency rooms (ERs) in the US by Behnam et al. [27] noted that 78% of emergency medicine (EM) physicians were exposed to work place violence at least once a year. Another survey of US ERs by Kansagra et al. [28] reported that 25% of staff did not feel safe with a median of 11 attacks per facility in 5 years. A Canadian survey of family practice (FP) physicians reported that 75% experienced major abuse [20].
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
Anesthesiology, Henry Ford Hospital
context of opioid management and disability. Discharging patient was the most common risk mitigation. A significant number of physicians carried firearms.
Violence Toward CPCP
The levels of violence in developing countries have been less studied but reports have noted concern for increased violence in multiple countries such as China, Saudi Arabia, India and Nigeria [10,14,19,31]. In Turkey, a high percentage psychiatrist reported verbal threat or physical violence (71%) although physical assaults appear to be less (2.7%) [8]. A Polish study noted aggression toward physicians at rates of 80% for inpatient services with the most common in surgery (48%), neurology (40%), and EM (33%) [23]. As can be seen in this literature, violence toward care providers was prevalent across countries and most reported in certain specialties such as EM, psychiatry, and FP. The literature, however, is limited for chronic pain care providers (CPCPs). Two papers by Fishbain et al. [4,5] studied violence in the context of chronic pain care. Both studies were limited in scope to case reports and focused on measuring self-reported violent ideation in acute and chronic pain patients. A survey of US pain physicians in 2013 by Gupta et al. [32] reported a 27% incidence of what they labeled as “definite risk of death/ bodily harm threats.” This survey was, however, limited in scope to academic training programs and only had 26 respondents (response rate 5.2%). This study attempted to measure the rates, character, and context of violence toward CPCPs in a larger national survey. It also attempted to see what risk mitigation techniques those CPCPs were using and to demonstrate if there were CPCP demographic risks factors for violence. Our current hypothesis is that given the psychosocial complexities of chronic pain patients, we would expect higher or at least
equal rates of violence when compared with other high risk specialties such as EM, psychiatry, and FP. Method Subjects Members of the American Society of Interventional Pain Physicians (ASIIP) were chosen for the study Instrumentation After internal review board approval through Henry Ford Hospital (Detroit MI), an e-mail survey was sent via Survey Monkey (Palo Alto, CA) to 2,000 members of ASIPP (Table 1). Data Collection Procedures The recipients were not allowed take the survey if they responded “no” to currently practicing pain medicine. The first part of the survey involved collection of demographic data such as level of training: physician (MD/ DO), physician assistant (PA), nurse practitioner (NP), and fellow. Other demographic data collected included percentage of practice in pain medicine, age, gender, location of practice (rural, suburb, urban), years in practice, specialty (anesthesiology, physical medicine and rehabilitation [PMR], neurology, internal medicine, palliative care, FP, pediatrics, and psychiatry). The second part asked the frequency of threats and if any injuries occurred. The respondents were asked to characterize the mechanism of the threat as well as the injury. They were asked what risk mitigation techniques were used and if weapons/personal protective equipment were used in the office. Lastly, the clinical context of the threats and violence was questioned. In the previous descriptive questions concerning violence, the participants were allowed to choose more than one option. Data Analysis Descriptive statistics were reported for each of survey questionnaire as well as demographics of respondents. Mean and standard deviation and proportion were summarized for continuous variables and categorical variables respectively. One-Way ANOVA and v2 test (Fisher test) were applied to comparisons of all violence related questions with each demographic characteristic. Results Response Rates There were a total of 372 responses to the survey. Residents (n 5 7), medical student (n 5 1), and nonpracticing pain management physicians (n 5 3) were removed from the dataset. In addition, respondents who did not answer the questionnaire at all were removed (n 5 9). There were 22 respondents who did not answer questions from 4 to 15, so they were removed from the 1883
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
In the developed world outside of the United States and Canada, the United Kingdom (UK) with its National Health System (NHS) has studied this phenomenon most extensively. UK medical sites in one report by the Health Services Advisory Committee found that 73% of staff suffered verbal abuse and threats vs 63% in other service sectors such as transport and public administration [29]. The percentage of NHS staff that had been threatened with a weapon was reported to be 5% [29]. Among physicians, 63% of FP physicians reported some sort of abuse or violence in the previous 12 months and 18% at least once a month [29]. Minor injuries were reported by 3% of physicians in the prior 3 months and 0.5% reported serious injuries [30]. In the hospital setting, one survey of a large UK ER noted 283 episodes of violence in 12 years [13]. An Australian survey by Forrest et al. [11] reported that 58% of FP physicians experienced verbal abuse, 18% reported property damage, and 6% reported physical abuse. A New Zealand survey of psychiatrist found 46% were verbally threatened, 39% physically intimidated, 16% assaulted requiring medical attention, 14% harassed by formal complaint, and 10% sexually harassed [21]. A Japanese survey of physicians by Saeki et al. noted workplace aggression and violence incident rate of 0.2 per practice hour. Interestingly, they reported three specialties with the highest incidence of violence as being dermatology (3.8), psychiatry (2.7), and ophthalmology (1.9) [9].
