San Diego internist David B. Bittleman, MD, was finishing an appointment with a patient when the man’s caregiver slipped Bittleman a note as the patient walked out of the room.
“Call me tomorrow,” the mysterious message read.
Bittleman phoned the caregiver, who was the patient’s ex-wife, the next day. He assumed she wanted to discuss a routine issue, such as the patient’s treatment. But the reason she wanted to talk privately was far more ominous.
“He wants to kill you,” she said.
Bittleman was shocked. He knew the patient was angry about the fact that his opioid regimen had been tapered, but he didn’t think his fury would rise to possible homicide. The caregiver told Bittleman she believed her ex-husband was serious.
“The ex-wife and two adult sons were very alarmed by his erratic behavior,” Bittleman recalled. “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.”
Patient Sends Alarming Message, Makes Threats
When he went into medicine, Bittleman never imagined that he’d have to worry about being attacked or killed by a patient.
After spending 20 years in private practice, Bittleman was excited to accept a position at the Veterans Affairs (VA) San Diego health system. His extended family lived in the area, and he looked forward to helping veterans and to working with students, he said.
Bittleman had practiced primary care at the VA for about 5 years when he encountered the threatening patient, a veteran in his 60’s. The man was suffering from musculoskeletal pain and mental illness.
The patient had taken opioids on and off for many years. Bittleman felt that to continue the medication would not be safe, considering the man’s lifestyle.
“He had been maintained on oxycodone for chronic pain by previous providers, but I thought that was dangerous, given that he was mixing it with alcohol and marijuana,” he said. “I met with him and a substance use disorder physician for a conference call, and we explained we would need to taper the medication and eventually stop the opioids.”
Bittleman pleaded with the patient to enter drug rehab, and he offered him inpatient care for treatment of withdrawal. The man refused.
A few weeks later, Bittleman was checking the health center’s electronic messaging system. He found a disturbing message from the patient.
“You better learn jiu jitsu and hand-to-hand combat if you ever take my opioids away,” the message read. “You better learn how to defend yourself!”
Bittleman contacted the VA police and reported the message. The patient was interviewed by mental health professionals, but they did not believe he was dangerous, according to Bittleman.
“They are pretty limited to what they can do,” he said. “At a private practice, the patient might be fired or no longer allowed to come into the building, but the VA is a safety net institution. I’m not sure if he was even reprimanded.”
Two months later, the patient’s ex-wife shared the alarming news that the patient wanted to kill the doctor.
Bittleman went back to the police. They suggested he file a restraining order, which he sought that afternoon. By the end of the day, the judge had issued the restraining order, according to Bittleman and court records. The patient could not come within 100 yards of the physician, his clinic, car, or home.
But there was one frightening caveat. The order was temporary. It would last for only 2 weeks. To make the order permanent, Bittleman would have to go before the judge and argue why it was needed.
He wouldn’t be alone at the hearing. Someone else would be just paces away ― the patient who wanted to murder him.
Doctor and Patient Face Off Before Judge
As the hearing neared, Bittleman felt anxious, outraged, and fearful. He wondered whether the patient might make good on his threat.
Some colleagues suggested that Bittleman buy a gun, while others recommended he carry pepper spray. Bittleman had no interest in learning how to use a gun, he said. He took comfort in the fact that there were armed guards and metal detectors in his building, and there was a panic button under his desk.
“I was not sure I wanted to take care of patients anymore, especially chronic pain patients,” he said. “However, I went for some counseling with the Employee Assistance Program, and the therapist was helpful in normalizing my anxiety and acknowledging my fear.”
On the day of the hearing, Bittleman sat in the back of the courtroom. The patient, who sat near the front, glanced at Bittleman with a slight smile.
When his case was called, the judge explained that as the plaintiff, the burden was on Bittleman to prove the patient was a threat to his safety. He provided the judge a copy of the threatening message and a copy of the ex-wife’s note.
After reading the documents, the judge asked the patient to explain his side. The patient complained that the VA had denied him certain benefits and that he was forced to receive mental health treatment rehab that he “didn’t need.” The judge eventually interrupted the man to ask if he had threatened to kill Bittleman.
