Physicians should not hesitate to contact the police if they feel their safety or the safety of others is at risk due to a patient’s aggressive or threatening behaviour. If reporting to police, only give the information necessary for the police to address the threat, such as the threatening individual’s name and the nature of the incident. Avoid divulging any further patient medical information that could be considered a privacy breach.
Most patient visits are agreeable, however, at times physicians and their staff encounter patients or family members who make unreasonable demands or display manipulative, aggressive, angry, or threatening behaviour. These encounters can be unpleasant, stressful, counter-productive, and even dangerous. Physicians need a combination of skills and strategies to successfully manage aggressive and demanding behaviours to have productive, effective, and safe physician-patient relationships.
Difficult patient encounters
While each physician has their own perspective on difficult patient encounters, these often involve patients who have unrealistic expectations of their care or health, insist on treatments that are not clinically indicated, are dissatisfied with their care, ignore medical advice, or engage in verbal abuse.  Difficult patient encounters can have a lasting impact on physicians and can promote feelings of negativity, unhappiness, or even self-doubt about clinical competence.
Physician and patient factors
Many factors can influence a physician-patient encounter. Being mindful of these can help physicians mitigate conflict and aggressive behaviour. Physicians should be aware of the following factors:
- their communication style and the emotions at play – both their own and their patients’
- situational stressors such as time pressures
- negative bias towards specific health issues
- personal concerns
Patient-related factors, including:
- language barriers
- poorly defined symptoms
- non-adherence to medical advice
- unhealthy lifestyles
- underlying health conditions, personality disorders
Communication helps manage conflict
Strong communication skills are essential not only for effective care but also for managing conflict and patient aggression. Making an effort to connect with the patient, listening actively, conveying empathy, and communicating clearly can help physicians understand and address patients' motivations, emotions, and expectations.
ACE model for challenging encounters
Tools like the ACE model can help guide challenging encounters.
- Authority: Patients exert authority by the information they choose to share with their doctors, their level of engagement in their healthcare, and their decisions to follow treatment plans. Physicians exert authority by controlling the flow of conversation with patients and the diagnostic and treatment options offered. Doctors should use their authority appropriately and effectively.
- Collaboration: Collaboration occurs when physicians and patients jointly define problems, pursue investigations, and undertake treatment. While not all patients will collaborate with their doctors, physicians’ abilities to enhance cooperation and foster a partnership with patients are important.
- Empathy: This is a hallmark of the physician-patient relationship. Extending empathy by focusing on the patient’s emotions, and being firm but compassionate, can help reset a difficult interaction.
During these tense moments, physicians should avoid arguing, talking over patients, and making judgmental statements. A calm, conversational tone helps, for example: “We seem to have different views, and that’s causing some difficulty between us. Do you agree?" Naming the issue acknowledges the problem without blame and opens the door to solutions.
FIFE model for challenging encounters
The FIFE model (feelings, ideas, function, expectations) is another approach to difficult interactions and way to explore what matters most to the patient. This model explores:
- patients’ feelings
- their ideas on what caused the problem
- the effects of the illness or problem on functioning and relationships
- their expectations for care and for the future
Asking questions such as, "Is there something else?" or "Is this what you expected would happen today?," encourages patients to fully express their concerns. This type of question will also help determine what can be covered in that particular consultation, and what may need to be discussed at a later visit.
When physicians cannot meet patients’ expectations, it is best to communicate this directly, for example, "Based on my clinical assessment, opioid medications are not indicated for your condition," or "I cannot discuss your friend’s care because it would be a breach of confidentiality."
When dealing with insistent or aggressive patients, consistency is crucial. For example, physicians who routinely avoid providing medical advice by telephone or email should remain firm, despite patient pleas. Physicians should maintain professionalism, even when patients indicate the doctor is the problem. Maintaining control of the situation without being overly authoritative is critical.
Handling patient complaints
When patients complain openly about an aspect of their care or the medical practice, physicians should try to address the complaint directly. Whatever the complaint, it is important to respond calmly and respectfully to the dissatisfied patient. Often, a face-to-face discussion helps resolve the matter or at least allows patients and physicians to clarify their issues or concerns and discuss how to move forward. It is also a learning opportunity. If appropriate, physicians should tell patients about any changes or specific steps that will be taken to address the issue. Such discussions should generally be documented in the patient’s record.
Remain calm and professional when speaking to patients and families, even when facing an angry patient or undeserved criticism. Staying composed may de-escalate a tense situation.
Maintaining a safe environment
Patients exhibiting aggressive behaviour can pose a threat to office staff and physicians. Although it is generally necessary to meet with patients in private, away from other patients and staff, physicians must be mindful of their own safety and may want to ask a staff member or colleague to join them. Physicians should maintain some physical space between themselves and aggressive patients and should try not to interrupt or talk over them. Physicians and staff should also know how to quickly contact security or the police. Discussions on how to approach patients with challenging behaviours and debriefs with the team after an occurrence may contribute to the overall positive culture for physicians and their staff. Also, physicians may be able to manage patient expectations by creating a policy on how they will respond to anyone’s use of aggressive behaviour or offensive language, and then making the policy public by placing a sign in their practice.
Members are encouraged to contact CMPA for case-specific advice. There are certain legal measures that can be taken to protect a physician and their staff if a particular patient’s behaviour is of significant concern for personal safety.
Considering ending a physician-patient relationship
Sometimes excessive complaints, significant conflict, or a loss of trust may lead physicians to consider ending the physician-patient relationship. While this may be necessary on occasion, physicians should think carefully before doing so. Physicians are permitted to end a physician-patient relationship for reasons other than retirement, relocation, or leave of absence provided the patient does not need urgent care. The patient generally requires adequate notice to find another physician. In all jurisdictions, physicians must have reasonable and just cause to end the relationship. Physicians should also be aware of any human rights legislation, regulatory authority (College) policies, and codes of ethics that prohibit discrimination in the provision of medical services and that may require reasonable grounds to discharge a patient or that may otherwise affect one’s ability to terminate the relationship. If the relationship is terminated, this should be documented in the patient’s medical record.
While always maintaining patient confidentiality, physicians may consider speaking to a trusted peer when thinking about parting ways with a patient. Sometimes a different perspective or wise suggestion may help physicians identify ways to assist a difficult or angry patient. Members can also contact CMPA to speak with a physician advisor.
Physicians’ self-care
Physicians who experience ongoing difficulties with aggressive or challenging patient behaviour may need additional support, particularly to avoid burnout.  While a colleague may be able to relate to the problem and provide comfort, CMPA members experiencing medico-legal difficulties can also contact the Association to speak with a physician advisor with expertise in these matters. Physicians are encouraged to take care of their physical and mental health, especially when significant levels of stress and conflict are part of their medical practice.
Additional reading
