In one of few studies of its kind, emergency department (ED) researchers at the Mayo Clinic reported violent incidents against healthcare workers have more than doubled during the COVID-19 pandemic.
“Incidents of workplace violence at our ED increased during the pandemic, and there was a positive association of these incidents with the COVID-19 case rate,” the authors wrote.1 “Violent incidents increased overall during the pandemic (2.53 incidents per 1,000 visits) compared to the previous year (1.24 incidents per 1,000 patient visits).”
A Confluence of Forces
A longstanding problem in healthcare, violence is multifactorial. Another study2 revealed “the unique environment of the ED contributes to its propensity for violence: stress among patients, families, and visitors; long wait times and delays; crowding; unrestricted 24-hour access; low socioeconomic status; substance abuse; patients with behavioral health issues; gang activity; and frequent delivery of ‘bad news.’”
“We all understand that people who are getting healthcare are in a difficult emotional position,” says Rana Awdish, MD, a critical care physician at Henry Ford Hospital in Detroit. “No one’s expecting perfect behavior, but when it crosses the line into abuse, then we need organizations to support our frontline providers. No nurse should expect that abuse is part of her job.”
The pandemic has created a confluence of forces, coming into the ED like a flash flood of viral surges, people coming in who previously deferred care, and overflow in the ED due to lack of intensive care beds.
“We were heroes in May and June, but in December and January people were screaming because they couldn’t get seen for their cough,” says Jennifer Casaletto, MD, an emergency physician based in Charlotte, NC, and president of the state’s College of Emergency Physicians. “They don’t seem to [understand] the concept that the emergency department was full of ICU patients who should be upstairs, but aren’t because we don’t have the space.”
Omicron is letting up in Charlotte, with hospitalizations falling as of this report, but another viral surge could overload the ICUs — which typically admit patients for five or six days in non-pandemic times.
“The COVID patients are here for three or four weeks, and then 50% of them still die,” Casaletto says. “I have seen people who are on boatloads of oxygen look at me and say, ‘Can I go home?’ I say, ‘No, you have COVID and need lots of oxygen. If you get intubated there is about a 50% chance you will die.’ They say, ‘Oh, I am not going to die. I’m going to go home.’ I have never seen people dying for their political beliefs. It’s just really sad.”
Still, in Casaletto’s experience, violence and verbal assaults are not driven by beliefs — political and otherwise — about COVID-19. It is a pre-existing problem that has been exacerbated, like so many others, by the pandemic.
“To me, it’s been a problem for more than a decade,” Casaletto says. “I trained about 20 years ago, and it is not something I remember even really being on my mind at the time. But within the last decade, definitely. I would say probably somewhere around 2011, 2012, we began to see more violence from patients and families.”
Most Have Seen Violence
In a 2018 survey,3 the American College of Emergency Physicians (ACEP) asked its members if they had seen violence in their ED that negatively affected patient care.
“Almost 90% said yes, and 47% said they had been assaulted themselves,” Casaletto says. “For me, that was a very sobering statistic. Many of the larger tertiary care centers are making some decent progress with security, and also they are not ‘blaming’ staff when they were assaulted. I’m not sure yet that we have been supporting our staff to press charges. Some centers have, some haven’t.”
In the ACEP survey, only 3% of those assaulted said they were supported and could press charges with the help of their hospital and either the police department or the local district attorney.
Gerald Harmon, MD, president of the American Medical Association (AMA), called for an end to violence and racism against healthcare workers in a strongly worded piece on the AMA website.4
“While not a new occurrence, the reported uptick in intimidation, threats, and attacks toward people in the medical field has been on the rise for at least the last decade — and has become even more of an alarming phenomenon since the beginning of the COVID-19 pandemic,” Harmon noted.
The AMA provided these recommendations:
- Develop surveillance and data collection systems to track hate-based violence directed at physicians and healthcare workers;
- Create ways to mobilize individuals and organizations across the healthcare continuum to name and confront hate-based violence and intimidation.
Protestors Confuse ‘Equality’ with ‘Equity’
“The recent neo-Nazi protest against leading anti-racist physicians at a Boston-area hospital is yet another sad chapter in the long history of threats and intimidation of healthcare workers for simply carrying out the duties of our profession,” Harmon wrote.
