In 2013, Dr Ronald Gilbert was fatally shot during an office visit because a former patient attributed his erectile dysfunction and incontinence to an operation done 20 years prior.¹ In 2013, Dr Charles Gholdoian was killed and Dr Christine Lajeunesse was injured for what the killer considered a botched vasectomy.² In July 2020, Stephanie Horton, a patient service representative, was killed in a urology clinic by an irate family member. Stories like these, of violence towards health care providers (HCPs), are unfortunately becoming more common.

According to the US Bureau of Labor Statistics, from 2011 to 2018, 156 (∼20/y) HCPs were killed in the workplace. Alarmingly, from 2020 to 2022, the annual rate tripled to 51, 57, and 65 deaths, respectively.⁴ However, these fatalities represent only a small portion of the hostile encounters that HCPs face. The incidence of violence against HCPs has steadily increased over time, from a prepandemic rate of 6.4 (per 10,000 full-time employees) in 2011, to 10.4 in 2018, then 14.3 in 2022. This represents a rate 3.3 times higher for HCPs than all other occupations.⁵

Workplace violence (WPV) is defined as “the act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior.”⁶ It is a growing problem that has worsened since the COVID-19 pandemic,⁷ nationally and internationally.⁸ Postulated reasons for this rise include provider factors (ie, necessary implementation of unwanted public health measures, intense provider workload, lack of training in de-escalation techniques), patient factors (ie, expectations, history of violence, prior negative health care experiences, psychiatric conditions, substance abuse), or administrative issues (ie, long waiting period, understaffing, lack of staff training, lack of administrative support). Regardless of the causes, the consequences are clear: higher levels of HCP burnout, attrition, post-traumatic stress disorder, depression, and anxiety, which can cascade into negative effects on patient care.⁸

In a 2019 Urology Times survey, 62% of urologists reported being threatened by a patient, while 23% reported being physically assaulted.⁹ A 2022 national survey of physicians noted that urology was associated with a higher risk of patient harassment or assault (odds ratio [OR] 1.33) than psychiatry (OR 1.21), general surgery (OR 0.83), or OB-GYN (OR 0.63).¹⁰

The AUA has published the AUA Workplace Violence Preparedness Toolkit, which consists of 6 chapters outlining a strategic planning guide and templates on WPV policy, threat assessment, procedures, and training.¹¹ Other various multifaceted mitigation efforts have been proposed, including enhanced security measures (ie, increased security cameras, security presence, panic buttons), staff training (ie, de-escalation techniques, communication skills, identification of high risk individuals), administrative safety standards (ie, protocols and reporting, zero tolerance policy), and provider recovery (ie, debriefing, psychological assessment).^8,12

At our institution, we have also witnessed this worrisome trend. In 2018, the Cleveland Clinic Police Department responded to 5353 Code Violet across all locations. Fifty included assault and 9 with injury. By 2023, this had increased to 6948 with 104 assaults and 892 with injury. Within our department, the incidence was 15 to 18 per year between 2018 to 2023 with 1 to 2 injuries.

At Cleveland Clinic, WPV is taken seriously and addressed in a multilayered fashion. Our current organizational approach involves reporting and appropriate review through SERS (Safety Event Reporting System), training modules for health care workers, and enhanced workplace awareness and security. That said, one of the top requests from our urological workforce in 2022 was to improve support to address these incidences. In April 2023, a procedure reporting and documenting such incidents in the urology department was developed. Providers were educated on proper documentation, required patient communication, and escalation of events departmentally through leadership and organizationally through our Ombudsman’s office and security. Every incident is reviewed and triaged by the department and the Ombudsman’s office. Future appointments are adjusted if necessary while the investigation is completed. Incidents are tracked in SERS, with the Ombudsman office, and by our departmental patient experience officer to monitor the progress until resolution. From October 2022 to January 2023, before the policy was re-evaluated, there were 8 known incidences, including threats to a provider and his family (1), threat of gun violence (1), and sexual harassment (2). After staff was educated on the new policy in April 2023 to present, 7 incidents—6 verbal harassment, 1 sexual harassment—have been reported and resolved.

At times, the situation calls for the termination of the patient-physician relationship. When considering this, most state oversight and accrediting bodies require the organization to: (1) provide the patient with written certified notice, (2) provide a brief explanation for termination, (3) continue emergency care for 30 days, (4) recommend another physician, and (5) transfer records to the new physician when requested.^13,14

Special consideration must also be given for certain vulnerable populations of providers. Caruso and colleagues note that a physician’s “younger age, inexperience, and gender (ie, female)” are risk factors.⁸ Anecdotally, we have observed more concerns from our advanced practice provider team than our physician providers. Female HCPs are particularly at risk for workplace harassment or violence by patients (OR 2.33).¹⁰ A 2020 thematic analysis of female internal medicine providers revealed an array of shared experiences of sexual harassment, stalking, and solicitation by patients.¹⁵ All developed methods to reduce risk by avoiding the physical exam, avoiding certain clothing (skirts, dresses), keeping physical distance from the patient, and limiting the duration of the visit. For the female urologist, many of these strategies are difficult to implement, particularly in andrology, as genital exams are required for accurate diagnosis, and history-taking involves personal details. Female trainees, who tend to be younger and less empowered to confront inappropriate patients relative to faculty, are particularly vulnerable.¹⁶ Chaperone policies have been developed at many institutions; however, the availability of staff to assist during an exam is variable in practice and can contribute to increased provider burden. The intent and execution of chaperone policies at most institutions are aimed at protecting patient interests and vulnerabilities, not providers.

Addressing WPV not only protects health care workers, it also protects the patients and the quality of care they receive and helps maintain the integrity of the patient-physician contract.