“I’m sorry, I can’t responsibly give you a steroid shot without a proper workup of your joint pain.” After a long and agonizing discussion with the 32-year-old male patient who came into my office demanding steroid injection for wrist pain, I gave up and suggested that he got a second opinion. This was not the first steroid injection he had in his hand: no previous imaging, no lab work up for plausible causes, just repeated shots.

“So you just wasted my time for nothin’?” He stood up abruptly, visibly angry.

A little taken aback, I said: “ I can see you are not satisfied with my care, please feel free to see another provider.”

To see a robust guy clenching his fists in front me in a small, closed space was not the most pleasant patient interaction I have ever had. My instinct was to leave the situation. So I got up and opened the door. And if there was ever a “stink eye”, I received it, as he stared at me when walking by my desk in our “open design” clinic, just moments later. I assumed he was just passing by me to go to another provider’s appointment.

The look on his face was a portrait of resentment, contempt, and perhaps a few other ingredients my gut told me there was.

Patient-initiated workplace violence against healthcare workers is a hidden pandemic, and unfortunately, compared to COVID-19, the recommended distance for safety is a lot farther than six feet. Globally, in 2019, 8-38% of healthcare workers suffered physical violence while working. And this excludes emotional abuse, threats, or sexual harassments. My home country, China, has one of the highest prevalence for this type of workplace violence: it’s estimated at 42.2 to 83.3%. In 2012 alone, according to news reports, 7 healthcare workers were murdered by patients or family. Undesired treatment outcomes such as patient death or suboptimal results were the main reasons behind such senseless killings.

By the time I left my medical school program in China to come to the U.S. in 2008, some of our teaching hospitals were advising doctors and nurses to wear a helmet to work. “It won’t be easy to get into or go through medical training in America, but at least you won’t be stabbed to death!” My medical school classmates said to me, jokingly.

Well, jokes on me. These are some U.S. data/incidents.

• 2011-2013: workplace assaults ranged from 23,540 to 25,630 annually, >70% occurring in healthcare and social service settings

• 2/2019-3/2019: 23% physicians participating in a survey study reported personal attacks online, and women physicians more likely to receive sexual harassment than men

• 2019: 38 fatalities in healthcare support occupations

• 2020: 44 fatalities in healthcare support occupations (this is a 15.8% increase compared to 2019)

• 2020: study shows the COVID-19 pandemic imposes 50% more bullying toward healthcare workers compared to other occupations

• 3/2020: a Chinese American physician was stalked and verbally attacked by a patient with xenphobic language in Boston; among other verbal attacks on Chinese/Asian American physicians both in healthcare setting and on their commute home/to work

• 3/2020-3/2021: 3,607 healthcare workers died on the frontline of the pandemic, most of which were considered preventable

• 11/2021: a 8-month-pregnant nurse was physically attacked by a patient, she lost her baby to stillbirth shorty after

• 1/2022: multiple healthcare workers brought forth the concerns of death threads while engaging in advocacy for social justice

  Then….

• 6/1/2022: four lives, including two physicians were taken by a gunman who blamed the doctor for his back pain

Violence toward healthcare workers is not a new phenomenon by any means, especially for those who work in acute/emergency settings. ER nurses have described themselves as “human punching bags”. Somehow, we have all come to accept the risks. “Simply telling our colleagues in medicine to cope with harassment and menacing behavior is unacceptable.” Said Dr. Harmon, the president of American Medical Association, in his recent post on this urgent topic. In the background of increasing safety concerns at work, we cannot let gun violence escalate attacks on healthcare workers. It’s one thing to be a punching bag, quite another to be a shooting target.

“Hey Luke, what did you end up doing for that patient who left my office angrily?” I asked my colleague who ended up seeing the young patient who demanded steroid injection into his wrist without a workup. I had asked the clinic manager to help me handle this situation after I sensed that the patient was so angry at me. After a discussion with patient, I was surprised to see that he ended up on my colleague’s schedule, the same day.

“I gave him a steroid injection into this wrist.” Luke slowly answered, with hesitancy, and an intriguing look on his face.

I wanted to ask Luke so many questions: Why did you give in to his demand? Should we be repeatedly injecting steroids into young people’s joints? What do you think is causing his pain that necessitates steroid shots?

But I held my tongue and asked none of them. I read Luke’s body language, and saw the look on his face. Then I understood. He gave in because he also felt pressured, and threatened by the patient. And with recent news on patient initiated workplace violence toward providers, he didn’t feel safe to argue with a fist-clenching patient head-on.

This made me want to give Luke a hug, instead. I nodded at him, and said: “Ok. Thank you for seeing him.”

Recently, I wrote an article for MedPage Today, titled “Are Any of Us Safe at Work?” In this article, I expressed concerns for the future of healthcare. Judging from existing data in both China and the U.S., the Great Resignation in medicine will no doubt be accelerated by these violent crimes. Preserving the safety of those who heal is of utmost importance, before there is no one left to care for those in need. But I often wondered, in the face of threat, how would I act? Do I have what it takes to insist on my ethical/therapeutic principles? Or would I give in to preserve my own safety, too?

What would you do?

*The story of the above patient and colleague was based on a true story, but the details and names were significantly altered to protect confidentiality.*