By Ana Gascon Ivey

In August 2021, at the height of the COVID Delta variant, a male patient in his early 50s visited the family medicine practice of Jacqui O'Kane, DO, at South Georgia Medical Center.

"He complained of upper respiratory symptoms," said O'Kane. "Specifically, he had a dry cough, fever, headache, and malaise." She was concerned that he might have COVID or influenza.

"When I recommended testing for COVID or flu, his tone changed from troubled to indignant," she recalled. "'Don't you dare test me!' he said. 'Just give me ivermectin.'"

She explained that she couldn't prescribe medication without a proper diagnosis. Furthermore, the patient revealed he was a teacher, so she wanted to help protect his students. Regardless, the patient stormed out of the exam room and yelled at her on his way out. "The kids have a field trip this week. You can't stop me from taking them!" Stunned, she quietly replied, "I just want to help you." But he ignored her and left.

Unfortunately, O'Kane's story is not unusual. Every day patients yell, bully or make threats or act on threats toward doctors and other healthcare providers. According to the World Health Organization, up to 38% of health workers suffer physical violence at the hands of patients at some point in their careers. Many more experience threats and verbal abuse.

What Are the Most Common Patient Harassing Behaviors?

We know that the pandemic exacerbated harassing behaviors, but the reality is that patients have long harassed doctors and continue to do so.

Sexual harassment, for instance, is prevalent. In 2022 Sexual Harassment of Physicians report of over 3000 physicians, 29% said that patients made comments about their anatomy; 23% deliberately infringed on their personal space; 22% received repeated date invitations; and 14% made unwanted physical contact, such as groping or fondling.

The angry outburst described above by O'Kane is just one type of behavior that physicians have to deal with. Physicians frequently see a range of other problematic patient behaviors, some of which may reflect underlying mental health issues. Here is a profile of five of them.

Illness Anxiety Disorder

Patients with illness anxiety disorder (also called hypochondria) may visit or call their physician for every ailment and for their constant worry over symptoms and care. When some don't get the attention or medication they want, they can become fearful about their health and become angry, believing that they are being ignored.

Debra Pinals, MD, former chair of the American Psychiatric Association (APA) Council on Psychiatry and the Law, encourages physicians not to dismiss patients who call or visit frequently.

"These are people who may have psychiatric illnesses with physical symptoms that are real to them," said Pinals. "Even if their symptoms aren't medically evident, a doctor may have to refer them to a psychologist or psychiatrist to help the patient manage the symptoms that manifest as physical complaints."

But a referral is not the only way to treat a patient with illness anxiety disorder. A recent study recommends:

Form an investigative partnership with the patient.

Determine what other psychiatric disorders the patient may be experiencing, such as depression or anxiety.

Delineate the patient's personality traits from the abnormal illness beliefs.

Focus on psychosocial problems instead of the concerns.

Flirting With the Physician

Some patients may continually compliment their doctor's looks or ask for dates. They engage in flirtatious banter and may cross the lines in subtle ways.

"It's the doctor's responsibility to set boundaries and limits and have appropriate decorum with their patients," said Pinals. Doctors must take precautions with this type of harassing behavior because the patient can misconstrue situations.

Pinals gives an example of a physician who started meeting a patient in the hospital cafeteria. Unfortunately, the patient believed they were dating because the doctor blurred the boundaries of professional behavior.

To avoid scenarios like this when dealing with this type of behavior, Pinals recommends:

-Set clear rules and boundaries from the start of the doctor-patient relationship.

-Limit physical contact to medical examinations only.

-Redirect the patient when they are challenging the boundaries.

-Ask a coworker to chaperone appointments with the patient.

-See the patient only in the office.

-Document the behavior if there's a pattern.

-Refer the patient to another provider if there's a change in behavior that warrants psychiatric care.

Verbal Abuse or Threats

A patient may be angry because they don't feel well, are in pain, or are unhappy with their health situation. They may threaten the physician or become verbally abusive.

Roberta Gebhard, DO, remembers a male patient who insisted on a prescription for a new erectile dysfunction medication.

"He was a big guy who reminded me that he had been to prison for being a violent serial offender," said Gebhard. "A lot of physicians will just fire a patient like that outright, but I usually don't do that. I'll tell them, 'I'll see you as a patient, but I'm not going to give you this prescription.'"

