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Row with a patient

A run-in with a patient may have hidden causes, writes Dr Melanie Wynne-Jones

ccasional arguments cannot be blamed solely on abusive or violent patients, and are inevitable (if undesirable) in an under-resourced demand-led service.

A patient's ideas, concerns and expectations are often the true reason for the disagreement, rather than the apparent cause (your diagnosis or management).

Working out what has triggered an argument may resolve it before it becomes a row.

Arguments started by patients

Consider whether the patient:

 · Is upset by something else completely ­ bad news, a family row, or even a traffic jam

 · Is angry with you ­ because of a previous consultation, a long wait, your refusal to give them (or a relative) what they want, perceived infringement of their rights

 · Is angry with life, or because someone else has upset them like the hospital or Benefits Agency

 · Has poor communication skills ­ frustration or feeling at a disadvantage can make people angry; some illnesses (dementia, head injury) can blunt social niceties

 · Has a confrontational style, or is simply a bully

 · Has misunderstood.

Arguments started by you

Consider whether you are:

 · Stereotyping the patient ­ appearances, family knowledge, previous encounters

 · Too busy or stressed

 · Transferring emotions from a previous consultation or unsatisfactory exchange with a staff member or the hospital

 · Neglecting your communication skills ­ you may have missed signs of anger or distress, or have inadvertently antagonised the patient

 · Having your buttons pressed ­ if your ability or beliefs are being challenged

 · Missing some vital piece of information

 · Lacking some clinical knowledge or skill

 · Being too confrontational

 · Party to a misunderstanding

If you sense a row blowing up:

 · Try to work out the cause; what was the trigger?

 · Decide whether a row is likely to have positive or negative effects; a fair and frank exchange of views can sometimes result in sudden enlightenment for either party, and may even strengthen the doctor-patient relationship, but it is important to recognise when patients are too vulnerable to cope

 · Do a rapid risk assessment ­ is your personal safety threatened, or that of your staff or patients? What are the other possible consequences of this row?

Defusing the situation

Self-control is vital to prevent saying or doing something unprofessional, or pushing patients past their limits. How you do this will depend on the situation; you may even need to leave the room, or curtail the consultation.

Watch your body language for 'leaks', and avoid sarcasm or point-scoring which may feel satisfying at the time, but cause embarrassment or trouble later.

Help the patient to get control, by using your body and verbal language to calm things down. Suggest time out if necessary ('for both of us'

if need be) or abandoning a topic altogether.

Consider discussing what is going on ('you sound angry' 'I find that upsetting'); asking about ideas, concerns and expectations may illuminate the discussion.

Show you are willing to negotiate (if that is indeed the case). Consider your 'musts, shoulds and coulds' and try to establish the patient's; if the patient agrees to try your proposed treatment, you could agree to a hospital referral if it doesn't work, or you may both agree that consulting a different partner would be best; be polite but firm about your 'musts'.

Remove the patient from the list if personal safety has been threatened or you feel a line has been crossed. Otherwise, it may be better to wait and see how things turn out ­ your relationship may be better, worse, or at least tolerable.

Calm down before seeing your next patient. Reflect on the event, its causes and outcome ­ it may help to debrief with a partner, immediately or later, or formally as a significant event analysis.

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