Ali H. Mesiwala, MD, FAANS, a board-certified neurosurgeon at DISC Sports & Spine Center in Newport Beach, Calif., says the Tulsa shooting is eerily similar to the murder of spine surgeon David Duffner, MD, on Valentine’s Day 2020.
Dr. Duffner was gunned down in his Southern California clinic by a patient who complained that failed surgeries had left him reliant on painkillers. “The surgeon was killed for reasons related to the patient’s incomplete pain
relief and dissatisfaction and frustration over his postoperative care,” says Dr. Mesiwala. “In both cases, it seems the patients were suffering from pain that could not be treated with an operation.”
These tragedies highlight the insidious psychological effects of pain and reinforce the need to set clear patient expectations about likely outcomes of surgery — especially when it comes to back and spine procedures that rarely leave
individuals completely free from discomfort. Of course, as Dr. Mesiwala points out, sometimes even the most clear-cut guidance on what to expect during recovery isn’t enough. “Regardless of how much time a surgeon spends with
patients, they might have unrealistic expectations about what surgery can accomplish,” he says. “When their pain does not respond or is not substantially reduced, they become distraught, frustrated and desperate.”
That’s why it’s becoming increasingly common for facilities to lean on psychological evaluations of patients, says Edgar L. Ross, MD, director of Brigham and Women’s Pain Management Center in Chestnut Hill, Mass., and an
associate professor at Harvard Medical School in Boston. “For elective surgeries, especially orthopedic procedures, a pre-op psychological review is becoming the norm, if not a standard of care,” he says. “A psychological
evaluation can also be used to plan for post-op pain management.” Dr. Ross says that such evaluations can help providers identify certain types of patients — such as pain catastrophizers — who are at higher risk
for chronic opioid use, non-compliance with rehab, long-term chronic pain and poor satisfaction with the care they receive.
Regardless of how much time a surgeon spends with patients, they might have unrealistic expectations about what surgery could accomplish.
— Dr. Ali H. Mesiwala
Drs. Mesiwala and Ross have had to calm frustrated and visibly upset patients. “Every healthcare professional will sooner or later encounter a situation like this,” says Dr. Ross. He adds that strategies such as actively listening
to their concerns, staying relaxed, avoiding the tendency to get defensive or argumentative — and even getting help from resources such as patient relations experts — go a long way toward defusing tense situations that arise
when patients clearly aren’t happy with the care they receive.
“The key aspect of a productive response is to never abandon patients,” says Dr. Ross. “Even if a referral is needed to continue contact after surgery, reach out to the patient periodically.” The toughest thing to do
professionally, says Dr. Ross, is to stay engaged and let the patient vent as much as they need to. “All healthcare professionals will experience complications, miss something important or make a wrong decision or judgement call,”
he says. “It’s how they handle these situations that is most important.”
Dr. Mesiwala agrees that hearing the patient out, listening without judgment and giving them an opportunity to vent uninterrupted are of paramount importance when it comes to de-escalating tense encounters. “While I’ve never been
in a situation where I felt physically threatened by a patient, we have had occasions where patients were angry and desperate regarding their postoperative pain
control or frustrated over access to care,” he says. “We
found that bringing the patient into a private room to have a discussion with several staff members and letting them vent helped to calm them down.” Ultimately, says Dr. Mesiwala, taking time to hear the patient out and addressing
their concerns can go a long way toward preventing devastating outcomes.
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The shooting in Tulsa was simply a tragic, horrible event ,” says W. Michael Hooten, MD, a professor of anesthesiology in the division of pain medicine at Mayo Clinic in Rochester, Minn. “It’s difficult
to even think about, and my heart goes out to those who lost their lives and of course those who will be affected forever by that occurrence. The human loss is incalculable.”
Dr. Hooten is immediate past president of the American Academy of Pain Medicine (AAPM) and a former chief resident of psychiatry at Yale School of Medicine who has researched workplace violence in the setting of pain management facilities.
He co-authored a study on the subject based on a survey of providers that was published in Mayo Clinic Proceedings and co-led a panel that discussed the findings in a special session at the AAPM’s 2019 annual meeting. The
survey sought to understand the rate of workplace violence in the setting of pain management, as well as the drivers and key clinical situations that seem to be most associated with it.
“We were very surprised by how many providers received threats in the workplace from patients,” says Dr. Hooten. “Some individuals who responded to the survey experienced physical violence — the rates were very high.
What we learned from our research is that in the setting of pain management, this is a more common occurrence than you might think. However, it is underrecognized and underreported.”
Dr. Hooten and his co-authors identified two areas where threats of violence and actual violence typically occur. “The first involved clinical situations surrounding the ongoing provision of opioids — particularly a change in treatment,
whether it’s discontinuation or dose reduction,” he says. “Another flashpoint seemed to be whenever there was ongoing litigation surrounding health care, such as workers’ comp cases.”
Dr. Hooten’s study was not designed for the more granular task of asking each individual respondent for more information about their experience. “That type of work is still needed,” he says. “What we can say, at least
in general, is that pain is highly distressing. Understanding how distressed individuals can become is critical. I think you can see types of behaviors emerge, either threats of violence or actual violence as you saw in Tulsa.”
A threat surveillance system driven by awareness and communication among providers is key to head off threatening patients before grievances and anger over clinical issues turn into attacks, according to Dr. Hooten. “There are at least
a couple key factors that I think are really foundational for building and developing a surveillance system,” he says. “Number one is just to raise the awareness and the level of vigilance among staff members. That not only
includes doctors and nurses, but the individuals answering the telephone and checking patients in at the front desk because this is often where threats are delivered.”
Dr. Hooten says threats that occur, regardless of the perceived level of severity, must be quickly communicated to everyone in the immediate area. “That at least provides an opportunity for early intervention to see if the threat can
be mitigated,” he says. “Explicit threats to individuals’ lives should be immediately reported to law enforcement.”
There is a risk of unanticipated consequences when surveilling and managing potential individual threats. “We don’t want to necessarily allow it to fracture our clinical relationships with patients,” says Dr. Hooten. “That’s
why these threats need to be assessed. Awareness should lead to assessment, and then there should be various levels of interventions. Human behavior is complex. This is what we’re dealing with.
“Threats and violent events occur intermittently,” he continues. “But if awareness and communication are raised, hopefully these types of tragic events can be mitigated in the future.”