Difficult conversations: anger in the clinician-patient/family relationship.

Abstract: Anger is a "syndrome" of thoughts, feelings and physiologic reactions. Behavioral responses to anger are influenced by multiple contextual factors. Patients and family members may express anger in response to their own experiences of illness, the healthcare system, or the physician-patient/family relationship. Anger may evoke a variety of clinician responses that while understandable, inadvertently escalate patient and family anger. Clinicians who cultivate personal awareness, practice mindful self-monitoring during their interactions, explore the differential diagnosis of anger, demonstrate specific communication skills, set clear boundaries and seek personal support can overcome the challenges of these difficult conversations, and begin to restore trust in the physician-patient/family relationship.

Key Words: relationship, conversation, anger

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Mr. S had been waiting several hours for information from the physicians treating his son in the pediatric ICU for a severe asthma exacerbation. When the attending physician, Dr. N, came out to the waiting room to speak with him, Mr. S exploded in an angry tirade, "Where's my son? What's happening with my son? I've been waiting here for hours and no one has come out to talk to me! What's the matter with you people? There is no excuse for this! Where's my son?!" (1)

Contextual Foundations of Anger

Communicating effectively and empathically can be challenging in today's healthcare settings. Clinicians feel pressured by tasks, time, productivity and quality expectations, and may experience high levels of work-related stress and psychological distress. (2) Patients may feel rushed or insufficiently listened to, their personal context, needs and values poorly understood. (3) They seek information from the internet, and treatment from complementary and alternative medical providers. (4,5) Systems of care that use financial incentives to influence physician behavior to limit costs may cause patients to question whose interest is being served. (6) It therefore is not surprising that disagreement, conflict and anger sometimes flare in clinical settings. Anger in the clinician-patient relationship challenges the ability of clinicians to manage their own feelings, maintain appropriate boundaries around anger expression, and sustain their capacity for empathy. This article describes factors that modify and precipitate anger, and emphasizes strategies that clinicians can use to respond to anger in clinical interactions.

Anger Modifiers

Psychologists define anger as a "syndrome" of feelings, thoughts, and physiologic reactions linked with an urge to injure some target. (7) Behavioral reactions to this emotion depend on how one construes and copes with a particular stressor within a specific context. The experience and expression of anger and other emotions may be influenced by gender, (8) age, (9) education, (10) cultural norms, (11) and other factors. For example, some authors suggest that while women are socialized to openly express most emotions, they tend to suppress rather than express anger for fear of damaging relationships. (12) Women may have trouble separating anger from feelings of being hurt, and report feeling internally agitated or crying when angry. (13) Gender may interact with socioeconomic and cultural influences on behavior. Women in countries with greater degrees of gender empowerment report more anger expression than women in countries with lesser degrees of gender empowerment. (14)

Anger Determinants

Some emotion theorists hypothesize that for anger to be generated, an event must be perceived as personally significant enough to evoke the need to preserve self-esteem against assault. Others note that anger can arise even when transient reward is prevented or temporary punishment is inflicted. (5) Some believe that anger is generated when an external agent is seen as being responsible for some negative event, or when a perceived injustice has occurred, while others point out that social stress, physical discomfort and pain can also induce anger. (15) Berkowitz and Harmon-Jones argue that a variety of aversive conditions may generate intense negative effect, activating the anger "syndrome," which is facilitated or intensified by how one construes the situation at hand. (7)

Precipitants of Patient or Family Anger in Clinical Settings

Patients, family members or significant others may experience and express anger in response to a variety of circumstances. Some common examples are listed in Table 1 and include patients' experiences with illness, responses to negative information, negative emotions, the healthcare system, and relational issues (Tables 2 and 3).

Common themes in these situations include patients' or families' sense of loss of control and vulnerability, perceptions that their needs or preferences are not being attended to, and that they are being treated unfairly or disrespectfully. Disempowerment and unacceptable diminishment of patients' sense of self by systems, clinicians, or illness itself seem to engender anger.

