August 12, 2016
This item appeared in the on-line medical news magazine Medscape:
“Tony Lee Cason, a burly patient at Timberlawn Mental Health System in Dallas, Texas, was standing outside his room at 1 pm on June 30 when Ruth Anne MarDock, MD, rounded a hallway corner and met him face to face.
The 55-year-old Cason had just heard that he was being transferred to another facility, “which appeared to upset him,” according to a Dallas police report. Six feet tall and weighing 213 pounds, he “violently tackled” the petite Dr MarDock, some 8 inches shorter, and slammed her to the floor.
She struck her head, lost consciousness, and died 2 days later. Cason now faces manslaughter charges.
Things might have been different, however, had the state of Texas carried out its threat to shut down the 99-year-old hospital over safety issues involving not clinicians but patients.
Her death highlights the outsized threat of workplace violence directed against physicians, nurses, and other healthcare workers, who experience 50% of all job-related assaults, according to the US Bureau of Labor Statistics. The risk for violence is even higher for workers in inpatient psychiatric facilities, a number of studies have found.”
By the time I read the article there were already some eighty comments appended, to which I added my own, (which was deleted by Medscape editors). Some of the previous commenters had attested to the unsafe, understaffed conditions at the hospital. Many had offered prayers for the young doctor and her family. There were lamentations and condemnations. A couple partly blamed the doctor for not being more aware of her surroundings. One excoriated hospitals for not allowing physicians with concealed carry permits to take their guns into the hospital with them.
One or two letters advocated having doctors accompanied by bodyguards when seeing patients.
I worked as a unit psychiatrist on a locked forensic ward for a little over eight years. All of the patients were placed there for having committed crimes, and many of my patients had killed people while in a psychotic state, or while pretending to have been in a psychotic state. Three in particular were clearly malingering mental illness in order to escape murder charges. Yet they had been in the hospital for years – in some cases many years – and no one in that setting appeared to be particularly dangerous.
Generalizing from my own experience I would say that the people drawn to work in the state hospital were empathetic and kind. Some had never seen the kind of violence that I experienced during my training, working for a time in a county psychiatric emergency facility, where patients were brought in by the police raving and combative.
During my years at the state hospital I knew of only two violent and brutal attacks upon staff, one of them fatal. In one case close at hand, a young woman clinical social worker on my own team, ignoring my concerned advice, had a habit of taking patients into her office for interviews and assessments. The unit consisted of two long, intersecting hallways with a nurses’ station at the crossroads. Patient rooms, common rooms and various staff offices opened off the hallways. Staff offices were locked and there were small windows in the ultra-heavy doors.
We all carried alarm pens on our key rings. Flicking the pen’s trigger would set off the nearest of many sensors, sounding an alarm throughout the area and summoning staff to wherever a ceiling light was flashing red.
When a large male patient in the social worker’s office became angry and attacked her violently the screaming and commotion were heard. Staff rushed to her door and could see the attack, but their own door keys were specific, the only pass key belonged to the unit’s nursing supervisor who was on an errand elsewhere, and the only other pass keys were in the possession of security guards, who had to be phoned and come from some distance away.
By the time they got the door open, the social worker had had the crap beaten out of her. Her face was bruised and swollen and she had some cracked ribs but was still alive.
In the other attack, a male doctor was merely walking down the hall when a patient stepped up behind him and hit him in the back of the head with a chair. He fell dead.
The office assigned to me was a few feet outside of the locked doors of the ward and the door had no window. I could have escorted patients through the door of the unit and to my office, but I never once did so. Always a cautious person, in my early sixties I was even more so. There were a couple of “fishbowl” conference rooms with windows all around whose doors could be opened by any staff key. Whenever I needed to talk to a patient to take a history or do an evaluation, I would use one of those rooms. Someone had once advised me that it was best to avoid sitting in a way to block the door to a patient wanting to leave, or to sit with a patient between me and the door in case I ever needed to get out of the room in a hurry. So I usually followed that advice, and also sat with the conference table between me and the patient, which seemed natural and random, but was intentional.
When I walked on the ward it was natural to keep my keys (and the alarm pen) in my hand. What was perhaps less unobtrusive was that I always arranged my path to leave a few feet of space between me and any patients in the hall, and when passing a patient, always managed a glance back out of the corner of my eye to be sure they weren’t moving towards me.
In describing that vigilant behavior I am reminded of when I was a sixteen-year-old college student on the south side of Chicago. If I had to go somewhere after dark and was walking on a lonely street, if someone was approaching on my side of the street, I crossed over while they were still some distance away, prepared to turn and run if they also crossed over. I realize this may seem like hypervigilance and uses up some energy, but I call it “situational awareness” and accept the cost. Turns out I was about the only person I knew who, by the end of college, had never been mugged.
When considering their advantageous retirement benefits following my psych residency I interviewed at the psychiatry departments of several state prisons. At one prison that specialized in “mentally disordered offenders” – Charles Manson was one of the inmates – I became aware of an example of a more extreme strategy. As I was escorted to the interview office, whenever we encountered prisoners in the hall, they were ordered to stop, turn and face the wall until we had passed.
I mentioned it to the interviewer, who told me that when a prisoner attacked any of the custodial or treatment staff, the guards would take him into a room and beat him severely enough to put him in the hospital wing. When I appeared shocked, he informed me that as a consequence there were almost no attacks in the prison side of the mental health system: that serious and fatal attacks almost always happened in the state hospitals. “These people may be crazy, “ he explained, “but they’re not stupid.”
I am not advocating beatings, but it should be noted that they do fulfill all the requirements for an effective “behavioral psychological” approach to behavior modification. The sanctions are immediate, consistent and painful, the very opposite of the stimuli applied in the jurisprudence and mental health systems, which are long-delayed, inconsistent and trivial by comparison. Worse than merely ineffective, such sanctions actually encourage repetition of the undesirable behavior.
In the Dallas case, there seems to be a need to change the behavior of the assailant, the county, and the institution that is intentionally chronically understaffed. (Hey! Somebody is deciding not to provide sufficient funding.)
With regard to the intentional understaffing, all that the article and most of the comments provided were hand-wringing and complaining, which will lead to no improvement whatsoever.
Large institutions, public and private, only respond to significant economic pain. They might also respond to immediate firing, fining or imprisonment of those in charge, if that were ever done. Given the recent examples of malfeasance in the VA Hospital system however, it is clear that will never happen.
In the case of this and many other complaints by physicians about those for whom they work as actual or virtual employees, individual physicians will never have sufficient power to prevail. The only possible solution is collective bargaining through labor organizations. Until physicians form and join unions, their compliant, benevolent and super-responsible nature will continue to assure their individual failures to achieve work conditions that match the performance standards of their profession.