Dealing with anger: the four A's
Mamta Gautam, MD
Back to Index
Whether you are dealing with an angry patient or a difficult colleague, strategies and advice are available to help you handle any situation with ease and success. Be aware of your own response to anger and be on the lookout for early signs of anger in others. Then apply the four As: Agree/Admit to the facts of the situation, Acknowledge its impact, Apologize for the situation, and Act to correct it.
Managing angry people is one of the biggest challenges leaders face. In medicine, we deal regularly with angry patients, family members, staff, and colleagues. Yet, many physicians are uncomfortable with angry feelings and prefer to maintain a positive environment, sometimes by trying to avoid or ignore the anger. Such a response is partial and temporarily effective at best, and it does not properly resolve the situation. It is important to recognize anger as a normal feeling and work to be more accepting and comfortable with it, so that it can be addressed more effectively. Top
Conflicts in any relationship are normal and inevitable. A useful way to understand the conflict is to focus on the solution, instead of the need. Acknowledge the needs of all sides, but then work together toward a mutually agreeable solution. As physicians, we are trained to have the answers, make decisions for others, and write orders. Thus, we often come up with the solution, even when we are not asked to do so or without including the other person in the process. Being right is not enough! To be a leader, we need people to choose to follow us — a decision more easily made by others when they feel engaged in the process. Top
As many as 15% of all patient encounters involve angry patients.1 Patients become angry for many reasons. This is particularly common when we break bad news to them. Anger is also a normal part of the grief reaction; it is important to expect it, accept it, address it, and not take it personally. Although some difficult situations are a result of the patient’s behaviours, there are times when the physician’s attitude, language barriers, cross-cultural issues, or the need to break bad news is a contributing factor. Patients can also become angry when they are dealing with pain, are afraid and worried about their illness and future prognosis, feel threatened, feel unheard or uninvolved in their care, or are dealing with complex medical or psychiatric problems.2
We will all encounter angry co-workers in our careers. We work with colleagues who are dealing with complex patients, who have to do more with fewer resources, who feel underappreciated and overwhelmed, and who may be experiencing stress and burnout. Other causes of angry behaviours include substance abuse, psychiatric disorders, such as depression or bipolar illness, and personality disorders.3 Top
Regardless of the root cause of the anger, there are strategies to help you handle any such situation with ease and success. Some excellent articles and guidelines offer advice and tips on managing difficult behaviour.4-7 After working with physician colleagues and leaders for over 25 years, I know how busy we are, but I also recognize how important it is to address this behaviour. Taking time to do so sooner can often prevent more time and energy required to deal with the issue later. With this is mind, I offer a streamlined approach.
Be aware of your own response to anger
Take time to think about your own experience with anger growing up and how you have handled it in the past. If your childhood was spent with adults with angry outbursts, you may have learned to react in a certain way — ignored the angry emotions, backed away, hid from them, became defensive, or joined in the angry behaviour. Chances are high that you continue to use this coping strategy, even though you are now an adult, have more power in this situation, and could respond differently. If you did not witness much anger as a child, you may feel uncomfortable during angry incidents now and not have confidence in your ability to cope with them as a leader. Top
Be on the lookout for early signs of anger in others
As stated earlier, conflicts are inevitable. Be aware that they can arise, and know how to spot them early. There are common signs that can indicate when people are no longer calm and may be losing their temper. They can exhibit changes in body language, such as a tightened jaw, tense posture, clenched fists, or fidgeting. They may start to raise their voice; or a talkative person may suddenly become quiet. It helps to recognize these signs early, before the angry person reaches a climax and loses control. Although it may be tempting to leave or rush the interaction, spending extra time with this person may actually be most beneficial. Remain respectful and courteous, calm, and professional. Listen carefully to the concerns being raised. Top
The four As
I have devised “four As” as a practical framework to manage a situation in which anger is being openly expressed. They are:
Agree with the facts in the situation — When people are angry, first let them “vent” without interruption. Just feeling that they have been heard can often help to decompress the situation. You do not have to agree with everything they are saying, especially if they are being accusatory or judgemental. Try to listen carefully, and try to find some facts with which you can agree. This also allows you to retain a degree of detachment and objectivity in a difficult conversation. Maintain eye contact, and take time to absorb what they are saying and understand why they may be angry. Top
Acknowledge other people’s right to be angry, and the impact of the situation on them. Putting this into words helps them feel that that you have actually listened to them and appreciate how this affects them. This expression of empathy and compassion is critical in a positive working relationship.
