The Unseen Cost of Gun Violence

It was another fairly typical Friday afternoon in the outpatient clinic. Lots to do, but a rhythm that seemed pretty usual. The weekend seemed close at hand. And then.

A family member of a patient I was scheduled to see called to warn me that

“He has a gun, and he will be angry.”

That just-in-time tip abruptly pulled my mind out of my Friday afternoon slump. Running behind and already dealing with the emotional stress from news of yet another recent shooting, my immediate reaction was a mixture of fear, anger, and frustration.

The threat and reality of gun violence by patients towards health care practitioners is neither new nor uncommon. These explicit threats and acts of violence are the worst of the consequences of failed expectations of the physician-patient relationship, as was the case for Dr. Preston Phillips and three others, when a patient with unresolved post-operative pain purchased an AR-style rifle and opened fire at Warren Orthopedics Clinic in Tulsa, OK.

Given this advance warning from my patient’s family, it was unclear how this scenario would play out — and more importantly what my plan of action should be. I knew this man well; a strong believer in the right to own guns, my patient considered himself a firearm aficionado, with a large supply of legally acquired firearms at his disposal. He was showing early signs of cognitive impairment and appeared to be struggling to maintain his sense of self, prone to aggressive outbursts whenever confronted about changes in his memory or personality.

My first reaction was to contact hospital security who escalated my concern to the local police. A police officer arrived quickly to discuss the threat and heightened it to his supervisor. All parties were concerned for my safety and the safety of those around me. My response was initially an out-of-body one — I was reassured by their presence, but in disbelief that this was happening to me firsthand.

Their question was simply, “Can you just cancel his appointment? Is it worth it to see him?” Could I really help him or would I just ignite his anger? This was not an angry patient presenting with a vendetta, but he had the potential to be just as dangerous.

The substantial immediate and downstream physical and mental health impact of gun violence on those who are injured or killed, those who were nearby but unharmed, and the general population are well described. Children afraid to go to parades and school, parents afraid to send them or equipping them with bullet-proof backpacks. Fear of attending places of worship and movie theatres — anywhere there may be a crowd. Fear lives in our minds.

We as healthcare providers are not immune to these fears. Nor are our patients who deserve a safe environment to receive care. Adding to this was that as the “leader of the healthcare team”, I needed to weigh how my decision to provide care to this one man would impact my colleagues, staff, and waiting patients. There was no doubt that he needed medical care, and that it would be best provided by me, a physician he trusted, who had cared for him for years.

Sadly, clinicians must face this increasingly common dilemma: where does our responsibility lie — to the care of our team or to our patient? Is there a gray space in the middle? For a patient who greatly needs care, but poses a real and imminent risk, what does one do?

I made the choice for myself and my team and agreed see the patient with the support of our excellent security team who came to the office and worked with us to ensure, as best we could, that the visit would be safe for all concerned. Fortunately, when the patient arrived there was no violence, and I was able to provide him care that he needed.

Although he refused a cognitive evaluation, I was able to provide documentation for law enforcement to subpoena to assist his family in gaining access to his firearms in order to secure or remove them from the home.¹ While there was no guarantee that his weapons were removed, this action is a critical one that clinicians can initiate to prevent a tragedy, either self-inflicted or one that impacts others.

While this specific incident did not involve violence, thirty years prior, a physician in my own health system was shot and killed during a routine visit for persistent vertigo. In fact, there have been 154 hospital-based shootings over the course of the last studied decade (2000–2011).² This gloomy statistic includes only the tragic events of when a gun was actually fired. This number does not include the broad impact of violent threats health care workers face every day.

All told, this single threat of gun violence had taken three hours out what was already a busy Friday. During those lost hours, I received 40 portal messages and 12 phone calls ranging from urgent matters such as requests for COVID anti-viral medications, to more mundane concerns about managing insomnia in a spouse with dementia.

This ‘distraction’ required me to stay late at work to address urgent issues, but I was unable to complete all the tasks that were put on hold due to the events earlier in the day. Many patients may have thought that I let them down — that I was too busy or left early on a Friday. But the root cause of this problem was our nation’s relationships to guns and the omnipresent threat they have become, especially in the hands of those who cannot safely use them. I was exhausted when I returned home, unable to give my three kids and husband a fun Friday night with Mom.

This episode raised some very important issues. As physicians we are trained to do a risk-benefit-ratio in our decision making with patients. Must we extend this weighing of benefits and risks to include our personal safety and that of our colleagues and patients when deciding to see those at risk of inciting violence? We as a community must better acknowledge the growing threats we face and carefully consider the tradeoff between the benefits of caring for a potentially dangerous patient and the direct risk of endangering staff, patients, and ourselves while also considering how this decision might impact the care of others.

Declarations

Conflict of Interest

The author declares that she does not have a conflict of interest.