“The threshold for aggression may be lower when a patient or accompanying relatives are frightened, in pain or anxious.”—Stephanie Bown, MD
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April 2013A patient arrives for his appointment on time and has been waiting for several minutes to be called back when another patient enters the waiting room and is summoned before the first patient, who then becomes irate and yells at the front office workers. Is his anger justified? How do you and your staff deal with this anger?
Chances are, this scenario has played out in your practice. Often, patient anger is legitimate; whether or not it is appropriate is another matter. This article will seek to establish how to determine when patient anger is justified, what to do when a patient becomes irritated and perhaps verbally abusive, and how to prevent future angry outbursts.
Within Reason?
When a patient becomes angry, first try to determine whether the anger is justified, said Charles Harkins, MD, FACS, professor of otolaryngology at the Medical College of Wisconsin in Milwaukee. “There are different reasons why a person may become angry: Maybe we’re rude or we’re running late,” he said. “So, the problem becomes that although the patient’s anger is justifiable, the response is inappropriate. It’s one thing to be mad that the doctor is running a half-hour late, it’s another thing to use foul language directed at the person at the front desk.”
It is important for medical professionals to understand how to defuse these situations, not only because verbal outbursts are unpleasant but also because they could escalate to physical conflict, said Stephanie Bown, MD, director of policy, communications and marketing at the Medical Protection Society in London, a nonprofit defense organization for health care professionals. “Doctors should be aware that aggressive situations can develop rapidly, particularly if a patient is drunk, mentally ill or a drug addict,” said Dr. Bown.
“They should also remember that the threshold for aggression may be lower than normal when a patient or their accompanying relatives are frightened, in pain or anxious.”
Next Steps
Once the cause of a patient’s anger is determined and deemed legitimate and the threat of violence has been avoided, the next important step is to listen to the patient with empathy, said Dr. Harkins. Tell the patient that you understand that he or she is upset about a situation, but that the response is improper.
“When a patient’s response to anger is out of line, I will speak to them directly,” Dr. Harkins explained. “Most of the time, once you tell the patient that they can’t cross that line, they’ll back down quickly.”
Monica Harris-Broome, MD, director of the communication skills program at the University of Miami School of Medicine, said that when dealing with angry patients, it’s important to listen—not just to the patient’s needs, but also to his or her underlying issues or concerns and unexpressed expectations. She has lectured extensively on the angry patient encounter, or APE, an acronym that she also uses to describe how to defuse a heated situation:
A = Agree: Find something to agree on with the patient.
P = Pause: Time helps defuse heated situations.
E = Emotions: Acknowledge the patient’s emotion, but avoid labeling him or her as “angry.”
Sometimes, however, there is nothing that you or your staff can do to calm down an angry patient. “These patients may have a pathological diagnosis,” Dr. Harkins said, and in these situations, security may have to be called. “This is rare, but it does happen.”
What Not To Do
The No. 1 rule when dealing with an upset patient is to not fan the flames of anger, said Dr. Bown. “Try not to escalate the situation by remaining calm rather than ‘matching’ the patient’s behavior,” she said. Dr. Harkins agreed: “There are two rules I follow when dealing with angry patients: I don’t ever raise my anger level, and I never swear.” He said that if you respond to anger in kind, you’re just creating a really bad situation that can quickly spiral out of control. Additionally, it’s essential to set an example, said Dr. Harris-Broome. “Don’t ask a patient to calm down; model calmness,” she said.
Back Up Staff
Another point to keep in mind is that it’s extremely important to support your front office staff. “They’re the ones who are usually being abused,” said Dr. Harkins, explaining that often they are on the front lines and experience the brunt of a patient’s frustration. “If you don’t back them up, they’ll feel insecure in the workplace and may leave,” he added.
While some instances of patient ire and frustration cannot be prevented, ensuring that you and your staff are sensitive to a patient’s feelings, that a sense of security and calm is maintained and that the lines of communication remain open, may help to mitigate and perhaps prevent the occasional angry occurrence. “Most people are reasonable,” said Dr. Harkins. “Most of the time they stop their anger when they realize there is a line they can’t cross, and that they’re being listened to and understood.”