At its 2023 Clinical Congress, the American College of Surgeons hosted its first-ever panel on how surgeons can protect themselves from rising violence in American hospitals and health clinics.

“We need to make the demand of our safety, our own personal safety,” said Amy Liepert, MD, an associate professor of surgery at the University of Missouri School of Medicine, in Columbia, who moderated the panel.

Violence in U.S. health facilities is now so common that healthcare workers suffer more nonfatal injuries from workplace violence than any other profession, including law enforcement, the Associated Press has reported. Last September, Sophie Chung, MD, a surgical resident from the University of California, San Diego, published an essay describing how she’d been punched in the face by a trauma patient (Ann Surg 2023;278[3]:e466-e467). And in October 2023, the CDC reported that the share of healthcare workers who said they felt threatened or harassed at work more than doubled between 2018 and 2022 to 13.4%.

During the session, Dr. Liepert described her experience being stalked by a patient. The patient sent gifts and cards to her at the hospital, bearing the message, “I do love you, Amy L.” The patient was removed from her practice and received a formal letter from the hospital. But he reached out again after she posted items for sale on social media. Dr. Liepert reported him to law enforcement, who issued a letter warning him to stop stalking her.

Four months later, the patient followed her 2,000 miles where she’d joined a practice at UC San Diego. Again, he sent gifts to her office. He also posted photos on social media taken near her home. Police issued an arrest warrant for felony stalking charges but couldn’t find the man for several days. Meanwhile, Dr. Liepert didn’t know what he planned to do. “Does he want to kidnap me? Does he want to murder me?” she told the ACS.

The man was arrested and held for a year due to COVID-19 but was released in April 2021 with a GPS monitor. Within days, he stopped charging the monitor and disappeared. Dr. Liepert lived in fear during this time. “This isn’t me feeling just unsafe in the community,” she told the ACS. “It is the hospital, my workplace, my professional community.”

The man was arrested, then extradited, tried and sentenced in Wisconsin to 18 months in prison with an additional 24 months of supervision or parole. He is due to be released in November 2024.

In the sentencing impact statement, Dr. Liepert told the court that she continued to worry about her safety. “I can’t explain to you how I feel and I have felt on a daily basis with the impact that this has had,” she said.

She’d heard suggestions that the stalking was “my burden as a professional,” she said. “And I disagree.” She read the names of surgeons killed by patients or patients’ families at work: Dr. Michael Davidson, the director of endovascular cardiac surgery at Brigham and Women’s Hospital, in Boston, murdered in 2015 by a patient’s son; Dr. John Kemink, an ENT (ear, nose and throat) surgeon at the University of Michigan, in Ann Arbor, shot to death by a patient in 1992; Dr. Ronald Gilbert, a urologist, fatally shot in 2013 by a patient he’d seen as a resident two decades earlier and who’d later been operated on by other surgeons; Dr. Preston Phillips, an orthopedic surgeon, killed in 2022 by a patient he’d operated on days earlier.

Dr. Liepert said she was sharing her story to bring awareness to threats that surgeons may face.

“Until we bring awareness to this crime, countless others will continue to suffer in silence, and some will undoubtedly pay the ultimate price,” she said.

Acute Stress Disorder

Dr. Liepert’s colleague, Jay J. Doucet, MD, told the ACS that her distress reminded him of what he’d observed in soldiers in war zones. Dr. Doucet, the chief of the Division of Trauma at UC San Diego, spent 22 years with the Canadian forces as a surgeon.

Surgeons need to support colleagues who are dealing with acute or prolonged stress as a result of threats to their safety, he said. He recommended surgeons are trained to recognize the signs of acute stress disorder: intrusive thoughts; involuntary dissociation; steering clear of people, situations and places that can cause triggers; negative moods, especially sadness or depression; and hypervigilance.

If left unaddressed, acute stress disorder can lead to post-traumatic stress disorder, and trigger substance abuse and suicidal thoughts. Dr. Doucet pointed out that more Canadian and American soldiers died by suicide after returning home from Afghanistan than were killed on tours of duty in the country. “Everybody breaks down after a while with this kind of continuous high-grade stress,” he said. “You will not be able to resist it indefinitely.”

Dr. Doucet urged surgeons to recognize that people who have been affected by threats to their safety can become disabled by the stress response. “They need help, and blaming them for not having enough moral fiber to fight back or to have resistance doesn’t help.”

Many people will not seek help on their own because they are ashamed, he said. But they need professional help. “We have to break the taboo that people have for reaching out for help when they’ve experienced these sorts of things,” he said.

“This is not a personal problem,” he added. “It’s a call for surgical leadership. As surgical leaders, we have to make sure that we look after our own.”

The Tulsa Shooting

On June 1, 2022, Nathan Powell, DO, a trauma and acute care surgeon in Tulsa, Okla., was witness to the aftermath of one of the worst episodes of violence in an American healthcare facility. Dr. Powell told the ACS what happened that day, and how his hospital system has changed.