The Jan. 22, 2021, incident included around 20 white nationalists standing in front of Brigham and Women’s Hospital, holding a long makeshift sign that said, “B and W Hospital Kills Whites.”5 Uniformly clad in brown khakis and black coats with faces covered, they passed out flyers with photographs of two principal physician researchers. The flyers accused the researchers of “anti-white policies,” and warned that “we will not tolerate the genocide of the people who founded this city.”
Those targeted were Michelle Morse, MD, chief medical officer for the New York City Health Department, and Bram Wispelwey, MD, a physician at Brigham and Women’s. They are working on research to improve equity in healthcare delivery and treatment. The pandemic exposed major fault lines in the level of care for people of color compared to whites. Both Morse and Wispelwey declined to comment for this report.
Joane Moceri, PhD, RN, racism researcher and associate dean of the University of Portland School of Nursing, gave her opinion on the incident, with the caveat that she did not know the full details.
“It sounds like the protesters were confusing ‘equity’ with ‘equality’ because of their racist lens,” Moceri offers. “If Black and brown people need additional care to ensure health equity, they should receive it, even if it appears to be more than a white counterpart, who may actually need less care. White power, privilege, and supremacy are at the heart of racism. Racism could not exist without it.”
The Boston incident and similar events are “too often decontextualized and classified as ‘disruptive’ rather than racial violence,” Harmon wrote. The AMA’s strong statement against violence and racism in healthcare is commendable, but it should be noted the association’s Journal of the American Medical Association (JAMA) released a podcast last year promoted with the tweet: “No physician is racist, so how can there be structural racism in healthcare?’
The AMA released a statement at the time, saying they were “deeply disturbed” and angry, emphasizing “Structural racism in healthcare and our society exists, and it is incumbent on all of us to fix it.”6 A major editorial shakeup at JAMA ensued.
How do such major blind spots exist after all the discussion and research on the health inequities during the pandemic? Consider the next example — was this malevolent, or just “heads up” from a fellow healthcare worker?
Allison Agwu, MD, ScM, FIDSA, an HIV clinician in Baltimore, recalled the incident in a recent blog post for the Infectious Diseases Society of America (IDSA).7
“This past summer, as I prepared to participate in a webinar on racial inequities in HIV in the South, I received an email from a healthcare provider who denied the existence of these inequities, and called the topic ‘a baseless idea for a chat,’” Agwu noted. “The provider concluded by apologizing for ‘rocking my boat’ in advance of my talk, stating that it was important for me to know.”
Agwu realized HIV healthcare providers who frequently interact with Black patients need to talk more about the experience and the inequities they witness. Without a clear understanding of inequities, providers like the one who reached out to her become “part of the problem,” she wrote.
Given the dismissive, condescending tone of the email she received, it is not surprising Agwu closed with a full fusillade.
“I have been quadruple-boarded in medicine, pediatrics, and pediatric and adult infectious diseases, and I proudly check the demographic box that most closely aligns with my identity and lived experiences — ‘African American/Black,’ Agwu wrote. “I, too, have many intersectionalities that enrich who and what I am. My boat is not ‘rocked’ by healthcare professionals who do not believe in the impact of race on public health and medicine. To the contrary, I am energized by those comments.”
REFERENCES
- McGuire SS, Gazley B, Majerus, AC, et al. Impact of the COVID-19 pandemic on workplace violence at an academic emergency department. Am J Emerg Med 2022;53:285.e1-285.e5.
- McGuire SS, Mullan AF, Clements CC. Unheard victims: Multidisciplinary incidence and reporting of violence in an emergency department. West J Emerg Med 2021;22:702-709.
- American College of Emergency Physicians. ACEP emergency department violence poll research results. September 2018.
- Harmon GE. Threats, intimidation against doctors and health workers must end. American Medical Association. Feb. 3, 2022.
- Martin P. Neo-Nazis target anti-racist doctors at Brigham and Women’s Hospital, calling them ‘anti-white.’ GBH News: All Things Considered. Feb. 2, 2022.
- American Medical Association. AMA statement on JAMA podcast and tweet. Mar 4, 2021.
- Agwu A. Yes, race matters: Addressing the continuing disparities and inequities in HIV among Black Americans. Infectious Diseases Society of America Science Speaks. Feb. 15, 2022.
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