JANUARY 15, 2006


When angry patients push your buttons

What to do when those you try to cure turn on you

You, as a doctor, are a man or woman of science. Reason may have got you all the way through med school but your logical mind doesn't necessarily prepare you for dealing with irrational, out-of-control patients. For many physicians the worst thing about these trouble-makers is that they tend not to test your medical skill and knowledge very much at all — but rather, they try your patience, push your most tender buttons and waste your time. It can seem like they're battering rams threatening to take down your professional demeanour. These cruel convalescents have a way of making you wish you'd chosen another field — like tiger dentistry or bee grooming.

But a physician who is a true master of dealing with angry patients can deflect negativitywith the finess of a black belt in interpersonal relations. The secret of these docs' success is unflappable resolve and an insistence on claiming the moral high ground. As ancient Chinese military strategist and author of The Art of War Sun Tzu said about 2,500 years ago, "supreme excellence consists in breaking the enemy's resistance without fighting."

When you first realize you've got an angry patient on your hands it's critically important that you don't "talk down" to them or act aloof. If you do slip up and insinuate the patient is a know-nothing crybaby then you're just resorting to paternalism. On the other hand, it's even worse when you allow the patient to bully you into agreeing with them or giving them a drug or treatment they want but you don't feel is appropriate. One of the very worst things you can do to deal with an irate patient is to accept blame needlessly. Saying, "I'm sorry" when you didn't do anything wrong may simmer a patient down for a while, but it will also erode their trust in your skill and knowledge as a doctor.

To be truly prepared for a difficult patient, you're really going to want to make enough time to know their story. If you get a tip from a colleague that the patient you're to see is a real handful, take the time to bone up on their medical history. Many of the most difficult patients you'll face fall into one or more of the following categories: malingerers, somatization disorder sufferers, people with a history of noncompliance, and know-it-all Google-addicted wannabe MDs with a history of challenging diagnoses. The better you understand where these people are coming from the less likely it is that you'll lose your cool and take things personally.

Knowing your patient's story is half the battle, but it's also helpful to know a bit about the specific type of anger that's driving a difficult patient.

"Defusing the Angry Patient" in last October's issue of the journal OBG Management talked of the "four faces of anger." First off, there's the positive sort of anger that we might call righteous indignation but the hundred-dollar name for it is "primary adaptive response." This is the sort of anger that prompts people to demand answers for what they perceive as a wrong — things like an obviously careless botched blood-draw that led to nerve damage. You can't really fault a patient for being angry in such cases.

"Primary maladaptive" anger is the sort you face when an enraged patient spews verbal vitriol reflexively. You see this "I'm mad as hell and I'm not going to take it anymore" type of anger driving a patient to demand to see a doctor straight away even when there's a long queue in the waiting room.

"Instrument" anger is subtly different from "primary maladaptive" in that it can be put on. Some shameless patients won't hesitate to act like complete jerks in order to manipulate caregivers into offering them special treatment.

Finally there's "secondary emotion" anger. This is the toughest anger to deal with because it's really just a case of the patient distracting him or herself from a real emotion that lies beneath the surface, like the profound fear of dying that follows a cancer diagnosis.

In a way, giving an angry patient more of your time seems like the wrong thing to do — it's a truly irksome feeling giving the squeaky wheel the grease, especially when you don't feel you have enough time for your thoughtful and cordial patients — however, nothing beats scheduling a one-on-one meeting with a malcontent to help patch up a damaged doctor-patient relationship. And don't procrastinate if you plan on setting up such a meeting. Sure their anger might dissipate if you wait, but there's also a good chance the patient will complain about you to his or her friends and family, needlessly dragging your name through the mud.

Conflict with patients is one of those things with an enormous potential to snowball out of control. An angry patient might have a whole slew of belligerent relatives ready to flood your facility with complaints. That's why extra-diligent record keeping is a must when dealing with these people. Imagine an angry, intractable patient who refuses treatment. You believe him to be sound of mind. If he were to take a turn for the worse, detailed documentation on his refusing treatment might come in handy.

Even if they have a valid point or two, an unruly patient has no right to get personal with you. Even if you're not particularly thin-skinned, don't be a hero. You shouldn't feel obliged to keep seeing an unruly patient who obviously doesn't respect your professional opinion. If you feel the doctor-patient relationship is poisoned, notify the patient and then turn care over to another physician.



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