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April 2026When the father of a pediatric patient undergoing pre-operative otolaryngology care verbally threatened physical harm to both the anesthesiologist and the surgeon, staff rescheduled the procedure and called in division director Julie Wei, MD, MMM, to take over the case. Dr. Wei, division director of pediatric otolaryngology at Akron Children’s Hospital in Ohio, and professor of otolaryngology–head and neck surgery at both the University of Cincinnati College of Medicine in Ohio and the University of Central Florida College of Medicine in Orlando, said that after the father left threatening voicemails, he followed up with a voicemail apologizing for his behavior. “I reached out to him by phone, explained that I was willing to assume care for the child as the surgeon, and scheduled a separate clinic office visit to meet him and the patient in order to reschedule surgery.”
“Upon arrival, he was presented with a hospital document that outlines acceptable conduct and a ‘behavioral contract,’ which he had to review and sign,” Dr. Wei said. “We didn’t have any issues after that. I was able to have a great conversation with him and acknowledged that his threatening posture was based on fear and concern for the child, but it hindered our ability to communicate and build a trusting relationship, which is required to provide optimal and safe care for his child.”
Violence and threats aimed at healthcare professionals are a growing concern. Although little is known about how commonly ENT surgeons and the broader otolaryngology workforce encounter these situations, system-level protocols are in place to help staff navigate safely while meeting ethical obligations.
Team-Based Response
Dr. Wei recalled a separate incident when she was threatened by the parent of a child undergoing pre-operative care for a tonsillectomy. “He looked at me and told me if I touched his child, he would kill me,” she said. “These extreme and rare experiences result in significant fear. I recall walking in the parking garage for months, constantly looking around in fear that this individual would harm me. For these situations, my team and I know we must contact hospital security and police, provide details, and alert our staff if the individual is present or comes to the hospital, and [teach them] what to do as far as escalation to managers and security.”
“Our hospital has a policy called Management of Disruptive Behavior that outlines what’s acceptable and what’s not, and the hospital has stated no tolerance for any violence,” Dr. Wei said. “As a free-standing children’s hospital, violent behaviors and/or verbal or physical threats come from adults, rarely from adolescent patients.”
Vinciya Pandian, PhD, MBA, MSN, RN, associate dean for graduate education and professor of nursing in the department of otolaryngology– head and neck surgery at Penn State College of Medicine in Hershey, Pa., and an adjunct professor at John Hopkins University School of Nursing in Baltimore, recalled when a tracheostomized patient in the intensive care unit (ICU) became increasingly agitated during routine airway care and tracheostomy management. “The patient began making verbal threats toward nursing staff and respiratory therapists, escalating to aggressive gestures when suctioning and humidification adjustments were attempted,” Dr. Pandian noted. “Importantly, this was not a life-threatening airway emergency, but rather routine care that could be paused safely.”
“The bedside team immediately shifted focus from task completion to safety. Staff used calm, clear communication, stepped back to reduce stimulation, and avoided physical confrontation. The charge nurse and ICU leadership were notified promptly, and hospital security was engaged to provide a visible but non-confrontational presence. Care was temporarily paused, and the plan was reassessed collaboratively with nursing, respiratory therapy, and the medical team,” Dr. Pandian continued. “Leadership reinforced that staff safety was the priority and supported the decision not to proceed with non-urgent interventions until the environment was safe. The patient was later re-approached with additional support, clear behavioral expectations, and a modified care plan that included additional staff presence. This experience reinforced for the team that early escalation and institutional backing are essential, and that clinicians should never feel compelled to ‘push through’ unsafe situations to complete routine care.”
System-Level Protocols
“Management relies on structured, system-level protocols rather than individual discretion,” Dr. Pandian said. “Common elements include clearly articulated patient behavior expectations, early identification of concerning behaviors in the electronic health record, predefined escalation pathways, and ready access to hospital security and risk management. Importantly, these protocols emphasize team activation (front desk staff, nurses, physicians, administrators, and security) so responsibility does not fall on a single clinician.”
