Defusing the angry patient
Some patients “boil over,” others simmer silently. Specific tactics lessen the likelihood of legal action
IN THIS ARTICLE
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 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.
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.
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.
Anger’s fingerprints: Watch for these clues
- Shortness of breath
- Rapid breathing
- Pressured speech: louder and faster
- Clenched teeth, fists
- Muscle tension
- Rapid heart rate
- Shakiness, trembling
- Tight jaw
- Indigestion, nausea, diarrhea
- Flushing, sweating
- Pointing a finger
- Getting in another person’s “space”
- Leaning toward the other person
- Rolling eyes
- Raising the voice
- Harsh or hostile tone
- Strong or extreme language
- Making accusations
- Slamming doors or phones
- Aggression toward a person or object
- Dichotomous thinking: all or nothing, black or white
- Exaggeration and generalization: always, never
- Distorted thinking
- Rigid ideation: “It must be this way or else,” “I will not stand for this,” etc
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.
When rage is only reasonable
Loss of control. Some diseases or conditions have uncontrollable outcomes. For example, a woman with ovarian cancer may feel angry when she realizes she cannot necessarily get better by following a particular plan of action.
“Why me?” Feelings of perceived injustice arise when circumstances seem particularly unfair, as when a woman experiences fetal death in utero despite responsible self-care, and sees less responsible women deliver healthy babies.
Not listening, inattention. Poor communication often leaves the patient feeling as though you failed to listen to her concerns. For example, when you give her less than full attention, an obese woman with gestational diabetes may feel blamed for her own problems.
History of sexual abuse. In women with a history of sexual trauma, obstetric or gynecologic procedures can sometimes remind them of abuse, and themes of powerlessness and lack of control may be reenacted. While it may have been unsafe—or even fatal—for these women to express anger at the original perpetrator, they may feel safer directing it at you.
When a patient pushes your buttons
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?