A medical resident on call is asked to see a 72-year-old woman who has a headache. The medical record indicates that she was admitted 5 days ago after a fall that caused a hip fracture requiring surgical correction. The patient developed postoperative chest pain and was transferred to the medical service for further care. She is stabilized and receiving morphine for her pain but frequently calls nurses to say that she is uncomfortable. According to the nurse, the patient developed an intermittent headache earlier in the day that recurred an hour ago after her daughter called to say she would be unable to visit today. When she sees the resident, the patient snaps, "You look so young. I hope you know what you're doing." The resident asks a few questions about her headache, but she gives very little information. When the resident attempts to perform a basic physical examination, the patient yells, "Don't touch me. I'm going to complain to the hospital administrators about you because you have no idea how to properly deal with a patient." Which of the following is the most appropriate response?
This patient is irritable, angry, and verbally abusive to the resident physician. Although the immediate cause of her anger is unclear, her complicated medical course, general discomfort and pain, and probable disappointment that her daughter did not visit are likely contributing to her distress. Although the situation is challenging, it is the physician's responsibility to be nondefensive, defuse the patient's anger, and attempt to preserve the physician-patient relationship. Acknowledging the patient's distress, remaining nondefensive, and asking open-ended questions regarding what is upsetting the patient are the best means of establishing an open dialogue. Professionalism should be maintained at all times, and the physician should not retaliate with defensive or negative comments, which will only worsen the situation.
(Choice A) Reminding the patient that she is in a teaching hospital and mentioning a lack of experience will likely further anger her and provide her with additional opportunities to criticize the resident.
(Choice B) Although patients have the right to file a complaint if dissatisfied with their care, suggesting this approach in a situation where there is no evidence of poor treatment is inappropriate and does nothing to resolve the issue or improve the physician-patient relationship.
(Choice C) Although the patient's disappointment that her daughter did not visit may be a contributing factor, it is inappropriate to assume this is the reason for her distress; this premature interpretation is likely to further aggravate the patient.
(Choice D) The best initial approach is to acknowledge the patient's distress and ask an open-ended question. It is likely that this situation can be resolved by the resident without involving the attending physician.
(Choice E) Although this patient's cooperation is necessary to complete the physical examination and make a diagnosis, her anger should be addressed first to facilitate her cooperation.
Educational objective:
When dealing with an angry patient, the most appropriate response is to remain nondefensive, acknowledge that the patient is upset, and begin the discussion with an open-ended question.