Which of the following is the most appropriate response when you are confronted with a patient procedure?

Patients in your exam room may be experiencing one of a number of forms of abuse—domestic violence, human trafficking or other violence—and identifying those being abused can sometimes be tough.

An article published in the AMA Journal of Ethics® outlined the challenges and identified ways for physicians to better spot and help trafficking victims. The authors noted research showing that 88% of victims had contact with a health professional while being trafficked, but none were identified or offered help in getting out of their situation during the medical encounter.

Family physician Anita Ravi, MD, MPH, MSHP, discovered that she has had to rethink the way she approaches patients to best help those facing abuse or violence. Dr. Ravi is co-founder and CEO of the PurpLE (Purpose: Listen & Engage) Health Foundation, a nonprofit organization that invests in the physical, mental and financial health of women and girls who have experienced gender-based violence. The foundation is based on her work pioneering a New York City primary care clinic for survivors of human trafficking as well as other forms of abuse and exploitation.

Dr. Ravi said her experience, including a study that involved interviewing sex-trafficking survivors about their interactions with the health care system, has taught her that patients experiencing violence or abuse can be of any gender, age, documentation status or background and they may be encountering a range of medical issues. It may be a patient who has never encountered the health care system before because traffickers deny their access to care or the person seeking care was never able to leave their abuser long enough to seek medical care.

Patients have told her there were times when they have left a medical setting because they felt they were being judged.

“We need to think differently about people we deem “frequent flyers”,” said Dr. Ravi, vice chair of the AMA Women Physicians Section Governing Council. For example, a patient may be coming in for frequent sexually transmitted disease testing because they are being forced to have unprotected sex.

She said physicians need to be nonjudgmental and let people know that mental health, housing, legal and social services are available. While a patient may not open up to what is really going on during a first or even second visit, those interactions can lay the groundwork that the physician’s office or an emergency department is a safe place.

Dr. Ravi said it is also important to establish a policy—even putting it in writing in the exam and waiting rooms—that says a patient needs to be seen one-on-one for part of the visit. Trafficked patients may come in with a man or woman who is trafficking them; sometimes that person could even be a relative.

The AMA Code of Medical Ethics offers physicians guidance on their obligation to take appropriate action to help patients avert harms that violence and abuse cause.

In Opinion 8.10, “Preventing, Identifying and Treating Violence and Abuse,” the Code explains that all patients may be at risk for interpersonal violence and abuse, which may adversely affect a patient’s health or ability to adhere to medical recommendations. Physicians, in light of their obligation to promote the well-being of patients, have an ethical obligation to take appropriate action to avert the harms caused by violence and abuse.

The Code says that to protect patients’ well-being, physicians individually should become familiar with:

• How to detect violence or abuse, including cultural variations in response to abuse.
• Community and health resources available to abused or vulnerable persons.
• Public health measures that are effective in preventing violence and abuse.
• Legal requirements for reporting violence or abuse.

Physicians also should:

• Consider abuse as a possible factor in the presentation of medical complaints.
• Routinely inquire about physical, sexual and psychological abuse as part of the medical history.
• Not allow diagnosis or treatment to be influenced by misconceptions about abuse, including beliefs that abuse is rare, does not occur in “normal” families, is a private matter best resolved without outside interference, or is caused by victims’ own actions.
• Offer treatment for the immediate symptoms and sequelae of violence and abuse and provide ongoing care for patients to address long-term consequences that may arise from being exposed to violence and abuse.
• Discuss any suspicion of abuse sensitively with the patient, whether or not reporting is legally mandated, and direct the patient to appropriate community resources.
• Report suspected violence and abuse in keeping with applicable requirements.

Discover five ways physicians can identify and help victims of human trafficking.

Before reporting suspected violence or abuse, the Code says physicians should:

• Inform patients about requirements to report.
• Obtain the patient’s informed consent when reporting is not required by law. Exceptions can be made if a physician reasonably believes that a patient’s refusal to authorize reporting is coerced and therefore does not constitute a valid informed treatment decision.

Physicians should also protect patient privacy when reporting by disclosing only the minimum necessary information.

Learn more about AMA policy supporting survivors of LGBTQ+ intimate partner violence.

