Dealing with angry patients.

As the new vice president of medical affairs at a children's hospital--and a new VPMA at that--I was surprised that one of my first official acts was to talk with a parent who was not happy.

I have since learned that a major part of the role of VPMA is dealing with people who are not happy. Dealing with patients (or parents of patients) who are angry requires special skills. However, successfully dealing with these issues can be quite rewarding.

In order to effectively meet the challenge of the angry patient, it is important to understand why people are angry. Although each individual has his or her own specific reason, most patients become angry because we have failed to meet their expectations. Whatever happened to make them angry, they had expected something else.

Whether they expected the food to be hot and it was cold, or they expected their surgeon to talk to them before surgery and she did not, we were not able to give to them what they expected to get. Understanding this, we can see that regardless of how far fetched or bizarre their complaint is we may have difficulty understanding it unless we know what their expectation was.

Additionally, because we have not met their expectation, patients develop emotional responses to the situation. While we often see only anger, many times there are other feelings such as despair, resentment, sadness or helplessness that must be addressed in order to satisfactorily resolve the patient's complaint.

It's ironic that the most important step in effectively dealing with unhappy patients is the thing that most people do poorly. That, of course, is to listen to the complaint. My own tendency is to want to quickly hear the problem and get on with the business of solving it! All to often, I hear the problem that I want to hear--not what is being told to me--and I run the risk of fixing the wrong problem.

When dealing with patient complaints, the basic skill required is listening. To many of us, listening is a passive activity, but when dealing with an angry patient, the listening must be active.

A contradiction? "Active listening?" Not at all. In fact, listening to a patient complaint should be a well-defined process.

Listen up

The process of active listening begins with sending a clear message that your major interest is hearing what a patient has to say. Introducing yourself, asking permission to sit (not on the patient's bed, of course) sends this message. Standing, especially by the door or over them as they lie in bed, sends negative messages.

Unnecessary distractions, such as the TV or radio should be eliminated. If guests are present, the patient should be asked to decide whom they would like present during the discussion or if another time might be better.

The next step is the "magic minute." Typically, when we ask a question, the respondent says several words or sentences and we will interrupt to ask questions, defend ourselves or offer explanations. More effective is to ask an open-ended question, and let the patient talk for at least a minute before you give any reply.

"Well Mr. Jones, the nurse told me that you had some concerns regarding your care. Would you mind telling me about this?" No matter what the person says, listen to them for at least a minute. No questions, no interruptions, no explanations.

Listening to someone, especially to someone who is not happy, for a full minute can be difficult! The temptation to interject a comment or ask a question will be overwhelming; it must be resisted.

The only exception to this would be if they use obscene, profane or language that you find offensive. Every patient's concerns should be heard, but we have the right to be treated civilly and not be subjected to abusive language. Should this happen, it would be totally appropriate to draw the line and say, "Mr. Jones, I really want to listen to your concern, but I can't do so if you continue to use foul language."

If the objectionable language continues, say, "It might be better if I come back another time when you can use better language. Please call my office when you can do this."

After the "magic minute," which may last several minutes, the patient should feel that they had the opportunity to say their piece. It is now time to check with them to see if what you heard is what they intended you to hear. This is done by a recapitulation or summary, and asking for their approval of this.

"So Mr. Jones, as I understand your concern, you expected your dinner to be hot when it was served, and that it was cold when you got it, and that this happened every day during your hospitalization. Is that right?"

The recapitulation may have to be repeated until the patient agrees that you got it right. It is also useful to phrase the summary as an unmet expectation, if possible. This might be helpful later on when it must be decided if the expectation was appropriate.

When a patient has a long list of grievances, it is often useful to ask them which of these is most important. "Of all the concerns that you have given, which is most important for you?" This will help focus on the key issue and the one or two that need to be addressed most quickly.

[ILLUSTRATION OMITTED]

Emotional ties

The complaints of the patient are always tied to an emotion or feeling. Many times merely stating the complaint amounts to complaining, but providing the patient the opportunity to express their feelings can be therapeutic for them.