Michael J. Brenner, MD, an associate professor in the department of otolaryngology–head and neck surgery at the University of Michigan Medical School in Ann Arbor, has encountered a patient who threatened violence. The patient, with a traumatic brain injury that required revision surgery, “had been off his usual medications and became agitated when he learned there would be a significant wait for a surgery date,” Dr. Brenner said. “Our first step was to slow the interaction and reduce triggers. I enlisted the patient’s spouse, who proved to be a critical ally in calming the situation, while our staff discreetly activated security protocols. The response was calm, coordinated, and team-based, prioritizing safety without escalating confrontation. Some would have dismissed such a patient from their practice, but after partnering with other professionals, we were able to safely provide him the necessary surgical care.”
“In our practice, violence prevention is approached as a system responsibility rather than an individual one,” Dr. Brenner said. “We rely on structured training for physicians and staff to recognize early warning signs, clear escalation pathways, and [we] have rapid access to institutional security. This includes pre-visit flagging when appropriate, standardized response plans, and clear guidance on when to disengage and involve trained security personnel. At the University of Michigan, these protocols are reinforced by institution-wide policies that emphasize early recognition, team communication, and prompt escalation to ensure safety for patients, families, and staff.”
The Ochsner Health System in Louisiana, where John Carter, MD, is system chair of otolaryngology–head and neck surgery, has a zero-tolerance policy for violence in the workplace. Acts or threats of physical violence, including intimidation, harassment, or coercion, are not tolerated. “If a patient is potentially violent, we have security in the clinic and on occasion in the exam room. Patients who threaten violence are alerted to the security team and our legal team. Physicians are also offered panic buttons to wear on their persons at all times to silently alert security if they perceive a threat. Any patients who exhibit violence are removed from the group practice, and law enforcement is immediately involved.”
Balancing Care with Safety
“We have a safety program that establishes procedural guidelines to identify potential security hazards and/or to mitigate security risk to staff, patients, and visitors,” Dr. Carter said. “While patient care is important, the safety of our staff, visitors, and other patients takes precedence.”
Staff safety is foundational to patient care, said Dr. Pandian. She highlighted practical strategies, including modifying visit logistics (e.g., room location, staff presence, and timing), ensuring security awareness or presence when indicated, and redirecting or rescheduling non-urgent care if safety conditions cannot be met. “This framing helps teams understand that safety planning is part of high-quality care, not a deviation from it.”
Dr. Brenner, using the aviation analogy of putting on your own oxygen mask first, said that “staff safety is a prerequisite for effective patient care. This also builds trust. Nurses, medical assistants, and front-desk staff are often on the front line, and they need to know that we as physicians and our leadership care about them and will step up to support them any time and every time that a safety concern arises.”
“Surgeons need to listen closely to their staff, who are often more attuned to early signs of escalating risk,” Dr. Brenner explained. “As surgeons, we are often focused on cognitively demanding tasks and technical decision-making, so we may miss behavioral cues that staff observe. Patients may also behave differently with staff than with physicians, sometimes directing threatening or intimidating behavior toward those they perceive as having less authority. These dynamics highlight the importance of team-based situational awareness and taking staff concerns seriously.”
Surgeons have an obligation to provide appropriate care, but that duty is not unlimited. “When credible threats are made, the standard shifts toward ensuring safety while facilitating continuity of care through appropriate channels,” Dr. Brenner explained. “This may include transferring care to another provider or setting, involving risk management, and documenting the rationale for any limitations or termination of the physician–patient relationship. Patient abandonment must be avoided, but care does not have to be provided in unsafe conditions. We are fortunate to have an excellent office for patient safety and clinical risk that can help us navigate such situations and ensure clear communication with patients.”
