I Want to Kill you: Facing a Threat and Finding Support and Safety

Listen to ASCO’s Journal of Clinical Oncology essay, “I Want to Kill You” by Dr. Noelle LoConte, Associate Professor of Medicine at the University of Wisconsin School of Medicine and Public Health. The essay is followed by an interview with LoConte and host Dr. Lidia Schapira. LoConte shares her experience of a patient's threat to kill her and her reflections on how health care can be improved.

TRANSCRIPT

Narrator: I Want to Kill You, by Noelle K. LoConte, MD (10.1200/JCO.22.02896)

 My patient threatened to kill me. I was in the middle of a busy medical oncology clinic. I was seeing her to discuss test results 1 week after I told her I was concerned that her cancer had returned. As I suspected, the test confirmed recurrent cancer, and this time, it was incurable.

I walked into the room to share this news with a woman who I had been seeing for about 3 years. I had been her oncologist since she was first diagnosed with stage III cancer and saw her through surgery and adjuvant chemotherapy. I had met her children, knew the names of her pets, and had discussed my children and pets with her. We were on very friendly terms, and I enjoyed seeing her name on my clinic schedule, certain that beyond discussion of her cancer and test results, we would also get into some interesting conversations about life, the weather, or college sports. Truly, it was a delight to be her oncologist. She had no known mental illness, no brain metastases, and had never been angry or violent with me. I used the SPIKES protocol to review why we were there and deliver the test results.1 I had done this many times before, and there was nothing that stood out to me in the moment about her or this clinical situation to make me think that I was in danger—a fact that made what happened next even more shocking.

When I paused to see what questions or thoughts she had, she said, “I want to kill you. I want to blow your face off. You should never have become a doctor.” I intellectually understood that she was upset about the news of her cancer recurrence and had understandable anger at the dramatic impact this turn of events would have on her future. I understood that, in her mind, someone had to be blamed, and, mostly out of convenience, it was going to be me. I have since wondered if her lack of close friends and family may have amplified her reaction, in that she had few outlets available to her to discuss her fears and concerns. I have wondered if she felt let down by me after our years of cordial and friendly visits. It was a real-life example of kill the messenger.

 She continued telling me that she could find my home address. At that moment, I scanned the room and recognized that I could be in real danger. I stood in the corner of the room. To get out, I would have to walk around the desk and between her and the examination table. I also realized that because it was a holiday, there were very few people around who might hear me yell for help. We did not have a panic button or hospital security on speed dial, and it would have taken them many minutes to get to me if I had used the phone in the examination room to call security. I looked down and saw that she had two large bags with her. Patients often bring bags such as these to their chemotherapy appointments, bags filled with things to pass the time such as iPads, books, knitting, board games, blankets, snacks, and water bottles. Suddenly, I realized that she was not scheduled to get chemotherapy that day, so why did she have these bags?

 I was sure I was about to be killed. I was certain she had a gun in those bags.

 I said anything I could think of to de-escalate the situation and get out of the room. I promised her a new oncologist, told her I would become a better doctor, and suggested that maybe the biopsy results were wrong (although I knew they were not). As she continued her tirade, I carefully walked past her to get out of the room, and although she never moved toward me, she continued to yell about what a terrible person I am. Once I was back in the workroom, a nurse escorted the patient out of the clinic. We called hospital security and were told they felt their services were not needed as the patient had left the clinic.

 Despite this horrific encounter, I managed to make it through the rest of the clinic day in a daze. After the clinic was finished, I emailed my supervisor since it was a holiday and other employees were not in the hospital for me to call. In this email, I conveyed my fear and concern about this encounter while making it clear that I was still worried about my safety and the ability of the patient to continue to harm me. The response I received was generic: We will look into it. The very next day while I was at home, I received an alert that there was an active shooter in the area and realized with dread that it was on my block. It was not my patient, but her words about finding my home address haunted me. I hid on the floor after closing the blinds and locking all the windows and doors. My children were with me. For days, I did not sleep more than 1 or 2 hours. I was on constant high alert.

 Three days later, I was seeing a different patient in the clinic and had what I now realize was a panic attack. I was barely able to complete the visit. The patient was kind and understanding, but I felt inadequate and knew that my patients deserved better. Importantly, I also knew that I deserved better. I reached out again to my immediate leadership team and said plainly that I was struggling and needed help. I was offered statements of support but no concrete actions.