It's important to remember that these patients can become violent. If you are feeling that you are in danger, leave the exam room. You may wish to return with another physician, or dismiss the patient from your practice. You must get out of harm's way if you sense danger.

O'Kane also recommends:

-Refrain from yelling or using inflammatory language, even if the patient is doing so.

-Project a calm, caring demeanor.

-Take time to debrief and decompress after an encounter with a harassing patient.

-Report the behavior and discuss how future meetings with this patient will be handled.

Pinals makes these additional recommendations:

-Remind the patient that respectful communication is expected in the practice.

-Try to find out why they're disgruntled.

Pinals also suggests referring the patient to another doctor. "Be cautious about eliminating the patient from the practice without making a referral to another provider because that could be construed as abandonment," she said.

Stalking, In Person or Online

Some patients may friend or follow their doctor on social media. They call after hours to check-in. They leave revenge comments across multiple review sites if they're unhappy with their care.

Gebhard remembers a female psychiatric patient who tracked her from New York to Montana to Ohio in the early 1990s. Even though Gebhard had unlisted phone numbers, the patient still managed to find her.

"I was very professional with her, but I got really bad vibes from her," said Gebhard. "I think she just wanted to connect with me, or maybe it was a sexual thing with her. I don't know for sure, but I told her outright that I didn't want her to contact me anymore." Eventually, the woman stopped stalking her.

Unfortunately, today patients have greater access to their physicians via the internet and social media. A recent study found that 1 in 10 US physicians have encountered a patient stalker. Researchers suggest that the primary reasons for stalking are either dissatisfaction with care or treatment mismanagement resulting in injury, according to the patient. Psychiatrists are more prone to stalking by erotomanic patients.

To address patient stalkers, the Psychiatrists have developed these interventions:

-Call local law enforcement if you sense immediate danger.

-Always keep a cell phone handy.

-Park near security.

-Plan an escape route.

-Minimize your online presence.

-Make sure your alarms and locks work properly.

-Install video cameras at entryways.

-Consult security firms or law enforcement for safety strategies.

-Document the patient's stalking behavior.

-Tell colleagues, staff, and family members.

Take out protection orders on the stalker, if necessary.

Sexually Harassing

These patients overstep the lines of the patient-doctor relationship. Their comments are typically inappropriate and create a hostile work environment. They may touch or grope themselves or the physician or display other full-on sexually harassing behavior.

Lauren Hock, MD, attending ophthalmologist at Wills Eye Hospital in Philadelphia, recalls comments from male patients who harassed her and her female colleagues during their residency training. They made remarks like, "Can I take you home with me?", "I've been thinking about you at night since my last appointment," and "What if I grabbed your breasts?"

In many cases, the patients believe the behavior is harmless or even flattering; but to the physician, it's insulting and harassing and must be reported.

According to the report, physicians who face sexual harassment like this can have trouble concentrating, become less engaged with patients, and think about quitting.

Thankfully, Hock was motivated to act. She met with her mentors and developed a curriculum, the I-Respond Toolkit, to empower physicians to respond to inappropriate comments.

"It's often when doctors don't know what to say that comments can escalate," said Hock.

The I-Respond Toolkit provides these tips:

-Use "I" statements: "I feel uncomfortable when you comment on my physical appearance."

-Emphasize shared goals: "Comments like that distract from my ability to focus on your care. Let's keep our conversation professional."

-Focus on the patient's actions: "I felt disrespected when you said that" rather than "You are disrespectful."

-Offer an alternative: "I'd prefer if you call me 'doctor' rather than 'baby' or 'honey.'"

Don't use humor. It can be misconstrued as reinforcement.

The strategies in the toolkit can also be used for other forms of harassment, such as comments based on race, ethnicity, religion, or sexual orientation.

Reporting a sexual harasser is often warranted, as well as transferring the patient to another doctor's care, having told them about the incidents. By reporting any type of harassing patient, physicians can help keep fellow doctors safe from patients who harass them.

Ana Gascon Ivey is a health and medical writer based in Savannah. She also teaches creative writing at a men's correctional facility.