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At the heart of general practice since 1960

how to prevent and manage patient anger

The open access nature of general practice makes conflict inevitable at times – Dr Matthew Johnson gives a reminder on how to defuse intense situations

The open access nature of general practice makes conflict inevitable at times – Dr Matthew Johnson gives a reminder on how to defuse intense situations

Most GPs will encounter threatening, abusive and even violent behaviour from patients during their working lives. There are things you can do though to reduce both the frequency and severity of such incidents. As always, prevention is better than cure.

minimising frustration

Preventive measures fall broadly into the organisational and the personal. A degree of conflict is unavoidable in an open-access generic service like a GP surgery and so it is how such situations are dealt with that is key to avoiding escalation and violence.

Some patients attending the surgery may already be in a state of smouldering anger or resentment, and in such circumstances it will not take much to push them over the edge. An unfriendly or badly organised reception may provide such a trigger.

Similarly a lack of clearly defined boundaries about even such trivial things as the turnaround times for repeat prescriptions can be a source of frustration and resentment, as can the impression that not all patients are being treated equally.

Unified approach

A practice that lacks regular meetings and a culture of openness is unlikely to present a unified approach, and in such circumstances it is a common experience to be ‘set up' by the expectations that a patient has developed from another GP.

A well-run practice will have in place written and consistently applied policies for potential problem situations such as: attending while ntoxicated, late arrival for appointments, abusive/racist/sexist language, provision of controlled substances, and so on. A transparent process for dealing with grievances and complaints will also go a long way to defusing anger and potential violence.

Practice environment

The practice should have considered the layout of the reception area to ensure protection from direct assault. Access to the working area should be through a security locked door and the counter should be too high to vault over and too wide to reach across.

Panic buttons should be provided and all staff should receive some basic training in handling conflict and violence. In the consulting room you should ensure that you are seated nearer to the door than the patient, ensuring that in an emergency he/she cannot block your exit.

Handling an angry patient

Even with all this is in place it is likely there will still be a small number of incidents. This is where you need to bring your personal skills and attitudes into play. The first and most important factor is awareness. The earlier you become aware that a patient is becoming angry, the more likely you are to be able to defuse it.

You will not pick up on the early warning signs (facial flush, dilated pupils, facial expression and so on) if you have your eyes glued to the VDU.

If you realise that someone is getting angry, you need to engage him, maintain eye contact (but don't stare him down!), and make him feel listened to. You need to stay calm yourself, and talk in clear measured tones, but try not to ‘talk down' or be condescending. Be empathetic but clear that you will not be bullied.

Sometimes moving a little bit closer to the person can help, but avoid direct contact unless you strongly feel that is appropriate, in which case this should be restricted to hand-to-shoulder touch. Be aware of your own body language (it is surprising how you may suddenly notice that your fists are clenched tight), and relax your posture.

Be prepared to allow the person to let off a bit of steam, as long as this does not involve abusive language or threats; these should be politely but firmly challenged. An apology for a misunderstanding or a minor error can often work wonders. Most such situations can be contained and can even lead to an enhanced therapeutic relationship if skilfully handled.

Handling a violent patient

On very few occasions, despite everything, you can sense that the person's anger is not abating and that violence is a real possibility. In such circumstances you must look to your personal safety. Use the panic button. Leave the room quickly and call for assistance.

Call the police and inform the patient you are doing so – the person often rapidly decides at this point that the best strategy is to leave the building.

Moving on

After any such incident the practice should conduct an event analysis at which any preventable factors can be identified and corrected. Possible sanctions against the patient need to be considered in the light of the circumstances and severity of the incident, and of the clinical situation of the patient.

A balance needs to be struck between over-zealous reaction to very trivial incidents, and letting unacceptable behaviour go unchecked.

Finally we need to remind ourselves that the vast majority of patients treat us very well, and that includes the mentally ill, addicted and socially marginalised.

Dr Matthew Johnson is a GP in Fitzrovia, London and a regular facilitator for the RCGP drug and alcohol training group

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