Defusing the angry patient

When a patient pushes your buttons

ERIN’S CASE

At 36 weeks’ gestation, Erin calls your office at the end of the day on a Friday with an emergency: She couldn’t sleep the day before. You feel angry; why? Is it because you had plans to go out to dinner and now will be late? Is it because Erin has been demanding and needy throughout her pregnancy? Is it because Erin doesn’t follow the protocol for nonemergencies and acts as though everything is an emergency? Is it because no matter what you do, Erin hasn’t been satisfied with her care?

These questions can help you decide how to proceed. In any tense situation, the first step is to identify the angry party. This is not always as straightforward as it sounds, since anger is frequently displaced. It may be the patient or her family who shows signs of anger. It may be you. Or it may be both.

Dealing with an angry patient is easier if you keep sight of your own triggers and sore spots. This self-awareness allows you to assert control and contain your emotional reaction.

Coach yourself through an angry encounter. When you recognize your own limits, it is easier to manage difficult situations using “self-talk” to coach yourself through them. For example, when your patient becomes angry, you might remind yourself, “Take a deep breath.” As she complains, you might tell yourself, “This is not personal, even though it feels that way. What is she trying to tell me?”

Formal role-playing and informal discussions of real or hypothetical cases are another strategy.

How to conduct an anger-defusing visit

Set an appointment to talk it out

When a patient expresses anger that does not abate with empathetic listening, consider scheduling a special visit to address her concerns. And prepare for it:

Don’t sit behind a desk. Determine where the conversation will be held, including the seating arrangement. It is inappropriate to sit behind a desk for the discussion, as this arrangement can exacerbate the division between you and the patient. If your office is not conducive to a “relaxed” talk, consider a more neutral site.

Check the exits. Always consider the possibility that the patient or a family member may feel outraged to the point of physical abuse. Make sure security personnel are readily available; if necessary, agree upon a prearranged signal for them to intervene. Also consider whether you will have easy access to the door. During the conversation, do not accept or tolerate threats.

Make it soon. When emotions run high, it is probably best to talk within a week. Avoid a delay of several weeks in hopes that anger will dissipate. What usually happens during such a long interval is that the family becomes angrier and seeks outside advice, much of which is negative. The patient also may change doctors because of the anger and abandonment she feels.

Schedule plenty of time. When enough time is devoted to the discussion, anger generally begins to dissipate. Therefore, do not limit conversation if the case is especially contentious and the risk of a lawsuit very real. On the contrary, it may take 2 hours or longer for the anger to soften.

Rehearse. A role-playing scenario with a colleague can help you experience the full impact of how anger alters a discussion.

Here’s what to say

JULIA’S CASE

A 48-year-old patient reported a breast lump at her last annual visit. At that time, upon examination, you palpated a small mass. Since Julia also has fibrocystic breast disease, you explained that the lump was probably benign, but you referred her for a mammogram and encouraged her to get it as soon as possible. When she finally did—8 months later—invasive carcinoma was diagnosed, necessitating a lumpectomy and chemotherapy.

At her next annual visit, Julia is confrontational, accusing you of downplaying the risk of breast cancer and causing her delay in seeking a mammogram. When she remains outraged despite your calm reminder that you recommended an expeditious mammogram, you schedule an appointment to discuss the matter.

What are your next steps?

Though the logistics are straightforward, success depends on the specific patient and any family members involved.

In general, you should strive to:

• Establish an agenda and review it with the patient.
  
• Describe the facts of the case in lay terms so that the patient, her family, and any others receive the same information. This helps eliminate erroneous assumptions and misinformation. For example, Julia’s family may not be aware that you encouraged her to obtain a mammogram as soon as possible.
  
• Express empathy that she has to go through this serious time in her life, and acknowledge that a cancer diagnosis and treatment are tremendously stressful.
  
• Search for the reasons behind the anger. Ask how the patient and her family have arrived at their conclusions.
  
• Control anger and prevent it from escalating. Keep your voice steady and maintain an open body language. Avoid signs of your own anger.
  
• Ask for her perception of what has been said, at the conclusion. If family members are present, ask for any other issues that need clarification.
  
• Close the discussion respectfully.
  
• Document the conversation by noting the time, persons present, what was discussed, attitudes of the family, and any plans for follow-up. How thorough should this medical note be? If you were to read your own documentation 5 years from now (the length of time it often takes a disputed malpractice claim to come to trial), would the written facts of the conversation enable you to reconstruct the complete interaction with the family? If the answer is yes, the documentation is complete.