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, give only 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.
Difficult encounters and disagreements with patients are inevitable at some point in a physician’s practice. Conflict can also arise with others affected by patients’ illnesses, such as family members, caregivers, and substitute decision-makers.
A combination of skills and strategies can help you and your staff deal with challenging encounters safely and effectively. These skills and strategies can be developed with training and continuing education in communication and conflict resolution, and by instilling conflict management principles and processes in the healthcare workplace.
Emotions may affect the doctor-patient relationship
Emotions may intensify disagreements. As a physician, you may be affected by stressors such as time pressures during patient appointments, unconscious and conscious biases that may influence your view of a situation, or personal matters. Similarly, patients may be experiencing stressors such as a recent diagnosis of a serious illness, language barriers, poorly defined symptoms, difficulty adhering to medical advice, or underlying health issues.
Listening and communicating
Just as good communication skills are necessary for effective patient care, communication is also at the heart of working through conflict or disagreements with patients.
The following tips may help improve your communication with patients:
- Restate what patients have told you, using their words. This reassures patients that they are being heard, and confirms you understand their concerns.
- Use language appropriate to patients’ ability to understand, avoiding medical jargon, where possible. Be aware that potential language barriers, cultural distinctions, and health literacy may affect how patients perceive your instructions and advice.
- Be clear about your intentions and the clinical reasons for your actions, such as when asking personal questions or performing a physical examination.
- Confirm patients’ comprehension of the diagnosis and recommended care plan by asking them to restate these to you in their own words.
- If you are in the middle of a challenging interaction with a patient, avoid arguing, talking over the patient, or making judgmental statements.
- In a factual and non-judgmental way, document in patients’ medical records any inappropriate statements or behaviour by patients toward you or your staff. You may choose to include verbatim statements made by patients, clearly attributing these to patients and shown in quotation marks.
Managing patients’ expectations
Patient expectations can be more effectively managed when patients have all the necessary information to make informed decisions about their health.
Nevertheless, patients may have unmet expectations for their care that can result in conflict. For example, they may ask for specific care that cannot be provided or for treatments that are not clinically indicated.
Often, patients’ expectations can be met by expressing compassion in difficult circumstances, and showing respect while providing care.
Handling violence and threatening behaviours
Despite your best efforts to resolve conflict, some situations may not improve and could escalate to threatening behaviours, even violence.
Imminent violence or threats
If you are faced with imminent violence or threats of assault, harm, or disorderly conduct, move away from harm and prioritize protecting yourself, your patients, and your staff.
Call security or 9-1-1, as appropriate in the circumstances.
Escalating threatening behaviour
When behaviours start to become threatening, such as the use of abusive language and threats of violence, tell the individual their behaviour is unacceptable and outline the consequences of continuing or repeating the behaviour.
In hospital or large clinic settings, consider using other available resources such as security, social work, and patient advocacy.
Be proactive to protect your safety
To prepare for the possibility of encountering threatening behaviour, consider the following strategies:
- Make time for learning for you and your staff. Consider learning about effective patient interactions and conflict de-escalation from a trusted education provider, including CMPA’s “Successful patient interactions” workshop.
- Develop a workplace security policy that outlines how you and your staff will respond to offensive language and aggressive behaviour. In a hospital or large clinic, be familiar with the organization’s policy and discuss it with staff where appropriate. In an office, develop and implement the policy, discuss it with your staff, consider renewing it annually, and post it in an area visible to all.
- Develop a workplace safety plan that provides guidance on making the workplace environment safer. In a hospital or large clinic, be familiar with the organization’s plan and discuss it with any relevant staff. In an office, adopt a safety plan that could include giving staff a clear view of patients in the reception area; using controlled access to certain areas (e.g. having a code entry system); ensuring everyone can make a rapid exit; securing medical records, computers, and medical equipment; storing medications in designated areas; having security alarms; having sufficient lighting near entrances and parking lots; and having additional security measures such as a lockdown procedure accompanied by drills with staff. (See the article “The office safety plan” for more.)
If your efforts in changing a patient's aggressive behaviour are unsuccessful and there is a breakdown in the trust relationship that cannot be resolved, assess if it is necessary to terminate the patient from your practice. In a clinic or hospital environment, there may be opportunities to develop and update protocols for managing difficult behaviours. Consulting with colleagues or your hospital or clinic administration may help guide you in managing individual cases. Follow your College’s guidelines when contemplating ending a doctor-patient relationship.
Document any abusive behaviours clearly and factually in the medical record. The medical record is the appropriate place for these types of notes.
Contact CMPA for advice
Disagreements may lead to medical regulatory authority (College) and hospital complaints and other difficulties. When a patient is exhibiting aggressive behaviour or threatening a physician’s personal safety, certain legal measures can also be taken to protect a physician in these circumstances. Contact CMPA for advice in these situations.
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