 While crying in my office, I searched our hospital’s website for possible sources of help. I was lucky enough to come across our Employee Assistance Program and eventually got connected to a therapist. I will never forget the kindness and help she provided. She (correctly) told me that I had suffered an intense trauma and walked me through the next steps, which included meditation, hydration and nutrition, and intense aerobic exercise. She explained that the aerobic exercise (telling me to run as hard as you can with a goal for high heart rate and lots of sweating) can help the brain to heal from trauma and will prevent or diminish the development of posttraumatic stress disorder. I resisted my urge to search on PubMed to ascertain if these were evidence-based solutions and decided to try whatever she suggested. She also helped me accept a 2-week leave from work and find a therapist who specialized in trauma for health care workers. I continued to see a trauma therapist for a year until I felt I had adequately recovered.

 Eventually, as is true with most traumas, time itself was the best healer.

A few weeks later, when hospital leadership learned of my experience, things started to happen. Security did a walkthrough of the clinic space. Patient relations notified the patient that this type of behavior would not be tolerated.

There was a backup plan put into place in the event the patient needed care when I was the only oncologist available (eg, on the in-patient unit). It was not all forward progress, however. I was told no changes needed to be made to the clinic and that we could not keep examination room doors open because of privacy concerns. The provider desk would continue to be in the corner of the room, and the patient would continue to sit between the provider and the door. 

This was understandable given the cost to reconfigure rooms and the unfortunate reality with firearms that even being close to a door may not matter. I asked for panic buttons to be installed—I knew these existed in other clinics—but was told this could not happen. When I asked to be scheduled in rooms where my desk could be next to the door, I was offered a single conference room with no examination table and no medical supplies. I usually work out of three rooms on clinic days, so this would not work. I figured this was as good as it would get and elected to move on and suck it up.

Fast forward to 2 weeks ago, when I learned that as much as I hoped these traumatic patient interactions would leave health care workers, they never truly do. I was the oncologist for the in-patient unit at our hospital, which is a liminal space of end-stage disease, anxious patients and families, and difficult decisions. The stakes and severity of the patients’ situations are high. One patient and her family were furious at their medical situation of rapidly progressive cancer, as well as the hospital parking and layout, the plan of care, and even the cafeteria options. I was the recipient of all their frustration.

 As the patient and her family yelled at me for being inept and stupid and not serving their needs, I had the distinct sensation that my spirit was floating away from my body. I was rising toward the ceiling, watching it all play out in front of me, seeing myself from a bird’s eye view. I thought, “Wow, I am dissociating.” It was a surprisingly effective tool to Protect me at that moment and one that I now recognize as a normal response to trauma. Once the patient and family got all their anger out and told me to leave the room, I became unsteady and had to hold the banister to stay grounded. To drive home how vulnerable we all are in facing these kinds of threats, I reflected on the job of an oncologist. I give bad news on a regular basis, I control opiate prescriptions, and many of my patients feel their pain is not well controlled, a phenomenon seen across many oncology patients.2 If we think physicians are only murdered in the emergency room or on the psychiatry unit, we are fooling ourselves. Recent changes to concealed carry laws and increasing levels of medical mistrust and anger directed at health care workers in the wake of the COVID-19 pandemic likely will increase all providers’ risk of gun violence.

 With reflection, I now understand that my experience then was made worse by the lack of informed response by leadership to mitigate my trauma and the lack of efforts to improve safety. We deserve leaders and hospital staff who know immediately what to do when a physician is threatened, including reassigning the patient to a new provider immediately, having hospital administration or patient care services review with the patient the zero tolerance policy to provider threats, and allowing a prompt leave from work to address the trauma response, which is best done immediately after the event not months later or only on request.

 We deserve urgent access to therapists and peer support who understand how to process and overcome trauma. Institutions should track threats to providers in real time and make rapid changes to improve safety. As individuals facing a traumatic patient encounter, we cannot afford to wait for the system to catch up to our needs. We can seek our own counseling and professional support while also providing critical support for our peers.3-5 I thought I was the weak one for not being able (even still) to let this death threat be in the past. I realize now that I am brave and strong for asking for help. We deserve safe environments and clinical practices to allow us to do the difficult work of being an oncologist without worrying about our personal safety. Together we can create clinics, hospitals, and teams that prioritize provider safety and proactively work to mitigate the trauma of patients and families who threaten their physicians and providers.

 Dr. Lidia Schapira: Hello and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I'm your host, Dr. Lidia Schapira, associate Editor for Art of Oncology and a professor of medicine at Stanford University. Today we are joined by Dr. Noelle LoConte, associate professor of Medicine at the University of Wisconsin School of Medicine and Public Health. In this episode, we will be discussing her Art of Oncology article ‘I Want to Kill You’.

