When an epidemic of violence against health care workers meets a pandemic [PODCAST]

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“The COVID-19 pandemic has exacerbated factors that cause violence in the workplace. At no time in recent history will you find clinical health care workers under this degree of stress. Physicians and nurses are operating under high alert in hospitals and clinics while facing COVID deniers and abusive treatment (name-calling such as “disease spreaders”) in their day-to-day life. Due to social distancing measures, shutdowns, and resultant economic fallout, patients are experiencing significant psychological and financial burdens. The politicization of the pandemic has elevated the level of difficulty for all parties.

This combination of clinical and societal strain increases the likelihood of overly (and overtly) aggressive or unpredictable reactions to day to day encounters.”

Mercy Udoji is an anesthesiologist.

She shares her story and discusses her KevinMD article, “When an epidemic of violence against health care workers meets a pandemic.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Mercy Udoji. She is an anesthesiologist, and she wrote the KevinMD article “When an epidemic of violence against health care workers meets a pandemic.” Mercy, welcome to the show.

Mercy Udoji: Thank you so much for having me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Mercy Udoji: I’m originally from Tennessee. I did my residency training at Duke in North Carolina. Then I did an interventional pain fellowship at Cornell in New York, and after that, I came back south, where I’ve worked in Birmingham, and I’m currently practicing in Atlanta, Georgia, as a pain specialist and an anesthesiologist.

Kevin Pho: And we are speaking towards the end of December. From a pandemic standpoint, tell us what you’re seeing, either in the hospital or in your practice.

Mercy Udoji: Well, the first thing I’m seeing, honestly, is hope on the part of the health care workers. It’s been a very long six, nine, I forgot how long it’s been. We’ve just been head down, and so the idea that we may be finally emerging from this pandemic is just amazing to me. We still have a lot of volume, still have a lot of patients admitted, still have a lot of health care workers who are testing positive for the virus, but at least from my and my colleagues’ perspective, there is finally light at the end of that long tunnel.

Kevin Pho: As you approach almost a year of the pandemic, tell us something that you’ve learned during these last few months.

Mercy Udoji: I have been astounded at the dedication of a lot of my colleagues who are in the ICUs, in the ORs, intubating and caring for the sickest of the patients, and they do so very selflessly, day in and day out. I know health care workers are a dedicated bunch at baseline, but just to see it manifest when this pandemic came out has, to me, just been an eye-opener.

Kevin Pho: All right, so let’s transition into your KevinMD article, “When an epidemic of violence against health care workers meets a pandemic.” Now, for those who haven’t read the article, can you just walk my audience through it and share the story of why you decided to write it?

Mercy Udoji: So the article itself begins with a semi-fictionalized encounter between an irate patient and a health care worker. Then it discusses in depth the statistics, the very bleak statistics, when it comes to health care workers’ safety, whether from patients or from other factors. Then it goes into the fact that we don’t have a lot of data, a lot of information, and the reasons why we don’t have a lot of information about this epidemic, whether it is due to lack of reporting on the part of health care workers or lack of support on the part of health care facilities in general for those who do report these issues. It just ends by saying we need to pay more attention to this issue, and we also need to support our workers as we care for our patients. Without a healthy health care worker system, you can’t provide good patient care.

My interest in it really stems from my practice in the interventional pain clinic, as well as my experiences in the OR and my interest in medical quality. Due to experiences I’ve had and experiences my colleagues have expressed to me, I began to look more into this topic, initially from a patient safety perspective, because a lot of people don’t know that workers who are affected by health care violence have been shown to provide less quality care. They are more prone to make errors in the care of the patient, they spend less time with the patient, and they call out more, which means that if you go in, you’re more likely to be treated by someone who is less qualified, due to the fact that the experienced people who were normally there may call out more often because of these things that happened to them.

My goal when I began to look at this was to shine a light on the topic, and then I realized how deep the hole went. The more I looked, the more I realized how very little data there was, especially in the field of anesthesiology and interventional pain medicine in general. There’s a lot of data about the ER, but not for our specialty. So my goal was to shine a light on this issue within the practice of anesthesiology.

Kevin Pho: Can you give us some specific examples of violence against health care workers, especially in your field?

Mercy Udoji: So it could be someone who comes to the pain clinic, for example, who is requesting opioid medications. The physician or provider taking care of them might not feel that they’re an appropriate candidate, so they refuse. What you end up seeing a lot of the time is the patient attempts, either physically or verbally, to threaten the provider or the physician into getting their way, or they may say things like, “I’m going to come back. You won’t see me coming. I’m going to wreck you.”

One of my personal experiences, I’m going to put it out there, was when I was six months pregnant. In my clinic, it was a late afternoon, and I had a patient come in who had been discharged from the ER. He was seeking opioids for his low back pain. We had never seen this patient before; he came to my clinic as a follow-up from the ER. When I explained to him that I would not prescribe opioids the very first time I saw him, and went over the steps necessary to help manage his pain, he became very irate, began to crowd me, and was so loud that my neighbors, my office mates, came in. I was very glad that they were there, actually, because at that point I was stuck in a room with this very irate patient and not able to move as fast as I normally would due to my pregnancy status. So that’s just an example.

