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James A Vohs Award:
A Focus on Obesity, Part 1
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••Spring 2003/Vol. 7, No. 2

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Health Systems


CPC Corner
Dealing With The Angry Patient
| pdf >>

By Edward C Wang, MD

The Importance of Keeping Cool with Angry Patients
A Lesson Taught by My Patient
By Scott Abramson, MD


 

Barbara is one of my most "challenging" patients. Although she has genuine neurological problems, she is also extremely anxious and quite demanding. A former librarian, now with a lot of disability time on her hands, Barbara is as adept at cross-examination of doctors as she is at Internet medical research.

Recently I had to refer Barbara for a surgical operation. Suitcase full of cyber-literature, she arrived at the surgeon's office. She began the interrogation of the surgeon with her usual vigor and determination. However, the more she pressed, the more relaxed the surgeon appeared. Barbara demanded explanations; the physician patiently explained. She insisted on detail; the physician calmly drew pictures. On her follow-up visit with me a few days later, Barbara summed up her experience at the surgeon's office. "I was tremendously impressed with the doctor. He will be my surgeon. I sort of gave him a rough time," she admitted, "but he never lost his cool. He must have a steady hand!"

All this got me to wondering. When angry, hostile, demanding patients attack us, maybe they don't really mean it. Maybe it's all a test. How steady is your hand?

 

Angry patients and families pose one of the biggest challenges for a clinician, for encountering this type of tense emotion often triggers one's own fight-or-flight responses. Any person who is met with anger tends either to react with anger or with the desire to flee. Remaining calm, professional, and empathetic to the emotions of the patients is sometimes very difficult for any of us, but there are communication skills that can be used to defuse anger and re-establish effective dialogue with patients and their families.

Patients' anger is often directed at a person or a situation that is unrelated to the physician. The patients' stories need to be heard. Our curiosity about what has happened has a therapeutic effect. By staying curious, we also avoid being defensive about ourselves. By arguing or expressing opinions before letting patients finish their stories, a power struggle may ensue which may augment their anger. Careful listening is just a part of defusing the patient's anger. It also involves some active-listening skills such as repetitions, summaries, validations, and empathetic statements.

When a patient is angry about a bad outcome, whether or not medical error was a possibility, empathy can still be used to address the patient's emotions. As clinicians, we usually do not know the details of what has happened in a particular adverse situation, and we often cannot and need not to resolve the problems. The clinician-patient relationship will benefit from such empathetic statements as "sounds like you are quite angry about your diagnosis, tell me more about that." In contrast, a statement of condemnation or judgment may not be very helpful for the patient or the medical group, such as "sounds like the other doctor missed your diagnosis."

If the physician feels uncomfortable about a clinician-patient interaction, there is almost always some barrier that is in the way of effective communications. Being aware of the tension, identifying the barrier, and acknowledging with the patient that there is difficulty in the relationship are important steps in re-establishing understanding between a patient and clinician. One possible question could be: "I sense that you are upset about something, can you tell me more about it?"

Patients assign meaning to what has happened to them. Anger is expressed sometimes as an emotion derived from the consequences of a medical condition, as well as toward the medical condition itself. An example of this is a patient who becomes angry about the disability of an operation for appendicitis, and is also upset about having the condition itself. As clinicians, we don't always consider the meaning behind the patient's anger. Helpful phrases such as "will the operation affect you or you family in any other way?" may bring out issues that are previously unrecognized.

The emotions that are unrelated to the business at hand often frustrate us, and we would prefer to pursue the solutions to the medical problems. A physician may need to be in tune with the speed at which a patient is able to vent and move forward. The patient may not be ready to move toward the possible alternatives to a medical problem until his grief is expressed. The following Quick Guide summarizes the behavior and phrases that a clinician can use to deal with the angry patient. Other Quick Guides can be found at the Clinician-Patient Communications Intranet site: http://kpnet.kp.org/cpc/.


Quick Guides

When a Patient is Angry About Others

  • Pause and be attentive
  • Avoid being defensive
  • Stay curious about the patient's story
  • Acknowledge the difficulty of the interaction
  • Find out the specifics of the story--encourage the patient to give the details
  • Express empathy for the patient--acknowledge the emotion by name
  • Make a statement guessing at the meaning behind the patient's anger and validate
  • Take an action on the patient's behalf if possible. Be an advocate
  • When possible, link the patient with the resources that can help
  • Transition to purpose for the visit

Rationale and Useful Phrases

Sometimes patients arrive at an appointment angry about other experiences they've had with trying to make appointments, long waiting times, seemingly unresponsive staff or providers, etc. It is important to address these issues because they can interfere with your effectiveness as a clinician if you do not effectively manage the situation.

Rationale and Useful Phrases Table

 

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