Opinion: Readers comment on Medical Economics stories.

After the violence

I was shocked and alarmed by the excellent article "Danger in the exam room" by Dr. Richard J. Mansfield [July 4, 2008]. In it, the author describes how he was threatened and physically assaulted by a narcotic-seeking patient. The author states that, after he was choked by the addict and held hostage in the exam room, he managed to escape by offering a prescription for Percocet.

It is fortunate that the author was able to?avoid further harm in this way. However, he does not state what action he took after the addict left his office to head for the pharmacy. Obviously, the physician's duty in such a case is to call the police, have the addict arrested, and to press charges. In this case, the obligation of the physician to protect others in the medical system - as well as society at large - from a violent criminal must supersede any sympathy for this patient.

How not to get attacked

Certainly Dr. Mansfield's experience is uncommon, but there were a number of mistakes that he made to build up to this turn of events.

The chief one was a lack of situational awareness. Particularly when dealing with potentially violent patients, his lapses in awareness are cardinal mistakes. Doubtless, his rush to catch up on his schedule and his attention to the EHR caused him to miss the clues in the patient's demeanor and movements prior to the attack, which signaled that aggressive behavior could be imminent.

He was dismissive of institutional precautions designed to alert him to danger. He failed to pre-plan the visit, including addressing the tardiness that both of them were guilty of.

Before this, however, he failed to plan the exam room. Even in a government-issue room, there is the opportunity to make sure that the patient is not arrayed between the doctor and the exit. His arrangement for the phone to not be right beside him is inexcusable as well. This patient would appear unlikely to injure him beyond the initial contact, because he had a purposeful goal of receiving narcotics. However, other patients in the Veterans Affairs Medical Center have psychiatric illnesses that render their behavior less predictable.

Training in self-defense methods should have been a part of this physician's personal exercise regimen since taking this position. He would have had the training of mind, of focus, and of body to not be in a position to have "nothing that I could use for self-defense." The time he took to think through his options was the time wasted that he would have needed to defend himself against a more potent attack.

Now that he has experienced this, he has lost his primary vulnerability: unawareness of helplessness. Writing the prescription when he knew where it would be filled is understandable, but to not follow it up with a call to security, meeting him at the pharmacy, arresting him for assault, and filing for termination of his VAMC privileges is an inexcusable validation of his approach.

GREGORY HOOD, MD
Lexington, Kentucky

Equal rights for docs

Starting a business and making money is never unethical ["How to set up a concierge practice," August 22, 2003]. Your doctor has as much freedom to make a career choice as you do. It often seems that physicians don't have any freedom anymore, having to rush as many patients in and out as possible just to make enough money, always beholden to the whims of insurance companies.

WILLIAM WEBBShreveport, Louisiana

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