A Patient Code of Conduct: The Rise of Incivility in Healthcare

Recently, a front desk staff member was reduced to tears by a patient who berated her for ten minutes about insurance verification, culminating in him telling her she was "too stupid to work in healthcare."  I heard him say to her with my own ears:  “You ignorant bitch!”

I've been practicing medicine for years, and I can tell you with absolute certainty: something has changed. Patient incivility isn't just rising—it's metastasizing. And healthcare workers are paying the price with our safety, our mental health, and increasingly, our willingness to stay in this profession at all.

It's time we had an honest conversation about patient behavior in medical settings. It's time we established clear codes of conduct. And it's time we stopped pretending that "the customer is always right" applies to healthcare, where the "customer" is actually a patient in a therapeutic relationship that requires mutual respect to function.

The data confirm what every healthcare worker knows from lived experience: violence and aggression toward healthcare workers have increased dramatically. A 2022 survey by National Nurses United found that 48% of nurses reported an increase in workplace violence. Emergency department staff report being assaulted, threatened, or harassed at alarming rates. And it's not just emergency departments—primary care offices, specialty clinics, and even telehealth visits are experiencing unprecedented levels of patient aggression.

Some of this traces to the pandemic, which frayed everyone's nerves and normalized confrontation over healthcare decisions. As a matter of fact, I have a tendency nowadays to blame a lot of things on the COVID pandemic.  Some reflects broader societal breakdown of civility and increasing acceptance of aggressive behavior. Some stems from healthcare system failures—long waits, insurance nightmares, fragmented care—that leave patients frustrated and looking for someone to blame.

But regardless of the reasons, the impact is clear: healthcare workers are being verbally abused, threatened, physically assaulted, and subjected to sexual harassment at rates that would be unacceptable in any other industry. And we've largely responded by telling our staff to "de-escalate," "understand the patient's perspective," and absorb the abuse as part of the job.

That needs to stop.

Let me be specific about what we're talking about, because I want to distinguish between patients who are frustrated or upset—which is understandable and manageable—and patients who cross lines into unacceptable behavior.

Understandable and acceptable:

Expressing frustration about wait times, insurance issues, or system failures

Asking pointed questions about care decisions

Seeking second opinions or questioning recommendations

Raising concerns about treatment quality or outcomes

Being anxious, worried, or emotional about health issues

Needing information repeated or explained differently

Not acceptable under any circumstances:

Yelling, screaming, or using profanity directed at staff

Racial, ethnic, or religious slurs or discrimination

Sexual harassment, including inappropriate comments, requests, or touching

Threats of violence, even "joking" ones

Physical violence, including hitting, grabbing, pushing, or throwing objects

Deliberately damaging property

Filming or photographing staff without consent, especially in threatening contexts

Following staff members outside the clinical setting

Repeated contact outside appropriate channels (calling staff members at home, showing up at their residences, etc.)

Refusing to be treated by staff based on their race, gender, religion, or sexual orientation

Demanding narcotics or other controlled substances aggressively or manipulatively

The line between these categories should be bright and clear. We can handle frustrated patients. We cannot and should not tolerate abusive ones.

In healthcare, we have professional obligations to patients that go beyond customer satisfaction. We have ethical duties. We have clinical judgment that sometimes conflicts with patient preferences. We have responsibilities to provide evidence-based care even when patients want something different.

And more consequentially, healthcare requires a therapeutic alliance built on mutual trust and respect.  When we tell healthcare workers to accept any and all patient behavior in the name of "customer service," we're not creating better patient care. We're creating hostile work environments that drive talented people out of healthcare and compromise the quality of care for everyone.

The patient isn't always right. Sometimes the patient is wrong. Sometimes the patient is abusive. And sometimes the patient needs to be told that their behavior is unacceptable and will have consequences.

Every healthcare facility should have a clear, posted, consistently enforced Patient Code of Conduct. Here's what it should contain:

1. Statement of Mutual Respect

"We are committed to treating all patients with respect, dignity, and compassion. We expect patients and their families to treat our staff with the same respect. Healthcare is a partnership that requires mutual courtesy and consideration."

