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Anger in patients and their relatives is a common reaction in the emotive area of sickness and healing. The anger, which may be concealed or overt, might be a combination of fear and insecurity. It is important to bear in mind that many apparently calm patients may be harbouring controlled anger. The practice of our healing art is highly emotive and can provoke feelings of frustration and anger in our patients, their friends and their relatives.
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Anger is a normal and powerful emotion, common to every human being, yet with an enormous variety of expression. The many circumstances in medicine that provoke feelings of anger include:9
disappointment at unmet expectations
crisis situations, including grief
any illness, especially an unexpected one
the development of a fatal illness
iatrogenic illness
chronic illness, such as asthma
financial transactions, such as high cost for services
referral to colleagues, which is often perceived as failure
poor service, such as long waits for an appointment
problems with medical certificates
poor response to treatment
inappropriate doctor behaviour (e.g. brusqueness, sarcasm, moralistic comments, aloofness, superiority)
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The patient’s anger may manifest as a direct confrontation with the doctor or perhaps with the receptionist, with litigation or with public condemnation.
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In an extreme example, a Melbourne doctor was shot and killed by an angry patient who had been denied a worker’s compensation certificate for a claim considered unjustified.
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When a patient expresses anger about the medical profession or our colleagues it may be directed at us personally and, conversely, if directed to us it may be displaced from someone else, such as a spouse, employer or other figure of authority.
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Anger is a person’s emotional response to provocation or to a threat to his or her equilibrium. If inappropriate, it is almost always the manifestation of a deeper fear and of hidden insecurity. Angry, abusive behaviour may be a veiled expression of frustration, fear, self-rejection or even guilt.
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On the other hand, its expression may be a defence against the threat of feeling too close to the doctor, who could have an overfamiliar, patronising or overly friendly attitude towards the patient. Some patients cannot handle this threatening feeling.
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Basically, anger may be a communication of fear and insecurity. The patient could be saying, ‘I am afraid there is something seriously wrong with me. Are you doing everything to help me?’
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Consulting strategies10
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When one feels attacked unfairly, to react with anger is a natural human response. This response, however, must be avoided since it will damage the doctor–patient relationship and possibly aggravate the problem.
The initial response should be to remain calm, keep still and establish eye contact.
‘Step back’ from the emotionally charged situation and try to analyse what is happening.
Ask the patient to sit down and try to adopt a similar position (the mirroring strategy) without any aggressive pose.
Address the patient (or relative) by the appropriate name, be it Mr or Mrs Jones or a first name.
Appear calm, comfortable and controlled.
Be interested and concerned about the patient and the problem.
Use clear, firm, non-emotive language.
Listen intently.
Allow patients to ventilate their feelings and help to relieve their burdens.
Allow patients to ‘be themselves’.
Give appropriate reassurance (do not go overboard to appease the patient).
Avoid a judgmental approach
Allow time (at least 20 minutes).
For the threatening aggressive patient, sit closest to the door to allow escape should the patient turn violent.
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Analysing the responses
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Recognising distress signals
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It is important to recognise signs of deteriorating emotional distress:11
body language (demonstrative agitated movements or closing in)
speech (either becoming quiet or more rapid and louder)
colour (either becoming flushed or pale)
facial expression (as above, tense, tightening of muscles of eye and mouth, loss of eye contact)
manner (impatient, threatening)
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Skilful consulting strategies should then be employed. It is worthwhile having a contingency plan, such as memorising a telephone number to summon security help.
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Questions to uncover the true source of anger
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The following represent some typical questions or responses that could be used during the interview.
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‘I can appreciate how you feel.’
‘It concerns me that you feel so strongly about this.’
‘Tell me how I can make it easier for you.’
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‘You seem very angry.’
‘It’s unlike you to be like this.’
‘I get the feeling that you are upset with …’
‘What is it that’s upsetting you?’
‘What really makes you feel this way?’
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Facilitation, clarification
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‘I find it puzzling that you are angry with me.’
‘So you feel that …’
‘You seem to be telling me …’
‘If I understand you correctly …’
‘Tell me more about this …’
‘I would like you to enlarge on this point—it seems important.’
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‘Do you have any special concerns about your health?’
‘Tell me about things at home.’
‘How are things at work?’
‘How are you sleeping?’
‘Do you have any special dreams?’
‘Do you relate to anyone who has a problem like yours?’
‘If there’s any one thing in your life that you would like to change, what would it be?’
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Some important guidelines are summarised in TABLE 6.2.
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