Are incivility and pandemic denial from unruly patients the new normal?

What happened to being “healthcare heroes”?

Medical group practices have always dealt with a few patients upset over wait times or payment issues, but two years of the COVID-19 pandemic have added several sources of discontent that have led to those patients becoming disruptive, unruly and sometimes violent.

The gamut of potential flashpoints for angry and upset patients runs from those who insist on receiving unproven and unauthorized COVID-19 remedies (e.g., ivermectin, hydroxychloroquine) to vaccinated patients who lament appointment wait times and lack of hospital beds due to continually high ICU utilization by unvaccinated COVID-19 patients.

A Jan. 4, 2022, MGMA Stat poll found that 71% of medical practices had incidents of disruptive patients increase in 2021, while 25% reported no change and 4% said they saw a decrease. The poll had 580 applicable responses.

Among all respondents who told MGMA about the sources of those disruptive patients:

• Refusal to wear masks in practice facilities was the most frequently cited reason.
• Several practice leaders cited patients who refused to believe positive COVID-19 results, even when symptomatic, and patients who refused to take COVID-19 tests or submit to screening procedures (e.g., temperature checks).
• Other practice leaders cited higher rates of patients expressing anger over not receiving return-to-work or school notes without COVID-19 testing.
• Many administrative leaders cited patients’ dismay over visitor policies that limited the ability of children or other guests to join the patient in the facility. The inability to bring children along for obstetrics visits especially resulted in disruptive behavior from some patients.
• Frustration over scheduling issues and patient wait times, often a byproduct of staff shortages causing longer-than-usual call-back times and/or lack of provider availability.

Matt Biersack, MD, president of Mercy Health Saint Mary’s in Grand Rapids, Mich., called the “unrelenting” disruption, verbal abuse and sometimes assault by patients and some family members as the largest crisis in the industry behind COVID-19 and staffing shortages, as reported by MLive last month. Jamie Brown, a critical care nurse at Ascension Borgess Hospital in Kalamazoo and president of the Michigan Nurses Association, noted that patients are increasingly becoming hostile and “unreasonable,” including when required to submit swabs for COVID-19 testing prior to surgery.

This is echoed in a survey from the National Nurses United union, in which 31% of hospital nurses reported small or significant increases in workplace violence, as reported by Insider.

Pain all around

Healthcare workers aren’t alone in suffering through interactions with short-tempered or disruptive customers amid the pandemic, nor are they necessarily the primary targets for these frustrations.

Americans reported not trusting others to be honest about their COVID-19 vaccination status, per a May 2021 Axios-Ipsos poll. That fundamental unease could be a cause for animosity and the potential for conflict among strangers.

The surge in disruptive behavior and violence during the pandemic is not limited to healthcare:

• Through Dec. 21, 2021, the Federal Aviation Administration (FAA) tallied 5,779 unruly passenger reports, of which 4,156 incidents were mask-related. The FAA launched more than 1,050 investigations in that period, more than double of any year dating back to 1995.
• School board meetings across the country became hot beds of incivility as several people used the forums to berate and threaten education officials about mask mandates and other issues.
• In June 2021, a grocery store cashier was fatally shot in Georgia after a customer argued with her about the store’s mask requirement.
• The frequency of anti-Asian incidents — sometimes seen as a byproduct of people of Asian descent being wrongly treated as scapegoats for the pandemic — grew in the first half of 2021 after a major increase in 2020, “despite months of political and social activism,” as reported by the Associated Press.
• One year following an attack on the U.S. Capitol that was prompted by false belief in election fraud, hundreds of individuals took to internet forums (such as Reddit’s r/QAnonCasualties) to lament the false beliefs and conspiracy theories that have radicalized family members and friends, several of whom have stopped listening to longtime primary care physicians.

Addressing workplace violence in healthcare and provider/staff mental health

As noted in a January 2021 MGMA Connection magazine article, healthcare had five times the rate of violence than all other industries prior to the pandemic in 2018, according to U.S. Bureau of Labor Statistics data.

• Read more about security and vulnerability assessments for practices.
• Emergency departments are high-volume traffic areas where potentially volatile situations arise daily. Read more about solving ED security challenges.

The psychological stress of the past two years of the pandemic makes it important for practices to continue focusing on the emotional health and well-being of providers and staff.

