Acad Psychiatry 29:350-353, October 2005
doi: 10.1176/appi.ap.29.4.350
© 2005 Academic Psychiatry
A Pilot Survey of Patient-Initiated Assaults on Medical Students During Clinical Clerkship
Andrea E. Waddell, M.D.,
Mark R. Katz, M.D., F.R.C.P.C.,
Jodi Lofchy, M.D., F.R.C.P.C. and
John Bradley, M.D., F.R.C.P.C.
Received June 1, 2004; revised September 12, 2004; accepted September 30, 2004. Drs. Waddell, Katz and Lofchy are with the Department of Psychiatry, University Health Network, University of Toronto, Toronto, Ontario, Canada. Dr. Bradley is with the Department of Anesthesia, University Health Network, University of Toronto, Toronto, Ontario, Canada. Address correspondence to Dr. Waddell, Wilson Centre for Research in Education, Toronto General Hospital 1ES-565, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4; a.waddell{at}utoronto.ca (E-mail). Copyright © 2005 Academic Psychiatry.
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ABSTRACT
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OBJECTIVES: To assess the incidents of patient-initiated assault (PIA) against clinical clerks during the first six months of clinical clerkship. To characterise the assaults with respect to service, location, clerk gender, patient gender. To examine the students’ perceptions of the reporting process for PIA. METHODS: A brief email survey was sent to all third year medical students after six months of clinical clerkship experience. Students were asked to describe assault experiences including: location, service, patient gender and injuries sustained. RESULTS: Six students reported experiencing physical assault in the first six months of clerkship. Assaults occurred on psychiatry (4) and internal medicine (2) services. Two of the assaults took place during consultations in the emergency department. All students reported having pre-clerkship training in management of violent situations. No students were aware of PIA reporting protocols for their hospital. CONCLUSIONS: Clinical clerks are at risk of PIA during their training. Students experiencing PIA feel that current levels of pre-clerkship training do not adequately inform them of the resources available after such an incident. These findings underline the need for PIA programs in the undergraduate curriculum including preclerkship training and clear, institution-wide reporting guidelines.
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INTRODUCTION
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Clinical clerkship is an exciting, albeit potentially anxiety-provoking experience that is anticipated eagerly by every medical student. Following the largely didactic preclerkship years, clerks become initiated into the world of clinical medicine—in inpatient care, rounding on the wards, and assessing patients in the emergency department. It is generally recognized by most medical students that this increasing clinical exposure leads to both greater responsibilities and potential risk in the form of needle sticks, accidental injury, fatigue, and medical error (1). The potential risk of patient violence toward medical staff, including students, however, is often not identified in clerkship orientation or seminars, and the issue of violent behavior in general is rarely addressed by medical curricula outside the context of psychiatry-specific lectures and training.
Patient-initiated assault against health care workers and its related sequelae have been increasingly recognized as a major occupational health concern. Although some of the patients who assault physicians and other health care workers have a psychiatric or substance abuse history (2, 3), these kinds of assaults are not specific to psychiatric patients, nor are the victims solely those working in psychiatric wards (4). Many assaults take place in the emergency department (5), on the medicine and surgical floors in the hospital (4, 6), and in the general practitioner’s office (7).
Physicians in training are also at risk. Previous work conducted in Canada showed that 40% of internal medicine trainees had been physically assaulted by patients during their residency (8). Similarly, a survey of Canadian psychiatry residents also demonstrated that 40% of trainees had been assaulted at least once. More than 25% of these assaults went unreported (9). A recent study from New Zealand supported these findings: 64% of psychiatry trainees, 29% of internal medicine trainees, and 20% of surgery trainees being subject to physical assault by a patient. Of the 52 separate assaults in this study, only one was reported to the program director (10).
There is a relative paucity of research that addresses this issue in undergraduate clinical clerks. Although there is a body of literature on medical student abuse, these articles usually address the issue of emotional, verbal, and physical abuse perpetrated by medical faculty, housestaff, nurses, and patients on clinical clerks (11).
The aims of this pilot study were to ascertain whether students were experiencing patient-initiated assault during their clinical clerkship at the University of Toronto, Ontario, Canada’s six teaching hospitals, to characterize the assaults (if any had occurred), and to examine the students’ experiences with preclerkship patient-initiated assault training and the postassault reporting process for patient-initiated assault.
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Method
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Six months after the clerkship began, a brief e-mail survey was sent to the third-year class (N=178) via the University’s class e-mail listserv. All students with patient-initiated assault experience(s) during clerkship were asked to respond. In the e-mail, patient-initiated assault was defined as direct physical contact or menacing behavior directed at the student by a patient in an aggressive and/or threatening manner. The e-mail also contained information about available supports for those who might have been assaulted. Students were given the opportunity to submit patient-initiated assault experiences via their own e-mail address or anonymously via an accessible Hotmail address. A follow-up e-mail was sent via the same listserv 2 weeks later in an effort to increase the response rate. Ethics approval was obtained from the Research Ethics Board at the University Health Network, one of the teaching hospitals at the University of Toronto, for the analysis and publication of this data.