Kevin Pho: Now, of course, this scenario that you describe also happens in primary care. Can you share some of the warning signs that physicians and other clinicians should look out for, and perhaps some techniques that you could recommend to potentially de-escalate situations like these?

Mercy Udoji: I will start by saying that sometimes you don’t see it coming, right? But things I tend to look hard for are patients with a history of psychological disorders. I’m not saying that they are more likely to do so, but sometimes psychological disorders in combination with pain can be very difficult to manage. And patients in high-stress scenarios: For example, if they’re coming to me and they’ve been seen by the neurologist, who said no to opioids, and by the primary care physician, who said no to opioids, then I already know that they’re coming to me expecting certain things, and if they don’t get it, they might be angrier than they would be in other scenarios.

High-stress clinical scenarios are also important. Patients who are coming in for surgery due to a cancer diagnosis, or even their family members, tend to be that way. Patients whose surgeries need to be canceled, from the anesthesiology perspective, for a variety of reasons: Perhaps their blood sugars are too high, perhaps the urine tox came up with something that wasn’t supposed to be there, and we have to explain to them, “Hey, this is an issue.” I’m kind of feeding off that: acute intoxication, patients who do present either high or on other substances for procedures and such and needing to be canceled, or having to interact with them to explain, “This is what’s going on, and this is why we can’t do what you came here for today.” That can be very upsetting. In the ICU setting, having to deliver bad news, perhaps. These are all sort of scenarios that, as a provider or physician, you need to be aware of and sort of work on skills for.

So in terms of skills, what I always advise people to do is to take a breath, put yourself in that person’s position, and talk to them as you would want yourself or your family member to be talked to. Be respectful, be direct. A lot of the time, patients aren’t mad at the news; they’re mad at the way the news is delivered. So being able to respectfully deliver news or information that the patient may not want to hear can go a long way towards de-escalation. And then being direct in your delivery and being empathetic in your delivery also helps to de-escalate that.

Kevin Pho: You mentioned that there isn’t a lot of data, especially in the field of anesthesiology, as to how often this happens. But from what you know and from your research, how common are situations like these, not only for doctors but, I guess, the nurses as well?

Mercy Udoji: The reason that we don’t have a lot of information about this is twofold. The first is on the health care systems. There’s not a lot of interest in this topic from a health care system’s perspective. You can look at it as, sort of, data about falls: falls in the ICU, falls on the floor, etc. You see those purple wristbands, you see those stars everywhere. There’s obviously an investment on the part of the hospital system to gather information about this issue and also put in systems and steps to stop it. So that’s the first thing: The health care systems have to be interested.

From a worker perspective, unfortunately, we tend to view these incidents as part of our job, part of our job description. In a recent survey we did, I think 60 to 70 percent of respondents indicated that they had been victims of workplace violence, either physical or verbal abuse or threats. But when you asked how many of them reported it, less than 50 percent reported it, and they don’t report it until it passes a certain threshold. When you ask why, a lot of it has to do with, “Well, what am I going to do? What are they going to do anyway?” meaning that the health system is not going to put in steps to protect the worker. So they don’t feel like the issue is resolved to their satisfaction, so then there’s no point in reporting it in the first place.

Kevin Pho: We’re talking to Mercy Udoji. She’s an anesthesiologist, and she wrote the KevinMD article “When an epidemic of violence against health care workers meets a pandemic.” Mercy, how has the pandemic affected the incidence of workplace violence cases?

Mercy Udoji: In my opinion, it’s made it worse, initially. I don’t have access to the more recent data. That same survey I was referring to, that my colleague and I recently completed, asked that question: “Do you feel as if the COVID-19 pandemic has exacerbated this issue?” And the answer to that was yes, a major yes, every time. The extent to which it will have long-term effects on worker morale and worker safety, we don’t know yet. But it has exacerbated it, because you have patients who are coming into a high-stress situation. They’re coming in for surgery, they’re coming into the ICU. They’re not there because they want to be; they’re there because they have to be. Then you top that off with societal stress, financial stress, and politicization of the pandemic itself, and people don’t. So this is just a boiling cauldron that’s just waiting to explode, and in some cases, it has done so in very spectacular fashion.

Kevin Pho: So if we’re a clinician or a nurse and we receive a threat from a patient, or you’re in a threatening position, what are some resources that we could turn to? Who can we report to, and what can we do if the situation just stops short of violence?

Mercy Udoji: If it stops short of violence, I would recommend, first of all, getting yourself to a safe place. That should be your first priority. After that, the next step will be to document the event and then report it to your supervisor. Often, in my health care system, there are ways to electronically report patients who behave in threatening manners. You report to your supervisor and electronically place that report, and then the supervisors have ways to escalate it so that the patient can either be canceled or there can be safeguards put in place to protect workers whenever the patient is being cared for in your facility.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Mercy Udoji: Number one is be safe. Recognize the environment that you’re in, recognize this scenario, and record. Just be safe, and take steps to protect yourself and also to protect your patients. We as health care workers tend to prioritize patient care even above our own, but I will go back to the old saying that you can’t take care of others until you take care of yourself, and we need to take care of ourselves better.

Kevin Pho: Mercy, thank you so much for sharing your time and insight, and thanks again for being on the show.

Mercy Udoji: Thank you for having me.

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