Preparing a response strategy for angry and aggressive patients

Ms Aisling Timoney, GP Lead Counsel, Medisec, outlines how doctors should respond to aggressive behaviour from patients

A year into the Covid-19 pandemic, both patients and doctors continue to face unprecedented challenges and stressors. In Medisec, we see daily queries regarding patients becoming irate and at times abusive over the level of access to healthcare services, as well as queries about managing patients who are unwilling to comply with medical advice around restricting their movements and wearing a mask in order to access care.

Unfortunately, we have noticed an unwelcome trend of these patients threatening doctors with Medical Council complaints. We hope imminent changes to the Medical Council process on foot of recent legislation will ensure that trivial and vexatious complaints are filtered out at an early stage. While we wait for those changes, we have been heartened to see the Medical Council supporting the stance of individual doctors in complaints where patients have clearly behaved unreasonably.

We firmly believe that many patient complaints are capable of being resolved locally, so now more than even, it is essential to have prepared and practised a response strategy for angry and aggressive patients.

Immediate response

“Fight or flight” is the natural response when faced with an irate or aggressive patient. Recognising this and consciously managing it is key to avoiding escalation.

If the situation is becoming heated we recommend, if possible, going to a private place to have the conversation. This preserves patient confidentiality and removes potential distractions, allowing you to focus on the problem. All too often we see complaints including allegations that the patient was embarrassed in front of other patients or that confidentiality
was compromised.

Consider asking a partner or colleague to join the conversation with you as a witness. However, a word of caution – always assess safety. You are not obliged to put yourself or your staff members at risk.

If you ask the patient to step into another room to continue the conversation, let them step into the room first. This allows you to enter the room second, staying closest to the door. You may choose not to close the door. Keep distance between yourself and the patient and never touch them.

Encourage the patient to take a seat and if they do, you should also sit down. This simple step shows that you are taking time to address the issue, which can help to de-escalate the situation. If they choose to remain standing, you should also stand.

Lower your voice and slow your speech using firm but respectful tones. It is
challenging for anyone to continue an argument with someone who is not responding in kind. Maintain a neutral facial expression, good eye contact (without staring) and open body language. Avoid defensive, paternalistic or power type stances, eg, hands on hips, arms crossed etc.

Think LEAP

The LEAP acronym is a helpful strategy for navigating a conversation with someone who is irate. Listen – Your initial objective should be to understand, not to respond. Active listening means listening and responding in a way that shows the person they have been heard properly.

If the patient has not articulated the issue clearly, wait until he/she has finished speaking and reassure him/her that you want to understand exactly what the problem is so that you can address it. Help the patient explain the issue by asking open-ended questions.

Try to avoid interrupting the patient and avoid giving reflex reassurance, eg, “don’t worry about that”. Although it may be genuine and well-intentioned, it can seem dismissive. Some of the ways you can show the patient that you are actively listening include leaning slightly towards them if you are sitting down, by maintaining natural eye contact, by nodding appropriately or by using minimal verbal prompts such as “okay”, “I see”, “I understand”, etc.

Allowing natural pauses or silences can help calm the situation and make the patient feel heard. Rather than filling an early silence with your response, try asking “do you want to tell me any more about that?”, or “is there anything else you want to add?”.

Check that you have understood the patient correctly by reflecting their comments back to them. Your next priority should be to find out what the patient’s preferred resolution would be. Ask the patient directly “What can I do to make things right?” The patient will usually tell you and it may be a simple and easy solution.

Empathise – Try to put yourself in the patient’s position. How would you feel or respond? What solution would satisfy you? Acknowledging the patient’s frustration can ease a difficult conversation.

Apologise – This does not necessarily mean admitting any wrongdoing. Comments such as “I am sorry that you had to wait longer than usual for your appointment, I know your time is valuable” or “I am sorry that the consultation did not go as you expected” can assuage an angry patient.

If you have concerns regarding an error or potential negligence, contact your indemnifier for legal advice. Medisec recognises that timely open disclosure is an essential element of patient-centred care and always supports its members in being candid with patients and apologising when appropriate.

Plan – Managing expectations and planning follow up is key. If there is a legitimate issue, can you offer an immediate solution? If not, what will your next steps be and when can the patient expect to hear from you? Reaching agreement on this can help to re-establish an element of trust.

Doctors should recognise that their own demeanour or stress levels can be contributing factors and patients are not always the only ones at fault

However, if there is no genuine issue that needs to be addressed and it is obvious that the doctor-patient relationship has irretrievably broken down, it is advisable to inform the patient at this point. Failure to manage expectations is one common pitfall.

Another is failure to follow through on the agreed plan. Both typically compound the situation and often cause a complaint to be escalated to the Medical Council. A robust complaints handling policy and a good communication strategy should address these risks.

Keep an open mind

Doctors should recognise that their own demeanour or stress levels can be contributing factors and patients are not always the only ones at fault.
Be conscious that inappropriate language or behaviour might distract from a legitimate point and that complaints are learning opportunities. We recommend logging complaints received to identify any emerging trends that should be addressed.

There are no winners in a situation where a patient is upset, aggrieved or complaining. As the professional, doctors need to work with the patient to resolve the issue as quickly as possible and without escalation.

If de-escalation is not working

If the patient remains irate or becomes abusive or threatening, flag your intention to end the conversation.

“We can only continue with this conversation if we can both discuss the issue calmly.

“I understand that you are upset and frustrated, but we do not tolerate verbal abuse or aggression so we can stop now and you can come/call back another day to discuss this issue.”

If a warning does not work, stop the conversation and ask the patient to leave. Escort him/her to the door, but never touch him/her. If he/she refuses to leave, call for help. In a hospital setting, you may be able to contact security. If necessary, contact the gardaí.

If the conversation is by telephone/video call, we recommend ending the call after signalling your intention to do so and giving the patient a warning and opportunity to amend their behaviour. If the patient has raised a genuine issue, we recommend following up in writing with the patient rather than leaving a complaint unaddressed because the verbal interaction escalated.

You should consider whether the doctor-patient relationship remains tenable or whether it is now in the patient’s best interest to attend a different doctor. Your indemnifier can advise you further.

Within your practice

All staff should be familiar with your complaints handling policy and agreed communications strategy for handling challenging patient interactions. Training should include role-playing and feedback on sample scenarios. The ability to navigate and de-escalate challenging interactions is a skill ideally honed in a practice environment rather than in reality.

We recommend developing a policy regarding unacceptable patient behaviours, such as offensive or abusive language, or threats. Respectful communication is essential to a functional doctor-patient relationship and doctors should not feel obliged to tolerate anything less
from patients.