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Results
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Six students reported experiencing physical assaults between October 2001 and May 2002. There was an equal number of male and female students assaulted. Of the patients initiating assaults, an equal number was male and female. Four of the six assaults took place on the psychiatry service. None of the students assaulted was aware of any reporting protocol.
All students gave descriptions of their assault experiences (Appendix 1). These descriptions provide insight into the types of assaults that took place (e.g., pushing, slapping, grabbing). The words used by the students convey the violence of the assaults and the fear these experiences evoked. These descriptions also serve to highlight some of the safety issues that could be addressed to prevent future incidents.
All students identified the lack of a formal reporting system as a source of confusion and/or frustration in the time following their patient-initiated assault event (Appendix 2). Students expressed confusion regarding their rights with respect to reporting incidents. Some students experienced frustration that support was not offered to them after the attack, and they were not aware of other resources available in the hospital or through the University.
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Discussion
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Clinical clerks are at risk of assault by patients. In the first 6 months of clerkship, six third-year students at the University of Toronto reported experiencing an assault by a patient. No students were aware of reporting protocols for assaults in place at their hospitals. In the absence of reporting guidelines, these incidents can and do occur without the knowledge of course directors and supervisors.
In our study, we used a strict definition of patient-initiated assault, which did not include uttered threats or aggressive speech. The survey administration had a positive response bias (i.e., we only asked for responses from students with a patient-initiated assault history), and thus we have assumed that absence of a response is equivalent to no assault experience. However, the incidents reported in this article reflect positive responses only and could be an underestimation of the actual experiences.
Our preliminary findings suggest that patient-initiated assault may not be as common in early clinical clerkship as has been reported in postgraduate training (8–10). This could be due to a number of protective factors, including the screening of patients by more senior house staff before clerks assess them, the decreased number of hours that clerks work relative to house staff, or the tendency for junior clerks to manage patients in close consultation with residents and staff.
Although patient-initiated assaults are reported most frequently in the emergency department and the psychiatric ward (3–5), it is not just a problem for educators in psychiatry. A significant number of trainees in internal medicine, surgery, pediatrics, and psychiatry will be victims of patient-initiated assault during their postgraduate training (8–10) or during their clerkship (11). Appropriate education and training increase the likelihood that incidents will be reported and trainees will receive the support they require (2, 12). The implementation of a formal reporting and crisis management program for assaulted health care workers has been shown to increase the likelihood of reporting and lead to a reduction in assaults (3).
Clinical clerks are a potentially vulnerable population with respect to patient-initiated assault. In other research studies, many nurses and senior house staff have been found to display self-blame and question their clinical judgment as a result of an assault (2, 9). Given the junior status of clinical clerks as well as their insecurities regarding their clinical skills, they may be more likely to view a patient-initiated assault as their fault and feel shame about reporting it. This may be even more pronounced in psychiatry due to the unfortunate and inaccurate perception that such violence can be seen as "part of the job description"(9). Without proper training and support, clerks experiencing patient-initiated assault can potentially fall through the cracks, possibly experiencing the serious sequelae of assault without support (13).
In Fall 2001, the University of Toronto held its first city-wide patient-initiated assault training for clinical clerks immediately prior to beginning clerkship. Clerks at all hospital sites completed a one-half day session that included: 1) a review of the literature on patient violence highlighting known risk factors and predictors; 2) video scenarios of agitated and escalating patients with group discussion; and 3) a brief session teaching basic defensive maneuvers.
In response to the findings of this survey, the half-day session has been expanded to include: a review of the findings from this survey; education of medical students regarding their rights as trainees in teaching hospitals; specific information from the division of Occupational Health regarding the logistics of reporting an incident; and the provision of a specific handout for students with contact information and support services available to them in the event of patient-initiated assault. In addition, the three medical education directors, who manage undergraduate education at the six teaching hospital sites, now include auditing of student assaults in their monthly reports.
The incidents of patient-initiated assault over an entire clerkship remains to be determined, as does the impact of assault experiences on students. It is possible that subsequent clinical encounters and future career decisions are strongly affected by patient-initiated assault. These questions can only be answered by a more thorough survey of patient-initiated assault experiences at the end of clerkship.
The findings of our survey highlight the need for clear, consistent guidelines for incident reporting, especially in medical schools where clerkship rotations occur at numerous sites. It is only through the creation of an environment, which fosters and facilitates the reporting of patient-initiated assaults that the true scope and impact of these incidents in clerkship can be assessed.
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This article has been cited by other articles:
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B. Miedema, J. Easley, P. Fortin, R. Hamilton, and S. Tatemichi
Crossing boundaries: Family physicians' struggles to protect their private lives
Can Fam Physician,
March 1, 2009;
55(3):
286 - 287.e5.
[Abstract]
[Full Text]
[PDF]
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J. H. Coverdale, A. K. Louie, and L. Weiss Roberts
Protecting the Safety of Medical Students and Residents
Acad Psychiatry,
October 1, 2005;
29(4):
329 - 331.
[Full Text]
[PDF]
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ABSTRACT
INTRODUCTION
