CHICAGO-A white coat is no shield from rage.   No one knows whether violence by patients against physicians is on the rise, as it is with lawyers and clients. But there’s little doubt that doctors are feeling the heat of patients’ fury over real or perceived mistreatment.   Internist Jeanette Morrison of the University of Chicago knows firsthand how it feels. And she was so shocked at having her life threatened by a deceased ICU patient’s family that she conducted a national mail survey to see whether her experience was unusual. It wasn’t.   She found that 226 of 684 physicians polled said they had been physically attacked at some point in their medical careers. In 95% of the incidents, which went back to the 1950s, the assailants were patients or their families. Seven percent of attacks were with weapons, most of the time guns or knives.   Verbal abuse is even more common, she says, with 82% of physicians saying they’ve been threatened, berated, or humiliated to a “profoundly upsetting” degree by patients or their families.   In Dr. Morrison’s study, the incidents were recounted by surgeons (37%), internists (24%), ob-gyns (20%), pediatricians (18%), and FPs (16%), though the frequencies were higher in the traditionally risky areas of emergency medicine (58%) and psychiatry (48%). Doctors’ gender wasn’t a factor.   Many she interviewed explained the incidents by saying “doctors are losing their position of prestige and power in society” and are no longer respected. Some blamed managed care for what they see as increasingly hostile patients.   Many feel the physician-directed violence is worsening. Some suggest that patients are angry because they believe care is deteriorating. Others say that physicians may trigger some of the attacks by appearing callous or abrupt, delivering news of unexpected or adverse outcomes poorly. The search for causes includes theories that society is more violent and people are more likely to carry weapons.   But the view that such acts of aggression are an inevitable part of medicine is giving way to calls for solutions. There’s a new California regulation requiring hospitals to provide self-defense training for emergency physicians. There’s also the Abuse-Free Medical Workplace Project, which blames physicians for some of the incidents and strives to make all health-care workers models of civil behavior in hopes it will spread to society at large. It’s sponsored by Hennepin Medical Society in Minneapolis, with the encouragement of the AMA.   Meanwhile, taking another tack, an Upland, Calif., group called Doctors for Responsible Gun Ownership is lobbying for less-restrictive rules on handgun-carrying permits. Surgeon Tim Wheeler, who heads a 1,000-member group based at Claremont Institute, says “it’s a way of preventing harm, not causing it.”   High-profile crimes show physicians are vulnerable both in the hospital and at the office. In 1994 three Los Angeles physicians were shot in a hospital ER. Dr. Selwin Cohen, a Bellevue, Wash., plastic surgeon, was fatally shot in his office in 1991 by a face-lift patient. In 1989 a New York University pathologist was raped and murdered by an intruder at her office at Bellevue Hospital.   The 1994 Los Angeles shootings led the state labor department to require hospitals to train emergency department workers, including physicians, in self-defense starting in 1995. Security firms offering the training say business is booming, and not just in California.   At the Abuse-Free Workplace Project, physicians are seen as sometimes being a part of the problem.   Dr. A. Stuart Hanson, a pulmonologist at Minneapolis’ Park-Nicollet Clinic, says the 500-physician network began the program 18 months ago by teaching that use of fear and intimidation is not acceptable, even though most doctors have encountered it in medical school. “A physician who berates a nurse will not be good for a patient who says her husband is abusing her,” he says.   Deborah Anderson, a Park-Nicollet consultant who devised the workplace plan, now at eight sites including Kaiser Permanente Rocky Mountain, says it calls for identifying the 2% to 3% of physicians who shout or throw things. If formal warnings don’t work, they can be referred for therapy or dismissed.   Two years after an HMO in one Western state began the program, the percentage of 750 employees who frequently witnessed pushing and slapping dropped from 13% in 1996 to 4% in 1998. Those rating humiliation as a frequent event dropped from 20% to 8%. The program identified three of the HMO’s 165 physicians as frequent offenders.   Dr. Morrison says medical schools should offer training in dealing with aggression. Or there’s former Connecticut state trooper Roland Ouellette, who teaches personal protection to ER workers.   One tip: if the aggressor suddenly shifts his gaze, duck. “That means he has decided to attack and is looking at the body part he’s going to hit, such as your chest,” says Ouellette. Next tip: When a gun is at your head, move. “Most people die because they freeze. That’s the common instinct.”   Meanwhile, Beverly Hills gun-safety instructor Paxton Quigley sees an increase in women physicians carrying firearms. One Quigley grad, she says, held an assailant at bay in a hospital parking lot with her .38-caliber special while she summoned police on her cellular phone. -Gale Scott