1. What physicians can do individually
2. What to consider before reporting

Over the last six months, the TMLT Risk Management Department has received a number of urgent requests from physicians looking for information on how to de-escalate angry patients or how to diffuse a tense situation in the office.

To begin, it’s important to understand that no single response or technique will work in every situation. When responding to escalating behavior, consider the individual patient, the circumstances, and the overall context of the situation. If at any time the patient threatens harm or you feel unsafe, contact the police or call 911 immediately.

De-escalation is one technique that can be used when confronted with violent or aggressive behavior. De-escalation means “transferring your sense of calm and genuine interest in what the patient wants to tell you by using respectful, clear, limit setting [boundaries].” (1)

The following tips — published by the Crisis Prevention Institute and the Western Journal of Emergency Medicine — may provide a useful starting point for the de-escalation process. (2-3)

1. Move to a private area.

If it seems safe to do so, it may be helpful to move the patient away from public spaces and into a private area to talk.
 

2. Be empathetic and non-judgmental.

“Focus on understanding the person’s feelings. Whether or not you think those feelings are justified, they’re real to the other person.”
Possible response: “I’m sure other patients have felt this way too.”
 

3. Respect personal space.

“If possible, stand 1.5 to three feet away from the person . . . Allowing personal space tends to decrease a person’s anxiety and can help prevent acting-out behavior. Do not block exits.”

4. Keep your tone and body language neutral.

“The more a person loses control, the less they hear your words — and the more they react to your nonverbal communication. Relax your body and keep your hands in front of you, palms facing outward.”

5.  Avoid over-reacting.

“Remain calm, rational, and professional. While you cannot control the person’s behavior, how you respond to their behavior can affect whether the situation escalates or defuses. Empathize with feelings, not behavior.”
Possible response: “I understand you are ___________, but it’s not okay to yell at staff.”

6. Focus on the thoughts behind the feelings.

“Some people have trouble identifying how they feel about what’s happening to them.”
Possible response: “Help me understand what you need.”
Possible response: “What has helped you in the past?”
Possible response: “Tell me if I have this right.”
Not: “Tell me how you feel.”
 

7. Ignore challenging questions.

“Answering challenging questions often results in a power struggle. If a person challenges your authority, redirect their attention to the issue at hand. Ignore the challenge, not the person.”
Patient: “Why is that other doctor such a ________________?”
You: “Please tell me again when your symptoms started?”
 

8. Set boundaries.

“If the person’s behavior is belligerent, defensive, or disruptive, give them clear, simple, and enforceable limits. Offer concise and respectful choices and consequences.”
Possible response: “It's important for you to be calm in order for us to be able to talk. How can that be accomplished?”

9. Choose boundaries wisely.

“Carefully consider which rules are negotiable and which rules are not. If you can offer a person options and flexibility, you may be able to avoid unnecessary altercations.”
Possible response: “I understand it’s confusing when rules change, but federal law says we have to check your ID.”

10. Allow silence.

By letting silence occur, you are giving the person a chance to reflect on what’s happening and how to proceed.
 

11. Allow time for decisions.

“When a person is upset, they may not be able to think clearly. Give them a few moments to think through what you’ve said.”
Sample response: “I’ve just shared a lot of information with you. I’ll come back in about 10 minutes after you’ve had time to think about it.”

More on de-escalation

Dealing with the aggressive patient
De-escalating anger: a new model for practice
The Joint Commission Quick Safety 47: De-escalation in health care
Crisis Prevention Institute’s Top 10 De-escalation Tips
 

Videos

Verbal de-escalation of the agitated patient (from the University of Colorado School of Medicine)

Understanding agitation: De-escalation (psychiatric care example)

Sources

1. Pope K. Crisis intervention in dealing with violent patients: De-escalation techniques. Available atpaetc.org/wp-content/uploads/2014/10/De-escalation-PACE.pdf.  Accessed March 19, 2019.)

2. Crisis Prevention Institute. Top 10 De-escalation tips. Available at https://www.jointcommission.org/assets/1/6/CPI-s-Top-10-De-Escalation-Tips_revised-01-18-17.pdf . Accessed March 19, 2019.

3. Richmond JS, et al. Verbal de-escalation of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012 Feb; 13(1): 17–25. Available at 10.5811/westjem.2011.9.6864.

Laura Hale Brockway can be reached at .

Additional Resources