State Medical Board Exposure to Threats of Violence: Analysis of data from a national survey to determine the extent of threats of violence aimed at U.S. state medical boards and steps they take in response to the issue

Violence and threats of violence in the workplace, topics that have been increasingly featured in the news, are serious public health problems. According to the Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health, an estimated 1.7 million injuries per year are due to workplace assaults, with simple assault the most common type of violence.1 In addition, the Bureau of Labor Statistics has reported homicide as the fourth-leading cause of fatal occupational injury in the United States. Of 4,349 fatal work injuries reported, 521 were related to workplace homicides in the preliminary count for 2009.2 

Certain occupations experience higher rates of violence directed at those who work in those professions (e.g., police officers, security guards, taxi drivers, and gas station workers). While the health care community has not experienced high rates of violence compared to these other settings, verbal and physical violence against physicians, other health care workers and staff is not uncommon. From 1997–2009, 8,127 occupational homicides occurred.3 Of the 73 homicides reported to have occurred in the health services industry, 20 occurred in hospitals and 17 in offices and clinics of medical doctors.3 

The stressful environment in some health care settings, the prevalence of weapons among patients, their families and friends, and the increasing number of acute and chronic mentally ill patients seeking health care related services all contribute as risk factors in violent attacks against physicians and health care workers.4 Numerous cases of violence against physicians have been reported in the last few years, putting a national spotlight on violence and security issues in health care settings.

As an integral part of the U.S. health care system, the state medical board community has cause to view these trends with concern. Moreover, the stressful conditions that often accompany state medical board investigations and disciplinary actions can create highly contentious and emotionally charged environments — which could be considered potential precursors to violence or violent threats.

Perhaps the most visible illustration of this possibility can be found in the case of Trent Pierce, MD, a practicing family physician and board chair of the Arkansas State Medical Board.

On the morning of February 4, 2009, Dr. Pierce was critically injured when a bomb exploded in his car as he prepared to travel to a board meeting, a calculated attack leaving him severely burned and without his left eye.5 Soon after the bombing, federal agents arrested an Arkansas physician on charges of illegally owning high-explosive grenades. The physician had become a “person of interest” in the attack against Dr. Pierce. According to prosecutors, the attack against Dr. Pierce was planned in retaliation after he and the Arkansas State Medical Board revoked the physician's prescription writing privileges.6 

After hearing a month's worth of evidence, including testimony from Dr. Pierce, a federal jury convicted the physician on August 9, 2010, on charges of using a weapon of mass destruction against a person and destroying a vehicle with an explosive device. On February 28, 2011, he was sentenced to life in prison for orchestrating the attack against Dr. Pierce. On June 13, 2013, the physician petitioned the U.S. Supreme Court to review his case.7 

While the violent attack against Dr. Pierce represents an extreme case — one that resulted in extensive national media coverage — the general topic of violence or threats of violence aimed at state medical board members or staff has not received attention in academic literature or been closely studied. Despite the recent high profile of incidents of violence in health care settings, the nature and extent of how the problem might impact state medical boards remain largely unknown.

The dearth of data prompted the FSMB Foundation to develop and distribute an online survey designed to determine the extent of violent threats against state medical board members and staff, and how state boards respond to the issue.

To better understand the extent of violent threats experienced by the board members and staff of the nation's 70 state and territorial medical boards, and to generate useful knowledge for the boards, the FSMB Foundation developed an online survey. While the primary objective of the survey was to estimate the extent of violent threats against state board members and staff, the survey was also established as a way to determine the actions taken by state boards in response to the threats of violence, and the security measures boards currently have in place.

