The first time a patient threatened to kill me, I was a third-year medical student on a trauma surgery rotation in Texas. A 22-year-old stabbing victim kept coming back to the trauma follow-up clinic asking for more Dilaudid, an opioid that helped lessen his pain as he was healing. I told him he had to follow up with his primary care physician. He huffed out but then came back four hours later and asked to speak to me. I brought him to an empty clinic room for the purpose of privacy and he proceeded to ask me how I wanted to die: by knife or gun, or both?
The first time a patient threatened to kill me, I was a third-year medical student on a trauma surgery rotation in Texas.
Patients threatening doctors is not new. But it became exponentially more common as opiates prescribed to control pain became more common. We’ve seen growing reports of violent threats against medical staff to procure drugs as a result, and the use of guns in these threats is common. In 2017 in Indiana, Michael Jarvis confronted Dr. Todd Graham with a semi-automatic weapon, killing Graham and then himself. Weeks earlier, the doctor refused to prescribe opioids to Jarvis' wife for her chronic pain. Gregory Ulrich shot five health care workers and detonated three pipe bombs at a clinic in Minnesota in 2021 after his doctor stopped prescribing painkillers. The stories persist, including the recent killing of Dr. Preston Phillips and three others at St. Francis’ Hospital in Tulsa, Oklahoma, on June 1.
The shooting reportedly happened a day after the gunman complained of pain from back surgery performed by Phillips the month before. Police recovered a letter the gunman had on him detailing how he was “killing Dr. Phillips and anyone who came in his way.” Police did not say whether the gunman was seeking opiates for his pain.
Purdue Pharma introduced OxyContin in 1995, a version of oxycodone that was heavily marketed to physicians as a gentler, less addictive opioid pill. The company’s aggressive marketing successfully normalized prescribing opiates for pain of any kind, despite the lack of evidence that they should be used for common conditions such as back pain and arthritis.
Even I felt comfortable writing opioid refills for a colleague’s patient I had never met or giving opiates to my 82-year-old patient with debilitating arthritis of the hip. And with the increased volume came addiction and overdoses. In 2012 there were 255 million prescriptions written for opioids with a dispensing rate of 81 prescriptions per 100 people. That year, 16,000 people died from an opioid overdose. In 2016 researchers found that more than 11.5 million Americans had reported misusing opioid prescriptions in the past year, underscoring that while there are valid uses for such medications, the United States simply had too many opioid pills in medicine cabinets. If that sounds familiar, think of the debate we’re having about guns in this country right now.
The worst outcome of our nation’s inability to manage double epidemics of opioids and guns is the complete breakdown of the relationship between doctor and patient.
The nation labeled and then grappled with reversing these trends by introducing incredible scrutiny and regulation in the form of prescription drug monitoring programs, limits on the quantities that can be prescribed and state medical boards investigating high volume prescribers. These efforts have started to yield results, but something else started happening: Millions of addicted patients began to resort to desperate measures to self-medicate when the generous supply of prescription drugs started to dwindle.
Patients would use fake names in different emergency rooms around the city to receive opioids; others would steal from friends and relatives and too many relied on nonprescription sources, which too often proved fatal. Some physicians I worked with instituted a strict “no narcotics” policy to avoid writing any prescriptions, while others would state that they would only prescribe up to five days and would require in-person office visits for re-evaluation. The programs that could help transition addicted patients, such as buprenorphine treatment, which can be administered safely in physician offices, are still too few and far between due to stigma (“we don’t want addicts in our waiting room”), regulatory barriers (prior to 2021 there were limits on who could prescribe the drug), financial considerations (reimbursement felt to be too low) and lack of time.
These days doctors, including myself, have taken measures to mitigate risk and protect ourselves and our staff. I have dismissed patients to get them out of harm’s way, worked in clinics with panic buttons and asked to reconfigure exam rooms so that I am closest to the door. Recent events will likely provoke more conversations of increased security presence or added barriers to access in hospitals and medical centers.
The worst outcome of our nation’s inability to manage double epidemics of opioids and guns is the complete breakdown of the relationship between doctor and patient. Preventive measures to deal with violence such as security and panic buttons can create an immediate assumption that the patient waiting in their room or on the gurney is guilty until proven otherwise. A flag in the electronic medical record that is commonly used to make prescribing physicians aware of the use of opioids also paints a scarlet letter before the doctor even sees their face.
In cases where the patient is a person of color, such as in the Tulsa killings, there are often additional stigma in both directions. Patients assume they will not be heard and doctors assume that they’re dealing with an addict who is potentially dangerous.
Social media only intensifies the divide — Google had to delete hundreds of one-star reviews of Phillips that said he deserved to die for not being empathetic or listening to the patient.
It is no wonder that the desire to shift to telehealth work and minimize the possibility of such intense interactions continues to climb. It leaves fewer doctors who can do the messy hard work of helping people heal.
Over the years, I have been able to hone my senses regarding which patients’ threats rise to the need for additional intervention. It’s not perfect, but it’s pretty accurate. When that sixth sense activates, I find myself being a bit more guarded, more transactional. I might schedule the patient for more frequent follow-up visits to try to avoid periods of frustration or anger to build. These are skills that are not taught in any medical school or training program in the country. But maybe they should be.
