Today, rising patient expectations make it more difficult for physicians to maintain patient satisfaction. When an “expectation gap” occurs between physician (or staff) and patient, the patient will likely experience feelings of anger and frustration that must be carefully addressed and defused. For today’s physicians and their staff, the ability to manage potentially hostile behavior is crucial for ensuring peace, safety and compliance in the practice setting.

Objective results vs. subjective expectations
Patient satisfaction is based largely on subjective expectations. The difference, or gap, between those expectations and actual interactions and/or outcomes is often the cause of dissatisfaction. Even though the interactions or outcomes may be considered reasonably acceptable by professional standards, the patient may have entered into the relationship with unrealistic expectations regarding reaching or regaining his or her personal concept of health.

If this is the case, the patient’s resulting behavior will vary according to the level of dissatisfaction produced by the gap, the overall state of the relationship, and his or her particular disposition. Reactions may include passing disappointment, verbal or written complaints, withdrawal from the physician-patient relationship and full-blown physical confrontation. In an especially tense situation, physician and staff must know how to recognize and manage escalating hostile and aggressive behavior.

Know your patients
There are various physical and psychological conditions that may contribute to a patient’s aggressive behavior. The following factors should be considered possible warning signs:

• History of aggressive behavior—Has the patient lashed out at anyone else?
• Problematic behavior—Does the patient become agitated or irritable quickly, show poor impulse control or display illogical thought processes?
• Dull, unresponsive demeanor—Does the patient seem to lack emotions?
• Abnormal behavior—Has the patient been diagnosed with dementia, or appear confused or intoxicated?

Of course, all patients have the potential for aggression, and any of the following feelings could serve as the trigger: fear, failure, the loss of personal power, the need to maintain self-esteem or the feeling of being inconvenienced or trivialized.

The entire office staff should be alerted about patients with histories of disruptive or abusive behavior through a system that protects the confidentiality of patients’ medical records.

Defusing anger and avoiding conflict
When dealing with an angry patient, the basic approach is to slow down, set limits, listen carefully and let the patient vent. The following recommendations should help de-escalate emotionally charged situations before they become confrontations:

• Move the patient to a quiet area of the practice and invite him or her to sit down if possible. In a calm and measured tone, the physician should ask the patient to “Step over here so we won’t be interrupted.” An angry patient with an audience is less likely to back down, even if he or she comes to understand the physician’s position. Further, sitting may help disarm a domineering patient.
• Let the patient speak without interruption. While paying full attention to the patient, the physician should be mindful of his or her own nonverbal behavior. Specifically, the physician should be aware of proximity to the patient (respect for personal space) and body language (gestures, posture, movements and expressions) that may escalate or de-escalate the situation.
• Acknowledge the patient’s feelings. This does not mean the physician is agreeing with the patient or admitting unreasonable conduct. The point here is to express sincere empathy.
• Use the patient’s name. When a patient is irate, the physician should use his or her name in a respectful way to help ease the tension. Using the patient’s name condescendingly will only make matters worse.
• Avoid making promises. The physician should resist promising future changes because that may lead to even bigger expectation gaps. However, it is reasonable to make reassurances of a more positive plan or action.
• Do not escalate a tense situation. The physician should always keep his or her own frustrations, urge to blame others and ego out of it. He or she should stay in control, avoid being impatient or condescending, keep the volume appropriate for the distance and speak at an even rate and rhythm. Also, the physician should refrain from using medical jargon, which would likely confuse and frustrate the patient further.
• Dos: Remain calm, isolate the situation, enforce limits, listen, be aware of nonverbal cues, be consistent and be courteous.
• Don’ts: Overreact, get into a power struggle, make false promises, fake attention, threaten or use jargon.

In the event of an assault
If all efforts to de-escalate an emotionally charged situation with a patient fail, and the patient becomes physically violent, the incident should be reported immediately to the local police and then to SCPIE’s Risk Management Department.

Also, the victim should get medical attention, regardless of the severity of the injury, and seek and use available counseling services.

Conclusion
It is inevitable that physicians will encounter frustrated and angry patients at times. The keys to de-escalating a tense situation are to listen to the patient, put yourself in his or her shoes and acknowledge the patient’s feelings. These actions should help defuse such stressful situations.