Anger is fraying the doctor-patient relationship

Kelly Collins, MD, often hears patients venting about high copays and insurance denials.  Many are working people who earn too much to qualify for Medicaid but too little to afford good-quality health insurance, and they are angry that their plans cover little of the care they need.

“A lot of my patients are struggling,” says Collins, who runs a solo family practice in Bellevue, Nebraska. “One little thing can push them over the edge.”

Collins is not alone. A large portion of the 145 physicians who responded to an exclusive Medical Economics poll reported that they are seeing greater numbers of angry patients these days. Compared to their practice environment a year or two ago, 87% reported an uptick.

Paying for care is the main spark of the anger, the survey found. Among physicians seeing more angry patients, 56% said the cause was financial concerns, such as high copays or deductibles.

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Other factors are adding to rage that’s simmering in physicians’ offices, the survey found. “Inability to get desired prescriptions” was the second-most cited reason in the survey, mentioned by 12% of physicians. In some cases, the desired prescriptions were for opioids. For other patients, they were for drugs not covered by their insurance or for which their share of the payment was more than they could afford.

Psychiatrist David Reiss, MD, often saw patients who were angry they could not get access to needed drugs during his two decades working in the California workers’ compensation system. Some of these
patients were pushed out of needed treatment, denied medication the system no longer would cover or forced to wait months to get a prescription filled.

“In workers’ compensation, the whole system is broken,” says Reiss, of Rancho Santa Fe, California. He finally left in frustration and now gives seminars on treating difficult patients, in addition to running a private practice.

Given the frustrations they are witnessing, many physicians are finding it is more important than ever to have plans in place to respond to angry patients in a constructive way.

Next: Planning ahead

Planning ahead

As many practice employees have discovered, it can be difficult to deal with an enraged patient when the waiting room is full-or even when it’s not. Developing a plan for preventing and handling patient anger can help minimize disruptions, experts say, saving valuable time and maintaining relationships with patients.

The key to calming patient anger is empathy-something that may be hard to convey when one is under verbal attack, according to Bernard Golden, PhD, a practicing psychologist for almost 40 years and author of the book “Overcoming Destructive Anger,” scheduled for publication by Johns Hopkins Press in June. 

When physicians or staff speak more softly and slowly to an angry patient, move from behind a desk and welcome a patient to sit in the most comfortable chair in the room, those gestures can go a long way towards calming the situation, he says. If a patient is making the staff or physician angry, he recommends deep breathing or other relaxation techniques to help calmly address the situation. 

“One of the things I emphasize is when someone is standing in front of you and is angry they are feeling threatened in some way,” says Golden. “It may be anxiety or insecurity about their finances.”

Acknowledging a patient’s anger can help defuse it. For instance, he says, a physician or team member might say, “I can tell you’re angry. Maybe you’re angry about finances. Can you talk about that and your frustration?”

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The key is listening closely, without rushing to offer a solution, he says. “Give them a few minutes to voice their concerns, and listen to the feelings of the person, not just the facts,” he says. “Help the patient clarify their main complaint or issue.”  

When patients report difficulties in affording prescription drugs, Reiss recommends being candid about the fact that physicians cannot control the prices. “I tell them, `It’s frustrating to me, and I’m not the one in pain,’” he says.

Of course, there’s a limit to how much time a physician can spend on this. If patients complain about the cost of care, Michelle Mudge-Riley, DO, asks about the medical concern that has brought them to her practice so as to draw their focus away from their anger and negativity-and away from the financial. “What they want is to feel better and have a plan of action,” says Mudge-Riley, who practices in the Dallas, Texas area. 

Training a front desk team to deal with patients’ anger can also be useful, given that these staffers tend to bear the brunt of it. Lee Ann Van Houten-Sauter, DO, one of two physicians at Pine Street Family Practice, P.A., in Williamstown, New Jersey, regularly invests in such training. 

When patients are upset about copays, the front desk staff has been trained to follow a script, says Van Houten-Sauter. “Basically, we tell patients we understand healthcare costs are getting higher but this is an amount your insurance has required that you pay and we do require you pay that at the check-in for your visits,” she says. “Then we give them multiple ways they can pay: credit cards, checks, debit cards or cash.”