“Oh yes, your honor, I did say that, but I was only joking,” he told the judge.
The admission was enough. The judge issued a restraining order against the patient that would last 1 year. He could not have firearms, and if he violated the order, he would be arrested.
The terrifying saga was finally over.
“I never heard from the patient again,” Bittleman said. “His [care] location was changed, and police were required to come to all his visits with his new provider. I was relieved that if he ever came near me, he was going to jail.”
To raise awareness about such ordeals and the hassles that can follow, Bittleman wrote an article about his experience, which was published in the Annals of Family Medicine. He continues to treat patients at the VA, including those with chronic pain, but the memory of the menacing patient resurfaces from time to time.
“I do still think about it,” he said. “I know how to use my panic button, and I test it every 90 days. If there is a patient who concerns me, I will have the VA police wait nearby. I am very aware and upset by violence. When I hear about a doctor getting killed, I feel a clutch in my chest. How could I not relate? Here is a doctor who worked hard, who dedicated their life to help patients, and it comes to this? It’s so revolting. It makes me sick.”
Can You Identify a Violent Patient?
Concern over threatening patients has grown across the country after recent violent attacks against physicians in Oklahoma and California. Two physicians were shot to death in June 2022 when a patient opened fire inside a Tulsa medical building. The primary target of the shooting was a surgeon who had performed surgery on the patient. Also in June, two nurses and an emergency physician were stabbed by a patient inside the 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 professionals are nothing new, but they’re finally getting the attention they deserve, says Derek Schaller, MD, an emergency physician and assistant professor of emergency medicine at Central Michigan University in Mount Pleasant.
“Violence against personnel in medicine has been an issue for a long time, it’s just finally making headlines,” he said. “Way back when, it almost seemed like it was part of the job, part of the gig. But it shouldn’t be part of the gig. It’s not something we should be dealing with.”
It’s common for healthcare professionals and health centers to take a reactive approach to violent patients, but Schaller encourages a more proactive strategy. Central Michigan University Health, for example, recently studied its past violent encounters and analyzed the characteristics of violent patients. The analysis came after an increase in violent patient episodes at the health center in the past year, Schaller said.
The study yielded some interesting results, including that a large percentage of patients who became violent in the emergency department did so within the first hour they were in the hospital, he said.
“You would have thought it’s the patients who have been there and have been stuck in the emergency department for awhile and who became disgruntled, but that was not the case,” Scahller said.
He recommends that physicians, medical practices, and hospitals carry out similar assessments of their patient populations and of past violent encounters to determine trends. His institution will be implementing a screening tool in triage to identify patients more likely to become violent so that healthcare professionals can intervene earlier, he said.
Such a screening tool is already demonstrating success in a variety of medical settings.
About 10 years ago, a research team led by Son 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 units.
Subsequently, the tool was modified for long-term care facilities, and again, researchers found that ABRAT was able to identify potentially violent residents with reasonable sensitivity and specificity, said Kim, ABRAT developer and a professor at Point Loma Nazarene University in San Diego.
In 2021, researchers embedded the checklist into an electronic health record (EHR) system and tested ABRAT in emergency departments.
“Currently, we are working with computer programmers to build an app that would make the ABRAT very easy to use in conjunction with EHR,” Kim said. “Instead of a nurse searching the EHR to find out if the patient has history of mental illness or aggressive behavior in the past, the app would automatically search the EHR and combine the nurse’s quick observation whether the patient is confused, agitated, staring, or threatening, to automatically calculate the violence risk.”
Kim and her team also developed a tool called VEST (Violent Event Severity Tool), a standardized objective workplace violence severity assessment. They are working with programmers to incorporate VEST into the app as well.
Kim’s hope is that the ABRAT tool can be modified for use in a range of healthcare settings.
Alicia Gallegos is a reporter for Medscape Business of Medicine and is based in the Midwest. She has previously written for the American Medical News, the ACP Internist, and the AAMC Reporter. Contact Alicia at firstname.lastname@example.org or via Twitter at @Legal_med.