With an estimated 65.7 million U.S. adults providing care for an ill family member or friend, it's likely those same caregivers will attend patient appointments at some point.
But if their behavior presents as aggression, anger, or general disruption, physicians need to take charge before it impedes their patient's care. And while there are tips to aid physicians in the prevention of this dilemma (see sidebar below), proven techniques to diffuse the situation and maintain a patient focus exist as well.
Emotions Run Deep
Emotions play a significant role in these exchanges. "People often react in a combative, argumentative way when they're scared, worried, or feeling something difficult to express," said Lindsey Hoskins, PhD, a Maryland-based Licensed Clinical Marriage and Family Therapist with additional training in medical family therapy. "It's much easier [for family members] to be defensive and combative. That's natural."
This sentiment is echoed by Mary Walton, MSN, MBE, RN, director of patient and family centered care at the Hospital of the University of Pennsylvania, and co-author of Person- and Family-Centered Care. She believes a family member's anger or disruptive behavior is usually a symptom of underlying feelings of fear and vulnerability. "It's not about you being a good or bad doctor and it's not personal," said Walton. "Their family member has a healthcare problem and they're feeling incredibly vulnerable."
Fighting Back Instincts
As humans, our natural response is to move away from situations that may be harder or more stressful to navigate. According to Walton, that's a mistake for physicians. "When somebody's challenging or angry, we actually need to think about moving closer to them," said Walton.
Facilitate Open Communication
Setting the stage for open, inclusive communication with patients and their loved ones is the ideal tactic to minimize troublesome situations. Creagan recommends physicians do the following:
• Understand the family dynamic before consulting with the family by reviewing the patient's history, including work, children, and marriage.
• Ask family members to introduce themselves and specify their relationship to the patient.
• Avoid turning your back to the patient and family members. Consider using a tablet or positioning your computer so that you can make eye contact with everyone in the room.
So consider a family member who is acting out because of their fear, whether that fear originated from their mother's new diagnosis or from the side effects of an alternative treatment. If the physician rushes through the appointment, ignoring the upset family member and thus failing to acknowledge the fear, it only allows the fear to fester and grow. And in turn, it inadvertently creates the breeding ground for even more displaced anger.
The better way physicians can address that fear is by probing deeper. "If a physician says, 'I can see you're really upset, what happened? Did I say something to upset you? I want to be helpful,' that allows the person to feel less afraid," said Walton. This tactic not only acknowledges the fear, but displays that the physician is invested in a positive outcome for all involved. It also forms a foundational trust, which is necessary for healthy relationships.
"You don't want to get into a power struggle with the person," said Hoskins. And it's best to approach the situation in a way that lowers one's natural defenses. "Being kind and gentle, but still direct; that's really the only way you can address it," said Hoskins.
Another technique that is not always instinctual for clinicians is reiterating understanding of what the family member is explaining. "We tend to listen and nod and try to move on," said Walton. "But it can be very effective to say, for example, 'What I hear you saying is that you're very upset because of the prescription error, and it's important to you that it be right. I understand you're upset and I'm so sorry that happened.'"
By summarizing what you hear the family member saying, it affords two opportunities. One, the person can correct you if your understanding isn't accurate. And two, the person knows their concerns have been heard and acknowledged, which can go a long way in deescalating the tense, emotional energy.
Walton finds this tactic effective because the physician is responding to the emotions and not the words. In doing so, you're able to validate the family member's emotions and they can see how much you care about the patient. Again, this offers a chance for the physician to display their vested interest and strengthen trust.
Drawing a Line in the Sand
Sometimes despite your best efforts to diffuse the situation, a family member may continue to be disruptive or aggressive. In those instances, physicians can take a more direct approach. "Honesty certainly is the best route," said Hoskins. "Physicians can explain that the interaction isn't in the loved one's best interest."
Then don't hesitate to ask the family member to hold their questions or comments until the end of the appointment. At that point, you can address their concerns specifically. Or if necessary, asking the family member to leave the room is completely appropriate too.
Edward T. Creagan, , a Mayo Clinic physician specializing in cancer, palliative, and hospice care, and author of How Not to Be My Patient: A Physician's Secrets for Staying Healthy and Surviving Any Diagnosis, agrees that it can be uncomfortable to work through these moments, but physicians need to handle it professionally.
By taking control, you minimize the odds of a free-for-all, although Creagan has a slightly different tactic than some physicians. "I would never dismiss someone accompanying a patient, but I make it clear [their input] is secondary," said Creagan. "I'm respectful of their opinion, but our time is limited and I want to focus on the patient."
Answers Aren't Always the Answer
During a recent hospice visit for a 40-year-old patient suffering from liver cancer, Creagan was confronted by the patient's husband, who was upset about the growing cost of his wife's care. "I simply respectfully listened, acknowledged his angst, and recognized that I might not be able to fix it," said Creagan. "I knew I wasn't the target [of his anger]."
Instead, Creagan referred the spouse to internal hospital resources that could more accurately address his concerns. As the complexity of the healthcare system deepens, navigation of that system leaves many frustrated. Pointing them in the right direction may be just the answer they're looking for.
Walton offers one final thought regarding why physicians need to resolve the concerns of family members: "These family members represent the patient's support network," said Walton. "So it's not about pushing them away, it's about drawing the family members in."
Steph Weber is a freelance writer hailing from the Midwest. She writes about healthcare, finance, and small business, but finds her passion for the medical field growing in sync with the ever-changing healthcare laws.