Patricia A. Bennett, PhD

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.

 

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.

Somatization

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.

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 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.
  

 

In short, directly address the causes of the anger after laying out the facts and expressing your empathy or condolence.

When anger flares

Ask the question. The first step is intervening to interrupt the momentum. One way is to ask, “What would you have wanted us to do?” This usually changes the pace of the conversation by giving the patient a chance to talk at some length.

Acknowledge. Another tactic is saying, “I would be very angry, too, if I were in your shoes, and I would want explanations as well.” By making such a statement, you co-opt the patient’s anger momentarily, which can be enough to defuse the situation.

From that point on, making sure the anger doesn’t get out of control is the challenge.

Uphold principles. During such a conversation, basic principles should prevail:

• Express respect
  
• Be honest
  
• Remain calm
  
• Articulate empathy for the patient’s loss or injury.
  

What if the patient is right? You must be prepared to admit your mistakes when the patient and her family are correct in their assumptions. This honesty will not necessarily make the patient forgive you. In fact, she may become even angrier. But she is less likely to sue if you are honest.

Practices that prevent suits

Address absence of facts

In the early aftermath of an event, key information may remain unknown. It takes time to complete and evaluate interviews, equipment analysis, and test results.

When the patient asks, “Why did this happen?” it is appropriate to respond: “We do not know and will not know until all the necessary information is collected and reviewed. I think you would agree that it would not be helpful for me to speculate or conjecture. But as soon as we have all the facts we can present them to you.”

Get key information from patients

Not only is it important for you to share information with the patient, but she should provide key details about the event in question, too. This step is especially important when there is a concern about patient noncompliance.

If such noncompliance comes to light, share it with the people who must complete an incident evaluation. It will help put the outcome in context and neutralize lingering hostility.

Identify 1 spokesperson

Angry, dissatisfied patients and their families often seek out answers from other health professionals, such as nurses who participated in treatment. Instruct staff members and colleagues to decline to comment directly to the patient.

Train staff in verbal control

Staff should be taught how to respond when confronted by an angry patient. Unfortunately, shouts and threats to go to the press or to sue are not unusual.

Books on negotiation or conflict management are available in most libraries, and many colleges or other institutions offer classes on anger management. Unfortunately, such training remains only a peripheral part of medical education.

Dr. Woods and Dr. Bennett report no financial relationships relevant to this article. Ms. Rozovsky is President of Quality Medical Communications LLC, a company that produces video and written material for care provider education.

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.

 

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.

Somatization

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.

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 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.
  

 

In short, directly address the causes of the anger after laying out the facts and expressing your empathy or condolence.

When anger flares

Ask the question. The first step is intervening to interrupt the momentum. One way is to ask, “What would you have wanted us to do?” This usually changes the pace of the conversation by giving the patient a chance to talk at some length.

Acknowledge. Another tactic is saying, “I would be very angry, too, if I were in your shoes, and I would want explanations as well.” By making such a statement, you co-opt the patient’s anger momentarily, which can be enough to defuse the situation.

From that point on, making sure the anger doesn’t get out of control is the challenge.

Uphold principles. During such a conversation, basic principles should prevail:

• Express respect
  
• Be honest
  
• Remain calm
  
• Articulate empathy for the patient’s loss or injury.
  

What if the patient is right? You must be prepared to admit your mistakes when the patient and her family are correct in their assumptions. This honesty will not necessarily make the patient forgive you. In fact, she may become even angrier. But she is less likely to sue if you are honest.

Practices that prevent suits

Address absence of facts

In the early aftermath of an event, key information may remain unknown. It takes time to complete and evaluate interviews, equipment analysis, and test results.

When the patient asks, “Why did this happen?” it is appropriate to respond: “We do not know and will not know until all the necessary information is collected and reviewed. I think you would agree that it would not be helpful for me to speculate or conjecture. But as soon as we have all the facts we can present them to you.”

Get key information from patients

Not only is it important for you to share information with the patient, but she should provide key details about the event in question, too. This step is especially important when there is a concern about patient noncompliance.

If such noncompliance comes to light, share it with the people who must complete an incident evaluation. It will help put the outcome in context and neutralize lingering hostility.

Identify 1 spokesperson

Angry, dissatisfied patients and their families often seek out answers from other health professionals, such as nurses who participated in treatment. Instruct staff members and colleagues to decline to comment directly to the patient.

Train staff in verbal control

Staff should be taught how to respond when confronted by an angry patient. Unfortunately, shouts and threats to go to the press or to sue are not unusual.

Books on negotiation or conflict management are available in most libraries, and many colleges or other institutions offer classes on anger management. Unfortunately, such training remains only a peripheral part of medical education.

Dr. Woods and Dr. Bennett report no financial relationships relevant to this article. Ms. Rozovsky is President of Quality Medical Communications LLC, a company that produces video and written material for care provider education.

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.

 

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.

Somatization

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.

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 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.
  

 

In short, directly address the causes of the anger after laying out the facts and expressing your empathy or condolence.

When anger flares

Ask the question. The first step is intervening to interrupt the momentum. One way is to ask, “What would you have wanted us to do?” This usually changes the pace of the conversation by giving the patient a chance to talk at some length.

Acknowledge. Another tactic is saying, “I would be very angry, too, if I were in your shoes, and I would want explanations as well.” By making such a statement, you co-opt the patient’s anger momentarily, which can be enough to defuse the situation.

From that point on, making sure the anger doesn’t get out of control is the challenge.

Uphold principles. During such a conversation, basic principles should prevail:

• Express respect
  
• Be honest
  
• Remain calm
  
• Articulate empathy for the patient’s loss or injury.
  

What if the patient is right? You must be prepared to admit your mistakes when the patient and her family are correct in their assumptions. This honesty will not necessarily make the patient forgive you. In fact, she may become even angrier. But she is less likely to sue if you are honest.

Practices that prevent suits

Address absence of facts

In the early aftermath of an event, key information may remain unknown. It takes time to complete and evaluate interviews, equipment analysis, and test results.

When the patient asks, “Why did this happen?” it is appropriate to respond: “We do not know and will not know until all the necessary information is collected and reviewed. I think you would agree that it would not be helpful for me to speculate or conjecture. But as soon as we have all the facts we can present them to you.”

Get key information from patients

Not only is it important for you to share information with the patient, but she should provide key details about the event in question, too. This step is especially important when there is a concern about patient noncompliance.

If such noncompliance comes to light, share it with the people who must complete an incident evaluation. It will help put the outcome in context and neutralize lingering hostility.

Identify 1 spokesperson

Angry, dissatisfied patients and their families often seek out answers from other health professionals, such as nurses who participated in treatment. Instruct staff members and colleagues to decline to comment directly to the patient.

Train staff in verbal control

Staff should be taught how to respond when confronted by an angry patient. Unfortunately, shouts and threats to go to the press or to sue are not unusual.

Books on negotiation or conflict management are available in most libraries, and many colleges or other institutions offer classes on anger management. Unfortunately, such training remains only a peripheral part of medical education.

Dr. Woods and Dr. Bennett report no financial relationships relevant to this article. Ms. Rozovsky is President of Quality Medical Communications LLC, a company that produces video and written material for care provider education.