One morning last summer, when I was seeing patients in a Bronx clinic, a nurse told me to lock myself in an exam room. A patient’s father was looking for me, angered about my report to child protective services. Even though he eventually left, my chest cramped when I learned that he planned to return. Just weeks before, a doctor in another state had been shot dead by a patient; and very recently, there had been three shootings near the clinic where I was working. I relayed my safety concerns to a clinic administrator and was handed a small silver plastic whistle.
Not long after, I decided to resign.
A year ago, Surgeon General Vivek Murthy, MD, MBA, sounded the alarm on workplace violence in healthcare as a contributor to skyrocketing health worker burnout and resignation. Despite his national advisory calling for zero-tolerance violence policies, the issue of gun violence in healthcare remains underreported and unchecked, particularly in clinics and other non-hospital settings.
From 2010 to 2020, the Joint Commission, the largest standards-setting and accrediting body in healthcare, received 39 reports of hospital shootings. Most were staff shot by patients. While the commission issued updated healthcare workplace violence prevention standards in 2022, they are mostly directed towards hospitals, leaving health workers in many outpatient facilities unprotected.
One healthcare facility shooting took place per week in July 2023, with two occurring at outpatient clinics. Three were intimate partner violence related.
On July 11, 2023, a disturbing notification popped up on my cell phone, “Patient shoots, kills orthopedic surgeon in clinic.” Benjamin Mauck, MD, a 43-year-old specialist in childhood hand deformities and father of two young children, had been shot dead in a Tennessee clinic exam room, allegedly by patient Larry Pickens.
Law enforcement characterized the shooting as an isolated “one-on-one interaction“; the public was advised to say something if they see something suspicious in the future. Yet, less than 1 week before and just 7 miles away, an affiliate orthopedic clinic had alerted police about concerning behavior by Pickens, as did his stepfather for violent behavior in 2016. But none of these red flags helped protect Mauck from getting shot.
Less than 2 weeks after Mauck’s death, 44-year-old hospital security guard Bobby Smallwood was shot to death on an Oregon hospital maternity unit. Then, 3 days later, a physician was found with a gunshot wound on the grounds of a medical building in Cedar Hill, Texas. The shooter’s girlfriend worked in the same building and may have been the intended target.
The Department of Homeland Security (DHS) describes healthcare shootings as “unpredictable,” but research indicates that there are some patterns. For example, a 2019 study of 88 acute care hospital shootings found that most occurred in the summer; winter was the second most violent season. A study of physician involved shootings found most were related to dissatisfaction with health outcomes. According to StatPearl, outpatient clinics are the second most dangerous site for healthcare shootings, next to the emergency department.
While there have been efforts to make healthcare safer, they often aren’t backed by science and may worsen health inequities. A recent JAMA article evaluated armed officers in hospitals and found that 17 patients were shot by hospital security from 2009 to 2022. Of those patients shot, most were Black and/or exhibited signs of mental instability.
Some hospitals now flag patients’ charts to alert staff to potentially violent behavior. Not surprisingly, a study published in JAMA found that Black patients were flagged more than white patients using this system, and suffered longer wait times, which can increase risk for healthcare violence, according to the Occupational Safety and Health Administration.
Recently, the International Association for Healthcare Security and Safety proposed new guidelines for weapons screening, including metal detectors and “amnesty boxes” for voluntary firearm storage at hospital entrances. While a study found that metal detectors were effective in confiscating weapons, whether they reduced healthcare violence is unknown.
This year, the Senate proposed the bipartisan Safety from Violence for Healthcare Employees Act, making assaulting healthcare workers a federal crime. Similar legislation has been proposed by the House and endorsed by the American Hospital Association. However, in states that have increased penalties, there is no evidence to support effectiveness.
So, what next? Are any interventions effective?
Extreme Risk Protection Orders, also known as “red flag” laws, offer a promising, evidence-informed tool for suicide, mass shooting, and homicide prevention. Through a non-criminal legal process, a patient at risk of harm to themselves or others can be temporarily prevented from possessing and purchasing firearms. While available in 21 states and the District of Columbia, and to health professionals in six states, red flag laws are underutilized. The Bipartisan Safer Communities Act offers federal funding to support state implementation.
What can we, as healthcare professionals, do?
First, we must speak up, for our profession and our patients. We can promote understanding and ways to reduce healthcare rage, before criminalizing patients. We can ensure healthcare organizations invest in gun violence prevention strategies that are evidence-based, and that prioritize our safety over industry profits. We can’t afford to wait.
Nina Agrawal, MD, is a pediatrician in New York City. She leads gun safety advocacy for the American Medical Women’s Association and New York State-American Academy of Pediatrics.
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