A new report that reviews research on assaults against doctors, nurses and other medical personnel concludes that health care workers often experience physical and verbal attacks, and, all too often, little is done to address it.

“Health care workplace violence is an underreported, ubiquitous, and persistent problem that has been tolerated and largely ignored,” said Dr. James Phillips of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, writing in the New England Journal of Medicine.

“Our industry is, statistically, the most violent non-law-enforcement industry in the United States. And that’s using government statistics that have been shown to under report the actual violence that takes place by up to 70 percent,” he told Reuters Health in a telephone interview. The violence is often tied to patients with dementia and mental health or substance abuse problems.

But in a significant number of cases, firearms can be involved. “Between 2000 and 2011, there were 154 shootings with injury either inside or on the grounds of American hospitals, most frequently outdoors on the hospital campus (41%), in the emergency department (29%), or on inpatient floors (19%),” Phillips writes. “The most frequently ascribed motives were revenge (27%), suicide (21%), and mercy killing (14%).”

Armed security guards may not be the answer. “In 8% of all events the perpetrator took the gun from a police or security officer,” he said. “In 28% of events involving firearms, a law enforcement officer shot a perpetrator in the hospital.”

Patients in police custody have been involved in 29% of shootings that took place in the emergency departments, 11% of which occurred during escape attempts, he said. In a mental health setting, 70% of staff members are physically assaulted each year and “among psychiatric aides, the rate is 69 times the national rate of violence in the workplace,” he writes. And in nursing homes, where dementia is a problem, one survey found that 59% of nursing home aides reported being assaulted weekly. Health care workers were the victims in 93% of hospital-related assaults in 2014. Most verbal assaults never get reported at all.

A 2015 study found that 80% of emergency services personnel had been the target of physical violence but only 49% had reported it to police. A separate study that looked at violence against doctors found that 89% of the assaults were done by patients, 9% by family members and 2% by a friend of the patient.

“One reason health care providers are reluctant to report these is that we have compassion for our patients, and we don’t want to treat patients like they’re criminals or the enemy,” Phillips said. “So we probably make excuses when we shouldn’t, and we overlook patients who are intoxicated or on drugs, and other patients who have altered mental status because of chronic dementia or acute delirium. They are already vulnerable, and we don’t want to treat them as if they are criminals.”

Phillips became interested in the issue after being assaulted twice within the past five years. The first time was while training in a Chicago hospital where an intoxicated patient “spit blood in my face knowing he had hepatitis C. I was forced to undergo six months of testing. I was never asked if I wanted to file a police report or press charges.”

The second time was in a community hospital when he asked an emergency department patient to stop screaming and cursing because there were two children in the next stall. The woman threw her cell phone, struck him in the face, and then stood up and spit on him in the presence of a police officer. She was ultimately convicted of assault and battery. “The majority of health care providers who have been assaulted don’t feel that their concerns are taken seriously,” he said.

Phillips said the best solution isn’t clear because little research has been done on the best ways to thwart attacks. Some possibilities include being tough on verbal assaults; acting aggressively against such cases may prevent them from escalating; changing the law to make a physical attack on a health care worker a felony; and redesigning patient charts to flag past instances of violence, a system in use in the Veterans Affairs system.

Metal detectors might appear to be an option. A 2003 study reported that one emergency department with a metal detector confiscated 3,446 weapons in 8 months. But firearms were seldom found. Most of the weapons were knives. And the system misses a lot of weapons because they’re often carried by the patients, who aren’t screened because they come to the emergency department on a metal ambulance stretcher.

“Metal detectors tends to be the knee-jerk reaction to any major violence that takes place, especially when a weapon is used,” Phillips said. “But there’s not any evidence that reducing the number of weapons, reduces violence because so much of the violence isn’t committed with a weapon. It’s committed with fists and feet.”

“We don’t have any evidence that shows that any one particular solution is actually effective at reducing workplace violence,” he said.