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Four Steps to De-Escalate With Hostile People

Imagine that you are a brand-new attending in a hospital. You have your new starched white coat and stethoscope around your neck. Before you enter your patient’s room, the nurse says, “Whew! Good luck! The patient’s dad is really angry! He’s been yelling for the last 10 minutes!”

Are you prepared? Do you know what to do?

The boundaries of unacceptable behavior have eroded in the past few years — think politicians, law enforcement, movie stars, healthcare providers, and society in general. Patients and family members behaving badly have captured headlines lately. I’m amazed, but no longer surprised every time it happens. I’m sad that in addition to code blue and code red, my hospital now has a code purple, indicating out-of-control parents. And I’m saddened that now, teaching residents how to deal with unruly people is a routine part of my curriculum.

I’m a female pediatrician, and in my personal experience, I’m pretty sure that women in the medical profession face this issue more often than men. However, it happens to everyone at some point.

It typically starts like this. I enter a hospital room, and an angry parent stands too close to me, shakes my hand too hard, and acts intimidating. He tells me exactly what I will do in no uncertain terms. He raises his voice. He may threaten to sue me or have me fired. He might use obscenities. Sometimes it’s a woman, but men often display this behavior.

Here’s my four-step response. Usually, steps one or two work; I rarely resort to step four.

Step One: Ignore the Behavior

I stand erect, stare him in the eyes, act unafraid, and act very nice but sternly. I start right into my history-taking.

“Hello, I’m Dr. Beach, and I’ll be taking care of your child. The most important thing right now is for me to know more about what is going on with your child. You can help me by answering some questions.”

Most of the time, that works. Most people are frazzled, worried about the sick person they love, sleep-deprived, and can recognize authority. They may have lost it by the time we see them because of inadequacies/inefficiencies in the healthcare system. But they calm right down and cooperate. And they usually apologize. It never helps to argue back, try to explain anything, tell them they are misbehaving (they know), or let my ego get involved. But if this doesn’t work and they continue to be aggressive, loud, or uncooperative, it’s time for step two.

Step Two: Sympathy

It goes like this.

“So, I see you’re upset. I’ve been doing this for a long time, and I’ve learned that most people when they act angry, are just really scared. I know you’re scared and worried about what’s wrong with your child. Let’s focus on your child, so I can figure out how to help her.”

Usually, the answer: “Yes, she’s been sick for a week, and nobody knows what’s wrong! We’re really worried!” And then things settle down. Still have a yelling/threatening person in front of me? Time for step three.

Step Three: Teamwork

“Look, your job as a parent is to do what’s best for your child.”

“You’re damn right it is!” (Most common response)

“My job as a pediatrician is to do what’s best for your child. We. Have. The. Same. Job. It is not you against me. We are on the same team. So, let’s work as a team and figure out what your child needs. I want to do that as quickly as possible.”

By now, most people have blown all the wind out of their sails, acted bossy as long as they needed to, and looked at me, standing there, calm, emphatic but unruffled, with my white coat and stethoscope on. They settle down, and we can get down to business.

But sometimes, people can’t settle down. They are drunk or high, have a psychiatric condition, have anger issues, or heavens knows what else. If they are still yelling at this point, they get to step four.

Step Four: Respect

My voice gets quite stern.

“You obviously are upset. I am going to leave this room for 5 minutes and give you a chance to calm down. When I return, I am going to treat you with a great deal of respect. And you, sir, are going to treat me with a great deal of respect. That is what we do at this hospital. If you cannot do that, I will call security and have you escorted out of the hospital so that I can take care of your child. Do you understand?”

Then, no matter what they say, I leave the room. Rarely do they follow me out of the room, yelling, and then security hauls them away. More often, I go do something else for 5 minutes. I call security, put them on standby, and then return to the room. It’s always interesting to see the atmosphere when I return. Sometimes, the angry person is not there, and another family member apologizes for them. I guess that family members shoo them out and tells them to behave and go home. (I don’t ask.) Usually, the angry person has settled down, although surly, they can cooperate. Rarely do I have to leave again and call security. The times I must go to step four are few and far between.

And the time it takes to go from step one to step four is only a minute or so. It is not a long-drawn-out process.

I try to remember and emphasize at each step that the goal is to care for the patient. The goal is not for me to win an argument or to show I am the boss. Neither is it to be abused. The goal is to get everyone in the room focused on the patient, where all the attention needs to be. And, if the unacceptable behavior is not repeated, it is never mentioned by me again. I continue to be professional and cordial. I can’t tell you the number of times I have gotten daily apologies after a rough start.

So, that’s my approach to bad behavior. It has stood me in good stead for many years.

I’ve written this as if it is a pediatric patient and a parent in the hospital. But this works the same with adult patients and their family members in the hospital, office, or emergency room. Here’s hoping you don’t have to use this often and rarely get to step four!

Ann F. Beach, MD, is a pediatric hospitalist.

This post appeared on KevinMD.

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