2. Expected Behaviors

"We expect patients and visitors to:

Speak respectfully to all staff members, even when frustrated

Follow facility policies and procedures

Arrive on time or call if running late

Provide accurate health information

Participate actively in care decisions

Ask questions and voice concerns appropriately

Respect other patients' privacy and need for quiet

Comply with treatment plans or discuss concerns with your care team

Handle billing and insurance issues through appropriate administrative channels"

3. Prohibited Behaviors

"The following behaviors will not be tolerated and may result in dismissal from the practice:

Verbal abuse, including yelling, profanity, or demeaning language

Discriminatory language or behavior based on race, ethnicity, religion, gender, sexual orientation, or disability

Sexual harassment of any kind

Threats of violence, including statements like 'I know where you live' or 'You'll regret this'

Physical violence, including hitting, pushing, grabbing, or throwing objects

Intimidation, stalking, or following staff members

Damage to property

Recording staff without explicit consent

Repeated refusal to follow medical advice without discussion

Seeking controlled substances through manipulation or threats

Refusing care from staff based on their identity characteristics”

4. Consequences

“Patients who engage in prohibited behaviors will be:

Given a verbal warning and asked to modify their behavior immediately

Asked to leave the facility if behavior continues

Reported to law enforcement if threats or violence occur

Potentially dismissed from the practice for severe or repeated violations

Required to find alternative care arrangements if dismissed"

5. Exceptions and Accommodations

"We recognize that some patients have conditions that may affect behavior, including:

Dementia and cognitive impairment

Acute psychiatric conditions

Delirium or altered mental status

Developmental disabilities

Pain or severe distress

We will work with these patients and their families to ensure safe, respectful care for everyone. However, safety of staff and other patients remains paramount, and behavioral accommodations do not include accepting abuse."

If you're a patient reading this, here's what I want you to know:

We understand that healthcare is frustrating. Wait times are too long. Insurance is a nightmare. Bills are confusing. Care is fragmented. You often can't get answers when you need them. The system is broken in multiple ways, and you bear the brunt of those failures.

We're frustrated too. We're frustrated that we can't spend enough time with you. We're frustrated by insurance denials and prior authorization nonsense. We're frustrated by electronic health records that take time away from patient care. We're frustrated by understaffing and burnout and all the systemic problems that make it harder to practice good medicine.

We're on the same side. We want the same things: good care, clear communication, efficient systems, reasonable costs, and genuine relationships.

But here's what we need from you: Treat us like human beings. Speak to us the way you'd want your own family members spoken to in their workplaces. Understand that the person at the front desk didn't create the insurance system, the medical assistant didn't cause your long wait, and the nurse can't magically produce medications that insurance won't cover.

When something goes wrong or you're unhappy, tell us. Advocate for yourself. Ask questions. Push back on recommendations you don't understand or with which you don’t agree. This is appropriate and necessary.

But do it respectfully. Do it without verbal abuse, without threats, without harassment. Do it recognizing that we're trying to help you and that we're constrained by systems neither of us controls.

But if you're choosing to behave abusively because you're angry and you think aggression will get you what you want—that has to stop. For our well-being, yes. But also for yours, because abuse destroys the therapeutic relationship and ultimately harms your own care.

I became a physician to care for people. To use my knowledge, training, and skills to reduce suffering and improve health. To build relationships with patients and walk alongside them through illness and recovery.

I didn't become a physician to be screamed at, threatened, or abused. Neither did my colleagues. Neither did the medical assistants, nurses, and front desk staff who make healthcare possible.

We all deserve to practice medicine in environments free from violence and aggression. Our patients deserve care from healthcare workers who aren't traumatized and burnt out from absorbing daily abuse.

Setting and enforcing patient codes of conduct isn't about being punitive. It's about creating the conditions necessary for therapeutic relationships to flourish. It's about protecting the people who've devoted their lives to caring for others. It's about preserving the humanity and joy in medicine that drew us to this work in the first place.

And I invite every healthcare organization, every practice, every clinic, and hospital to join me in saying: not here. Not to our people. Not anymore.

Earl Stewart, Jr., MD, FACP, is an internal medicine physician and Medical Director of Health Equity for WellStar Health System in Atlanta, Georgia. He is a Fellow of the American College of Physicians, a 2023 Doximity Digital Health Fellow, and a 2023 Climate and Health Equity Fellow with the Medical Society Consortium on Climate and Health.