PERIPHERALIA

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For several years, I was the managing partner of a large 
general practice clinic. It is an interesting position to 
occupy in this 21st century of zero tolerance. Expectations 
are high and delivery is often slow. There is a general 
increase of complaints against doctors and services and the 
phenomenon of the angry dissatisfied patient has arisen 
in the last few decades, so I found myself working as the 
designated complaints department.

Why has anger become, worldwide, an emotion of epidemic 
proportions? It appears to ride on the horses of entitlement. 
This has been the downside of the human rights movements 
and patients’ charters, which have raised the often unrealistic 
expectations of clients worldwide when they encounter 
failing health services. The complaints may often be about 
being kept waiting and the general problems with service 
delivery and not so much about the treatment itself, although 
litigation against doctors’ treatment continues to rise.

The venue for the confrontation with the angry patient is 
usually the waiting room or the hospital corridor or the 
nurses’ station, so the first thing to do is to move out of 
the public arena. This should be a singles match with no 
audience. No one wins a sword fight in the waiting room 
as you have to double-think what you say because of the 
audience. Humiliation in front of others destroys all parties.

In management language, the process is called de-escalation 
of anger and in theory has calming, relating and managing 
phases. The first step is to find chairs and sit down. Remember 
that an angry person needs three times more body space 
than a normal person. Initially, don’t touch them. Set the 
stage by phoning reception or switchboard and telling them 
you are not to be disturbed. Take the phone off the hook – it 
is a great gesture – then accept the fact that your day and its 
appointments are now ruined.

Get your breathing right and ask the patient to open the 
dialogue while giving assurances that you have time for him 
or her. You can start with what is called Low Level Connecting.  
This involves finding some truth in what the client-patient is 
saying and reflecting this back to them, even if you believe 
that they are essentially wrong. I used to feel rather guilty and 
hypocritical when doing this as you find yourself agreeing 
with the patient out of natural altruism and not wanting to 
upset them further, until I found out about Second Positioning. 

Second Positioning is when you find yourself saying that you 
understand  the angry, dissatisfied person or that you agree 
with them when you don’t. What you are saying is that if you 
were in their position you might feel aggrieved or angry.

The next phase is to allow the anger out without hindrance, 
whether it is legitimate or illegitimate. The patient may 

include many other problems and slights from the past 
(called replaying adverse life scripts) many of which may be 
irrelevant. Continue to hold on to your breath and opinions. 
Connecting to the client-patient is helped by objectifying the 
situation which is achieved by repeating the complaints back 
to the client in his or her exact words so that they recognise 
that they have been heard (called backtracking or empathetic 
listening).

After the venting stage, which also goes by the magnificent 
title of Free Emotional Spillage, comes the reframing and 
negotiation phases. Remember that only about twenty 
percent of what you say will be taken in because they are 
already overloaded with emotions. A useful approach is to 
indicate that you value their input and allow them to give 
you their own solutions to the problem. 

In this context also remember that if the client is armed, 
psychotic or intoxicated then none of this applies and 
external agencies should be used to remove the client, 
especially if others are in danger (as an aside, all practices and 
departments should have a policy in place for this).

If you find your voice squeaking at this stage make a conscious 
effort to lower the tone of your voice and lean backwards in 
your chair.  If you find your own anger rising then ask to leave 
the room for a moment (known as a break-state) and when 
outside go into a karate stance and do a couple of chopping 
movements and some brisk kicks, and return to the room 
with an angelic smile.

At the end, rational anger should have subsided and 
grievances may be resolved and the conversation moved to 
a shared productive resolution. If this has not happened, try 
and set up follow-ups or ways in which the communication 
can continue with facilitators or other agencies. 

On some occasions, you may find yourself being personally 
insulted or devalued in which case you are probably 
dealing with an AXIS 11 condition, which is unlikely  
to reach a conclusion. They are very clever at recognising 
your weaknesses and are able to mobilise guilt in you,  
which results in you trying to appease them in whatever way 
you can.

Confrontation by the angry patient is one of the most 
stressful of life encounters and the memories often linger on 
for a long time in the mind of the wounded healer.

Chris Ellis is a family physician in Pietermaritzburg, 
KwaZulu-Natal

E mail: cristobalellis@gmail.com

Negotiating With The Angry Patient