San Diego internist David B. Beetleman, M.D., was finishing a patient appointment when a nurse handed a note to Beetleman as the patient left the room.
“Call me tomorrow,” the mysterious message read.
The next day, Bittleman called the nurse, the patient’s ex-wife. He suggested that she wanted to discuss a routine matter, such as treating a patient. But her reason for wanting to talk in private was much more sinister.
“He wants to kill you,” she said.
Bittleman was shocked. He knew the patient was angry that his opioid regimen had been cut, but he didn’t think his rage would escalate into a possible murder. The guardian told Bittleman that she thought her ex-husband was serious.
“The ex-wife and two adult sons were very disturbed by his strange behavior,” recalled Bittleman. “She made it very clear that he said he planned to kill me. I feared for my life because I took his threat at face value.”
The patient sends an alarm message, threatens
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When he went into medicine, Bittleman never thought he would have to worry about assaulting or killing a patient.
After spending 20 years in private practice, Bittleman was delighted to accept a position with the San Diego Veterans Affairs (VA) Health System. He said his extended family lived in the area and he looked forward to helping veterans and working with students.
Beetleman had been practicing primary care in Virginia for about 5 years when he encountered a threatening patient, a veteran in his 60s. The man suffered from musculoskeletal pain and mental illness.
The patient has been taking opioids for many years. Bittleman believed it was unsafe to continue taking the medication given the man’s lifestyle.
“Previous providers treated him with oxycodone for chronic pain, but I thought it was dangerous given that he mixed it with alcohol and marijuana,” he said. “I met with him and a substance use disorder physician for a conference call and we explained that we would need to reduce the dose of medication and eventually stop taking opioids.”
Bittleman begged the patient to go to drug rehab and offered him inpatient withdrawal treatment. The man refused.
A few weeks later, Bittleman was testing the medical center’s electronic messaging system. He found a disturbing message from a patient.
“You better learn jiu-jitsu and hand-to-hand combat if you ever take my opioids,” the message said. – Learn to defend yourself!
Beetleman contacted the Virginia State Police and reported the report. According to Bittleman, the patient was interviewed by mental health professionals, but they did not consider him dangerous.
“They are quite limited in their capabilities,” he said. “In a private practice, a patient may be fired or no longer allowed to enter the building, but the VA is a welfare institution. I’m not sure he was even reprimanded.”
Two months later, the patient’s ex-wife shared the disturbing news that the patient wanted to kill the doctor.
Bittleman returned to the police. They suggested that he issue a restraining order, which he requested the same day. By the end of the day, the judge issued a restraining order, according to Beetleman and court records. The patient could not come within 100 yards of the doctor, his clinic, car or home.
But there was one frightening nuance. The order was temporary. This will only last 2 weeks. To make the order permanent, Bittleman would have to stand before a judge and argue why he was needed.
He won’t be alone at the hearing. Someone else would have been a few steps away – the patient who wanted to kill him.
Doctor and patient face off in front of a judge
As the hearing approached, Bittleman felt uneasy, outraged, and afraid. He wondered if the patient could carry out his threat.
Some colleagues suggested that Bittleman buy a gun, while others recommended that he carry pepper spray. According to him, Bittleman did not want to learn how to handle weapons. He was consoled that there were armed guards and metal detectors in his house, and there was a panic button under the table.
“I wasn’t sure I wanted to take more care of patients, especially patients with chronic pain,” he said. “However, I went for a consultation with the Employee Assistance Program and the therapist helped normalize my anxiety and acknowledge my fear.”
On the day of the hearing, Bittleman was seated at the back of the courtroom. The patient in the front looked at Bittleman with a slight smile.
When his case was called, the judge explained that, as a plaintiff, Bittleman had to prove that the patient posed a threat to his safety. He provided the judge with a copy of the threatening message and a copy of the ex-wife’s note.
After reviewing the documents, the judge asked the patient to explain his position. The patient complained that the VA denied him certain benefits and that he was forced into mental health rehab that he “didn’t need”. The judge eventually interrupted the man to ask if he had threatened to kill Beetleman.
“Oh yes, Your Honor, I said that, but I was just joking,” he told the judge.