Patient and Family Predisposing Factors

Patients with antisocial and borderline personality, alcohol and drug intoxication or withdrawal, and post-traumatic stress disorder may have difficulty controlling displays of anger. (16) Some people are predisposed to anger by virtue of relatively stable personality traits measurable by standardized, validated scales. (17) Still others may not understand the limits of medical science or professional conduct, and may have expectations or make requests that clinicians simply cannot fulfill. Such conflicts, if unresolved, often result in frustration and anger on both sides of the clinician-patient/family relationship. (18)

Mr. S and Dr. N's Experience

We now return to the interaction about to unfold between Mr. S and Dr. N. Mr. S's son has had a long history of severe asthma with multiple exacerbations and trips to the emergency room, but this is the first time his son has ever required an ICU admission. Watching his son struggle to breathe and the subsequent intubation procedure has terrified him. He has been in and out of the ICU asking the nurses questions, but now has been sitting alone in the ICU family waiting room for what feels like an interminable length of time. Dr. N knows none of this, and assumes that the other physicians have spoken with Mr. S.

Maladaptive Clinician Response to Anger

Mr. S: "Where's my son? What's happening with my son? I've been waiting here for hours and no one has come out to talk to me! What's the matter with you people? There is no excuse for this! Where's my son?!"

Dr. N: "Mr. S you have to calm down. You're not making things any easier."

Mr. S: "I'm not going to calm down. I want to know what's going on with my son!"

Dr. N: "We'll tell you but I don't appreciate your talking like this. I've been up all night with your son."

Mr. S: "I don't care. I've been up all night too!"

It is extremely challenging to maintain one's professional demeanor, capacity for empathy, and clear boundaries about acceptable anger expression. Patient and family anger may evoke a variety of clinician responses including defensiveness, avoidance, acting as though nothing had happened, transferring blame, hostile distancing, passive-aggressive behavior, or anger in return. (10,11,19) Dr. N may initially have been trying to control or contain Mr. S's emotions in an attempt to make the interaction more manageable. Mr. S, however, perceives his admonition to "calm down," as an affront and criticism. Dr. N's statement that he had been up all night may have been intended as an assertion of professional vigilance, but Mr. S matches the physician's statement, asserting his own sense of "paying dues" and ultimately his own importance in this scenario. Furthermore, Dr. N's implicit suggestion that he is owed civility and respect because of his professional role places the focus on the physician rather than the patient and parent in this scenario, further enraging Mr. S. This scenario replays some of the themes mentioned earlier. Mr. S's intense anxiety and sense of powerlessness as a father to protect his son from harm are compounded by his perceptions that his needs are being disregarded, and that he is being treated disrespectfully, thus engendering anger.

It is best to try to address anger before it escalates. This can be challenging for clinicians who may themselves be feeling stressed by time pressures, the need to make critical decisions, multiple competing demands, and fatigue. The anger determinants that operate in patients and family members, such as disempowerment and unacceptable diminishment of sense of self, also operate in clinicians. Challenges to clinicians' sense of professional role, performance, control, judgment, or efforts to help, may evoke anger.

Adaptive Clinician Responses to Anger

Several strategies can help clinicians respond adaptively to patient and family anger. These include fostering personal awareness, mindfulness in the moment, exploring the differential diagnosis, using specific communication skills, setting clear boundaries, and seeking support.

Personal Awareness

We develop personalities and interactional styles that are patterned over the course of our developmental trajectories and by our social experiences. We bring with us into each interaction the momentary sum of our values and attitudes, personal and family histories, cultural and social contexts. Certain patients may evoke in us unrecognized anamnestic responses. Attitudes, thoughts, and feelings toward other people or situations in our past may be unconsciously superimposed on a relationship in the present and may affect our interactions. (20) If we are unaware of these thoughts or feelings, we run the risk of reacting counterproductively when our emotional "hot buttons" are pushed. Novack et al. define personal awareness as "insight into how one's life experiences and emotional make-up affect one's interactions with patients, families, and other professionals." (21) Personal awareness can be fostered in a number of ways including curricula and support groups to promote group discussion in this domain at all levels of training and practice, and individual psychotherapy when desired. (18)

