The killing this week of Rockville psychiatrist Dr. Wayne S. Fenton served as a grim reminder of the rare but serious dangers of treating the severely mentally ill.
"It's not common, but there is always a risk," said Dr. Steven Sharfstein, a psychiatrist and the president and chief executive of Sheppard Pratt Health System in Towson.
Montgomery County police say Fenton, 53, was beaten to death in his Bethesda office Sunday by a 19-year-old patient.
The man attacked Fenton during an appointment, police said in a statement. In the session, which had been arranged that day, the man struck the doctor with his fists after being encouraged to continue taking his medications, charging documents said.
Police said the man was being treated for bipolar disorder and schizophrenia. On Wednesday he was assessed by a psychiatrist at the request of the man's attorney and found to be psychotic and suffering from persecutory delusions.
Friends and colleagues of Fenton's were shocked by his killing. Many considered him an excellent therapist and leader in his field. He was associate director for clinical affairs and director of adult translational research at the National Institute of Mental Health, where he helped establish standards for evaluating patients with schizophrenia.
While experts emphasize that the majority of people with mental illnesses are not violent, they acknowledge that certain patients warrant caution. In particular, those with a history of substance abuse, violence and psychotic illnesses can pose a higher risk.
"Psychiatry is a solitary profession for most clinicians and there are some patients that probably shouldn't be seen alone," said Dr. John Lion, a clinical professor of psychiatry at the University of Maryland School of Medicine.
While not much data is available, anecdotal evidence suggests psychiatrists are at a greater risk of being attacked than other health care professionals.
A survey of 190 psychiatrists and psychologists in Massachusetts published in March found that 65 percent had been threatened and nearly 50 percent had been the subject of some kind of "physical aggression" during their careers.
According to Lion's research, nine psychiatrists were murdered by patients from 1984 to 1995 in the United States. Two of the cases were in Oregon. In one, a patient killed his psychiatrist with a shotgun, after he developed a delusion that the doctor was causing him to have terrible headaches.
In the other case, a man warned his doctor not to enter his hospital room, but the doctor ignored the warning and the patient hit him over the head with a metal object, killing him.
"The lesson there is never to be macho with a patient," said Lion, who helped Maryland's state mental hospitals develop safety procedures for identifying and handling potentially violent patients.
Young resident physicians are now taught to take precautions when working with psychotic patients. Patients who are yelling or displaying paranoid behavior should not be seen alone. If no staff members are available, doctors may insist on having a family member present. They can also leave a door open so others might hear a disturbance. In addition, most emergency rooms have panic buttons.
Some doctors with private practices - particularly those who work with high-risk patients - take similar measures. One who does is Dr. Neil Blumberg, a forensic psychiatrist retained to diagnose the man charged in Fenton's killing. In an interview on the day before he became involved, he discussed the precautions he takes.
In his office in Timonium, he keeps the doors between his waiting room and consultation room locked and has a buzzer that lets him know when someone has entered the waiting room. He also can hit a panic button that alerts an alarm company if someone assaults him.
"The most important thing is to be alert and aware of the potential," he said.
One professional hazard is being too comfortable with a certain setting or patient.
About 25 years ago, shortly after he finished training at Sheppard Pratt, Blumberg began working at Clifton T. Perkins Hospital Center in Jessup and thought it would be a good idea to have periodic ward meetings for patients to discuss what was on their minds. He had been at Perkins about six weeks.
The sessions were for 30 "violent and psychotic men" in a ward where half the patients were too violent for treatment in the state's regional hospitals; the other half were state prison inmates, many of whom had been found not guilty of their crimes by reason of insanity.
"There were others on the staff that were against this," Blumberg said, "but I wanted to apply what I had learned in my forensic training."
During one session, a patient came in late, grabbed a chair and approached Blumberg.
"I thought he was going to sit next to me, but instead he hit me in the head with the chair and split my head open," Blumberg recalled. "Suffice it to say, the ward meetings were discontinued after that."