Next: Providing payer assistance

Providing Payer assistance

Many physicians find that offering practical help with navigating the insurance system can be the best salve for anger. Collins used to have her office manager call insurance companies on patients’ behalf to make sure procedures would be covered. However, insurers sometimes said a procedure was approved-then refused to pay when the claim was submitted, leaving patients with a big bill.

Frustrated by the discrepancies between what her office was hearing and what patients were later told, she now hands out a brochure with the codes for common procedures and suggests patients call the insurance companies themselves. If they are told a procedure will be covered, she advises them to ask for the name of the representative they spoke with and the call center location and to record the exact date and time of the call. 

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Collins also keeps careful records when she prescribes a procedure such as a colonoscopy. “I always write `For screening,’ unless there is an actual problem,’” she says. “Screening is paid for by the insurance company. If it gets billed as diagnostic, the insurance company doesn’t have to pay for it. That is when the patient gets a huge bill.” 

Collins, whose practice does not use electronic health records, makes a copy of every prescription, walkout sheet and note for patients before they leave the office, so they have their own documentation.

Still, when she feels the situation warrants it, her office manager will sit down with the patient and call the insurance company together on the doctor’s line. “That way, you don’t get two different sets of information,” she says. 

When patients say they can’t afford to pay, Collins’ office manager will offer a payment plan. The practice takes their credit card numbers and charges a predetermined amount at set intervals.

Next: Honesty goes a long way

Honesty goes a long way

Different approaches make sense when patients are upset about non-financial matters, say experts. If a patient is angry about a mistake by the practice, such as a prescription that wasn’t submitted quickly, Reiss says being truthful is the best approach.

“If, as a doctor, you screwed up, and sent something a day late, take responsibility,” he says.

When patients ask for prescription painkillers that their apparent level of discomfort does not warrant, Van Houton-Sauter has found that being direct prevents further discussion, and thus saves time. After she tells patients point-blank that she won’t prescribe the narcotics they are requesting, “most of them will quietly leave.

“Some patients are persistent and continue to try to make their plea and may become agitated,” she adds. “I then tell them that I will return their copayment and end the visit.”

Heightened security

To be sure, not all patient outbursts can be prevented through smart policies and procedures alone. In such cases many physicians are turning to formal security measures.

Collins is among them. What often helps defuse patients’ anger, she says, is a camera she had installed in the waiting room. When a patient’s tone starts to turn angry, the office manager points to the device. “Do you realize you’re on camera?” she asks. “That usually shuts them down,” says Collins.

Of course, a camera may not be enough to disarm a patient whose anger has turned dangerous. Golden says it’s important for practices to have plans in place to contact law enforcement as well as to practice drills for handling angry and possibly violent patients.

Collins realized she needed to improve security in her practice after a mentally disturbed patient disrupted the office. When she and her office manager tried to use the panic button to call her security firm and 911, neither responded. They realized later that the system was not connected to the security firm. Fortunately, “he eventually got scared the cops were going to come and left,” she recalls.

Today, she takes no chances. She and her office manager have an exit strategy, doors that can be locked to create a barrier in an emergency and a room with a panic button, in case the main panic button can’t be reached. “I think every office should have a plan,” she says. 

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Kevin Carey, owner of Kevin P. Carey & Associates, an investigative services firm, is also managing director of two neurology practices in New Jersey-where his wife, Tatyana Mars, MD, is a physician. He has applied his knowledge of security to her practice after some worrisome experiences.

On two occasions, the staff had to threaten to call the police when an unruly patient caused a disruption-once when someone was upset about a copay and another time when the patient mixed up the date of his appointment and demanded that a doctor see him then. “He said, `You’re lucky I’m in a good mood today or I’d kill you,’” recalls Carey.  The patient later told Carey he was just kidding. 

As a result of these disruptions, the practice now keeps the door locked between the waiting area and the treatment rooms and has receptionists sit behind a glass partition. 

Fortunately, most patients are not dangerous, say experts. “You have to know your patient,” says Reiss. “If you’re honest and explain what the situation is, even if people don’t like it, they are not going to focus their anger on you.”