Apologize for the situation — Too often, we feel that to apologize is to accept responsibility and be accountable and, so, we hesitate to say we are sorry. In fact, we know that apology is perceived by patients and families affected by adverse events as essential and that an apology has a significant impact on minimizing risk of litigation.8 Aside from the litigation issue, the apology is a powerful tool. It helps to heal, improve communication, and improve relationships. It is the right and compassionate thing to do.9 Even if we are not referring to a specific event or have a role in the situation, we can still apologize and express regret that the situation occurred. Top
Act to correct the situation and minimize the consequences. Let people know what you plan to do next to help them. Define the next step, and let them know what it is and when you will be doing it. Conducting a root-cause analysis is a longer process that can help you isolate the factors that led to the problem and prevent it in the future. Inform the other person that you will do this, and follow up. A future clash can be much more challenging if someone believes that you promised follow up but did not deliver.
The four As are easy to remember in the midst of a difficult situation and will help to defuse tension effectively, gain time for reflection, and build trust, setting the stage for you to function at your best in your leadership role. Top
1.Hinchey SA, Jackson JL. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med 2011;26(6):588-94.
2.Vahabzadeh A. 4 reasons why patients may become angry. KevinMD; 2014. Available: http://www.kevinmd.com/blog/2014/04/4-reasons-patients-angry.html
3.Magnan A. The difficult colleague: am I or is he the problem? Le Médecin du Québec 2009;44(9):49-54. Available: http://www.nhphp.org/Documents/Them%20or%20Me,%20Who%27s%20the%20problem%202011%20Quebec.pdf
4.Guidebook for managing disruptive physician behaviour. Toronto: College of Physicians and Surgeons of Ontario and Ontario Hospital Association; 2008. Available: http://www.cpso.on.ca/CPSO/media/uploadedfiles/policies/policies/Disruptive_Behaviour_Guidebook.pdf
5.Managing disruptive behavior in the healthcare workplace: guidance document. Edmonton: College of Physicians and Surgeons of Alberta; 2010. Available: http://www.cpsa.ab.ca/Libraries/Res/MDB_guidance_document_toolkit_for_web.pdf
6.Dealing with conflict in the doctor-patient relationship. Safety of care series. Ottawa: Canadian Medical Protective Association; 2013. Available: https://www.cmpa-acpm.ca/-/dealing-with-conflict-in-the-doctor-patient-relationship
7.Adams J, Murray R. The general approach to the difficult patient. Emerg Med Clin North Am 1998:16:689-700.
8.Taylor J. The impact of disclosure of adverse events on litigation and settlement: a review for the Canadian Patient Safety Institute. Edmonton: Canadian Patient Safety Institute; 2007. Available: http://www.patientsafetyinstitute.ca/English/toolsResources/disclosure/Documents/The%20Impact%20of%20Disclosure%20on%20Litigation%20a%20Review%20for%20the%20CPSI.pdf
9.Woods, MS. Healing words: the power of apology in medicine. Doctors in Touch 2007;Jan. 1. Top
Mamta Gautam, MD, MBA, FRCPC, CPDC, CCPE — a psychiatrist with 25 years of experience treating physicians and physician leaders — is also a coach, author, and president of Peak MD, Ottawa, Ontario.
This article has been reviewed by a panel of physician leaders.