The Canary in the Coal Mine

Scott Tcheng, MD

The emergency department (ED) has been called many things by many

people: “The front door to the hospital.” “Society’s safety net.” “The canary in the coal mine.” We are, in fact, all these things, but the troubling part of the last metaphor is the unspoken implication. Historically, canaries were carried deep into coal mines where their small size and high metabolism made them especially susceptible to carbon monoxide and other toxic gases, providing the miners an early warning and hopefully enough time to escape. In other words, the canary is meant to be sacrificed, and its loss is considered acceptable as part of the cost of doing business.

The last several years of the COVID-19 pandemic have accelerated growing burnout among healthcare workers, including emergency physicians (EPs), who ranked highest in burnout on a recent Medscape survey. As more attention is paid to wellness and burnout, we are finding that a substantial proportion of nurses and physicians are considering leaving the professions entirely, which will only worsen existing staffing shortages and create a positive feedback loop of resignations. The roots of burnout in healthcare run deep, with violence and workplace safety being just one of them. To be sure, they are not the top driver of burnout in medicine, but they are a symptom of a larger disease and still warrant attention. Recent high-profile incidents involving hospital shootings continue to make the news, but there are data going back decades indicating that a large majority of nurses feel unsafe in their workplaces due to workplace violence. Moreover, despite California passing a law requiring hospital safety standards after a nurse was attacked and killed, a 2020 survey showed that in the three years since going into effect, California healthcare facilities reported nearly 23,000 assaults, while 77% of hospitals made no safety improvements following an assault.

A more recent survey in August of this year by the American College of Emergency Physicians (ACEP) revealed that nearly nine out of ten EPs agree that violence in the ED has increased in the last five years, and almost eight out of ten have either witnessed an assault or been assaulted themselves. Similar percentages feel that this has negatively affected patient care (89%), increased wait times (85%) and adversely affected physician and staff productivity (87%). Most assaults were by patients or by patients’

friends or family. However, almost 30% of assaults resulted in no response by the hospital or hospital security, and in only 2% of cases were charges pressed by hospital security. Several respondents indicated that they were encouraged NOT to press charges out of fear that it would reflect negatively on the hospital. “Word cloud” from physician survey question re "What are the potential So how did we get here, to contributors to patient violence?" a point where the system prioritizes protecting the abusers over the abused? There is a term known as the “normalization of deviance.” It has been used when examining the root causes of large-scale disasters, such as the ill-fated Challenger space shuttle launch and Chernobyl power plant meltdown, as well as to the healthcare system. It holds that people within an organization become so accustomed to a deviance from standard or proper behavior that they no longer consider it abnormal. We would never (or at least should never) tolerate daily verbal and physical attacks in any other workplace, and yet they have come to be viewed as “just part of the job” for us. I would argue that the simmering possibility that a patient might erupt and lash out has been normalized in healthcare, to our detriment. Chronic exposure to such toxic behavior has a pernicious effect on the healthcare workforce through a gnawing, indolent decay in morale, and it is time for change. As a first step forward in ensuring the safety of our healthcare workforce, I would propose several ideas: (1): Establish and enforce a definitive code of conduct for hospital patients with zero tolerance for abusive or assaultive behavior. Voluntary violations of this code of conduct, that is, not as the result of mental illness or medical delirium, should have tangible consequences. Mass General Brigham, which includes two of the most prestigious teaching hospitals in the country, recently implemented such a system, and “violations of this Code may lead to patients being asked to make other plans for their care and future non-emergency care at Mass General Brigham may require review.”

(2): Establish legal protections for healthcare workers, akin to those afforded to crew members on airplanes. The FAA has responded to an alarming rise in aggressive and violent behavior on flights by adopting a zero-tolerance policy with legal enforcement and consequences. It is a violation of federal law to interfere with, intimidate, or assault the flight crew on an airplane, and such actions are punishable through fines and jail time. They have even released public service announcements with the tagline

“You Don’t Want Your Pilot Distracted: Unruly Behavior

Doesn’t Fly.” I would argue that an unruly patient can be just as distracting to the smooth functioning of a hospital as an unruly passenger is to a flight. Healthcare adopted measures like safety checklists from the airline industry, and we would benefit from adopting this as well. The bipartisan “Safety from Violence for Healthcare Employees (SAVE) Act” has been proposed, and it has the backing of the American Hospital Association and ACEP. A separate bill, the “Workplace Violence Prevention for Health Care and Social Service Workers Act,” has been passed in the House but is still awaiting passage in the Senate. (3): Commit to adequate staffing and security. A large driver of patient anger and frustration can be boiled down to long wait times and ED boarding. The pandemic has exacerbated

ED boarding times and left without being seen (LWBS) rates, bringing EDs across the country to their breaking points. These have been historically viewed as problems of ED “flow,” rather than larger hospital or systems-level dysfunction, but the entire pipeline, from patient arrival to hospital discharge, needs to be re-examined, including the effect of “lean” nurse and ancillary support staffing.

It is also not enough just to have a security presence in hospitals; security staff need to be trained and empowered to respond to incidents in an effective manner, whether that be through verbal de-escalation, or physical intervention if that fails. Often, they are not allowed to physically touch patients, even ones who have become dangerously violent and disruptive. Such policies signal to the rest of the staff that their lives are not worth protecting and are acceptable collateral damage.

In the end, platitudes about practicing mindfulness and using meditation apps are insulting at best, and ineffectual at worst, gaslighting us into believing that the problem is just a matter of being more resilient, and not that the current system has grown increasingly untenable. After we all spent the greater part of a decade (or more) in training to get where we are today, our fortitude should not, and cannot, be questioned. We all strapped in and helped pull society back from the brink of the worst pandemic in a century. We will continue to do so, with the love and empathy that we have always strived to show. All we ask is that that same care and compassion be extended back to us. Otherwise, there might come a day when we look up and realize there are no more canaries left.

Scott Tcheng, MD is an emergency physician at multiple San Francisco hospitals and co-chair of the San Francisco Emergency Physicians Association. The views expressed here are his own.