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New York's tony Upper East Side was in shock last February after Kathryn Faughey, a 56-year-old psychiatrist, was slashed to death with a meat cleaver while at work in her office. Charged with the crime is a former patient of Faughey's partner in the practice, Kent Shinbach, 70, who was seriously injured trying to save Faughey.

Simple Internet searches reveal a growing number of physician assaults across the country: a Chicago dermatologist stabbed to death by a patient whose acne treatment caused impotence, and a pain-management doctor in Port St. Lucie, Fla., who was beaten by a patient wielding a walking cane.

If you think these incidents only happen in larger cities, Richard J. Mansfield, MD, would disagree. In July, Mansfield, an internist in White River Junction, Vt., published a commentary in Medical Economics about his experience when a patient's hands were curled around his throat. "My mind raced. Should I try to break his grip on my neck? Hit him in the gut? Aim lower, hitting him in the crotch out of desperate self-preservation? As a primary-care physician, I had an arsenal of weapons to fight disease, but in the face of physical aggression, I was helpless," he wrote. The patient eventually loosened his grip, but Mansfield thought later, "Even my exam room is designed for patient comfort, not physician security. My exam table and desk with the EHR on it are both situated in a way that keeps patients between me and the door. This is troubling, to say the least."

In England, General Practitioner Magazine reports that more than 50 percent of British general practitioners say they've been physically abused by patients.

Procedures and Staff Training

When most U.S. physicians discuss safety, it's usually related to patient safety, and when they discuss security, it's information security that dominates the conversation. Yet safety and security of practitioners and their staff members in a physician office environment should be addressed, say two consultants with the Medical Group Management Association's Health Care Consulting Group.

"I think it's something that has to be discussed. I don't think you can ignore it," said Kenneth T. Hertz, who added that an office policy addressing safety and security issues is "absolutely appropriate." Hertz is an MGMA consultant based in Alexandria, La.

Nick A. Fabrizio, PhD, an MGMA consultant in Syracuse, N.Y., concurred. "When I go in to do an assessment of a practice, I'm looking at the practice overall, and one of the things I'll look at is policies and procedures, including patient and office-staff safety," he said. That's because Fabrizio knows what it's like as a practice administrator to have your gut wrench when a manager tells you there's a patient in the building with a handgun.

It happened about seven years ago, when Fabrizio was the administrator of Family Medicine-Medical Service Group in Syracuse, a large practice affiliated with State University of New York Upstate Medical University. "We had a patient who brought his handgun to the practice," he recalled. The weapon was "sort of concealed," and the receptionist spotted it.

Here's what Fabrizio did: While the patient sat in the waiting room, he reviewed the patient's history and reason for his visit with managers and the treating physician. "You want to make sure that the patient doesn't have any psychological issues going on and you might startle him," he said. "Then we simply called the patient back and brought him into the manager's office, where the manager and I talked to the patient about the fact that bringing his gun to the office was not appropriate and made staff and patients feel uncomfortable, and that if he wanted to remain a patient in our practice … he would have to leave his handgun either locked in his car or at home. And he took it great. It was a good outcome, but it really makes practices in general take notice of where they are in the world."

Fabrizio said that, while it's impossible to craft a policy for every potential occurrence, it's critical that staff members at all levels feel comfortable approaching supervisors with an urgent safety concern. "Unfortunately, sometimes staff hears the message that if someone is behind closed doors, don't interrupt," he said.

Hertz said, especially in larger practices, staff members should wear identification badges and they should be trained to be aware of unusual circumstances. "In a doc's office, your staff needs to be trained to understand that there probably shouldn't be people wandering around in the hallway, and if there are, maybe we need to stop and say, 'Can I help you? Are you lost?'"

Hertz said state medical societies could help practice managers identify training resources. Hospital or outpatient experts in behavior and substance abuse could brief staff members on warning signs of violence, or the local police department could provide tips on safety and security measures and how to diffuse a potentially volatile situation.

"Everybody just needs to be in tune and aware and trained in terms of what to look for, how to identify some of these kinds of issues before they become problems," Hertz said.

Candid Cameras?

Both Hertz and Fabrizio believe security cameras are probably overkill, unless the office is located in a high-crime area. "They need to consider the patient mix, the population, whether they're in an urban or rural setting," Fabrizio said, adding that he is aware of some offices that have installed a "dummy camera" to act as a deterrent.

"I can't say I would be a big proponent of that," Hertz said when asked about security cameras. "Once you put in a security camera, there are all sorts of issues you have to deal with in terms of where you put it, how it impacts employees, how to store the images and the information. Practices have a big enough problem figuring out how to back up their practice-management systems," he said. He added that it could "develop paranoia on the part of the staff, who feel they're being watched."

Buzzer doors between the reception and the clinical areas are a "very common" option, Fabrizio said. The doors are released by a remote switch, usually activated by the receptionist, and they usually buzz when the lock clicks open. A panic switch at the front desk is another relatively inexpensive security step.

And About the Drugs

Practices should keep only the minimal amount of drugs necessary on the premises. Of course, the drugs should be secured, but it's also important that their access be limited.

"When I was a practicing administrator, a group that I worked with had three offices across the street from housing projects. So we had some security issues, if you will. There had been gunshots toward the practice over the years, there were burglar bars on the windows, the doors had multiple locks and there was actually bulletproof glass in the receptionist's area," Hertz said. Yet he added that one of the most effective deterrents to crime was word of mouth -— letting it be known throughout the community that the few drugs on the property were inaccessible, that physicians weren't easy marks for prescriptions and that medications weren't dispensed "willy-nilly" at that location.

"I think practices just have to be aware of issues like this. Certainly, depending on your location, you have to be more sensitive. We have to be very vigilant," Hertz said.

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