'You need to put your **** in a bath of cold water and realign your chakras.'
The patient was twice my age and roughly twice my size, standing no more than three inches away from me, shouting and clearly less than happy. I was on a home visit and not succeeding in persuading her to be admitted to the psychiatric ward.
To this day, I am not sure quite how I calmed her down, but my training and experience as a psychiatrist worked. The encounter left me shaken, wondering whether I could have prevented it and wary on home visits for some time to come.
All doctors are likely to encounter angry patients or relatives. General practice, psychiatry and the Emergency Department are obvious areas of risk, but anger can be encountered anywhere. Rather than having to face a situation like the one above, taking steps to recognise potential anger and manage this can be preferable for you, your patient and your colleagues.
Lighting the fuse
Anger can be triggered by bad news, fear, misunderstanding and being kept waiting. Some patients arrive already angry. A brief delay in being seen, or a receptionist that they perceive to be rude may light the fuse.
Early warning signs of an impending outburst include irritable comments, sighing and agitation. Keeping people informed with respect to delays, and apologising can help limit this.
A more frightening situation is when a patient becomes angry during a consultation. You may sense that the patient is not happy with the way things are going. Continuing in the same vein is unlikely to resolve things. Defusing the situation at this stage is preferable for all concerned.
When patients feel as though they are not heard and their concerns are being ignored, their anger can escalate.
Acknowledge their frustration
A helpful first step in turning things around can be to acknowledge their frustration. When patients feel as though they are not heard and their concerns are being ignored, their anger can escalate. By showing that you recognise they are not happy, and that you want to understand why, you can provide your patient with the opportunity to share their fears or frustrations and, hopefully, find a way to resolve these.
However, the words 'I understand how you feel' are not always helpful. A very angry patient may well challenge your assumption, however kindly meant. It may be better to say something such as, 'I can see that you are angry/upset by this', and provide them with an opportunity to explain what has angered them. Understanding the source of their frustration may help you find a solution.
When anger turns violent
A minority of patients become violent. Some may have a history of violence, while others might be more likely to become aggressive because of pain, psychosis, confusion, fear or intoxication. While knowledge of your patient's history may help you identify those with a higher risk of violence and take appropriate measures, such as being escorted and making sure colleagues know where you are, in other cases the aggression may be unpredictable.
It's vital to protect yourself against sudden outbursts of violent anger. For example, ensuring that the furniture in your room is arranged such that you can easily leave but also that your patient does not feel trapped can be helpful in reducing tension and maintaining safety. Unfortunately, it may be that you are unable to rearrange the room to suit. If you are concerned that a room is potentially unsafe, I would advise you to raise this concern promptly.
Photo credit: Science Photo Library
Panic alarms are fitted in many consulting rooms and hospital departments may have handheld alarms. I recommend knowing where these are and how to use them. In a GP practice it is important that all staff know what the alarms sound like and what to do when they are activated.
Don't be afraid to end a consultation if the patient is becoming increasingly angry. This may be achieved by acknowledging that the consultation is not going well, and offering to arrange for the patient to see one of your colleagues. If physical aggression seems imminent, it may be best for you to leave the room.
If you are fearful for your own safety, or that of others such as receptionists or other patients, you might need to summon the police to the practice or call hospital security. Remember, though, that if the police are called, you would have to justify disclosing any confidential patient information to them. Some areas of the UK have specific schemes for violent patients, and it could be useful to know how to access these.
After a difficult consultation or an incident where you have felt threatened or vulnerable, you may need to take a break before you see your next patient. Despite the time pressures, making sure that you are calm and ready to be attentive to the next patient is important, and may help reduce the likelihood of a further difficult consultation. Discussing the incident with a trusted colleague can also be helpful.
Five tips for staying safe
- Assess risk in advance.
- If you know that a patient may be angry, ensure someone knows where you are and how long you will be.
- Observe body language and listen to the patient to spot anger at an early stage.
- Acknowledge anger or frustration.
- Consider calmly ending a hostile consultation and arranging another review.