My patient threatened to kill me. I was in the middle of a busy medical oncology clinic. I was seeing her to discuss test results 1 week after I told her I was concerned that her cancer had returned. As I suspected, the test confirmed recurrent cancer, and this time, it was incurable.
I walked into the room to share this news with a woman who I had been seeing for about 3 years. I had been her oncologist since she was first diagnosed with stage III cancer and saw her through surgery and adjuvant chemotherapy. I had met her children, knew the names of her pets, and had discussed my children and pets with her. We were on very friendly terms, and I enjoyed seeing her name on my clinic schedule, certain that beyond discussion of her cancer and test results, we would also get into some interesting conversations about life, the weather, or college sports. Truly, it was a delight to be her oncologist.
She had no known mental illness, no brain metastases, and had never been angry or violent with me.
I used the SPIKES protocol to review why we were there and deliver the test results.1 I had done this many times before, and there was nothing that stood out to me in the moment about her or this clinical situation to make me think I was in danger—a fact that made what happened next even more shocking.
Kill the Messenger
When I paused to see what questions or thoughts she had, she said: “I want to kill you. I want to blow your face off. You should never have become a doctor.” I intellectually understood she was upset about the news of her cancer recurrence and had understandable anger at the dramatic impact this turn of events would have on her future. I understood that, in her mind, someone had to be blamed, and, mostly out of convenience, it was going to be me. I have since wondered if her lack of close friends and family may have amplified her reaction, in that she had few outlets available to her to discuss her fears and concerns. I have wondered if she felt let down by me after our years of cordial and friendly visits. It was a real-life example of kill the messenger.
She continued telling me that she could find my home address. At that moment, I scanned the room and recognized I could be in real danger. I stood in the corner of the room. To get out, I would have to walk around the desk and between her and the examination table. I also realized that because it was a holiday, there were very few people around who might hear me yell for help. We did not have a panic button or hospital security on speed dial, and it would have taken them many minutes to get to me if I had used the phone in the examination room to call security. I looked down and saw that she had two large bags with her. Patients often bring bags such as these to their chemotherapy appointments, bags filled with things to pass the time such as iPads, books, knitting, board games, blankets, snacks, and water bottles. Suddenly, I realized she was not scheduled to get chemotherapy that day, so why did she have these bags?
I was sure I was about to be killed. I was certain she had a gun in those bags.
Noelle K. LoConte, MD
I said anything I could think of to de-escalate the situation and get out of the room. I promised her a new oncologist, told her I would become a better doctor, and suggested that maybe the biopsy results were wrong (although I knew they were not). As she continued her tirade, I carefully walked past her to get out of the room, and although she never moved toward me, she continued to yell about what a terrible person I am. Once I was back in the workroom, a nurse escorted the patient out of the clinic. We called hospital security and were told they felt their services were not needed as the patient had left the clinic.
On Constant High Alert
Despite this horrific encounter, I managed to make it through the rest of the clinic day in a daze. After the clinic was finished, I e-mailed my supervisor since it was a holiday and other employees were not in the hospital for me to call. In this e-mail, I conveyed my fear and concern about this encounter while making it clear that I was still worried about my safety and the ability of the patient to continue to harm me. The response I received was generic: We will look into it.
The very next day while I was at home, I received an alert that there was an active shooter in the area and realized with dread that it was on my block. It was not my patient, but her words about finding my home address haunted me. I hid on the floor after closing the blinds and locking all the windows and doors. My children were with me. For days, I did not sleep more than 1 or 2 hours. I was on constant high alert.
In Search of Help
Three days later, I was seeing a different patient in the clinic and had what I now realize was a panic attack. I was barely able to complete the visit. The patient was kind and understanding, but I felt inadequate and knew my patients deserved better. Importantly, I also knew I deserved better. I reached out again to my immediate leadership team and said plainly that I was struggling and needed help. I was offered statements of support but no concrete actions.
While crying in my office, I searched our hospital’s website for possible sources of help. I was lucky enough to come across our Employee Assistance Program and eventually got connected to a therapist. I will never forget the kindness and help she provided. She (correctly) told me that I had suffered an intense trauma and walked me through the next steps, which included meditation, hydration and nutrition, and intense aerobic exercise. She explained that the aerobic exercise (telling me to run as hard as you can with a goal for high heart rate and lots of sweating) can help the brain to heal from trauma and will prevent or diminish the development of posttraumatic stress disorder. I resisted my urge to search on PubMed to ascertain if they were evidence-based solutions and decided to try whatever she suggested. She also helped me accept a 2-week leave from work and find a therapist who specialized in trauma for health-care workers. I continued to see a trauma therapist for a year until I felt I had adequately recovered. Eventually, as is true with most traumas, time itself was the best healer.
Some Action at Last
A few weeks later, when hospital leadership learned of my experience, things started to happen. Security did a walkthrough of the clinic space. Patient relations notified the patient that this type of behavior would not be tolerated. There was a backup plan put into place in the event the patient needed care when I was the only oncologist available (eg, on the in-patient unit).