Mindfulness

Mindfulness in the moment involves the ability to be both a participant and observer during clinical interactions to self-monitor, to adjust to nuances of information, behavior and feelings in oneself and others, and to integrate this with one's professional knowledge and experience. (22)

Dr. N could have prepared himself ahead of time by asking his colleagues if anyone had spoken with the family, but because he hadn't done so he was caught off guard by Mr. S's intense emotions. At that moment, he might have noticed his own internal agitation/anxiety titer begin to rise and muscles tense in response to this perceived "attack." Sometimes physical sensations can help clue us into our emotions even before we consciously recognize them. Dr. N will need to take a fleeting mental "time out" to become an observer within this encounter, assess his own personal responsibility for Mr. S's anger, as well as other possible precipitants. The extent to which Dr. N is able to marshal his own self-awareness, presence of mind, curiosity, positive sense of professional identity, and empathy in the initial moments of that interaction will determine its outcomes. If Dr. N is able to recognize Mr. S's words as an expression of intense distress rather than a personal attack, he will be better able to orient himself as an ally rather than as an antagonist.

Differential Diagnosis

If anger is a "syndrome" of thoughts and feelings, it is important to consider and explore its differential diagnosis, just as we would for any other clinical syndrome. The precipitants listed in Table 1, as well as the psychiatric, personality disorders, and other patient and family factors mentioned above may be helpful guides. Clinicians who are not mental health providers may not routinely consider the differential diagnosis of emotions, but doing so helps guide appropriate responses. This exploration requires knowledge of potential contributing factors and precipitants, compassionate curiosity, empathy, and communication skills. After acknowledging the patient or family member's emotions, the clinician can state briefly his or her understanding of their sources and ask if this understanding is accurate. If uncertain, and if the patient or family member is calm enough to be able to engage in dialogue, the clinician may ask what the individual is thinking and feeling and then probe further by asking, "Can you help me understand why you're feeling this way?"

Communication Skills

Mr. S: "Where's my son? What's happening with my son? I've been waiting here for hours and no one has come out to talk to me! What's the matter with you people? There is no excuse for this! Where's my son?!"

Dr. N: "Mr. S, I'm Dr. N." He reaches out to shake hands, sits down and listens until Mr. S finishes speaking.

Mr. S: "I've been 3 hours down in the emergency room and now 5 hours up here in the ICU. I've asked the nurses and the doctors and they all say 'We'll be right with you Mr. Simpson,' but no one has come out to talk with me all this time. I want to know what's going on with my son!"

Dr. N: "I'm sorry. I thought somebody had come out to speak with you."

Mr. S: "Well obviously no one has spoken with me. I know nothing. What's going on with my son?"

Dr. N: "I'll tell you." He speaks quietly and slowly, arms resting in his lap. "We had the pulmonary specialist come in. He's been working with your son. We've all been working with your son, and your son is beginning to respond."

Mr. S: "Well that's certainly a relief. But that's no excuse. This is wrong! I shouldn't have to wait and I'm very angry!"

Dr. N: "I'm sorry no one has spoken with you ... Are you going to be ok?"

Mr. S: "I don't know. His brother had the same thing 2 years ago. I waited hours before someone came out and told me he had died."

Dr. N: He reaches out to touch Mr. S's shoulder, "I'm sorry. " He waits quietly until Mr. S is ready to speak.