Helping the patient express these feelings can be a valuable tool in resolving the conflict, and letting the patient know that you truly understand how they feel. Reaching for feelings involves empathizing with the patient.

After the patient describes their concerns, ask them how they feel about it. "How did you feel when your soup was cold last night." Many times the feeling expressed to you is quite different that you might expect.

While we often expect anger, other feelings may be divulged. If the patient has difficulty clarifying a feeling, expressing how you would have felt can be useful. "If I received a cold dinner tray, I would have felt neglected! How did you feel?"

People have a right to feel however they want to, and it is important to acknowledge that. "I can understand how that would make you feel neglected!" This is, however, not the same as agreeing with them, nor is it an acknowledgment of guilt. It is merely validating their right to feel the way they do.

At this point, we should have a clear understanding of what the patient's concerns are, which is most important to them, and how they feel about these issues. It is now the time to resolve the concerns. Since until now we have let the patient drive the process, why not ask the patient to offer a solution?

What would make them feel better about what has happened? Often we make assumptions based on our past experiences of what people expect. These may include an apology, an explanation, assurance that it won't happen again, a new doctor or nurse, a change in policies or procedures or, of course, a reduction or write-off of the bill.

Unless we ask the patient, we may be making the wrong assumption and risk again not meeting their needs. "What would make you feel better about this now?" is a question that clearly seeks the patient's expectation, and puts the focus on the present and future, not the past.

Clearly, we cannot always meet the patient's expectation. Many of the requests are reasonable and easy to comply with. While each administrator must have his own philosophy regarding this issue, if what they want is reasonable, do it! If what they want is unreasonable, address this and offer a reasonable alternative.

"I understand that you want me to fire Doctor Jones, but that violates our personnel policy. What I can to is see that your complaint is put in his file."

Writing off bills is a more sensitive issue. Each institution should have a consistent policy and follow that policy. There are some circumstances where writing off a bill is warranted, such as a charge for a service that was not delivered. Writing off a bill because the patient was not happy with the service delivered must be looked at carefully and comply with policy.

As VPMA, I would consider a write-off if, after reviewing the situation, I am in agreement that the care delivered was inadequate, negligent or if there are circumstances that would put the institution in a bad light. Writing off a small bill for a very angry patient may sometimes be prudent, but write-off must comply with the institution's policies and contractual arrangements.

At this point there are two possibilities. Either the patient is happy with what has transpired or they are not. Again, the way to determine this is to ask. "Are you satisfied that I understand the problem and with what I am going to do about it?"

If the response is "yes," thank the patient for taking the time to bring this matter to your attention and if possible make a return visit in a day or to just to see how things are going or if they have any other concerns. If the response is "no," take a deep breath, and go back for another try. "At this point, what would you like to see me do?"

Again, if this is reasonable, do it. If it is not reasonable, it is time to review your options. These may be to refer the complaint to a higher authority, such as the CEO or the compliance officer. Another option is to "agree to disagree" and express regret that there is nothing that we can offer them.

The patient may demand to be discharged or transferred to another hospital. These requests should be followed in accordance with your institution's policies, but done in a helpful and courteous manner. Regardless of the outcome and how unpleasant it may be, a follow-up visit should be made, and communication should continue with the patient.

Dealing with angry patients can be quite challenging, but also quite rewarding. There are lessons to be learned from each situation, and it might be beneficial to review the case with a colleague both to provide you with insight about how you might have better handled the case, and also to express your feeling.

Don't take these complaints personally and recognize that no matter how hard you try, you can't please everybody.

RELATED ARTICLE: IN THIS ARTICLE ...

Understanding what angers patients, how to listen to their concerns and what steps to take to find a resolution sound like relatively easy tasks. But, in reality, they can be one of the toughest challenges physician executives face.

By Stephen Lazoritz, MD, CPE, FACPE 

Stephen Lazoritz, MD, CPE, FACPE is vice president of medical affairs at Children's Hopsital in Omaha, Neb. He can be reached at 402-955-4117 or [e-mail] (photo by Andrew Baran)

[ILLUSTRATION OMITTED]