 Our guest disclosures will be linked in the transcript.

 Noelle, welcome to our podcast. Thank you for joining us.

 Dr. Noelle LoConte: You're welcome. Thanks for having me.

 Dr. Lidia Schapira: It's our pleasure.

 Dr. Lidia Schapira: I like to start the conversation by asking authors what it is that they're reading or what book they would recommend to a friend.

 Dr. Noelle LoConte: Oh, that's a good one. I'm reading a book called Hell of a Book right now. Highly, highly recommend it. It's phenomenal. And a book that I would recommend that I recently read - well, Pachinko is a book that I read last year, but I just can't stop thinking about it. So I think that would be my recommendation.

 Dr. Lidia Schapira: So good fiction is a wonderful way of releasing stress after a hard day at work.

 Dr. Noelle LoConte: Truly.

 Dr. Lidia Schapira: Can you talk a little bit about what made you write this particular piece? Are you somebody who likes to write to process experiences, or was this a particular message that you needed to convey?

 Dr. Noelle LoConte: Yeah, I used to journal quite regularly, but gave that up when I started residency and haven't really picked it back up. But this story kind of wrote itself for me. I felt compelled. I could not stop thinking about it, and eventually, I had to do it.

 Dr. Lidia Schapira: Reading it is very impactful. And you start with this amazing line, "My patient threatened to kill me." So you're telling us immediately what happened. And the story is quite awful, and I don't know if I should ask you to tell us a little bit about it, but just for the sake of bringing the listeners into the story, can you very quickly recap what happened and how that made you feel?

Dr. Noelle LoConte: Yeah, the quick version is I had a long-standing patient in Oncology who I had an established relationship with, who had no red flags for me, who was getting the news of a recurrence, and in response to that news, gave me what I thought was a credible threat to kill me. And the story is about sort of what happened after that, the ripple effect even years later, and how the response of my boss, my health system, my colleagues maybe amplified or made it worse. And then what really compelled me to write this story was when there was a physician that was murdered by a patient, I think not an oncologist, but I just felt the circle sort of tightening in that eventually we're all going to have to think about this. And so that's really what pushed me to write it.

 Dr. Lidia Schapira: Yes, and we're grateful for you bringing it to our attention. Let's just start by reflecting on this relationship you had with a patient. You opened the essay by saying that you seemed to trust each other, that you were delighted to see her name on the schedule, that she knew about you, that you had shared freely about your life. And then this threat comes out of nowhere. You didn't anticipate it, and it also comes at a time when there were very few people around because it's a holiday. So tell us a little bit about how you felt in that moment. You basically wanted to make a quick exit from the room, and that comes across, but can you tell us a little bit about what the feelings were that you experienced at the time?

 Dr. Noelle LoConte: Immediately, I felt terrified because whether she intended to or not, I believed her that she had a firearm and was going to kill me. The story goes into why I felt that way, but suffice to say; I couldn't sort of intellectualize my way out of this one. I really, deep in my heart, felt panicked. I think after the fact after I got out of the room and got through that day of clinic, I felt ashamed. I think that was probably the emotion I felt, that I fell for it, so to speak, that I didn't just trust that everything was going to be fine.

 Dr. Lidia Schapira: Can we talk a little bit more about that shame? I think that is such an important feeling that many physicians share an experience at some point and often doesn't get talked about. How long did it take you to understand that it was perhaps some shame that you were also feeling and perhaps that that was also isolating and compounding the trauma?

 Dr. Noelle LoConte: I would say I felt ashamed because I got back to the workroom, and I had to ask for help. I'm of a generation of physician before work hour restrictions and caps and so forth, where I worked many a day, totally sick. I don't think I had ever called in sick to that point. I'm not saying that to say that's the right approach. I, in fact, do not think that's the right approach, but that's the type of physician that I am and how I grew up. I'm also from the upper Midwest, where work ethic really is like the most important personal characteristic, so I take my work pretty seriously. So I felt I had let myself down, I'd let my team down, I had let my patients down, that if I had been a “better physician,” that this wouldn't have gotten to me the way it did. So I would say I felt shame almost immediately. It's been the letting go of the shame that has taken a lot longer.

Dr. Lidia Schapira: Talk to us a little bit about the process of letting go of the shame. You mentioned very specifically some activities that helped, finding a therapist that helped, taking time away from work that helped. But walk us through that process.