Even if some aspects of the pandemic seem routine more than two years into dealing with COVID-19, it is still a crisis that manifests through employee stress, labor issues and patient behavior. As such, medical group leaders should consider developing and sustaining behaviors that help manage a crisis, including:

Engage the team; connect with individual team members

• Relate on a personal level first then focus on work; conduct a “pulse check” throughout the week with different individuals
• Lead with empathy
• Support employees as well as patients and others who work with you outside the organization
• Collect and share the positive — acts of kindness, patient feedback, coworker acknowledgments, obstacles that have been overcome during this time.

At the same time, leaders need to watch for how employees might be exhibiting or communicating different types of stress symptoms:

Emotional symptoms of stress

• Becoming easily agitated, frustrated and/or moody
• Feeling overwhelmed or not being in control
• Low self-esteem; feeling lonely, worthless, depressed
• Lack of motivation
• Defensive, extra sensitive to criticism

Physical symptoms of stress

• Headaches
• Low energy, tiredness
• Upset stomach, digestive problems
• Body aches and pains
• Rapid or racing heart rate
• Nervousness and shaking, cold or sweaty hands and feet
• Fidgety, pacing, not able to sit still or relax
• Clenched jaw and grinding teeth

Cognitive symptoms of stress

• Constant worrying
• Forgetfulness/disorientation
• Racing thoughts
• Poor judgment
• Inability to focus or concentrate
• Procrastination or avoiding responsibilities.

How leaders can reduce stress at work

• Act as a positive role model; remain calm during stressful situations.
• Talk to employees — find out what factors are causing the most stress (e.g., failing equipment, understaffing, uncertainty about their jobs and futures).
• Communicate one-on-one with employees — make sure they feel heard.
• Deal with workplace conflicts in a positive way.
• Give employees the opportunity to participate in decisions that affect their jobs.
• Make sure expectations are clear and help employees define their roles, responsibilities and goals.
• Recognize employees for a job well done.
• Over communicate during these stressful times so that everyone is on the same page.

Ending the patient-provider relationship

In many cases, unruly and disruptive patient behavior might lead to the decision to terminate the physician-patient relationship, despite how tenuous and challenging the process may be.

As noted in the September 2019 MGMA Connection magazine, if you have verified that an established relationship with the patient exists, it becomes an issue of providing proper notice of the provider’s decision to end the relationship.

Prior to notifying the patient, you need to consider a few points:

• Will the termination violate an insurance payer contract?
• Is the termination based on something discriminatory in nature?
• Is there an ongoing medical condition that needs to be resolved first?
• Will the termination violate the Americans with Disabilities Act (ADA)?

Every situation is unique, so it is important that the rationale is justifiable.

To avoid an accusation of patient abandonment you also need to give appropriate notice to a patient, which can occur verbally but generally needs to occur via certified mail with return receipt requested. If the notice was communicated directly by the physician to the patient, it should be carefully documented in the medical record. Regardless of the method, the patient should be given a reasonable amount of time to find a new physician before his or her care is discontinued. This should be a minimum of 30 days in most cases, but it may vary by state law or by payer contract.

As you are completing the letter to mail to the patient it is best practice to inform him or her why you are terminating the relationship: include information on how to obtain or transfer his or her medical records, how much longer you will provide care and provide suggestions about where he or she should look to find a new medical provider (e.g., contact his or her insurance carrier, medical societies, physician websites, etc.). It is also recommended to include a release of medical records form along with the letter to expedite that process.

Finally, you should document the entire process in the medical record and retain all documentation such as proof of receipt of the letter. Your EHR should also include a notification for staff so that the patient is not scheduled in error beyond the 30-day period after notice has been given. This is also why it is recommended in most cases that a patient should be terminated from the entire practice, because if other providers aren’t available, the provider may have to treat the patient he or she terminated.

If there are extenuating circumstances around the termination of any physician-patient relationship, it is also advisable to notify your legal counsel or malpractice insurance as necessary.

<h2>Additional resources</h2> <ul> <li><a data-cke-saved-href=">Read more about how to address provider and staff mental health amid COVID-19.

• Learn eight ways to create an atmosphere of psychological safety in your practice.
• Download MGMA’s Crisis Management Checklist (PDF).

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