Frontlines Archive

Violence in Medical America

Sheldon H F Marks, MD
Tucson Urologist and Security Consultant  (Tucson SWAT Member)

William M. Schiff, MD
Fresno Urologist and Security Consultant

This article first appeared in-part in the CUA Report Spring/Summer 2015 Issue

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Negligent failure to plan – a new legal paradigm.
The old idea that, “Well, that’s never happened to me,” is not a good legal defense.

Employers have a legal duty to exercise reasonable care in providing a safe workplace. Your patients have the expectation of a safe environment. Your Department of Labor issues regulations and guidelines to define standards of care to be followed by employers. With regard to hazardous materials, there are no longer unforeseen risks of unsafe workplace environments; this is about to include workplace violence.

wsauamauiwkshop1 300w" sizes="(max-width: 450px) 100vw, 450px" /> Dr. William Schiff (standing) addresses a large audience at WSAUA/CUA “Threat Awareness Program” in Maui during the WSAUA 2014 annual meeting. The panel of speakers also included CUA past-president Dr. Eugene Rhee and Dr. Sheldon Marks (seated at right). Dr. Jeffrey Frankel (seated at left) moderated the overall course as part of the Health Policy Forum and is the chairman of the WSAUA Health Policy Committee.

We all spend tremendous time and resources training for those rare but serious “just in case” issues. We all have routine fire drills. We all know where to find the fire extinguishers. The medical staff has to go through lengthy recertification every 2 years for ACLS, though most of us will spend our entire careers without having to run a code.

Is your organization taking reasonable action to prevent predictable critical events which could take a significant toll on our workforce and our customers? Are we prepared to respond properly in such an event – not just management or even the doctors? What have we done to train and educate the receptionists, housekeeping, nurses and lab personnel? There is a wide gap between having a well thought out plan, approved by the legal department and neatly bound in the administration office, and the actual active training of all employees for violent encounters. Failure to train is an already established liability issue. What have we done to mitigate these foreseeable tragedies?


We need to assess our vulnerability to risk and determine the potential of its occurrences. Risk of loss includes financial, life and reputation. Not properly managing this vulnerability may, in the eyes of the law, be WILLFUL NEGLECT. We cannot completely protect our organizations from all vulnerabilities. We are relegated to fix, mitigate or accept these vulnerabilities. We must embrace policies that offer a plan of action (e.g. procedures to support our policies of security and safety). How easily and quickly can police access your clinic, hospital or surgery center floorplan in an emergency 24/7? Have you invited your local police to come and walk through your practice, offering advice on how you can improve your safety?

The concept of security is to take reasonable steps to DENY an opportunity for crime by interrupting a plan for crime. Deter crime by transforming your surroundings to a hardened target. Detect a threat by personal awareness and electronic analytics. Index of suspicion is key. Delay the perpetrator by adding sequential obstacles for bad, hostile behavior. The key is to prevent the violent encounter by involving and empowering all employees, at the same time creating a bottom-up system to intervene if one occurs, and finally to provide the skills and knowledge to mitigate any criminal event. It is important to teach staff, security, front desk, and all employees how to break the bad guys’ “ooda loop” cycle1.

Administration must accept the value in addressing violence in medical America. Staff at all levels (including most junior and nonmedical support staff) needs to be empowered and supported by management. Development and training for procedures to support policies must be advanced by management. Management and administrators, and even the doctors, must understand and accept that security assessment and creating effective protocols are not in their “wheelhouse” and so defer to contracted professionals with experience and training. Then, with that information, management becomes involved in using this information and advice to develop and create their own practice or facility-specific policies, procedures and protocols. Evaluation and modification of these procedures are an ongoing effort. Risks and vulnerabilities constantly change; so must their remedies. Preparation, assessment and modification are essential for a successful program.

When You Leave the House:
• Trust your sixth sense – FEAR
• Stay aware of your surroundings. Does someone not belong? Does something not make sense? You can always go back into office or building.
• Maintain situational awareness – do not be texting or talking on the phone as you walk to your car. Refrain from cell phone use.
• Develop an exit strategy, then a backup plan. Where will you run; what can you get in your hand?
• Do not drive high-end flashy cars or stand out. Try to blend in. Don’t be an obvious target.
• Avoid routine routes.
• Avoid “named” designated parking.

Arm Yourself:
• Awareness
• Guns – on person, secured or hidden in panels, drawers, desk, etc., of course with regular training
• Policies or a policy of no policy
• WASP or bear spray
• High intensity “tactical” flashlight
• Taser
• Baton (collapsible)
• Baseball bat
• Knife
• Crowds

Consistently evaluate potential threats in the work environment. Observe for opportunities for criminal behavior. Develop procedures for a policy of safety.

Incorporate local law enforcement to develop appropriate procedures. Utilize facility walk-through and threat assessment opportunities.

Understand that restraining orders are important to do sometimes, though they can be ineffective to protect you from the mentally disturbed, criminal or suicidal. Occasionally they may actually inflame. Discuss specific situations with local law enforcement.

