Rachelle "Shelley" Shannon recently was released from prison, and suddenly, I found myself with one more thing to worry about as a physician. Shannon shot and injured family physician George Tiller, M.D., in 1993, and the anti-abortion terrorist also was responsible for firebombings and acid attacks on several clinics in three states. Clinicians throughout the country who provide abortions are concerned because Shannon continued to communicate with extremists during her incarceration, is considered to have mentored and motivated other attackers, and is part of a larger group that believes killing doctors who perform abortions is an act of justifiable homicide.(www.kansascity.com) Tiller survived Shannon's attack but was murdered in 2009 at his church by Scott Roeder, who communicated with Shannon and visited her while she was in prison. I have colleagues who provide abortions and have had protesters show up at their homes and distribute pamphlets in their neighborhoods, causing them to worry not only for their own safety but for that of their children. Other colleagues have received threatening letters in the mail. These intrusions into physicians' private lives are in addition to the risks we take on every day in our clinics. Regardless of whether you provide abortions, physician safety is an issue we all need to consider. As family physicians, we see the gamut -- patients with mental health battles, patients in need of pain management, patients struggling with the social inequities that are impacting their abilities to lead healthy lives. Unfortunately, we sometimes become the target of their anger and the recipient of their violent outbreaks. Houston cardiologist Mark Hausknecht, M.D., was murdered(www.cnn.com) by the son of a former patient as he rode his bike to work in July. Steven Pitt, D.O., a forensic psychiatrist,(thedo.osteopathic.org) was shot and killed in June outside his office in Arizona by a suspect who had undergone a mental health evaluation by Pitt during a divorce and custody battle. Todd Graham, M.D., was fatally shot(www.washingtonpost.com) in July 2017 in a rehabilitation center parking lot in Indiana by a patient's husband after Graham denied the woman's request for opioids. Family physician Tracy Sin-Yee Tam, D.O., was killed and six others were injured in June 2017 when a disgruntled physician sought revenge at a New York hospital. Psychiatrist Ruth Anne MarDock, M.D., died in 2016(www.dallasnews.com) when a patient attacked her at a Dallas psychiatric hospital. The fundamental reasons that lead us to become physicians in the first place -- to help people -- can set us squarely in harm's way when we offer assistance outside the workplace. Family physician Jerry Rabinowitz, M.D.,(abcnews.go.com) was murdered last month while responding to the sound of gunshots at the Tree of Life synagogue in Pittsburgh. According to the Bureau of Labor Statistics, violence in health care settings(health.usnews.com) accounts for 45 percent of workplace violence in the United States. And the rate of serious workplace violence -- that which leads to days of missed work -- is four times higher than the average for private industry. In fact, violence is likely underreported,(www.osha.gov) in part because many threats and incidents of verbal abuse are considered part of the job. How many of us can recount stories of being attacked verbally by an irate patient? Did you report it as an act of violence? Not likely. Luckily, I have never been physically injured by a patient. However, I have been verbally attacked many times throughout my medical career. One incident, when I was seven months pregnant, truly scared me. A patient at the hospital was upset he hadn't yet received the pain medications he was requesting and started yelling obscenities, ripped his IV out and demanded to see the doctor in charge. Security was called, the nurse manager assisted the patient back to his room, and I followed to attempt to de-escalate the situation. With the nurse manager by my side and security in the room, I began a conversation with the patient, using the well-practiced skills I had developed in residency during similar situations. This was different. At one point, the patient stood up and came toward me. Security and the nurse manager stepped forward as I backed away. Although the patient eventually calmed down, I reacted differently than I had in the past and realized that I felt vulnerable, in my current pregnant state, in a way that was quite foreign to me. It made for a good teaching moment for both me and my residents: As physicians, we must have an awareness of where we stand emotionally, physically and mentally as we care for our patients. Moreover, we must recognize and be flexible with how this may change depending on what is happening in our own lives. Similar to understanding and acknowledging our own biases, we need to continuously evaluate how the events in both our personal and work lives are affecting us, because they will impact how we perceive and react to our patients, particularly in highly emotional, tense situations. We may inadvertently escalate a situation if we aren't aware of the possible triggers a patient presents. In addition to being self-aware, there are many steps we can take to keep ourselves safe. Within our clinics, we can put in place the following practical measures: Set up exam rooms so the patient is not between you and the door. Be alert as you enter and leave your building (not distracted by your phone). Train office staff to de-escalate and defuse tense situations, have safety protocols in place, and practice drills as a team. Recognize which patients have potential risk factors for escalation and, when possible, do what you can to prevent or minimize a conflict before it starts to become heated (e.g., be clear with patients about expectations, be firm about boundaries, be sure to acknowledge patient concerns and fears). Review Occupational Safety and Health Administration (OSHA) resources(www.osha.gov) and CDC recommendations(www.cdc.gov) for minimizing workplace violence and managing conflict. Within the exam room, a shared problem-solving approach often can help patients feel as though they have some control regarding what is likely an anxiety-producing interaction for them. I've found the best approach is to show compassion for my patients and to approach them with an understanding that I haven't walked a day in their shoes. Moreover, I remind myself that we, as family physicians, are here to care for these patients holistically. Many times, the patients I treat have been judged, mistreated and dismissed by the medical community. Although they may be challenging, they, too, need care. More broadly, work with local, state and national organizations to discuss with lawmakers and advocate for protections within our clinics and hospitals. Here in California, U.S. Rep. Ro Khanna has spearheaded the Health Care Workplace Violence Prevention Act,(www.congress.gov) which would direct the secretary of labor to issue an OSHA rule requiring health care facilities to adopt comprehensive workplace violence prevention plans. It is important that our voices and our concerns are heard. We deserve to be safe as we work hard for the health of our patients and communities. 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