David et al.
Survey questionnaire
Number
Question
Response Choices
Q1
What level of training / practice are you currently in?
Q2 Q3 Q4 Q5
Are you practicing pain management? What is your age? What is your gender? What is Your Primary Specialty?
[ ]Medical Student [ ]Nurse Practitioner (NP) [ ]Physician Assistant (PA) [ ]Residency/Fellowship [ ]Practicing Physician (MD or DO) [ ]Psychologist [ ]Other (please specify) [ ]Yes [ ]No
Q6
How many years have you been practicing pain (exclude residency)?
Q7 Q8
Location of Practice How often do you call security / police due to a disruptive or argumentative patient (Approximately)? How often are you threatened by a patient with bodily harm (approximately)? How have patients threatened you (check all that apply)?
Q9
Q10
Q11 Q12
Q13
Q14 Q15
Have you ever been physically harmed or injured by a patient? If you have been physically injured by a patient, what was the method of injury (check all that apply)? If you have been verbally or physically threatened with violence what risk mitigation have you taken (check all that apply)? Do you carry any weapons / protective equipment to work (check all that apply)? What was the clinical context of the threat (check all that apply)?
[ ] Anesthesiology [ ] Family Medicine(FP) [ ]Internal Medicine (IM) [ ]Pediatrics[ ]Neurology [ ]Palliative Care [ ]Physical Medicine and Rehabilitation(PMR) [ ]Psychiatry [ ]Psychology 10)Nurse Practitioner (NP) [ ]Physician Assistant (PA) [ ]Other (please specify) [ ]Currently in fellowship [ ] 0 – 5 years [ ]6 – 10 [ ]Years11 – 15 years [ ]16 – 20 years [ ]21 – 25 years [ ]261 years [ ] Rural [ ]Suburban [ ]Urban [ ]Never [ ]Weekly[ ])Monthly [ ]Every 2 – 3 months [ ]Every 6 months [ ] Once a year or greater [ ]Never [ ]Weekly [ ]Monthly [ ]Every 2 – 3 months [ ]Every 6 months [ ]Once a year or greater [ ]Never been threatened [ ]Gun shot [ ]Knife [ ]Physical violence (punch, slap, kick ) [ ]Use of a blunt object (brass knuckles, trash can, chair, . . .) [ ] Verbal [ ]Other (please specify) [ ]Yes [ ]No [ ]Never been physically injured [ ]Gun shot [ ]Knife wound [ ]Physical violence (punch, slap, kick, . . .) [ ]Use of a blunt object (brass knuckles, trash can, chair, . . .) [ ]Other (please specify) [ ]Never been threatened (verbally or physically) [ ]Carry personnel protective equipment (firearm, stun gun, mace, body armor) [ ]Discharge patient [ ]Hired security guard [ ]Moved or closed practice [ ]Request police check-in [ ] Restraining order [ ]Other (please specify) [ ]Don’t carry any weapons [ ]Blunt object [ ]Body armor (ex: bullet proof vest) [ ]Gun [ ]Knife [ ]Mace [ ]Stun Gun [ ]Other (please specify) [ ]Never been threatened [ ]Auto accident litigation [ ]Disability request [ ]Interventional treatment [ ]Non-opioid medication management [ ]Opioid management [ ]Workman’s compensation [ ]Other (please specify)
analysis as well. Therefore, 330 respondents were used for final analysis with a response rate of 16.5%. Demographics The average age of the 330 participants was 44.3 with a range of 27–77 (Table 2). Female physicians (43.8 6 10.2) were significantly younger than male physician (47.0 6 9.5; P 5 0.01). Male physicians were the majority with 78% of total participants. Physicians (MD or DO) made up over 90% of respondents. Most listed anesthesiology (66%) as their primary specialty. Other specialties included PMR (21.24%), neurology (2.42%), 1884
and FP (1.52%) being the next most numerous. Despite pain management being practiced by different specialties, the vast majority of physicians (90%) practiced pain management as their primary focus, >50% of the time. Half of the CPCPs had more than 10 years practice experience. Practice location was distributed as follows: suburbs (50%), urban (39%), and rural (10.3%). Frequency of Threats On the frequency of “having to call security/police due to disruptive patients,” the majority of CPCPs (64.85%) reported having to do so at some time (Table 3). “Once a
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Table 1
Violence Toward CPCP
Table 2
Demographics Frequency
Percent
Fellowship Nurse Practitioner (NP) Physician Assistant (PA) Practicing Physician (MD or DO) Percent of practice pain management 1– 25% 26–50% 51–75% 76–100% Gender Female Male Primary Specialty Anesthesiology Physical medicine and rehabilitation Neurology Family medicine Nurse practitioner Palliative care Physician Assistant Internal medicine Pediatrics Psychiatry Other Years of practice Currently in fellowship 0 –5 years 6 – 10 years 11 –15 years 16 – 20 years 21 – 25 years 261 years
21 6 2 301 Frequency
6.36 1.82 0.61 91.21 Percent
8 22 30 270 Frequency 71 259 Frequency 218 80
2.42 6.67 9.09 81.82 Percent 21.52 78.48 Percent 66.06 21.24