The survey was designed to be simple to complete to ensure that a substantial portion of the target population would respond. The survey did not attempt to gauge the frequency of threats or to analyze the root cause(s) of violence against state board members and staff, but to explore the risk of exposure to violence. The survey consisted of four distinct sections:

1. The occurrence of explicit or perceived threats against board leadership and staff.

2. The actions boards took in response to the threats of violence.

3. The boards' current and future security measures for board leadership and staff.

4. Questions about state legislation regarding the consequences of threatening a public official.

The online surveys were generated by the FSMB Foundation and were administered using the web-based survey tool, Survey Monkey. The online surveys were initially distributed via email to all 70 state medical boards in October 2010. The invitation to participate in the study was emailed to all state board executive directors and included a link to the online survey. State boards were asked to complete the online survey six weeks after receiving the invitation.

Initial data was shared with representatives of state boards at the FSMB's 2011 Annual Meeting, who suggested that the survey be distributed a second time to generate additional responses. The FSMB Foundation redistributed the violence survey via Survey Monkey in January 2012 to the executive directors of those boards who had not responded to the initial survey. The questions asked on the redistributed survey were identical to those of the original survey. Boards were asked to complete the online survey within 30 days after receiving the subsequent invitation.

In both rounds of data collection, respondents were asked to identify their board affiliation but were not required to respond.

Fifteen fundamental questions were developed for this study:

1. In the history of your board, have there ever been any threats of violence (either overt threats or covert perceived threats) against board members or board staff?

2. If there were threats, were they against board members, board staff or others?

3. If there were threats of violence, what type of action(s) did the board take?

4. If your board is appointed by the governor and there was a threat, did you notify the governor's office?

5. If you notified the governor's office, what was their response?

6. For whom does your board routinely provide security?

7. What type of security does your board provide?

8. If your board routinely provides security for specific individuals, which individuals do you cover?

9. If your board routinely provides security, where do you provide it?

10. Please comment on your future plans for security.

11. If you are planning to change your level of security, what are you planning to do?

12. What barriers do you face in providing the level of security you would like?

13. Does your state have legislation regarding consequences of threatening a public official?

14. Would you be interested in pursuing legislation in your state if a draft were provided to you?

15. What other comments do you have?

Of the 70 state medical and osteopathic board executives receiving the initial survey, 22 were returned (31.4%). Of the 22 responding boards, 16 (73%) noted their board affiliation: Colorado, Washington, D.C., Georgia, Montana, North Carolina, Nevada-Medical, Nevada-Osteopathic, Ohio, Oklahoma-Medical, Oklahoma-Osteopathic, Tennessee-Medical, Texas, Washington-Medical, Washington-Osteopathic, Virginia and the U.S. Virgin Islands.

Subsequently, when the survey was redistributed in January 2012 to the 48 remaining boards, 15 additional surveys were returned (response rate, 31.3%). Boards participating in this second round of data collection included Connecticut, Florida-Medical, Hawaii, Idaho, Indiana, Kentucky, Maryland, Maine-Medical, Maine-Osteopathic, Mississippi, Nebraska, New Hampshire, West Virginia-Medical and West Virginia-Osteopathic.

Combining the results from the first and second rounds of data collection produced an overall survey response rate of 52.9% with 37 returned surveys.

Based on the pooled data, of the 37 state boards that responded to the question of whether their board members or staff have ever experienced threats of violence at the board level, 73% (n=27) reported that in the history of their board, there had been threats of violence (either overt or covert [explicit or perceived]) against board members or board staff (see Figure 1).

Of the responding states, 85% indicated that board members had been the target of violent threats, followed by board staff (78%) and others (15%). Threats directed at “others” included individuals who are associated with a state board, but not employed by a board, such as an assistant attorney general, a hearing officer, a district judge, and, in one case, the state's governor.

Many of the threats directed at board members occurred after board meetings. Most of the threats were made by either a physician or a family member of a physician, and were verbal, including threats of death.

When asked what actions were taken as a result of threats of violence, the responding boards indicated the vast majority of actions taken revolved around ensuring a security presence at board meetings, whether that was through local law enforcement agencies or the hiring of private security. Most state boards that experienced threats of violence tended to notify law enforcement (62%) or seek private security (38%). For 48% of boards, the threat(s) resulted in law enforcement investigations (see Figure 2).