Documentation and Communication
“In all matters of patient care, documentation should be factual, objective, and free of judgmental language. Behaviors, statements, and actions should be recorded, rather than interpretations or speculations on motives. Internally, communication should ensure that staff are aware of safety plans and escalation pathways while maintaining professionalism and confidentiality,” Dr. Brenner said. “Clear documentation also supports institutional learning and quality improvement efforts. If I have a conversation with the patient that addresses acceptable behaviors and interaction with staff, then I will often document that conversation in the medical record.”
Protocols should be in place for documenting and communicating about these patients internally. Dr. Carter suggested that a “practice needs to document and maintain records clearly with both their legal and patient advocacy teams. The security team needs to have knowledge of patients who exhibit behaviors that are at risk of workplace violence.”
Dr. Wei finds it helpful to reach out to the hospital’s legal team for guidance when in doubt about how or what to document. She suggested that it’s essential to “document facts, no narration or emotions, and state events clearly, [along with] who was involved, witnesses, what was said by patient/caretaker, our responses, what we did to de-escalate, and also document next steps and options for clinical care for the patient.”
“We also need to protect and alert our own teams,” Dr. Wei said. “I recall joining a daily 8:30 am huddle to share with our nurses, audiologists, and office administrative leaders about potential risks and threats for any individual so that they are aware, and if the patient/ family self-schedules an appointment with another provider, everyone is on alert.”
Reporting fatigue can occur when frontline clinicians, particularly ENT nurses and respiratory therapists, invest substantial time in documentation and reporting but do not see resulting changes in practice, staffing, or policy, Dr. Pandian said. “Over time, staff may disengage from reporting not because risk has resolved, but because concerns are not visibly addressed. Institutions that manage this well close the feedback loop by communicating outcomes, acknowledging staff input, and demonstrating concrete actions such as protocol revisions, added security support, or leadership presence.”
Dr. Pandian co-authored a 2024 qualitative study that explored the challenges with reporting violence against healthcare workers in the emergency department. “Strategies such as integrating reporting mechanisms into the health record, creating nuanced definitions of reportable events, and consistent education with positive feedback can promote reporting by staff. These efforts should be combined with prevention strategies to ensure we are collecting correct data about the success or failure of these programs,” the authors concluded. (Int Emerg Nurs. doi:10.1016/j. ienj.2024.101500).
Psychological Profiles and Triggers
“No single psychological profile predicts violent behavior,” Dr. Pandian noted. “Common contributing factors include untreated mental health conditions, substance use, cognitive impairment, high emotional distress, perceived loss of control, and dissatisfaction with prior care. Operational stressors such as long wait times, complex care pathways, and poor communication are frequent triggers and represent modifiable risk factors.”
In otolaryngology, triggers may also include unmet expectations around surgical outcomes, chronic pain, intractable tinnitus, communication disorders, or underlying neurologic or psychiatric conditions. “Many patients are experiencing distress,” Dr. Brenner said. “Long wait times, perceived loss of control, and fear related to illness can amplify frustration and, in some cases, lead to threatening behavior. When a patient assumes an adversarial stance, rather than working together, the risk of violence increases.”
As a pediatric otolaryngologist, Dr. Wei finds that the most common scenarios of threatening demeanor or difficult adults tend to be couples who are in the middle of a contentious divorce or have been divorced and are using children as leverage in their fight with one another. “Often they each provide a different history; one is adamant about wanting surgery while the other is strongly opposed.”
Most experienced clinicians know within moments into any encounter if there is unusual tension or body language between two adults and/or between the adult and the clinician, Dr. Wei said. Conversations or communication with patients/families can escalate quickly. “I have had an experience where I had to quickly disengage. A father started raising his voice, stating on the phone that I best get an attorney. That’s the moment to stop interacting and ask for help and document,” she said, highlighting that patients can access these notes.
De-Escalation Strategies
“De-escalation is now a training module for every employee, it seems, just as quality and safety training is,” Dr. Wei said. “De-escalation should be a ‘team sport,’ not based just on any individual surgeon or physician or team member.”
When attempting to de-escalate tense situations, surgeons and other staff should maintain a calm tone and use respectful and clear language, while setting boundaries and avoiding power struggles.
