Clinical Review

Defusing the angry patient

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Some patients “boil over,” others simmer silently. Specific tactics lessen the likelihood of legal action


 

References

Forego anger and save yourself 100 days of trouble, the Chinese proverb advises. If only it were that simple. Consider the angry patient, possibly the most feared and least understood of all patients. Effective risk management goes far beyond things that stand to reason, such as “listening.”

The cases below show why patients get angry, what clues signal anger, what to say, and what not to say. But the focus throughout is how to prepare yourself and your staff to defuse the angry patient, from the first encounter through the essential follow-up: the office visit that you set up specifically to address her anger and reduce the risk of legal action.

Tracing anger’s fuse

KIM’S CASE

Kim is a 21-year-old G1P0000 with type 1 diabetes who did not comply well with her insulin and diet regimens. At 39 weeks’ gestation, with an estimated fetal weight of 4,000 g, she demands a vaginal delivery. At delivery, severe shoulder dystocia occurs, resulting in what the family later recalls as chaotic activity in the delivery room and severe nerve damage to the newborn’s left arm. When you meet with the couple and the wife’s sister later that day, all 3 express intense anger at you.

How should you respond?

Anger can occur when there is an unexpected adverse outcome, or when a patient feels responsible for a poor outcome. Either way, you may be a “safer” target than the actual cause.

In Kim’s case, each family member feels angry for a different reason, and you should try to draw their reasons out in conversation so they can be addressed. Don’t assume all are angry for the same reason.

  • The new mother feels terrible because her noncompliance contributed to the outcome. She expresses her anger at you to overcome feelings of failure.
  • The husband is angry with his wife because she did not follow her diet and insulin instructions carefully, but he is afraid to confront her after nearly losing their newborn son. He therefore directs his anger at you.
  • The sister is angry with you out of a sense of helplessness and a desire to “make someone pay.”
How do you sort out these different causes of anger? Even a simple phrase can initiate an open-ended discussion, such as, “There are many reasons people become angry. Perhaps in our conversation we will be able to identify those reasons.” Then, using a hypothetical “third-person” approach, you can safely explore the patient’s guilt, the husband’s misdirected anger, and the sister’s need for vengeance. Addressing the guilt, for example, you might say, “In some cases a patient’s choice of medical care may differ from what is suggested by her doctor. If that care is not contrary to medical standards, yet results in a bad outcome, the patient may feel very guilty, and that guilt sometimes masquerades as anger. Have you felt any of these emotions?”

In conversation, describe each step of the delivery process, to clarify misconceptions, and discuss the controversy over how best to manage a 4,000-g infant when the mother has diabetes. Also realize that the “chaotic activity” the family witnessed during the delivery may have contributed to their anger. An explanation of what was actually taking place may allay some of their concern.

In this case, knowing the patient was diabetic, the physician should have discussed the risks of various delivery methods well before the actual birth.

4 faces of anger

When is anger a healthy response and when is it pathologic?

It is beneficial when we use it to inform our actions. For example, if a physician feels angry about the proposed changes to Medicaid and writes a letter to her congressman, she is using anger constructively.

Anger is a problem when it changes to aggression, is buried, or is used to manipulate others. Research has linked chronic anger-management problems with interpersonal strife, difficulties at work, poor decision-making, increased risk-taking, substance abuse, coronary heart disease, stroke, chronic pain, disruption of motor activities (such as driving), and susceptibility to depression, guilt, and shame.2

Greenberg3 identified 4 ways of classifying expressed emotions such as anger, which the following 4 cases illustrate:

CASE 1. When anger sparks a change for the better A patient expresses anger at having to wait more than an hour to see you. By bringing it to your attention, she makes it possible for you to address the issue with office staff.

When anger is a primary adaptive response, it enables one to organize for action and to hold another responsible for injuring her. This is a healthy expression of anger; it lets a person act in congruence with both cognition and emotion.

CASE 2. When anger gets stuck Upon arrival, a patient informs your staff that she has no intention of being kept waiting. This woman considers even the slightest delay a personal affront.

When anger is a primary maladaptive response, it indicates a stuck pattern of behavior and emotional expression in which anger becomes a reflexive reaction, rather than an action. When anger takes this form, it can cause an individual to overestimate the threat to herself and damage relationships through aversive behavior.

CASE 3. Anger as a cover A woman with a newly discovered breast lump is afraid she has cancer. Rather than express this fear, she accuses you of withholding information.

In this instance, anger conceals an underlying emotion, and is therefore the secondary emotion. Sometimes the person is aware of the underlying feeling, sometimes not.

CASE 4. Anger as manipulation A patient wants cab fare provided for her and her children to get to their appointments; the norm is to provide bus fare. The patient threatens action and negative word-of-mouth, complains to the insurance company, and ultimately gets the cab fare.

Anger can be used as an instrument to manipulate others, to bring about a desired outcome.

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