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Tuesday May 31, 2016

Diagnosis Dangerous: What Do You Do When a Patient is Armed, Hostile?

I don't get nervous easily, I don't avoid confrontation, and I usually feel safe in situations where others might not. I do a lot of home visits, and I am not afraid to confront patients if I think they are lying to me. And I don't hesitate to have difficult conversations with patients even when they are angry.

I actually would say I have a track record of making patients angry because I am honest and willing to confront them, especially about narcotics. And like most family doctors, I have had my fair share of threats.

I've had answering service calls from patients who say they will die if I don't refill their benzos, that they will kill themselves if I don't prescribe pain pills. I've had face-to-face threats from patients who say they are going to sue me, report me to the board of medicine and tell everyone I'm a terrible a doctor. (I consider that good publicity most of the time.) Often, this involves yelling and swearing. Through years of dealing with irrational, repetitive drug-seeking behavior, I've developed a thick skin.

But when a patient brings a loaded gun into my office, I feel 100 percent terrified.

Before I go on, I should give some background about my experience with guns. I own guns. I grew up with guns. I don't have a concealed carry permit, and I don't carry a gun on home visits, but I am not frightened by the presence of a gun.

In residency, we had to do a patient education video, and one of my colleagues and I focused ours on gun safety. It explained how to unload and turn on the safety mechanism on different types of handguns.

I live in a part of the United States where guns are part of life. I think every house in my neighborhood has a gun (or lots of them). That is why this is such a difficult topic, and why I was so surprised I was shaken by a patient who came into my exam room with two loaded handguns.

He wasn't pointing them at me and demanding meds. He actually handed them to my nurse so she could do an electrocardiogram. The thing that made it scary was that I didn't feel comfortable around this patient even before he showed up with guns.

As physicians we are in difficult situations all day, making diagnoses, struggling to find the right treatment for a complicated patient, delivering bad news or even saying goodbye. We have to be comfortable with uncertainty, but we make evidence-based decisions and probably look things up more than we need to just to be certain our memory is accurate about a medication dose or length of treatment. We spend hours at home reading and researching yet we still sometimes have to make decisions about people's lives that are not clear, and we reassess and re-evaluate those patients to ensure we've made the right choices. And through all of that we often ignore ourselves, putting the patient first.

After my first visit with this patient -- just a few months before this gun-in-the-exam-room encounter -- I told my office manager that if any patient were ever going to shoot me, I had just met him.

I didn't have anything specific on which to pin that feeling, although multiple people witnessed uncomfortable exchanges between the patient and me, and a few even said they didn't think I should keep taking care of him. But he is complicated, and it's a really long drive to the next primary care doctor. Besides, why should I subject some other doctor to him instead of dealing with him myself?

During a visit with me the week before, he voiced a threat toward a subspecialist to whom I had referred him. I notified that doctor, fully expecting him to dismiss the patient, but it never occurred to me to consider all the reasons I should dismiss him until he presented with two loaded guns.

It was pretty darn clear at that point -- so clear that I felt I had jeopardized the safety of my entire office by not dismissing him sooner.

What came next is my motivation for writing this blog.

I have dismissed other patients for threatening me or my staff. I give them 30 days to find a new medical home and will see them for emergencies. But I didn't want this patient anywhere near the office again. I wanted his dismissal to be effective the moment he walked out the door.

What I found, however, is that I didn't have the ability to make that happen. Law enforcement officers told me I would have had to confront him about the guns, specifically that he was not allowed to have them in my office. I needed to point out that we have a sign on the front door stating no weapons are allowed on the premises, and that he was violating our policy. Then, and only if he refused to take the guns out of the building, did I have the right to keep him out of my office.

It took so long to figure this out that he came back to the office before we had a chance to write our dismissal letter. Fortunately, the receptionist told him she would need to take a message, and he left without any conflict.

When we have doctors getting shot in hospitals (www.annemergmed.com) and offices (www.cnn.com) around the country -- sometimes by accident(www.nydailynews.com) -- why am I not allowed to stop a patient from coming into my office with loaded guns?

As a physician, I don't feel I can simply refuse to see patients based on who makes me uncomfortable. I have an obligation to take care of people with violent histories, and I have no moral issue with that. But I am struggling to decide where to draw the line.

I'm not the only physician thinking about safety. During the AAFP's recent National Conference of Constituency Leaders, delegates adopted resolutions that addressed workplace violence. One substitute resolution that was adopted requested that the AAFP help state chapters advocate for legislation that protects physicians from violence. Another one asked the AAFP to oppose legislation that allows guns in civilian clinical settings.

Unfortunately, some states are passing laws that will reduce protection for us and our patients. And that is how I see it: Allowing guns in clinical settings means less protection. I shouldn't have to have a conversation about an inconsistent urine drug screen or board of pharmacy report with a patient holding a gun. And just as I don't want to get shot in my office, I definitely don't want one of my patients to get shot, either.

Starting next year, legislation will make it legal for people in Kansas to carry concealed weapons on college campuses and in health care facilities with no requirement for permits or training. In West Virginia, our state legislature eliminated a concealed carry permit process that included a gun safety class.

I know that after my experience I want my guns in my house where they've always been, and I want no guns in my exam rooms where I sometimes make people mad while I'm alone with them behind a closed door.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.

Posted at 01:03PM May 31, 2016 by Kimberly Becher, M.D.

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