AAPM: Pain Can Make Patients Want to Kill Physicians

By Ed Susman
KISSIMMEE, Fla., Feb. 18 -- Patients in pain are particularly prone to want to take it out on their physicians in one way or another, even to the point of having thoughts of homicide, according to research reported here. "We haven't performed a prospective validity test on our findings -- that is, do their patients carry out their wish," said psychiatrist David Fishbain, M.D., of the University of Miami. "While we don't know if these patients will take you to court or kill you, we do know that healthcare workers are at a significant risk for patient perpetrated violence."
Dr. Fishbain noted that in one study conducted from 1983 through 1990, pharmacists were at greatest risk for work-related homicides -- 16 per 100,000 -- but physicians were a close second at 15 per 100,000.
In scrutinizing study questionnaires used to develop the Battery for Health Improvement test, Dr. Fishbain found questions pertaining to a patient's hostile wish to sue his physician and the hostile wish to kill the doctor. More than 2,200 patients and healthy participants took part in the process of developing the test.
Dr. Fishbain said a logistic regression analysis confirmed that the characterization of the acute and chronic patients was statistically significant (P<0.001).
"Acute pain patients and chronic pain patients were at greater risk than patients without pain for affirming the hostile wish statements," Dr. Fishbain reported at the American Academy of Pain Medicine meeting.
The study found that the chronic pain patient most likely to harbor the hostile wish is involved in litigation -- and most frequently that is a worker's compensation legal tussle. These patients are forced to see physicians against their will -- often because of dictates of the litigation, and patients don't trust the doctors.
For the acute pain patients, the portrait of the person with the hostile wish are those depressed by the state of their health and the tasks they cannot accomplish. Because of this, they are angry with people in general, including the doctor.
In the healthy community, Dr. Fishbain found that about 1.58% of the people expressed the hostile wish to kill their doctor while 1.5% harbored an urge to sue. The relative risk of having the hostile wish to kill increased by 2.8 times in patients who are not healthy and this group's wish to sue is increased by 3.36 times or about 5.5% of the population.
Acute pain patients in rehabilitation under workmen's comp claims are five times more likely to have a wish to kill the doctor than a healthy person and are three times more likely to sue. A chronic pain patient is a little less than five times more likely to hold a hostile wish, and they are more than four times more likely to think about suing.
Remarkably, 22% of the 18 patients identified in the surveys as having acute pain and are in rehabilitation under workmen's compensation rules and are in litigation have thoughts of killing their doctor -- 14 times that of a person in good health. However, they are seven times more likely than a healthy person to think about suing the doctor.
A person with chronic pain, in rehabilitation programs and involved in litigation is 10 times more likely than a healthy person to harbor a wish about killing the doctor, are 8 times more likely to think about suing.
"I think that doctors should try to diffuse the issues when they are involved in a workmen's compensation case," Dr. Fishbain said. "Tell the patients you are there to render an independent evaluation and treatment and you aren't on his side or on the insurance company's side. Get that in the open -- especially among those patients who are assigned to see you."
"These thoughts about killing a doctor or suing him are part of the ripple effect caused by chronic pain," said Rollin Gallagher, M.D., a clinical professor of psychiatry and anesthesiology at the University of Pennsylvania. "These patients may be more inclined to sue and may harbor wishes of violence if they have pain and are in litigation."
Dr. Gallagher, who was not part of the studies, said that pain patients tend to be frustrated and have loss of hope, problems that doctors need to address and be aware of when they are treating these individuals.
He also said the study points out the need for further education of doctors on the complexity of chronic pain and "emphasizes the need for the timely referral of patients to pain specialists."
Dr. Fishbain disclosed possible financial conflicts of interest with Lilly; Dr. Gallagher reported no financial conflicts of interest. The studies were funded through Pearson Assessments.
Primary source: American Academy of Pain MedicineSource reference:Fishbain D, et al "What are the variables that are associated with the patient's wish to sue his physician in patients with acute and chronic pain?" AAMP Meeting 2008; Abstract 102.