This story is hard for me to tell. I'm going to tell it with a heavy bias in my favor.
I was tired. I was done for the day, but I decided to see one more patient to help a colleague who was running behind. I met, for the first time, a frustrated woman who had waited two hours to be seen as a walk-in patient.
I tried my usual ways to smooth things over: "Thank you for waiting." "It's nice to meet you," with my hand outstretched for a handshake. "Same-day visits can take a long time." "How is everything going today?"
I was met with: "Don't touch me." "We don't need to have a conversation. I just want my medication." And, "You're the doctor, you figure it out."
In retrospect, I realize this patient was probably scared. Her chronic illness was flaring up and she needed help. However, in that moment, I was hungry and tired at the end of a long day, and I felt baited. All I could think was, "Hold my earrings, I'm going in."
And metaphorically, I did.
She told me I wasn't trying to help her.
I told her to stop being disrespectful.
She told me to stop wasting her time.
I raised my voice and asked, "Do you want me to help you or not?"
She told me she wished the nurse could see how I was treating her.
I thought that was an excellent idea, so I asked the nurse to come in and conduct the remainder of the visit. The nurse gathered enough information so I could give the patient the medication she requested. The patient left angry but with what she needed. I stayed in the patient room, typing up my note, embarrassed and holding back tears, mortified by my part in a tense interaction.
Later, a colleague commended me for holding my ground. "I would have just let her treat me however she wanted and then felt horrible for allowing myself to be abused."
I appreciated the support, but given how awful I felt, I knew my approach wasn't the right way.
A quick Google search for "What to do when patients are angry" leads to a slew of blog posts with titles like "How to handle an angry patient." (As an aside, the word "handle" makes me uncomfortable. I am not a handler, and patients are not animals who need to be "handled" when they are upset.)
The recommendations in these articles are always similar: Stay calm, don't argue, and don't try to set limits. In other words, the best way to de-escalate a situation is to allow the patient to feel heard and to try and redirect as best you can.
I get the importance of this approach as a tenet of conflict management. But having patience and compassion in the moment is easy when we are feeling well and nourished. If anything disturbs that -- being hungry, tired or fatigued, or having other interpersonal issues in the background -- this advice is useless. It chips away at our own need to express normal human emotion.
Conflict is a part of life. This weekend, I watched ticket agents at the airport fielding a frustrated group of travelers. People were tired and in transit, and tensions were running high. A recent conversation with a friend who is a host at a cocktail bar made me grateful to realize that at least when patients direct their frustration at me, it's usually because they're worried about something as important as their health, not simply because they're inebriated.
So, my question is, when we're tired and feeling down, and patients are directing their frustration at us, what should we do?
I'm really envious of the mental health clinicians at our practice who have weekly "supervision." During these sessions, they discuss challenging patient interactions with a supervisor. They learn to be aware of what they bring into a room: any transference, projection and countertransference they may experience with a patient. They're not just using these words as jargon; rather, they apply these concepts to describe how patients make them feel and, more profoundly, how to help patients despite negative emotions that may come up for them during a session.
As family physicians, we have so much human contact and we learn a lot of the theory of human behavior in medical school and residency. But unlike in psychiatry or psychology, we don't study our own interactions with patients. We don't spend enough time talking about how patients make us feel or how to help them despite our own negative emotions.
When I talk with colleagues, friends and family about some of my more challenging interactions, I often get empathy. Sometimes I am met with validation. Other times I get responses like, "Don't take it personally," or, "This is all about the patient. It has nothing to do with you."
But how can that be? I am half of a two-person interaction. I bring my own experiences and baggage into the room with me every single time, even though I think I have compartmentalized them. In fact, the more I shove away my own feelings and emotions, the less aware I am of how they spill out and influence my exchanges with patients.
In this particular story, the best thing I did was to bring the nurse into the room. She served as a buffer and luckily, instead of seeing her as another authority figure, the patient liked her. Together, the nurse and I were able to get the patient what she needed.
But I wonder, with more awareness, could I have salvaged the interaction sooner instead of hitting a breaking point and making everything worse? Is there a way to learn how to avoid getting into the boxing ring when I'm tired and patients seem on the edge of a fight? Or am I just going to struggle through these interactions until I gain experience?
Lalita Abhyankar, M.D., M.H.S., is a family physician practicing in New York City. You can follow her on Twitter @L_Abhyankar.