How to manage upset patients in real time

By Jules Murtha
Published November 10, 2021

Key Takeaways

  • It's inevitable that residents and seasoned physicians alike will encounter a difficult or challenging patient at some point in their careers.

  • Physicians get frustrated when patients miss appointments, engage in risky activities, don't follow recommendations, or are simply difficult to communicate with. But healthy, sustainable patient relationships require doctors to follow their patients’ cues.

  • When dealing with difficult patients, share your challenges with colleagues, set down your ego, listen carefully, and practice empathy; these are among the many ways to improve these relationships.

When Lalita Abhyankar, MD, MHS, found herself holding back tears after seeing a frustrated patient, she knew her approach was all wrong.

After a long day, the physician’s battery was running low, but Abhyankar agreed to see one last patient to lighten her colleague’s load. The patient had waited 2 hours and wasn’t in any mood to swap pleasantries. Instead, the two exchanged a series of curt, cold remarks. Tensions rose between the overworked doctor and the concerned patient.

This story, detailed in a blog post on the American Academy of Family Physicians website, gets at a larger issue facing doctors and the healthcare system: the tall order of caring for angry and difficult patients.[]

What can physicians do to navigate the most challenging patient interactions? Here are six practices that physicians can adopt to ease tensions and make the most of their time with patients.

Communicate with colleagues

One of the best ways to relieve tension and stress in the middle of a sticky situation is to talk it out. Who better to do that with than someone who intimately understands the weight of the job?

Doctors who share their challenges with each other often receive sound advice from their colleagues and inadvertently build sympathy for their patients, according to a study published in SAGE Open.[]

Physicians can also relieve themselves of sole responsibility for a patient by referring them to a doctor specializing in a complementary skill set, opening the door to a dialogue about the patient and each clinician’s experiences with that individual.[]

Build relationships

Although fostering bonds with patients doesn’t happen overnight, physicians can immediately improve the experience by not admonishing patients for questionable behaviors, according to the SAGE Open study.

It’s understandble that physicians get frustrated when patients miss appointments, engage in risky activities, or refuse to follow recommendations. But healthy, sustainable patient relationships require doctors to follow their patients’ cues.

By getting to know a patient’s day-to-day world and communication style, doctors can accurately assess when and how to advise that patient for optimal results.

Finding opportunities to encourage healthier behaviors based on the patient’s readiness to receive that information can help physicians and patients maintain a quality relationship.  

Set reasonable expectations

Physicians may benefit from scrapping their grand, “ideal” vision of patient treatment and replacing it with a series of smaller goals for patients to gradually meet, according to the SAGE Open study.

Start by encouraging patients to address one aspect of their health per appointment, such as improving their relationship with food. That’s more manageable for the patient than giving them a checklist that also includes quitting smoking and exercising daily.

Notice skill deficits

If the exam room is clouded by heavy emotions, doctors can be mindful of their patients’ skill deficits, as noted in an article published in the AMA Journal of Ethics.[]

A case study uses the example of a “difficult” patient to provide physicians with advice on repairing doctor-patient relationships.

When a patient gets heated, the authors note, it may be a result of their inability to regulate emotions during stressful situations. That patient might rely on their doctor, a substance, or another external source to wind down.

Physicians who consider these factors are more likely to step back and approach the patient with kindness and greater motivation to serve, instead of fueling the fire with anger or judgment.

How to access empathy

In the words of Jodi Halpern, MD, PhD, chancellor’s chair and professor of bioethics at UC Berkeley, empathy is “not only spontaneous emotional attunement … but also a conscious process of cultivating curiosity about another’s distinct perspective.”

To access empathy in a hostile conversation, physicians can return to the basics, according to the AMA Journal of Ethics article. A patient sees a doctor because they have a problem. If the patient doesn’t feel seen, heard, or adequately treated by the doctor, they might resort to inappropriate behaviors, such as yelling—which can be effective. The doctor can react or calmly address the patient’s concerns and offer a new plan to meet their needs. This way, the patient walks away feeling validated and driven to keep trying. 

Strategize going forward

The final step doctors can take to avoid a difficult patient interaction is strategic communication and collaborative planning for the future.

Physicians can focus on the positives before a visit starts, even if a patient regularly misses appointments, experts say. It’s key to avoid setting a harsh tone that may color the rest of the appointment. Doctors can also suggest different approaches to better meet their patient’s needs, such as developing a scheduling plan to prevent missed appointments.

Physicians can ask their patients to lay out a list of goals over the course of a few months. This incentivizes self-care and commitment to appointments, all while maintaining peace in the exam room.

When Abhyankar was struggling to communicate with a frustrated patient, the physician brought a nurse into the room, hoping to alleviate the tension. It worked beautifully: The patient gelled with the nurse, creating a communicative flow that allowed Abhyankar to better meet the patient’s needs.

Reflecting on the experience, Abhyankar wondered whether greater self-awareness could have mitigated the friction. Perhaps, however, stressful patient interactions are simply inevitable. While there is no clear-cut answer, physicians everywhere may benefit from implementing new strategies into their practice.

Finally, in a blog post discussing difficult patients on MDLinx, experts offered the following advice[]:

  • Physicians, keep your ego in check! If a patient doesn’t seem to be listening to you, don’t take it personally. Instead, take your ego out of it and find out what’s really wrong.

  • Seek first to understand then be understood. Understand the patient’s situation by asking questions and listening carefully to what they have to say. Wait to offer an opinion until they’re done explaining themselves.

  • Converse, don’t lecture. Your face-to-face communication should have a natural ebb and flow, like a conversation. This will keep the patient engaged.

  • Check for understanding. Verify that the patient or patient’s family knows what to do. Don’t assume that just because they listened well that they understand you.

What this means for you

Residents and experienced physicians are likely to encounter challenging patients from time to time. Rather than take it personally, or let your anger get the best of you, try focusing on positive actions. Listen actively to your patients, avoid lecturing them, seek out their point of view, ensure they are truly understanding you, and keep your expectations realistic. And, when you need support, share your frustrations and feelings with trusted colleagues, minding patient privacy concerns, of course.

Related: Cultural competency: How to work with a patient who is not like you

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