If safety is at risk, contact police
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 and physicians take great satisfaction in helping patients with their health needs. At times, however, 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. Doctors need a combination of skills and strategies to successfully manage aggressive and demanding behaviours to have productive, effective, and safe doctor-patient relationships.
Difficult patient encounters
While each physician has his or her 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.1 Difficult patient encounters can have a lasting impact on physicians and can promote feelings of negativity, unhappiness, even self-doubt about clinical competence.
Many factors come into play in every physician-patient encounter. Being mindful of these can help doctors mitigate conflict and aggression. Physicians should be aware of their communication style, as well as the emotions involved—their own and their patients’.2 Situational stressors such as time pressures during patient appointments, negative bias towards specific health issues, and personal matters can all affect the encounter. Patient factors such as language barriers, poorly defined symptoms, non-adherence to medical advice, unhealthy lifestyles, underlying health issues, and personality disorders may also play a role.
It all comes back to communication
Just as good communication skills are necessary for effective patient care, communication is also at the heart of dealing successfully with conflict or patient aggression. Making an effort to connect with the patient, listen actively, convey empathy, and communicate clearly can help physicians understand and address patients' motivations, emotions, and expectations.
There are a variety of tools to assist physicians with difficult encounters. In the ACE model,3 the ‘A’ refers to authority or power. Patients exert power or 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. ‘C’ refers to collaboration, which 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. ‘E’ signifies empathy, a hallmark of the physician-patient relationship. Extending empathy by focusing on the patient’s emotions, and being firm but compassionate, can help return a difficult patient encounter to success.
A key aspect of the ACE model is proportional application of each element (A,C,E) depending on the clinical scenario and the patient.
When in the midst of challenging interactions with patients, physicians should avoid arguing, talking over patients, and making judgmental statements. It is advisable to speak in a conversational tone. Verbalizing the difficulty can help define it. Consider saying something like, "We both have very different views about how your symptoms should be investigated and that’s causing some difficulty between us. Do you agree?" This approach names the problem without assigning blame. Supporting patients, finding common ground, and focusing on solutions may increase the possibility of finding a way to work more effectively together.4
The FIFE model (feelings, ideas, function, and expectations) is another possible approach when dealing with conflict and aggression. This model explores patients’ emotions, their ideas on what caused the problem, the effects of the illness or problem on functioning and relationships, and their expectations for care and for the future.5 Eliciting patients’ expectations helps develop trust, and assists physicians and patients to understand why they have come together and what they are hoping to achieve. When patients appear to have finished discussing their expectations, it may be appropriate to ask, "Is there something else?" or "Is this what you expected would happen today?," which allows patients to more fully express their needs and feelings.6 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."6
When dealing with insistent or aggressive patients, it is also important for physicians to be consistent and follow their own practice rules. For example, physicians who routinely avoid providing medical advice by telephone or email should remain firm, despite patients’ pleas. Physicians should keep their professional perspective, even when patients indicate the doctor is the problem.7 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.8 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 and not raising your voice 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. Doctors should maintain some physical space between themselves and aggressive patients, and should try not to interrupt or talk over them. Doctors and staff should also know how to quickly contact security or the police.7 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 doctors 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 the 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 the physician-patient relationship
Sometimes excessive complaints, significant conflict, or a loss of trust may lead physicians to consider ending the doctor-patient relationship. While this may be necessary on occasion, doctors should think carefully before doing so. Physicians are permitted to end a doctor-patient relationship for reasons other than retirement, relocation, or leave of absence provided the patient does not need urgent or emergent care. The patient generally requires adequate notice to find another doctor. While important in all jurisdictions, doctors in Québec must have reasonable and just cause to end the relationship.9 Doctors 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.10 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 the CMPA to speak with a physician advisor.
Physicians who experience ongoing difficulties with aggressive or challenging patient behaviour may need additional support, particularly to avoid burnout.11 While a colleague may be able to relate to the problem and provide comfort, CMPA members can also contact the Association to speak with a physician advisor with expertise in these matters. Doctors should also take care of their physical and mental health, especially when significant levels of stress and conflict are part of their medical practice.
- An P, Rabatin J, Manwell L, Linzer M, Schwartz M. Burden of difficult encounters in primary care: Data from the minimizing error, maximizing outcomes study. Arch Intern Med [Internet]. 2009 Feb 23 [cited 2016 Nov 4]; 169(4):410-4. Available from: http://archinte.jamanetwork.com/article.aspx?articleid=414793 doi:10.1001/archinternmed.2008.549
- Goleman D. Emotional intelligence, why it can matter more than IQ. Toronto: Bantam Books; 1995. 384 p.
- Elder N, Ricer R, Tobias B. How respected family physicians manage difficult patient encounters. J Am Board Fam Med [Internet]. 2006 Nov-Dec [cited 2016 Nov 4]; 19(6):533-41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17090786 doi: 10.3122/jabfm.19.6.533
- Davies M. Managing challenging interactions with patients. BMJ Careers [Internet]. 2013 Jul 31 [cited 2016 Nov 4]. Available from: http://careers.bmj.com/careers/advice/view-article.html?id=20013822
- Khalil T, Bhopal J. The patient-centred interview and international medical graduates: A preliminary view. BCMJ [Internet]. 2009 July, Aug [cited 2016 Nov 4]; 51(6):246-9. Available from: http://www.bcmj.org/article/patient-centred-interview-and-international-medical-graduates-preliminary-view
- Managing unrealistic patient expectations [Internet]. Sydney (AU): Avant Mutual Medical Defense Organization. [cited 2016 Nov 2]. 3 p. Available from: http://www.avant.org.au/uploadedFiles/Content/Resources/Member/Risk-201005-Managing-Unrealistic-Patient-Expectations.pdf
- Parrott S. Practice pearls: Navigating difficult patient encounters. Physicians Practice [Internet]. UMB Medica, LLC; 2011 Oct. Available from: http://www.physicianspractice.com/pearls/navigating-difficult-patient-encounters
- Dealing with patient complaints [Internet]. Sydney (AU): Avant Mutual Medical Defence Organization [cited 2016 Nov 4]. 3 p. Available from: http://www.avant.org.au/uploadedFiles/Content/Resources/Member/Risk-200912-Dealing-With-Patient-Complaints.pdf
- Code of Ethics of Physicians. Collège des médecins du Québec, RLFQ cM-9, a 19. Available from: http://www.cmq.org/publications-pdf/p-6-2015-01-07-en-code-de-deontologie-des-medecins.pdf?t=1478274056270
- Canadian Medical Protective Association [Internet]. Ottawa (ON): CMPA; July 2015. Ending the doctor-patient relationship [cited 2016 Nov 4]. Available from: https://www.cmpa-acpm.ca/en/safety/-/asset_publisher/N6oEDMrzRbCC/content/ending-the-doctor-patient-relationship
- Bruener C, Moreno M. Approaches to the difficult patient/parent encounter. Pediatrics [Internet]. 2011 Jan [cited 2016 Nov 4]; 127;1. Available from http://pediatrics.aappublications.org/content/pediatrics/127/1/163.full.pdf