Boards seldom notified the governor's office of a threat (25%). When they did, the governor's office would take note of the information and then instruct them to contact and coordinate with capitol police or proper law enforcement to ensure the issue(s) was addressed properly.

Approximately 76% of the respondents indicated that their board provides some type of routine security. For these boards, security is typically provided at board offices (69%) and board meeting locations (62%).

The type of security varies, but locking office doors (47%) or having offices in buildings that require identification for access (42%) are the most widely used security types. Private security (33%), local law enforcement (28%), and panic alarm systems (19%) are also utilized. Seventeen percent of the respondents reported their board did not provide any kind of security (see Figure 3).

As indicated in Figure 4, less than half of the respondents (49%) are satisfied with their security but only 26% are planning to increase it. However, if finances were no object, 72% would choose to increase their security.

For the eight boards planning to change their level of security, four are considering a security presence at board meetings, one is taking steps to better secure its office building by installing video cameras, one is having security use handheld metal detectors at meetings, one is adding a panic button at the receptionist desk and another is moving to a new building with security officers, bag checks and scanners — although the move was not related to security.

For the boards that are not planning to make any security changes, funding to pay for added security (both initial and ongoing) is the primary barrier. Building factors are a distant second (i.e., a building houses other entities or must allow for public access when open).

Approximately 64% of the responding boards indicated that their state has legislation regarding consequences for threatening a public official. However, only 39% indicated they would be interested in pursuing legislation in their state if a draft were provided (see Figure 5).

Among those responding to this question, a handful provided additional comments:

The results from this study indicate that threats of violence against state medical board members and staff are not uncommon. The finding that nearly three-fourths of the state boards that responded to the survey had experienced some form of violent threat is remarkable and suggests that the issue occurs in a wide range of jurisdictions.

Executive directors reported a variety of threats anecdotally, including both explicit and perceived forms, and including threats of death. In one reported incident, the threat was so credible that a board staff member wore a Kevlar vest during a hearing for his own protection. In another, a physician under investigation by a board threatened to bring a bomb to a board meeting.

Survey results show that state boards have taken steps to respond to such threats of violence. However, while less than half of the respondents are satisfied with their present security level, only 26% are planning to increase security. The initial and ongoing costs for additional or new security are the primary barrier, as 72% indicated they would increase security if finances were no object.

It is important to note that this survey was limited in scope and should be considered only the beginning of an effort to better understand the issue of violence aimed at state medical boards. For example, respondents were asked if there have “ever” been threats of violence against their boards, without a specific timeframe, raising the possibility of recall bias. More research examining specific time periods could yield a better understanding of the scope of the problem and the direction of any trend lines in the incidence of violent threats.

Additionally, more analysis should be conducted on the demographics of state boards and whether there are any correlations between board composition, geographic location and the incidence and nature of violent threats. Further study could also examine the role of other agencies, such as the Occupational Safety and Health Administration (OSHA), in helping state boards address the potential for violence against state board members and staff as a unique workplace issue.

A comprehensive study of the incidence of actual acts of violence throughout the medical regulatory community could also yield important data. In responding to this survey, board executive directors provided a description of physical violence in addition to violent threats, ranging from an incident in which a physician whose license had been suspended fire-bombed the house of a witness to an altercation in a parking lot in which board members were accosted following a hearing.

These survey findings suggest that the state medical board community should be aware of the possibility of violent threats. Since it is impossible to know if and when a violent threat might be carried out, understanding the risk factors and formulating prevention and threat assessment policies may be the most effective approach to addressing the issue.

Additionally, educational and training resources may be needed at the state board level. This could include the development of educational modules to train state public officials in conflict management, the prevention and handling of acts of violence, and how to identify and assess the seriousness of a potentially violent or stressful situation.