That day, an angry patient barged into a clinic on the campus of the Saint Francis Hospital and killed five people, including his surgeon Dr. Phillips. Nearby, Dr. Powell and colleagues waited outside the trauma bay in hopes that they could save lives.

“We had heard that there could be multiple shooters or multiple people shot. I really didn’t know,” he said.

The gunman had become enraged after having spine surgery 12 days earlier. He complained about pain and his incision. Staff, after seeing him, believed his wound was healing normally. The man kept insisting that his appointment with the surgeon be moved up. Although he was frustrated, the patient did not seem overly threatening prior to the attack, Dr. Powell said.

On the afternoon of the shooting, the perpetrator had purchased an AR-15–style rifle. Barely three hours later, he arrived at the clinic. A patient on a video appointment with another physician called 911 when the attack began. The gunman shot and killed Dr. Phillips, then stormed through the office. He killed the husband of a patient, a sports medicine physician and a medical receptionist before turning the gun on himself. One of the gunshot victims was rushed to the trauma bay, where Dr. Powell and his team waited, but the man died from his injuries.

Dr. Powell described “devastation across the campus, across our community and really nationwide.” The incident came eight days after 19 children and two adults were killed in a shooting in Uvalde, Texas.

After the Tulsa shooting, it became clear that the health system’s security did not share a radio frequency with the local police department, Dr. Powell said. That has since changed, making it easier for police and hospital security to communicate.

Police also train in health facilities to prepare for future violence in a clinic-based setting, which they had not done before, Dr. Powell said. The hospital increased the frequency of security training for staff from quarterly to weekly, and one-time participation is mandatory for employees. Safety training made a difference in the moment of crisis, he said.

“When you talk to some of the people that were involved in our situation, they do state that their muscle memory going back to their training [helped],” Dr. Powell said. “Run, hide, fight training really assisted them in knowing what to do in the middle of chaos.”

The hospital has also tightened badge access inside buildings and added panic buttons. They developed codes to identify an active shooter or threatening situation. The risk for another mass shooting event on the campus may be low, but “the risk for violence is not,” he said.

Dr. Powell stressed that he did not want to turn his comments into a political discussion but wanted to acknowledge the heavy burden of gun violence in health centers. In the last year, there have been eight fatal acts of gun violence in healthcare facilities.

The Need for Institutional Leadership

Institutions need to take the lead role in addressing the stress that healthcare workers feel from violence or threats of violence, said Carter Lebares, MD, the director for the Center of Mindfulness in Surgery at the University of California, San Francisco.

They need to take steps such as installing metal detectors, providing security guards and mandating defense training for staff where appropriate, she said. She also called on governments to make legislative changes to put additional protections in place for healthcare workers.

“It’s just beyond appalling that people who devote their lives to caring for others would have to deal with something like this,” she said.

Two federal bills should, if passed, improve security for people who work in health facilities. The Workplace Violence Prevention for Health Care and Social Service Workers Act would mandate health employers to adopt plans to prevent workplace violence, and the Safety From Violence for Healthcare Employees Act would create federal criminal penalties for people who assault healthcare workers.

Individual healthcare workers can also take action to help them manage their response to stress and reduce their risk for PTSD, Dr. Lebares explained.

Medicine may find a model in the U.S. Army’s Comprehensive Soldier Fitness program, which trains soldiers, officers and their families in mindfulness techniques, she said. The program was developed to help soldiers deal with the psychological devastation of conflicts, and is founded on the principle that psychological training can help reduce PTSD symptoms. Similar programs are now being used for police officers and firefighters.

These programs need to be led by institutions, she said. “People who suffer from this can’t do it in isolation. It really takes employers, people at the very top, family members, everyone around them understanding what’s going on and what they’re going through because it’s that profound.”

Mindfulness training has been shown to help surgeons and trainees manage their response to stress. In two randomized trials led by Dr. Lebares, PGY-1 surgical and nonsurgical trainees had improvement in executive cognitive function, mindfulness, burnout and pro-inflammatory gene expression after a program of Enhanced Stress Resilience Training (Ann Surg 2021;273[3]:424-432). With this training, surgeons learn techniques to help focus their attention differently to keep their thoughts from returning to a high-stress event.

“It seems like offering a piece of Kleenex to a hurricane in terms of something that is so big and huge, but it is something evidence-based that surgeons can do to help themselves,” she said.

Increasing Personal Security

Joseph Dalu, a former police officer and the president at Premier Group International, an investigation and security company, works with clients to increase their personal security.

Anyone who is being targeted with stalking or violent threats should have access to a threat assessment team that includes human resources, campus administrators, a security and risk manager, legal counsel, a union representative where applicable, an information technology director, and a security expert, he said. They should also reach out to mental health professionals, their employee assistance program and law enforcement agencies, he said.

Mr. Dalu recommended people get training to defend themselves, and advised physicians to remove their names from designated parking stalls, consider carrying pepper spray, or being escorted to and from their vehicles. They may want to register their homes and utilities using an LLC, and have their homes blurred on Google.

Healthcare workers can protect themselves from harm without limiting their patient relationships, he said. “Do not lose the caring nature that you have,” he said.