Reception was sufficient. The judge issued a restraining order against the patient, which will last 1 year. He could not have a firearm, and if he violated the order, he was arrested.
The terrible saga is finally over.
“I never heard from the patient again,” Bittleman said. “His [care] the location was changed and the police were required to come to all his visits with his new provider. I felt relieved that if he ever got close to me, he would go to jail.”
To raise awareness of such trials and troubles that could ensue, Bittleman wrote an article about his experience that was published in the Annals of Family Medicine. He continues to treat patients in the VA, including those with chronic pain, but the memory of a threatening patient pops up from time to time.
“I’m still thinking about it,” he said. “I know how to use my panic button and I check it every 90 days. If there’s a patient that bothers me, the Virginia State Police will be waiting nearby. I am very aware of and upset by the violence. Doctors are being killed, I feel a lump in my chest. How could I not understand? Here is a doctor who worked hard, dedicated his life to helping patients, and it came to this? It’s so disgusting. I’m sick”.
Can you identify the violent patient?
Concern about threats to patients has grown across the country following the recent brutal attacks on doctors in Oklahoma and California. Two doctors were shot dead in June 2022 when a patient opened fire in a Tulsa medical building. The main target of the shooting was the surgeon who was operating on the patient. Also in June, two nurses and an emergency doctor were injured by a patient at Encino Hospital Medical Center. They survived.
The attacks raise questions about how to identify potentially violent patients and how to mitigate possible violence.
Threats and violence against healthcare workers are nothing new, but they are finally getting the attention they deserve, says Derek Schaller, MD, an emergency physician and assistant professor of emergency medicine at Central Michigan University, Mount Pleasant.
“Violence against medical staff has been a problem for a long time, it’s just that it’s finally making headlines,” he said. “At one time it seemed almost part of the work, part of the concert. But it shouldn’t be part of the concert. It’s not something we have to deal with.”
Healthcare professionals and health centers typically take a reactive approach to aggressive patients, but Schaller encourages a more proactive strategy. Central Michigan Health University, for example, recently looked at its past history of abuse and analyzed the characteristics of violent patients. Schaller said the analysis came after an increase in patient violence at the medical center last year.
The study yielded some interesting results, including that a large percentage of patients who became violent in the emergency room did so within the first hour of their hospital stay, he said.
“You would have thought that these were patients who were there and stuck in the emergency room for a while and became unhappy, but that was not the case,” Skuller said.
He recommends that physicians, healthcare providers and hospitals conduct similar assessments of their patients and past violent encounters to identify trends. His institution will be implementing a triage screening tool to identify patients who are more likely to become violent so health professionals can intervene sooner, he said.
Such a screening tool is already showing success in various healthcare settings.
About 10 years ago, a research team led by Song Chae Kim, PhD, RN, found that the 10-item Aggressive Behavior Risk Assessment Tool (ABRAT) was able to identify potentially violent patients with reasonable sensitivity and specificity in hospital medical-surgical departments. .
The tool was subsequently modified for long-term care facilities, and again the researchers found that ABRAT could detect potentially violent residents with reasonable sensitivity and specificity, said Kim, ABRAT developer and professor at Point Loma Nazarene University in San Diego.
In 2021, researchers implemented the checklist into an electronic health record (EHR) system and tested ABRAT in emergency departments.
“We are currently working with programmers to create an application that will make using ABRAT very easy in combination with EHR,” said Kim. “Instead of the nurse looking into the EHR to find out if the patient had a history of mental illness or violent behavior, the app will automatically search the EHR and combine the nurse’s quick observations, whether or not the patient is confused. , excited, staring or threatening to automatically calculate the risk of violence.”
Kim and her team also developed a tool called the VEST (Violent Event Severity Tool), a standardized objective assessment of the severity of workplace violence. They are also working with programmers to include VEST in the application.
Kim hopes that the ABRAT tool can be modified for use in a variety of healthcare settings.
Alicia Gallegos is a reporter for Medscape Business of Medicine based in the Midwest. She has previously written for American Medical News, ACP Internist and AAMC Reporter. Contact Alicia at firstname.lastname@example.org or via Twitter at @Legal_med.
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