In this issue, Waddell et al. (1) describe a survey of medical students at the University of Toronto regarding students’ risk of being assaulted by patients. Six of the 178 third-year medical students surveyed reported having been physically assaulted by patients over a 6—7-month period; four of the assaults occurred on a psychiatry service. The seriousness of the events was underscored by their description (1).
This is a topic that has not previously received attention by Academic Psychiatry as far as we are aware. Indeed, we know of only three previously published studies on this specific topic area of the psychological and physical safety of our learners. This dearth constrains our ability to understand the frequency and circumstances of threats and assaults by patients against medical students and how best to respond. In one (2), half of the 46 responding medical students had been fearful of violence by patients, and four had been physically assaulted. In another (3), the majority of the 93 third-year medical student respondents surveyed had been yelled or shouted at by a patient or had been subjected to inappropriately nasty, rude or hostile behavior. The negative effects resulting from mistreatment by patients most commonly interfered with students’ emotional health, social life, recreation and work (3). In a third study of students at the end of their internal medicine clerkships across 11 schools (4), a small minority reported abuse by patients that included sexual harassment and racially motivated comments.
Considerably more is known about the related topic of threats or assaults by patients against psychiatry residents. Surveys of psychiatry residents indicate that assaults or the threat of violence is the most stressful adversity during psychiatry training (5). Further, the percentage of psychiatry residents who report having been assaulted at least once during the course of training ranges from 36 to 64 (6—12), and the overall percentage in one of these programs (10) could be higher. In another study, when residents and junior attendings in psychiatry were grouped together, as many as 90% reported having been assaulted (5). Moreover, psychiatry residents may be more likely to experience various types of threats (12) or assaults (12, 13) and to report higher levels of longer term distressing psychological consequences as indicated by scores on the impact of event scale when compared to trainees in other specialties (12). A commentary in 1989 by Halleck in this journal (14) described methods for both preventing physical attacks on residents and aiding victims.
What then are some of the priorities for research? First, it is worth appreciating that many of the studies concerning violence by patients toward residents in particular are somewhat dated (6—10). In addition, with few exceptions (4, 5, 8, 9), the studies concern single programs only and are therefore limited by generalizability. Methodological limitations also include low numbers (3, 6, 7, 10, 12, 13); response rates that are not formally defined (1) or less than 60% (2, 6, 9, 11), thus limiting the validity of the findings; a lack of precision of definitions of threats or aggressive acts (2, 5, 8, 10, 11); and a focus on assault with or without physical injury being incurred as opposed to other forms of aggression by patients (1, 2, 5, 7, 8, 13). Of interest is that many of the surveys asked medical students or residents to report on occasions that had occurred up to one or more years ago, introducing a possible recall bias. Perhaps a more rigorous research design is to prospectively inquire about students’ experiences, as well as to record and describe specific incidents and their consequences on individual clinical rotations.
Few of the studies have addressed the context in which violence occurred. Some have described the context in very general terms such as by identifying the place or basic sequence of events. Demographic, clinical and cognitive variables that might contribute to the prediction of aggression by patients should be appreciated (15—19). None, however, have reported the patient’s perspective. One important recognition is that certain institutional practices or alternatively rude or discourteous behavior by the clinician may precipitate some occasions of aggression by patients. Information on the context of events including the patients’ perspective may allow a more thorough determination of how similar events might be prevented. Monitoring of patients’ level of satisfaction, analysis of individual occasions of aggression and identification of patients with a propensity for violence should facilitate the planning of preventive interventions.
We do not know the consequences of these incidents for the morale of residents in terms of days off work or on dropout from training. We also do not know how these incidents impact patients’ treatment. Negative feelings, (20) undue caution in engaging some patients in treatment, or a failure to ask about violent thoughts (21) may impair patient care.
A related question concerns whether or not adverse events in the training of medical students in particular have implications for their choice of psychiatry as a career. In recent editorial comments on risk management in the British Journal of Psychiatry, Peter Tyrer expressed a concern that such adversities may influence career choice (22). He lamented that he continually needed to protect his own students from abuse, personal assault and dismissive rejection, while finding himself both apologizing and insisting that most of psychiatry was not like that.
Of interest is that in the study by Waddell et al. featured here (1), none of the students assaulted were aware of any reporting protocol. Without clearly defined and well appreciated reporting mechanisms, directors of medical student training and other relevant faculty may not know to respond. In some cases, reporting processes may be unclear for residents (11) and training directors may not become aware of incidents (12). In addition, some faculty may respond inappropriately when residents are threatened (5). Waddell et al. recommended the implementation of a formal reporting program and the routine provision of information to students about the program in case of an assault. A national survey of medical student training directors concerning their knowledge of and response to such events and concerning processes for reporting could be instructive.
In developing these programs, it is also worth appreciating that some of the distressing psychological consequences might follow verbal threats or other forms of aggression and not just physical assaults alone (12). One research priority, therefore, is to delineate efficacious responses to these events. In this regard, we should also look to support residents training in other specialties (12, 13, 23—25) and other professionals in training who have been traumatized (2, 26). Single-session individual psychological debriefing after a traumatic event does not, however, appear to prevent post traumatic stress disorder (27). Moreover, training in the early recognition and management of possible occasions of aggression and violence by patients has been perceived as minimal or as less than adequate in some circumstances (8, 10—12). In one example (12), residents identified a need for refresher courses and requested that more attention be given to understanding the impact of assaults, recognizing risks and methods for de-escalation.
We have therefore emphasized the need for more comprehensive data on the prevalence, context and consequences within different settings of threats or violent acts by patients toward medical students and psychiatry residents. Developing this research is essential to understanding the priority for further developing specific preventive interventions. We welcome your contributions to this end. For now, the available data indicates that we should be vigilant in protecting the psychological and physical safety of our learners.