I have been a care provider for many years, but I find moments when my patients are angry at me, even though I may not have done anything to justify their reaction. Can you help me to understand?

Your Menopause Question: I have been a care provider for many years, but I find moments when my patients are angry at me, even though I may not have done anything to justify their reaction. Can you help me to understand clinical anger? 

Our Response: Dealing with the angry patient is one of the most feared challenges in medicine. Anger has several components. Understanding these components and developing a strategy to address an appropriate response provides the care provider a roadmap for effective communication. 

Anger often reflects a reaction to an injustice or unfairness. It can alert us that a boundary or a limit has been crossed. In short, anger is a sign that something is not right and it needs to change. Anger may be expressed in basic ways. The most frequent, clinically, is as an adaptive primary emotion. Used constructively, the faculty member on clinical rounds may express anger that the first-year resident was late. Since there was no legitimate reason for the tardiness, the resident will not let that happen again. When used defensively, however, whether justified or not, a person may hold another person responsible for injury to him or her. In this case, the patient’s message is “what is happening is not right, and someone needs to be held accountable.” This easily could be reworded as “I am not in control and my anger is a way to try to regain control.” Unfortunately, the care provider, perhaps not involved in the causative event, may draw the brunt of this anger.

There are other explanations for anger. For example, anger may be a reflexive response in the office staff member labeled as “always angry” who actually feels a lack of appreciation from the rest of the practice. Anger can be a secondary emotion as a defense when the individual knows consciously or unconsciously that he or she could have done something different to avoid the outcome. And, there is anger that is used to manipulate a desired outcome. Imagine that a woman would like to take a cab to the hospital, but her medical condition warrants a bus token only. She threatens to sue and the insurance company makes an exception, only to learn later that the woman uses this approach to get what she wants. 

When patients express anger, almost always it is because their outcome was not what they expected or, worse, that it should have been prevented. But behind a patient’s anger may lie a reality disconnect between their awareness of the rules of their non-medical world and our rules of medicine. They recognize the importance of cleanliness, trust, and respect. Medical decisions are not likely on that list. Meanwhile, our attention may be drawn to patient safety, infection control, and mortality rates. How could these two worlds
be further apart? 

From published analyses of root causes of sentinel events, communication is always the major failure. Defusing anger may start with the question, “I understand you are angry. Please explain why, so that I can help you.” The best defense to accommodate anger in our patients is effective communication. 

James Woods | 2/25/2021

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