The affective intensity of Mr. S's anger was fueled by his terror that his second son might die, compounded by his sense of powerlessness and fury at being ignored. Dr. N's sharing information about his son, his apology, and his nonverbal behavior helped calm Mr. S's fears and begin to build rapport. Apology can be healing, especially if the person apologizing acknowledges the injury or suffering incurred, shows remorse, tries to make amends and prevent recurrence. (23) In one of the few studies of how patients want physicians to respond to anger, McCord et al. studied research participants' ratings of 12 physician responses to a videotape of a patient telling a physician she was angry at being kept waiting. Participants consistently rated an apology with ownership ("I apologize for your long wait.") combined with explanation ("Some of the patients took extra time.") highest in satisfaction and importance. In this ambulatory scenario, they also preferred physician follow-up questions that facilitated moving along with the interview ("Shall we get started? What brings you in today?"), rather than exploration of the patient's feelings at that juncture. (24) The context, depth, nature and intensity of emotions, whether a potential or actual error has occurred, and clinical outcomes may influence patient preferences regarding the process of physician responses to anger, an area requiring further study. (25)

Nonverbal communication is critically important in building rapport, and has been linked with both patient satisfaction and outcomes. (26) By sitting down, maintaining an open, relaxed posture and a quiet, calm tone of voice, Dr. N expresses care and concern, and helps lead the patient toward composure. (27) Dr. N's verbal and nonverbal communication bring him into relationship with Mr. S sufficiently to facilitate Mr. S's disclosure of his son's death. Dr. N's willingness to sit quietly and bear witness to Mr. S's reawakened grief is another expression of his compassion and willingness to help sustain Mr. S through his current ordeal.

Specific communication skills in addition to apology and nonverbal expression can help clinicians respond to emotions and convey empathy. These include reflective statements, validation, respect, support, and partnership. Not all of these skills can or should be used in any one conversation. Rather, these skills represent a menu of options the clinician can use when appropriate to a particular conversation. Reflective statements are mini-paraphrases or snapshots of what one has just heard or observed. They are simple statements (not questions) that tend to deepen conversation and facilitate further elaboration. Clinicians should validate emotions only when they are sure they truly understand their nature and source. Premature validation can be off the mark, truncate discussion, and prevent disclosure about the actual underlying source of the emotions. Expressions of support indicate the clinician's willingness to be of help, whereas partnership indicates a willingness to work together.

Clear Boundaries

Some patients and family members are unable to control their anger despite appropriate responses by clinicians. They may continue to vent, make angry demands, or use profanity. Anger can result in violence, and it is important to be on the alert for signs of escalating agitation and impending aggression such as pacing, clenched fists, and yelling. A significant number of clinical clerks, residents, and nurses are victims of patient-initiated assault. (28) It is appropriate to set clear boundaries and to tell the patient or family member you will speak with him only if he is able to engage in civil dialogue. If this is unsuccessful, let the patient know you will need to call security to ensure everyone's safety, and leave the room.

Seek Support

Many clinicians find it helpful to seek support and other perspectives from peers and colleagues when trying to manage difficult situations. Most institutions have psychiatry consult-liaison services, social workers, psychologists or other mental health professionals who can be of help. Reflecting on difficult interactions in ad hoc or ongoing small group discussion sessions is extremely valuable. Many academic medical centers, training programs, and national organizations (29) have faculty who are able to facilitate (and teach faculty how to facilitate) Balint groups, critical incident discussions and other reflective formats to help clinicians process their own emotional reactions and learn new coping and management strategies.

Conclusion

Angry patients and families challenge clinicians' ability to maintain their composure, professionalism, and empathy. They evoke responses that may be maladaptive and harmful to themselves, the clinician-patient/family relationship, and subsequent clinical outcomes. Anger, however, is a syndrome with its own differential diagnosis and management strategies. If clinicians practice self-awareness, and are able to be mindful during these stressful interactions, they can consider the precipitants and patient/family factors that may have engendered anger, and respond in ways that build relationships, restore trust, preserve safety, and enhance personal support.

References

1. Egener B. Responding to strong emotions. In: Novack DH, Clark WD, Saizow RB, Daetwyler CJ, eds. doc.com--An interactive learning resource for healthcare communication. Internet: American Academy on Communication and Healthcare/Drexel University College of Medicine; 2005. Available at: http://www.aachonline.org. Accessed December 18, 2006.