Understand and detect potential threats:

Disenfranchised Staff
• Instruct human resources to have ongoing background checks, both initial and perpetual.
• Be aware many employees remain in contact with fired employees, keeping past employees up-to-date on internal office issues, staffing, routines, etc.
• Identify victims and perpetrators of domestic violence.

Forensic Patients
• Understand parking locations, entry and exits to be utilized. Develop a predetermined safety profile for each forensics patient. It may be determined that the prudent policy is to not allow a predetermined profile of forensic patient in your facility.
• Remain anonymous. Remember every forensic patient has contacts on the outside. Do not fight agency protocols. Your safety and the safety of other staff and patients is your primary directive. This is not a time when personal biases against law enforcement should be illustrated.

Develop multiple layers of perimeter security. Incorporate a “Castle Security” or “Defense in Depth “concept.

Utilize every staff member as an observer. Empower them to SEE something and then SAY something.

Augment Visual Awareness:
• Video of entrances, doorways, back doors, parking facilities, lobby
• Badges
• Uniforms

• No public access
• Restricted area
• Stop
• Be aware that many violent criminal events occur in “gun free” or “knife free” zones. Signage or laws do not stop those intent on harming others.

Limit entry doors; maximize exit doors.

Cost-Effective Electronic Security:
Purchase for the immediate future, much like purchasing a cell phone or computer. Don’t buy the latest and greatest technology – it’s too expensive. Understand that even the best and most expensive equipment requires ongoing maintenance and repairs. Utilize off-site digital storage for evidence purposes. Utilize a centrally accessible location in your office for video monitoring in the event that an emergency law enforcement response is required. Notify responding law enforcement agencies of the location, type of equipment, and capability of your surveillance system. Give that agency access to online information. Incorporate pre-designated locations for panic buttons and personal panic devices. Cell phones may be reprogrammed to notify personnel en masse as well as your office operator.

Reassess Patient and Visitor Flow:
Utilize signage to help manage and control entry points. Assess all entry points and minimize duplication. Limit unaccompanied patient and visitor traffic. Reassess the appropriateness of accompanying family members. Keep non-physician traffic to an absolute minimum in the areas of private offices.

If there is any concern or it is after hours, escort employees in and out by security or other employees.

• Lighting – Be sure it is timed with seasons, motion sensitive, day/night (access control).
• Close doors. Many times doors are left open or ajar.
• Bells or buzzers on doors when open so staff is aware.
• Reinforced doors and locks.
• Locks – push button to limit access.
• Security grade window film (even on reception windows) or bars.

Develop a zero-tolerance protocol for inappropriate behavior. This includes entry into a databank with specific information, access restriction into the facility, discharging from practice, and law enforcement involvement.

The value of this databank serves to observe trends and identity profiles of an aggressor as well as to support facility action against that individual.

Information to be compiled includes:
• Date of incident
• Name of offender
• Date of birth
• Case number
• Incident
• Evidence
• Witnesses
• Resolution
• Follow-up

Coordinate and have regular training and drills, when everyone is at their regular workstation and when not – especially important with new staff. Lockdown is not enough. Think of other atypical scenarios – walking to or from car, when talking with family in waiting room, staff at lunch, greeting patient in hallway. What will you do? What will staff do?

Focus on the most likely first contact – front desk employees. Address awareness and action to take if they have any concerns. Be proactive and not reactive.

Recognizing Early Warning Signs of Violent Behavior:
• Observe for behavior that is not normal
• Inappropriate clothing for the weather – trench coat on hot summer day
• Newly shaved head
• Look for apprehension
• Direct or veiled verbal threats
• Intimidation of others
• Paranoid behavior or comments
• Moral righteousness
• Difficulty in taking criticism
• Expressions of extreme desperation
• History of violent behavior
• Disregard for the safety of co-employees
• Being a loner
• Clenched jaw or fist
• Narrowed eyes
• Angry look with reddened or blanched face
• Increased perspiration
• Tremulous loud or muttering, incoherent speech
• Movements that are exaggerated
• Exhibiting nervousness; pacing and wringing of hands
• Behavior that is irritable, hostile or demanding

The first sign of violence is often sounds of screaming, yelling, gunshots or alarms – sudden and unexpected. Training should include these.

Identify personnel in your office who are adept at de-escalating aggression – individuals who are even-tempered, nonthreatening, active listeners. Individuals who have the authority to impact change and offer answers, and who are comfortable instituting a 911 call.

How To Call 911:
• Develop a universal code that will trigger a 911 call.
• Remember in some offices 9 needs to be dialed first for an outside number.
• Use a landline when possible.
• Leave phone on – do not hang up!!

The operator should be aware of the floor plan of your particular office or where police can access that information.

Be specific with information:
• Your location
• The number of assailants
• The number and kind of weapons
• Features of the assailant (not the type or color of clothing)
• Any injuries you know of, and number of injured

When 911 Arrives:
• Be prepared to be disoriented and distracted
-Flashing strobes

Police are there to address and neutralize the threat. They will move in fast and in large numbers. They consider everyone to be a “bad guy” until proven otherwise, so do as you are told. Expect to be treated roughly until the scene is secure. Police are functioning on limited, incomplete and often incorrect information.