8 5 3 3 2 1 1 1 8 Frequency 20 79 64 56 41 46 24
2.42 1.52 0.91 0.91 0.61 0.30 0.30 0.30 2.42 Percent 6.06 23.94 19.39 16.97 12.42 13.94 7.27
year or greater “and “never” were the highest responses at 36.15% (n 5 122) and 35.15% (n 5 116) without significant difference in rates between the two responses (P 5 0.24). Among those who did call security,” once a year or greater “was the most frequent response (P < 0.0001). There were, however, CPCPs who called every 6 months (14.55%; n 5 48), every 2–3 months (9.39%; n 5 31), monthly (2.42%; n 5 8), and weekly (1.52%; n 5 5). On the frequency of “being threatened by a patient with bodily harm,” over half of the respondents (51.52%) were threatened at some time. The response “never” was significantly the most frequent response at 48.48% (n 5 160; P < 0.0001). The most frequent response by those who were threatened was “once a year or greater” at 37.27% (n 5 123) (P < 0.0001). Characteristics of Threat and Risk Mitigation Verbal threats were the most frequent type of threat at 90.75% (n 5 206; P < 0.0001; Table 4). There were
Correlation Between Demographics and Response Among specialties, PMR was most likely and anesthesiology least likely to report “never being threatened” (P 5 0.02; Table 5). Anesthesiology was also most likely to report verbal threats (P 5 0.02; Table 5). Practice location was not much of a factor in responses except urban practices were less likely to move or close the practice if threatened (P 5 0.0292) and rural practices were more likely to use restraining orders (P =.0023) (Table 5). Surprisingly rural practices had the highest violence in the context of nonopioid-based medication management (P 5 0.0046). NP/PA/fellows were consistently more likely to report never being threatened vs MD/DOs (P 5 0.0004–0.049; Table 6). MD/DOs reported higher rates of verbal threats (P 5 0.002), were more likely to discharge patients (P 5 0026), and request police check-in (P 5 0.0024; Table 6). They were more likely to carry weapons (P 5 0.0122) and more likely to have the threat being in the context of opioid management (P 5 0.0013; Table 6). Comparing percentage of practice in pain management to responses, those who practiced in the middle range (51–75%) were more likely to be physically injured (P 5 0.0290) and more likely to hire security guard (P 5 0.0342; Table 6). For gender, females were more likely to report “never been threatened” (P 5 0.0507; Table 7). Age was a factor only in that younger CPCPs were more likely to report never having been threatened (P 5 0.0039) and less likely to carry a weapon (P 5 0.0497; Table 7). More experienced CPCPs with >10 years’ experience were more likely to carry a weapon (P 5 0.0029) and in particular a gun (P 5 0.0212; Table 8). 1885
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Level of Training
more significant threats including gun shot at 7.05% (n 5 16), knife at 2.64% (n 5 6), physical violence such as punch or kick at 21.15% (n 5 48), blunt object at 7.49% (n 5 17), and other at 13.22% (n 5 30). A small number of respondents reported physical injury at 2.73% (n 5 9). The majority of those injured were injured by physical assault 77.78% (n 5 7) such as kick or punch with none by a weapon. The most frequent risk mitigation technique reported was to discharge patient at 85.33% (n 5 192; P < 0.0001). There were more serious security measures including requesting police check in at 27.56% (n 5 62), personal protective equipment at 16.89% (n 5 38), restraining order at 7.56% (n 5 17), hire security guard at 5.78% (n 5 13), moved or closed practice at 1.78% (n 5 4), and other at 16.44% (n 5 37). No protective equipment was carried by 84.85% (n 5 280) of the respondents. Among those who did carry protective equipment, the most frequent was a gun at 54% (n 5 27; P 5 0.0075). Other responses included knife 30% (n 5 15), mace 28% (n 5 14), stun gun 8% (n 5 4), blunt object 8% (n 5 4), body armor 2% (n 5 1), and other 26% (n 5 14). The most common clinical context for violence was opioid management with the highest response at 89.91% (n 5 205; P < 0.0001). The next highest responses were workman’s compensation at 11.4% (n 5 26) and disability request 10.53% (n 5 24).
David et al.
Table 3
Frequency of threats
Responses
Frequency of Calling Security Due to Argumentative /Distruptive Patient Frequency of Threats
Never Weekly Monthly Every 2 – 3 months Every 6 months Once a year or greater Never Threatened Weekly Monthly Every 3 months Every 6 months Once a year or >
116 5 8 31 48 122 160 2 4 12 29 123
Percent
P-Value
35.15 1.52 2.42 9.39 14.55 36.97 48.48 0.61 1.21 3.64 8.79 37.27
0.24*
Percent Excluding “Never”
P Value Excluding “Never”
2.34 3.74 14.49 22.43 57.01
(< 0.0001)
1.18 2.35 7.06 17.06 72.35
(