It was not all forward progress, however. I was told no changes needed to be made to the clinic and that we could not keep examination room doors open because of privacy concerns. The provider desk would continue to be in the corner of the room, and the patient would continue to sit between the provider and the door. This was understandable given the cost to reconfigure rooms and the unfortunate reality with firearms that even being close to a door may not matter. I asked for panic buttons to be installed—I knew they existed in other clinics—but was told this could not happen. When I asked to be scheduled in rooms where my desk could be next to the door, I was offered a single conference room with no examination table and no medical supplies. I usually work out of three rooms on clinic days, so this would not work. I figured this was as good as it would get and elected to move on and suck it up.
Coping With Traumatic Patient Interactions
Fast forward to 2 weeks ago, when I learned that as much as I hoped these traumatic patient interactions would leave health-care workers, they never truly do. I was the oncologist for the in-patient unit at our hospital, which is a liminal space of end-stage disease, anxious patients and families, and difficult decisions. The stakes and severity of the patients’ situations are high.
One patient and her family were furious at their medical situation of rapidly progressive cancer, as well as the hospital parking and layout, the plan of care, and even the cafeteria options. I was the recipient of all their frustration. As the patient and her family yelled at me for being inept and stupid and not serving their needs, I had the distinct sensation that my spirit was floating away from my body. I was rising toward the ceiling, watching it all play out in front of me, seeing myself from a bird’s-eye view. I thought, “Wow, I am dissociating.” It was a surprisingly effective tool to protect me at that moment and one that I now recognize as a normal response to trauma. Once the patient and family got all their anger out and told me to leave the room, I became unsteady and had to hold the banister to stay grounded.
To drive home how vulnerable we all are in facing these kinds of threats, I reflected on the job of an oncologist. I give bad news on a regular basis, I control opiate prescriptions, and many of my patients feel their pain is not well controlled—a phenomenon seen across many oncology patients.2 If we think physicians are only murdered in the emergency room or on the psychiatry unit, we are fooling ourselves. Recent changes to concealed carry laws and increasing levels of medical mistrust and anger directed at health-care workers in the wake of the COVID-19 pandemic likely will increase all providers’ risk of gun violence.
A Call for Informed Response by Leadership
With reflection, I now understand that my experience then was made worse by the lack of informed response by leadership to mitigate my trauma and the lack of efforts to improve safety. We deserve leaders and hospital staff who know immediately what to do when a physician is threatened, including reassigning the patient to a new provider immediately, having hospital administration or patient care services review with the patient the zero tolerance policy to provider threats, and allowing a prompt leave from work to address the trauma response (which is best done immediately after the event not months later or only on request). We deserve urgent access to therapists and peer support who understand how to process and overcome trauma. Institutions should track threats to providers in real time and make rapid changes to improve safety. As individuals facing a traumatic patient encounter, we cannot afford to wait for the system to catch up to our needs. We can seek our own counseling and professional support while also providing critical support for our peers.3-5
I thought I was the weak one for not being able (even still) to let this death threat be in the past. I realize now that I am brave and strong for asking for help. We deserve safe environments and clinical practices to allow us to do the difficult work of being an oncologist without worrying about our personal safety. Together we can create clinics, hospitals, and teams that prioritize provider safety and proactively work to mitigate the trauma of patients and families who threaten their physicians and providers.
DISCLOSURE: At the time this article was published in the Journal of Clinical Oncology, Dr. LoConte had served as a consultant or advisor to AbbVie and Personal Genome Diagnostics and had received research funding from Exact Sciences.
REFERENCES
1. Baile WF, Buckman R, Lenzi R, et al: SPIKES—A six-step protocol for delivering bad news: Application to the patient with cancer. Oncologist 5:302-311, 2000.
2. Romem A, Tom SE, Beauchene M, et al: Pain management at the end of life: A comparative study of cancer, dementia, and chronic obstructive pulmonary disease patients. Palliat Med 29:464-469, 2015.
3. Servino K: To the cadaver with the port. J Clin Oncol 40:2277-2278, 2022.
4. Hlubocky FJ, Shanafelt TD, Back AL, et al: Creating a blueprint of well-being in oncology: An approach for addressing burnout from ASCO’s clinician well-being taskforce. Am Soc Clin Oncol Educ Book 41:e339-e353, 2021.
5. McNeil CM: Grace and forgiveness. J Clin Oncol 36:1045-1046, 2018.
Acknowledgment: This manuscript has been edited by the University of Wisconsin School of Medicine HIPAA privacy staff.
Dr. LoConte was employed at the University of Wisconsin School of Medicine and Public Health and Carbone Cancer Center in Madison at the time this article was published in the Journal of Clinical Oncology.
Originally published in the Journal of Clinical Oncology 40:3344-3345, 2022. © American Society of Clinical Oncology. All rights reserved.