 Dr. Noelle LoConte: Yeah, and I think part of the story, too, is that I kind of bumbled into this, and it would have been better for people above me or supporting me to be like, “You need to do X-Y-Z.” And ultimately, it was when I landed with Primary Care that they were like, “Oh yeah, we get threatened all the time. Here's how we do it.” But yeah, what I did was I used employee assistance program, and then they connected me with a trained therapist who worked with providers that have been threatened - so unfortunately, a growing population for her - and I just in that moment decided to set aside my need to kind of be evidence-based and intellectualize my way out of everything, and I said I am just going to trust that whatever they tell me is sound, and no matter how ‘woo’ it sounds to me, I'm just going to do it. Because, at the time, I wasn't sleeping at all. At this point, it had been days, I think since I had slept. And she talked about hydration, nutrition, exercising to really get your heart pumping, get really sweaty, having a safety plan, not being alone. And so I just really just said, ‘I'm just going to do it.’. And then, ultimately, it's really time away from the incident. I mean, it still has not left me, but it is much better.

 Dr. Lidia Schapira: Can you share with us a little bit how this impacted your life away from work, at home, how it impacted your relationship with your kids, with your peers, and with people you interact with outside of medicine?

 Dr. Noelle LoConte: Yeah, I mean, the most immediate thing was that, unfortunately, there was an active shooter alert that happened shortly after my incident. And I was at home with my kids, and in the moment, I thought I was going to die, and I thought my kids were going to be left without a mother. So, my kids, I wanted to keep them safe from harm, and so I had real moments of thinking like, I should leave my job. It's not worth it. As far as my husband, he's also a physician, and so he implicitly understood.

 Dr. Lidia Schapira: I'm glad you had the support that you needed. But you talk a little bit about the lasting trauma, and in the article, you mentioned that what led you to write about this was that there was a trigger that occurred. Can you share a little bit about that? And not only what the triggering incident was, but how do you continue to deal with sort of this ripple effect of what happened now several years ago?

 Dr. Noelle LoConte: Yeah, the triggering event for me was I was up on our inpatient unit. So I'm an academic oncologist, we have an inpatient oncology unit. At the time, it was staffed by medical oncologists, we do a week at a time. Now it's shared with the hospitalist, which is wonderful. Actually, it's a great model. But I was the medical oncologist up there, and so you get whatever comes in the door for that week, and there was a patient who was angry and frustrated and had a very bad cancer and the recipe for possible aggressive behavior. And so we were rounding, and I was in the room, and she started yelling at me, and her mother started yelling at me about parking and the food in the cafeteria and when her CAT scan was going to happen - things I have zero control over. But I'm used to– I think all oncologists are used to kind of being the receptacle for people's feelings about an out-of-control situation. At least they can control their conversations with us.

 So in the moment, I was like, “Okay, she's not really mad at me, she's mad at the situation, and I'm just going to let her get this out.” But what happened was it brought me right back to that room with my patient, and I dissociated for the first, and I think maybe the only time in my life where I physically could feel myself, like, leaving my body. It was very unsettling for me in the moment, and I had to kind of back up against the wall and ground myself. I realize now what I was doing. But yeah, so that happened. And then that same day, I think, was the day that the orthopedic surgeon got killed. And so I was just like, ‘What is going on?’ There's so much gun stuff right now that it's just impossible to be like, “Well, I'm never going to think about this again,” because it's in your face all the time.

 Dr. Lidia Schapira: I'm so sorry this happened to you. And again, on behalf of all of our readers, we're grateful that you took the time to share the experience with us.

 So thinking a little bit about how we can respond to colleagues and how we can perhaps prevent some of these consequences of violent threats or acts of violence, what have you learned, Noelle? How should organizations respond? What do we need? What can we expect?

 Dr. Noelle LoConte: Yeah, I think if you're in a leadership position over a clinic, over a group of providers, including physicians, NPs, APPs of any variety, learners, medical students, residents, fellows, you need to know at a moment’s notice what to do if that person is traumatized. And I would include threats of violence in that trauma. Ultimately, it was sort of a game of hot potato with me, and nobody really knew, and they were looking into it, and it's really time sensitive. So I would say if you're a leader, know what to do and know it immediately. I think the other thing is, if you're a male, know that this happens to your female colleagues and non-binary colleagues much more. One of the strategies is to transfer the patient to a male provider. I think hospital security could have been more responsive to my concerns. So in my workspace, and it continues to this day, the provider’s in the corner of the room, so you have to walk past. I think we could take some cues from psychiatry and emergency medicine, having things like panic buttons, easy exit for providers, security walk-throughs.

