In a particularly disturbing finding, researchers conducting a follow-up study1 of emergency physicians found a near sevenfold increase in those who felt “constantly fearful” at work.

In the original 2005 study2 of emergency physicians in Michigan, only 1.2% said they were constantly fearful, said Terry Kowalenko, MD, FACEP, co-author of the study and an emergency physician in Rochester, MI. The 2018 study found matters had drastically worsened, with 8.1% reporting a constantly fearful state.

In addition, “21.9% reported they were ‘frequently fearful,’ up from 9.4% in 2005,” Kowalenko said recently in San Diego at a press conference at the annual meeting of the American College of Emergency Physicians (ACEP).

Part of the nature of fear of violence is its unpredictable nature in healthcare.

“It is very difficult to predict who the perpetrator will be or who the victim will be,” he said. “Every job title has violence perpetrated against them. We did find that the more time you spend with patients increases your chances of having violence perpetrated against you.”

Designed as a follow-up to the 2005 research of physicians in Michigan, the study found that violence was increasing even though security measures improved.

“We know that this is an ever-growing problem, but we don’t know if we are finding [the increase] because we are finally starting to report it or there really is increased incidence of these things,” he said.

Physical Assaults on the Rise

Whether it is a surveillance artifact or not, the finding that 30% of emergency physicians are either frequently or constantly afraid at work adds to the accumulating evidence that there is a crisis in the ED.

“We also know that physicians are the least likely to be assaulted or threatened in the ED,” he said. “Our nurse and tech colleagues are even at a higher rate than we are.”

An electronic survey was sent to 1,102 emergency physicians in Michigan, and 268 (24.3%) were completed and analyzed. Respondents included 33.5% female physicians.

Comparing the results to a similar study in Michigan in 2005, the percent reporting any type of violence in the previous year (72.4%) was relatively unchanged over the 13-year period. However, those reporting a physical assault went from 28.1% to 38.1% in 2018.

Though the fear of workplace violence increased, other measures from the prior study declined. For example, those asking for a security escort to their vehicle fell from 31% in 2005 to 17.5% in 2018. Those who considered leaving the hospital after a threat of violence fell from 16% to 8.6%.

These findings may be explained in part by increased security presence over the period.

“Between 2005 and 2018, more hospitals were reported to have security personnel that perform rounds throughout the entire hospital (53% versus 27%) and security personnel assigned to the ED (34.3% versus 24%;),” the authors noted.

In particular, the presence of armed security officers more than tripled over the period, going from 9% to 30.2% in 2018. A social media question in the most recent survey found that 6.3% of the physicians reported threats of violence online. That finding was linked to working in a large urban hospital, but the 17.9% reporting violent threats through patient satisfaction surveys represented all demographics.

“Workplace violence is still a common occurrence in the ED,” Kowalenko and colleagues concluded. “Despite increased hospital security measures since 2005, emergency physicians across all demographics still experience various forms of violence, are increasingly concerned about becoming a victim of violence, and continue to take personal measures to ensure their safety.”

Noting that he recently saw similar findings on ED violence in Turkey, he said, “This not just the United States — it is all over the world.”


  1. Omar H, Yue R, Amen AA, Kowalenko T, et al. Reassessment of Violence Against Emergency Physicians. Abstract 368. ACEP Conference. San Diego, Oct. 1-4, 2018.
  2. Kowalenko T, Walters BL, Khare RK, et al. Workplace violence: a survey of emergency physicians in the state of Michigan. Ann Emerg Med 2005;46(2):142-147.