• Remain calm and follow instructions.
• Keep your hands empty and in plain sight.
o Do not carry out ANY belongings – purses, briefcases, etc.
o Do NOT have cell phones in your hands or cameras
o Do not take “selfies” or videos
• Raise and keep hands slowly above head and spread fingers.
• No sudden movements.
• Do not reach into pockets or behind back.
• Avoid movements towards officers unless asked to do so.
• Follow ALL law enforcement directions.
• When told to leave the area, do not ask for help or directions.

During a Hostile Event:
• Responsibilities for safety include physicians/staff/patients/visitors.
• An accounting mechanism for all innocents is to be employed.
• Run if you can away from the threat/danger – avoid long routes. Do not stop to reassess or go back.
• Hide if you can’t run, in an accessible, lockable and barricaded location. Brick walls are better than drywall. Glass is not protective. Stay silent and keep everyone else silent. Lollipops work great to keep small children quiet.
• Turn off cell phones and vibrate status!

If necessary, or if you find yourself face-to-face with the bad guy, fight for survival:
• Hit first, hard and fast
• Eyes, face, head, neck and groin
• Use what you can
• Pencil, fire extinguisher, purse
• No rules!
• Goal is to stop the bad guy at all costs

After the event consider that many will have some degree of PTSD. Address openly with counseling and supportive care.


1 Wikipedia definition:
The phrase OODA loop refers to the decision cycle of observe, orient, decide, and act, developed by military strategist and USAF Colonel John Boyd. The OODA loop has become an important concept in litigation, business and military strategy. According to Boyd, decision-making occurs in a recurring cycle of observe-orient-decide-act. An entity (whether an individual or an organization) that can process this cycle quickly, observing and reacting to unfolding events more rapidly than an opponent, can thereby “get inside” the opponent’s decision cycle and gain the advantage.


Author Biographies:


Sheldon H. F. Marks, M.D. has been in practice in Tucson, Arizona for more than 27 years after training in Boston and Mayo/Rochester.  

Dr. Marks has been a member of the clinical faculty at the University of Arizona and Tufts/New England Medical Center. He is the author of several books, including “Prostate & Cancer,” originally written in 1995, now in its 4th edition, 8 languages with 500,000 copies sold. He has been involved in community education, speaking around the country and on radio for many years. Sheldon has been the WebMD urologist for more than 10 years and the integrative urologist for

Of relevance to today’s topic, Sheldon has been a volunteer with the Tucson Police Department’s SWAT team for more than 13 years, where he teaches, attends team trainings and participates in call-outs. He has taught tactical trauma (TCCC) and wilderness/austere medicine in Northern Virginia to forces being deployed to high threat regions in the Middle East as well as to Special Operations Command (SOCOM). As part of the Med Reserve Corp’s Tucson Resiliency Project and the regional MMRS disaster task force, Sheldon frequently teaches violent encounter/active shooter and advanced trauma training to physicians, nurses, teachers, hospital administrators, government and business leaders. He can be contacted at or through



Dr. William Schiff is a Board Certified Urologist practicing in Fresno, California. He earned his B.A. in Social Ecology with a minor in Criminal Justice and Mental Health in 1977 at U.C. Irvine. In 1982 he was awarded his Medical Degree from Chicago Medical School and completed his training in General Surgery and Urology in 1988 at Los Angeles County Medical Center.

In addition to his work in the medical field he remains active in the private sector in investigation, served as an expert witness in criminal trials and continues to consult with legal teams in case management as it relates to medical issues. Prior to pursuing his current clinical responsibilities in medicine, he developed programs and trained staff in assertion training, management of aggressive psychiatric patients and crisis ”hot line” intervention.

Dr. Schiff continues to be an active national speaker in areas of sexual health medicine and department development as well as maintaining an appointment with UCSF School of Medicine as an Associate Clinical Professor of Urology. He serves as a medical liaison in safety and security for schools, medical facilities and large scale mass gatherings.



2009 – Present:           Department of Sexual Health – Founder & Director

2006 – Present:           Associate Clinical Professor Urology Division, University of California San Francisco/Fresno Education Program

1997 – Present:          Urology Associates of Central California, Private Practice

1991 – Present:           Medical Liaison to Police Science Institute

1989 – Present:           Founding member and Chief Medical Officer of Fresno County Private Security/Monterey Private Security

1988 – 1997:               William M. Schiff, MD, Private Practice



American Society for Industrial Security International

International Association for Healthcare Security and Safety (pending)


Copyright 2015 © Violence In Medical America (Schiff and Marks) and California Urological Association.

All Rights Reserved.

Disclaimer: The CUA believes the information in this newsletter is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any kind are disclaimed. This newsletter is not intended as legal advice nor is the CUA engaged in rendering legal or other professional services. Articles and letters to the editor reflect the opinion of the author, not necessarily that of CUA or its members.