• David A Fishbain, Daniel Bruns, John Mark Disorbio, and John E Lewis.
• Department of Psychiatry, Miller School of Medicine at University of Miami, FL 33136, USA. d.fishbain@miami.edu
• Pain Med. 2009 Apr 1;10(3):573-85.

ObjectivesPhysicians are at risk for patient-perpetrated violence. This study attempts to identify predictors for violent ideation against medical doctors (VI-MD), in acute-pain patients (APPs) and chronic-pain patients (CPPs). This is the first such study in the literature.DesignPatients were asked if they had thoughts of killing one of their physicians (VI-MD) during the development of the Battery for Health Improvement (BHI 2). This instrument was developed utilizing a healthy community sample (n = 1,478), a community patient sample (n = 158) and a rehabilitation patient sample (patients undergoing rehabilitation for pain or physical injury in a variety of settings) (n = 777). Of the rehabilitation patient sample, 326 were identified as APPs, 341 as CPPs, and 110 as having no pain. The APPs and CPPs were compared for the risk of affirming VI-MD, and those two groups were then compared by t-test and chi(2)-square on categorical demographic variables, categorical nondemographic variables, and BHI 2 scale scores. Significant variables (P < 0.001) were then utilized as independent variables in logistic regression models for APPs and CPPs to predict VI-MD affirmation.SettingPatients treated in a variety of settings.ResultsRisk for affirmation of VI-MD was increased in the following groups relative (number of times) to the healthy community sample as follows: rehabilitation patients, 3.5; rehabilitation patients without pain, 2.8; rehabilitation patients with acute pain, 3.1; rehabilitation patients with chronic pain, 4.1; rehabilitation patients with Worker's Compensation or personal injury 4.6; rehabilitation patients with litigation 7.3; and rehabilitation patients with Worker's Compensation and litigation and chronic pain, 10.4. In the APPs logistic regression models, demographic variables did not predict VI-MD affirmation, but some BHI 2 scales and items did (P < 0.001). These pertained to depression, hostility and doctor dissatisfaction (angry at the physician). A high perseverance score on the BHI 2 predicted against VI-MD affirmation among APPs. For CPPs, three major variables predicted VI-MD affirmation: being in litigation; borderline traits and doctor dissatisfaction (trusting/not trusting the physician, forced to see physician, patient does not trust). The logistic regressions classified 95.7% of APPs and CPPs correctly. However, because of the total low numbers of rehabilitation patients affirming VI-MD (5.5%), the logistic regression prediction was only slightly better than the base rate prediction of 94.5%.ConclusionsBeing a rehabilitation patient increases the relative risk of affirming VI-MD. This risk is further increased by such variables as chronic pain, Worker's Compensation status, personal injury status, and, most important, litigation. We cannot as yet predict VI-MD affirmation significantly better than base rate prediction. Some variables implicated in this study for VI-MD affirmation relate to the physician-patient interaction and are clinically useful.

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