Dealing with Disruptive Patient Behavior

The vast majority of your patients are a pleasure. They make the job rewarding and treat your staff with respect. But there are also those few who seem to enjoy making everyone squirm. They use inappropriate language, make unreasonable demands, and may even resort to physical abuse.

Disruptive behavior often stems from the stress associated with being sick - patients fear that their health may worsen and experience anxiety about the out-of-pocket costs they will incur. But it can also be rooted in mental illness. Behavior that most of us would consider counterproductive is common in patients with late-stage dementia or those who suffer from personality disorders. Whatever the cause, however, such behavior must be dealt with in a swift and effective manner. And it's your job as administrator to prepare your team for the next encounter, says Ken Hertz, a consultant with the Medical Group Management Association Health Care Consulting Group. "The role of the administrator in today's practice is continually evolving with new skills required on a regular basis; however, one thing remains constant - their role in ensuring that their staff is trained in customer service, specifically in dealing with dissatisfied patients," he says.

Set expectations

Disruptive behavior, which can also be exhibited by the patient's family members, includes anything that impedes the caregiver's ability to provide safe and effective care. Examples include interference with the physician's treatment plan, yelling, kicking, use of profanity, sexually inappropriate comments, and threatening statements.

Your patients must be made aware that such behavior will not be tolerated. "Set expectations," says Marshall Baker, a consultant with Physician Advisory Services in Boise, Idaho. "Every practice should have a patient's rights and responsibilities document posted in a visible place, and include that in their new patient packets, as well." It should outline the types of behavior your practice expects; including respect for providers and staff, protocol for refill requests, and showing up for appointments on time. Just as important, though, it should also delineate the behaviors for which your office has a zero tolerance policy, including physical and verbal abuse.

When a patient exhibits disruptive behavior, Baker says, an incident report should be produced and reviewed by management to determine whether to contact the patient for "his side of the story." It should also cover whether that patient will be dismissed from the practice, who will communicate with that patient about his behavior, and who will provide resources where needed. Those experiencing anger or depression, for example, may need a psychiatric consultation. "Medical groups need to have a consistent application of consequences and they have to be prepared to excuse the patient from their practice," says Baker.

Prepare your team

Next, equip your team with the tools they need to diffuse tense encounters. That includes taking patients aside who are complaining loudly or being belligerent, since they are often energized by an audience, says Kate Clarke, manager of patient relations for Cadence Health hospital system in Winfield, Ill. "The last thing you want is to have a confrontational discussion in front of a waiting room." Ask that patient to step around the corner or into the hallway to resolve the matter privately, she suggests, but don't use an exam room or office where an employee could be at risk by being alone with an irate patient. Another effective tool for dealing with angry patients is to lower the volume of your voice, she adds, which naturally deescalates the situation.

Try, too, asking the patient to explain the problem from the start, making eye contact while you listen, and repeating the problem back when they're done, says Hertz. "Acknowledge by 'playing back' to the patient what you are hearing, and be sure that the patient knows you understand the problem," he says. Ask how you can help. Find out what outcomes they are seeking, and determine together how best to resolve the matter.

Consider, too, that while your patient may be reacting inappropriately, they may have a legitimate complaint. Perhaps your wait times are too long, the parking lot is problematic, or a member of your staff was rude or dismissive. Negative feedback is not fun to hear, but it is an opportunity to improve, says Hertz. "There are many reasons why patients are disruptive," he says. "If it is caused by a problem in the practice with your processes or procedures, then fix it."

When patient encounters become heated, never, ever blame someone else on the staff or ask the patient to "calm down," says Hertz, which only fuels frustration. And while empathy is always important, be wary of telling patients "I understand." "You may or may not understand," he notes. In situations where patients are acting in an inappropriate or intimidating manner, Clarke suggests the following technique instead: Tell them "I really want to help you through this, but I need you to stop swearing, yelling at me to do that."

Instruct your staff to make a genuine effort to be helpful as well, says Baker. Your patient may be struggling to pay a bill, in which case you can suggest a payment plan, or is unable to resolve a situation with their insurance company. "If you can't provide an answer, adopt the role of information broker," he says. "Obtain the pertinent information, get answers and then communicate it to that patient as quickly as possible."

Role playing

Your staff (both clinical and clerical) also needs a vocabulary they can turn to when patient encounters take a turn for the worse. That requires practice. "When someone is yelling at you, the normal response is fight or flight," says Clarke. "You freeze cognitively. It's a lot harder to come up with something constructive under pressure."

Role playing drills are a great way to prepare, she says. "You have to go through that process of getting confronted and then work through it," says Clarke. "Get [staff] in that uncomfortable place and help them script their own words that they can access in a tense situation." Ask staff members, too, to share their own experiences in dealing with disruptive patients, either at your practice or with a prior employer, and discuss as a group how such scenarios can be most effectively resolved.

Baker agrees that role playing drills are important. "You have fire drills and emergency drills regularly, but you're going to have a disruptive patient long before you have a fire," says Baker.

Be firm

Patients who repeatedly try to get your practice to break its policy (renew prescriptions without a check-up, for example), should be told in a calm, but firm tone of voice what your practice requires. The Texas Medical Association recommends repeating the policy clearly and standing your ground. Don't attempt to come up with new excuses or rationale, which only encourages the patient to develop their argument. Do not open the door to negotiation.

You should also notify your staff in advance when a patient who is notoriously difficult is on the schedule, says Baker, giving them time to prepare. Likewise, all staff members should be given a heads up when a patient who was agitated over the phone is coming in to speak with your office in person.

Finally, make sure your employees know that you support them and that they can always refer such patients over to you, says Clarke. "Many staff want to do the right thing, but report being fearful of retaliation from their employer if their actions or words upset the patient, when, in reality, most leaders in healthcare would not want their staff to quietly endure the verbal abuse that occurs in these situations," she says.

Disruptive patient behavior is unfortunate, but inevitable. Thus, it's important to arm your team with strategies that are most effective at diffusing difficult encounters. "It's not realistic for practice administrators to be all places at all times," says Clarke. "It's important for front line staff to have the skills, permission, and comfort level to establish boundaries and limits when individuals present with behaviors that are significantly problematic in the office environment."

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 20 years. Her work has appeared on CNBC.com, CNNMoney.com, and Bankrate.com. She can be reached via editor@physicianspractice.com.

This article originally appeared in the June 2014 issue of Physicians Practice.