Hospitals are environments where emotions can run high. These emotions cross all boundaries and can affect physicians, hospital staff, patients and their families. Dealing with an “angry” patient is a common challenge that physicians face.

The first step for a physician encountering an angry patient is to remain calm and allow the patient to express his or her concerns. In my experience, “angry” patients can be viewed as falling into several different categories. By understanding these categories, physicians can begin to identify the root of the anger and take measures to address it.

Why do patients become angry? What are the common “root” causes?

1. Pain. Medical illness is often accompanied by pain, so much so that pain is often considered the fifth vital sign. Assessment and treatment of pain is an important factor for all medically ill patients. Anger is a common emotion in patients with pain, especially chronic pain. It is thought that the presence of significant anger may in fact further aggravate the feeling of pain. Physicians must not only be able to assess pain, but also to weigh the benefits and the risks in prescribing analgesics. When any patient appears to be “angry,” the presence of pain, especially untreated/undertreated pain, must be considered and rectified as a matter of urgency.

2. Fear and worry. Being medically ill, especially if one is hospitalized, can be an intensely destabilizing experience for both the patient and his or her caregivers. In some cases, an unknown prognosis, the occurrence of complications or the impact of the illness on their independence, can make patients fearful about the future. This worry can manifest as anger, and since patients cannot direct their worry or anger toward their illness, this anger may be displaced onto people around them, including hospital workers. Attempting to recognize, and where possible alleviate, their worries is often very helpful.

3. Feeling unheard or uninvolved . Any patient who displays anger in a hospital setting is guaranteed to attract attention. For some patients the expression of anger may actually suggest that they feel “unheard” in the medical setting. They may feel that they do not have enough information about their condition or their concerns have not been addressed. The question then arises, how do we make them feel heard? Do they understand why they are in the hospital? Do they understand what their treatment options are? Do they feel they have been part of the decision-making process? Ensuring that patients feel they are involved in their care can reduce the anger that can arise out of being “unheard” in a hospital.

4. An unidentified medical condition or psychiatric disorder. Some individuals may become very angry or irritable in the context of a medical or psychiatric problem. Withdrawal from an addictive substance such as heroin or the presence of major depression or delirium can present with irritability or agitation. It is important to ensure that patients who present with anger are evaluated for the presence of an underlying psychiatric or medical condition.

Collateral and risk

Obtaining collateral information from their family members, caregivers or other health care professionals is also often illuminating. Ensuring that the medical team is delivering a consistent message to patients regarding their treatment is also useful, as conflicting messages may undermine the patient’s confidence in the medical team.

Anger may suggest that there is a risk of violence. It is therefore important to ensure that an assessment is undertaken to reduce the risk to the patient and people around him.

Summary

In summary, there are many situations where physicians may have to deal with patients who are angry. In most cases the most helpful intervention is to look past the anger and attempt to identify, and alleviate, the underlying reason for the anger. Attempting to do this in a busy clinic or hospital setting can be quite difficult and requires both perseverance and practice.

Arshya Vahabzadeh child and adolescent psychiatry resident. This article originally appeared in The American Resident Project.