Dr. Carter suggested telling the patient that you will not tolerate the behavior and may have to end the visit. “Involve office management and security early in an escalating interaction. Ask to take a break from the clinic visit so that they can calm themselves.”
Dr. Pandian, who highlighted the need for listening actively, offering validation without reinforcing harmful behavior, and offering choices when appropriate, suggested that it is important to recognize when de-escalation is no longer effective and to promptly shift to safety protocols.
A useful conceptual framework comes from Never Split the Difference, a book by Chris Voss, a former FBI hostage negotiator, Dr. Brenner said. “The book emphasizes tactical empathy, labeling emotions, and finding common ground to prevent escalation (https://www.blackswanltd.com/never-split-the-difference). That said, surgeons do not receive training in these areas, and the threshold for calling security is low. De-escalating potentially volatile situations should be done by professionals with these specialized skills.”
Duty and Ethics
Duty to treat exists within ethical and practical boundaries. “When personal or staff safety is threatened, the obligation shifts toward risk mitigation and alternative care arrangements,” Dr. Brenner explained. “This is not a failure of professionalism but an affirmation that safe systems are essential for ethical medical practice. Usually, the threat of violence can be defused and the duty to treat addressed under calmer and safer conditions.”
“Ethical guidance supports terminating a physician–patient relationship when behavior becomes threatening, if termination is conducted with appropriate notice, documentation, and assistance in identifying alternative care. Boundary setting is an expression of respect, not rejection, and helps ensure safety for everyone involved,” he added.
Physicians should never risk their own safety, but ethically, they should help the patient find another person to care for their condition. “However, this needs to be done in conjunction with law enforcement if physical violence has been threatened, because the next provider should not be placed at risk either,” Dr. Carter said, adding that involvement from patient advocacy may be necessary, as may referral for psychiatric care.
Dr. Wei noted that every hospital and their legal team has a policy that defines criteria to terminate a patient from the practice. “This is important to discuss and review; such decisions should not be made lightly, particularly when the patient is not at fault.”
Clinicians are not obligated to place themselves or their teams in danger for non-emergent care, explained Dr. Pandian. Institutional support for clinicians who step away from unsafe situations is essential to maintaining a culture of safety. “Termination of care, when necessary, follows established ethical and legal safeguards: documented rationale, written notice when appropriate, emergency coverage during transition, and assistance with referral or alternative care when feasible. These processes are handled at the organizational level rather than by individual clinicians.”
Final Thoughts
One of the strongest lessons learned is that “managing threatening patients is a systems issue, not an individual failure. Clear policies, leadership engagement, staff training, and visible institutional support are what ultimately protect patients, clinicians, and staff while preserving trust in the care environment,” Dr. Pandian said.
Some injuries that can cut the deepest needn’t be physical. “Violence in health-care is often framed narrowly as physical assault, but this perspective overlooks a broader spectrum of harm,” Dr. Brenner noted. Neuroscientific research demonstrates that emotional pain activates neural pathways that substantially overlap with those involved in physical pain, underscoring that threats, intimidation, humiliation, and chronic verbal abuse can be experienced by clinicians and staff as injury.
“Non-physical violence in healthcare settings may include repeated verbal aggression, discriminatory or demeaning language, sexual harassment, coercion, stalking behaviors, deliberate noncompliance used to intimidate staff, or threats directed at team members or their families. These behaviors can create sustained psychological trauma, erode situational awareness, impair team communication, and compromise patient safety in ways just as deleterious as the effects of physical violence.
“While non-physical violence does not leave visible injuries, it often exerts a more insidious and enduring impact, accumulating over time and affecting morale, retention, and performance,” Dr. Brenner concluded. “Conceptually, these behaviors should be understood not as lesser offenses, but as closely related manifestations of violence that demand proactive recognition, clear institutional standards, and the same seriousness of response as physical threats.”
Katie Robinson is a freelance medical writer based in New York.
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