2. Schindler BA, Novack DH, Cohen DG, et al. The impact of the changing health care environment on the health and well-being of faculty at four medical schools. Acad Med 2006;81:27-34.

3. Gerteis M, Edgman-Levitan S, Daley J, et al eds. Through the Patient's Eyes. San Francisco, CA: Jossey-Bass, 1993.

4. Tindle HA, Davis RB, Phillips RS, et al. Trends in use of complementary and alternative medicine by US adults: 1997-2002. Altern Ther Health Med 2005;11:42-49.

5. Murray E, Burns J, See TS, et al. Interactive Health Communication Applications for People with Chronic Disease. Cochrane Database Syst Rev 2005;19:CD004274.

6. Levinson W, Gorawara-Bhat R, Dueck R, et al. Resolving disagreements in the patient-physician relationship: tools for improving communication in managed care. JAMA 1999;282:1477-1483.

7. Berkowitz L, Harmon-Jones E. Toward an understanding of the determinants of anger. Emotion 2004;4:107-130.

8. Thomas SP. Women's anger, aggression, and violence. Health Care Women Int 2005;26:504-522.

9. Gross JJ, Carstensen LL, Pasupathi M, et al. Emotion and aging: experience, expression, and control. Psychol Aging 1997;12:590-599.

10. Schieman S. Education and the activation, course, and management of anger. J Health Soc Behav 2000;41:20-39.

11. Russell JA. Culture and the categorization of emotions. Psychol Bull 1991;110:426-450.

12. Hollinworth H, Clark C, Harland R, et al. Understanding the arousal of anger: a patient-centred approach. Nurs Stand 2005;19:41-47.

13. Thomas SP. Anger: the mismanaged emotion. Medsurg Nurs 12:103-110.

14. Fischer AG, Rodriguez Mosquera PM, van Vianen AE, et al. Gender and culture differences in emotion. Emotion 2004;4:87-94.

15. Fernandez E, Turk DC. The scope and significance of anger in chronic pain. Pain 1995;61:165-175.

16. American Psychiatric Association. DSM-IV-TR. Washington DC, 2000.

17. Spielberger CD. State-Trait Anger Expression Inventory-2. Psychological Resources, Inc. 2003. Available at: http://www3.parinc.com.. Available February 25, 2006.

18. Bell RA, Kravitz RL, Thom D, et al. Unmet expectations for care and the patient-physician relationship. J Gen Intern Med 2002;17:817-824.

19. Jack DC. Understanding women's anger: a description of relational patterns. Health Care Women Int 2001;22:385-400.

20. Hughes P, Kerr I. Transference and countertransference in communication between doctor and patient. Adv Psych Treatment 2000;6:57-64.

21. Novack DH, Suchman AL, Clark W, et al. Calibrating the physician: personal awareness and effective patient care. JAMA 1997;278:502-509.

22. Epstein RM. Mindful Practice. JAMA 1999;282:833-839.

23. Lazare A. On Apology. Oxford: Oxford University Press, 2004.

24. McCord RS, Floyd MR, Lang F, et al. Responding effectively to patient anger directed at the physician. Fam Med 2002:34:331-336.

25. Mazor KM, Simon SR, Yood RA, et al. Health plan members' views about disclosure of medical errors. Ann Intern Med 2004;140:409-418.

26. Roter DL, Frankel RM, Hall JA, et al. The expression of emotion through nonverbal behavior in medical visits. Mechanisms and outcomes. J Gen Intern Med 2006;21:S28-S34.

27. Carson CA, Shorey JM II. It Goes Without Saying. In: Novack DH, Clark WD, Saizow RB, Daetwyler CJ, eds. doc.com--An interactive learning resource for healthcare communication. Internet: American Academy on Communication and Healthcare/Drexel University College of Medicine; 2005. Available at: http://www.aachonline.org. Accessed December 18, 2006.

28. Waddell AE, Katz MR, Lofchy J, et al. A pilot survey of patient-initiated assaults on medical students during clinical clerkship. Acad Psychiatry 2005;29:350-353.

