Defusing the angry patient

How anger rears its head

“In your face”

Although a woman may express—or contain—her anger in any number of ways, a few styles tend to predominate. Probably the most fearsome patient is the one with an “in your face” style, who yells, swears, or threatens people. If a nurse doesn’t jump to her demands, she asks for the supervisor and threatens to file a report.

Although it can be intimidating, there is one advantage to this style of anger: At least you know where you stand.

“I don’t do anger”

At the other end of the continuum is the woman who denies her anger. We once had a patient who proclaimed, “I don’t do anger,” but the midwife who referred her described her as one of the angriest patients she had ever seen. In our encounter, she was visibly tense and responded in short, clipped sentences, but we could not address her anger directly because she refused to admit its existence.

Noncompliance as power struggle

Indirect anger falls somewhere between the above 2 extremes. Women tend to be socialized to withhold their anger to preserve relationships, so they often feel safer expressing it indirectly. Passive-aggressive behavior is one example. The patient may arrive late or forget her insulin logs, or she may say everything is fine but call later in the day with an important concern. This conduct may seem like noncompliance, but noncompliance can be rooted in anger. Communication can become a power struggle in which the patient demonstrates her anger by refusing to do as you ask. Dropping out is the ultimate expression of indirect anger; the patient merely quits.

Somatization

Another way indirect anger manifests is through somatization, an unconscious process in which the patient does not articulate her emotions but experiences them physically. Treatment often has little effect.

The quiet woman

Also be aware that women often stifle their emotions until they feel overwhelmed and resentful, at which point they may explode.

The slippery slope of how to respond

The correct response to anger is empathy, which should be heartfelt, if at all possible.

Unfortunately, personality and personal issues sometimes impede our ability to empathize openly. It is important to avoid paternalism, evasiveness, and self-blame.

Paternalism in many ways is built into the medical hierarchy. Our specialized knowledge is the reason we’re consulted in the first place, and an intellectual or condescending remark on our part may be a natural defense to a patient’s angry attack, but such a reaction only fuels the fire. Nor should we ever use our role as an authority to dismiss the patient’s anger.

Evasiveness is another frequent response to anger, but can lead to detachment and feed the patient’s perception that you are unfeeling.

Acquiescing to her demands in hopes of avoiding further confrontation or a lawsuit may decrease her anger, but increase your own resentment.

Worst of all is self-blame, in which the physician assumes and internalizes responsibility for failing the patient or lacking perfect knowledge. Though this approach may quickly quell the patient’s anger, it can harm the physician-patient relationship and your emotional health.