Defusing the angry patient while keeping your cool

Issue: May/June 2010

ByJennifer S. Morse, MD

Taking steps to assess and address an unhappy patient’s concerns can go a long way in avoiding future outbursts.

Question: Although the majority of my premium IOL patients are quite happy, occasionally we have unhappy patients who just seem to go from irritated to smoldering to flaming within a short time despite my interventions and those of my staff. These interactions often upset the staff and put me behind in my schedule, and I wonder if you have any tips on managing upset/angry patients.

Answer: Yes, patients who are irritated or upset about even small things can quickly escalate from just voicing a complaint in a tone that says, “I am annoyed,” to a full-blown anger outburst that leaves people (including other patients, such as new consultations) ducking for cover or wishing they could escape. The key is to manage it early without escalating the situation. A common mistake that I often see or hear about is when healthcare professionals actually make the situation worse because they respond based on their own automatic thoughts and feelings about anger, rather than having stepped back and studied the process before it occurs. Because most people experience heightened emotions in response to another person appearing upset or angry, they often lack the ability to “self-observe” how they may have appeared to the patient in real-time and why their actions may have added fuel to the fire, so to speak.

Let’s look at a typical situation that can end badly if not handled appropriately. See that 55-year-old female executive who keeps glancing at her watch while sitting in the clinic reception area? She does not want to be perceived as being a bother, but she has to be back at work soon and she does not want to reschedule. When she asks when she will be seen, her voice is loud and sounds irritated. The receptionist hears “rude/angry,” and although she apologizes for the delay, she does not quite manage to keep the look of disapproval off her face. The patient now feels it is clear she is unimportant, and she thinks the staff person is arrogant and rude. By the time the surgeon enters the room to see this patient, he has been told by the staff that the patient is “rude, demanding and angry.” He feels somewhat tense as he enters the room, unsure what to expect. The patient who has been sitting in the exam room now certainly feels angry and upset. She intends to complain about her rude treatment, and she is suspicious that the surgeon must be rude and uncaring, as well. Will the surgeon be able to defuse the situation and turn it around, or will this situation deteriorate and end up as a negative review by the patient back at her boardroom?

I always encourage people to start by thinking about why people display anger, and how they as individuals think and feel when they are confronted by anger. A patient may visibly display what looks like “anger” for a variety of reasons. Common ones include feeling unimportant or ignored, scared or vulnerable, and frustrated. If you can think of the underlying reasons for the person’s emotional display, it often makes it easier to deal with it more objectively and with less reactivity. Many people experience some of these common automatic feelings when they are faced with someone who is upset or angry: disdain, defensiveness, anxiety, fear, disgust or nervousness. These automatic feelings may arise from childhood or life experiences. People often have a “default” reaction to someone they “read” as angry or upset based on what those emotions look like to them. These reactions are shown not only through words, but also vocal tone, inflection, facial expressions and body language. Certain statements are almost guaranteed to result in escalating, rather than de-escalating a situation. These include “You need to calm down, Mr. X,” “There is no need to be rude,” and “Now, look here….” Avoid statements that make the patient feel you are treating him or her like a child. Other common default reactions of surgeons and staff that can escalate patients’ anger include: maintaining poor eye contact with the patient or glancing at a coworker while the patient is telling their side of the story; demonstrating cold disapproval; taking “flight” from the patient out of nervousness rather than dealing with the complaint; or becoming defensive and arguing with the patient.

Let’s look at the “Steps for Defusing Angry Patients”:

Do not take it personally. This is one of the most important rules of dealing with upset and angry patients, and one that many people continue to have difficulty implementing. They understand it cognitively, but in the heat of the moment, they react as if they are personally being attacked.
Be proactive. Monitor your clinic environment. Make certain your clinic staff keep an eye out for patients who seem irritated or anxious, and that staff know to provide them extra reassurance. If a patient appears to be getting angry or upset, move them out of the clinic area so they do not create anxiety for other patients.
Calm yourself before you respond. You cannot expect to calm someone if you cannot calm yourself.
Listen for the real message. Listen for the message beneath the emotional outburst. Do not respond to the emotions by counter-attacking. Spend adequate time actively listening and demonstrating warmth.
Reassure and respect. Always reassure the patient of their importance to you, and make certain you demonstrate respect for the patient. Both of these actions can greatly defuse an unhappy or angry patient yet are often overlooked during a heated interchange.
Restate their concerns. Check with the patient to see if you understood their concerns. By doing so, you prove you were listening and that you care enough to make certain you understood their concerns.
Respond to their problem. Even if you can’t automatically fix their complaint, say what you can do. Don’t make promises you can’t keep, and always followup.
Restart. Allow the patient to exit with as much dignity and as little awkwardness as possible. Everyone should start at the next visit as if the slate were wiped clean without any bias.

In summary, I suggest that you and your staff take the time to examine your automatic feelings and reactions to anger, practice the steps I’ve outlined, and then review some of your past cases to see if there might have been some areas for improvement. Use these techniques the next time a patient becomes upset or angry, and feel free to e-mail me regarding the outcome.