29. The American Academy on Communication and Healthcare, National Faculty Development Courses. Available at: http://www.physicianpatient.org.

Arithmetic is where the answer is right and everything is nice and you
can look out of the window and see the blue sky--or the answer is wrong
and you have to start over and try again and see how it comes out this
time.
--Carl Sandburg

Beth A. Lown, MD

From the Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, MA.

Corresponding author: Beth A. Lown, MD, Director of Faculty Development, Department of Medicine, Mount Auburn Hospital, 300 Mt. Auburn Street, Cambridge, Massachusetts 02138.

References 1, 27, and 29 refer to the American Academy on Communication and Healthcare and its product, doc.com--An interactive learning resource for healthcare communication. Doc.com was funded by a grant from The Arthur Vining Davis Foundations.

Beth Lown, MD authored six chapters in this resource and received an honorarium for doing so. Doc.com is now available by subscription, but the author receives no income from its sales.

Accepted March 31, 2006.

RELATED ARTICLE: Key Points

* Anger is a "syndrome" of feelings, thoughts, and physiologic reactions.

* One's response to anger depends on how one makes sense of, and copes with a stressor within a specific context.

* Patients and their loved ones may become angry in response to a sense of vulnerability, diminished sense of self, or disempowerment.

* It's best to address anger before it escalates.

* Clinicians can respond more effectively to patient and family anger by exploring its differential diagnosis, fostering self-awareness and the capacity to adjust one's own reactions, using specific communication skills, setting clear boundaries, and seeking support.

Table 1. Precipitants of patient and family anger in clinical settings

Reactions to the experience and process of illness
Physical or psychological discomfort
  * Experiencing acute or chronic pain, or discomfort
  * Living with a life-threatening illness
Negative information
In response to learning about:
  * "Bad news" about diagnosis, prognosis, disability, or death
  * A complication of treatment
  * A medical error in care
  * Failure to diagnose, or clinical misjudgment leading to adverse
    outcomes
Negative emotions
  * In response to anxiety or fear about illness in oneself or a loved
    one

The healthcare system
  * Long waiting times for care
  * Intrusive procedures
  * Institutional depersonalization
  * Denied claims or referrals
  * Paper work
  * Inability to access one's providers
  * Perceived physician conflicts of interest within managed care
    systems
  * Financial burden of insurance and medications
  * Lack of access to care
  * Perceived disparities in care received because of gender, ethnicity,
    and other factors
  * Lack of communication and coordination among providers

Relational issues
Perceived clinician negative attitudes:
  * Arrogance or disrespect
  * Bias or prejudice
  * Humiliation, shaming or judgment
Perceived clinician inattention to the patient's:
  * Emotions
  * Personal, physical or psychological needs
  * Need to be understood as a whole person in his or her psychosocial
    context
  * Informational needs
  * Expectations and requests
Undiscussed or unresolved conflicts about:
  * Goals of care
  * Tests, procedures and treatments

Table 2. Responses to anger

Adaptive strategies:
  * Foster personal awareness
  * Practice mindfulness, and be a participant-observer in the moment
  * Consider and explore the differential diagnosis
  * Use communication skills that convey empathy
  * Set clear boundaries, and maintain safety
  * Seek support

Maladaptive responses:
  * Anger or defensiveness
  * Disrespect
  * Avoidance
  * Acting as though nothing had happened
  * Transferring blame
  * Hostile distancing
  * Passive-aggressive behavior

Table 3. Communication skills to respond to emotions: a menu of options

  * Nonverbal communication: Calm, slow voice tone, open posture
  * Apology: With ownership when appropriate
  * Reflection: "You look worried and anxious"
  * Validation: "I can understand why you'd be angry after waiting so
    long, worrying about your child"
  * Respect: "I respect your dedication to your son's welfare"
  * Support: "I'll be here if you want to talk later on"
  * Partnership: "Let's figure out a way you can check in regularly with
    the team"