Dr. Lidia Schapira: It saddens me to think that we need to think about it and plan for it in a way because we talk so much and train so much for establishing trusting relationships with our patients, and what you're saying is, basically, we can't take anything for granted, even in the context of what appears to be a functioning longitudinal relationship. And that's a scary thought. How do you go to clinic every day and think that this might happen again when you walk into a room?

 Dr. Noelle LoConte: I mean, I'd be lying if I didn't say I sort of compartmentalize it, right? I am much more cautious about what I share with my patients about my family. I always kind of take a scan of the room when I'm entering right now and kind of know my surroundings a little bit better, I would say. And I don't assume, I think before this, I had assumed if they have brain mets, if they have a history of a psychotic mental illness, something like that, that I would be more concerned. I'm sort of always aware that this could happen. I think advocating for things like metal detectors, hospital security are all good things too, and I have much less tolerance for being the punching bag, I would say right now. So when people get angry, I just say, ‘I'm leaving the room. When you've calmed down, I'm happy to come back. Here's how to get a hold of me.’ And that's all just self-preservation. That's not because I think patients are bad for being angry. I would probably be angry too, but I need to have clear boundaries about what I can and cannot do.

 Dr. Lidia Schapira: How do you think this experience has changed you? And do you think that your colleagues and your patients appreciate the change?

 Dr. Noelle LoConte: I think it's made me less open. It's definitely made me not want to have super close relationships with patients anymore. Less trusting. I mean, I know that my colleagues happily covered my clinic, but I know there are also hospitals where that wouldn't happen. I'm eternally grateful to those few weeks where they let me take a breather because that's when I realized I really love patient care, and I missed it. I don't know if everybody loves the new me, but I don't know that we had a choice.

 Dr. Lidia Schapira: Do you think this is, in part, a gendered conversation? You mentioned that it's more likely to happen to women. Can you expand a little bit on that for listeners?

 Dr. Noelle LoConte: Well, when you go to the literature, which of course, being an academic oncologist, was my first response, this happens all the time in emergency medicine and psychiatry. Much more common against women, I'll say providers, but physicians in particular. So yes, it is absolutely a gendered conversation. I think the expectation when we walk in the room is a different expectation about how relational we're going to be, how caring and compassionate. It's not just enough to be competent and intelligent. You also have to be motherly and loving and all this. So, yes, I absolutely think it's a gender conversation for sure. For sure.

 Dr. Lidia Schapira: Are there any texts or papers that have been particularly helpful to you or stood out to you that you would recommend to others?

 Dr. Noelle LoConte: There was a series, I believe, in emergency medicine literature. I can circle back to you guys and get you the exact reference, but I found their strategies for dealing with aggressive patients very helpful. And I actually found talking to my nursing friends and colleagues was really helpful because they are really experts in de-escalation. So I really rely on them to kind of get language that makes sense coming out of my mouth like that whole, “I'm going to come back when you stop being angry.” So I would say more than any individual article, it was talking to nurses.

Dr. Lidia Schapira: I imagine a simulation exercise could be helpful as well for all of us, right? Especially those of us who may be more at risk or have the sort of open, sincere approach to patient care as if we can trust everybody, and perhaps we can. We're very glad that you shared what you were able to share.

 Dr. Noelle LoConte: Thank you.

Dr. Lidia Schapira: That you brought attention to this very important topic to our community, and I'm sure you've already had responses from colleagues. We've certainly heard from a lot of people who really appreciate your honesty and bringing this story forward and have unfortunately heard similar stories from colleagues.

 Dr. Noelle LoConte: Yeah, I think it's pretty common.

Dr. Lidia Schapira: So good luck, read well, play a lot, exercise your brains out until your heart rate is in the stratosphere. And thank you. Thank you for sending it. Thank you for sharing it. I know it's been very difficult.

 Dr. Noelle LoConte: You're very welcome. Thank you for reading it.

 Dr. Lidia Schapira: Until next time. Thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review, and be sure to subscribe, so you never miss an episode. You can find all of the ASCO shows at asco.org/podcasts.

 The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. 

Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

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 Guest Bio:

 Dr. Noelle LoConte is an associate professor of Medicine at the University of Wisconsin School of Medicine and Public Health.

 Additional Reading:

 1.         Richardson SK, Ardagh MW, Morrison R, Grainger PC. Management of the aggressive emergency department patient: non-pharmacological perspectives and evidence base. Open Access Emerg Med. 2019 Nov 12;11:271-290. doi: 10.2147/OAEM.S192884. PMID: 31814780; PMCID: PMC6861170.  

2.         Incivility in Health Care: Strategies for De-escalating Troubling Encounters