When Patients are Angry: De-escalation and Risk Mitigation are Vital Tools

In some situations, anger can be a good thing. It can provide an outlet to express negative feelings or motivate the search for solutions to problems. But when an angry patient manifests their feelings into threatening behavior such as yelling, cursing, stalking or even violence, practice owners must intervene. As employers, they are obligated to provide a safe working environment for their staff, one in which employees are not fearful for their own safety. Caution should be taken to address threats to the well-being of staff just as seriously as threats to the practice owner.

The Dentists Insurance Company’s Risk Management Advice Line, which provides guidance to TDIC policyholders and dental association members, has received an increasing number of calls recently regarding patients who are overly aggressive or display unreasonable anger toward dental providers and staff.

Risk Management Analyst Shelli Macaluso reports, “We get calls where the patients are refusing to leave the office and are acting aggressively, using profanity and making threatening statements while other patients are present. Staff members are usually fearful.” Unfortunately, these matters can escalate to the point where staff and practice owners feel threatened.

The following case studies illustrate how TDIC’s Risk Management analysts have advised practice owners to respond when patient behavior crosses the line from anger to aggression and even outward displays of physical threats or action.

Case Study One

In one recent call, an adult patient accompanied by both of her parents — as they had on previous visits — was seen for pain in tooth No. 9. The dentist recommended a crown due to a fracture at the gingival crest and placed a temporary crown. The patient was cautioned that the temporary crown had little retention due to the lack of remaining tooth structure and could become loose or fall off. Therefore, the dentist encouraged her to see the endodontist as soon as possible, as the existing root canal would need to be retreated.

A few days after the initial treatment, the patient’s mother called the general dentist demanding an immediate appointment, stating the crown had indeed come off. The office scheduled her for an afternoon appointment that same day. The patient arrived an hour early, accompanied by her mother, and began loudly demanding that the dentist fix the tooth immediately. Both the patient and her mother stated that they were not willing to comply with the endodontic referral and insisted that the dentist “fix” the tooth instead.

Despite the dentist’s assurance that she would see the patient at her scheduled appointment time, the mother became increasingly hostile. There was a waiting room full of patients and every operatory was full.

The mother became more aggressive as she waited with her daughter, causing disruption and concern for other patients and staff. The dentist recognized that the matter was escalating and asked a staff member to call the police. When the police arrived, the patient’s mother continued her tirade and refused to leave. The officer explained to the parent that her refusal to leave would be treated as unlawful trespassing on private property and instructed her to immediately leave the premises. She again refused, so the officer informed the mother that his next course of action would be to place her in handcuffs and remove her from the premises.

At this point, the patient and parent agreed to leave. Regrettably, before exiting, the parent witnessed a staff member relaying events to the police and reached out and struck the staff member, which resulted in the parent’s arrest by the attending police officer.

When the dentist contacted TDIC’s Advice Line, the Risk Management analyst who took the call assured her that contacting law enforcement had been the best choice and recommended that the next steps should be an immediate patient dismissal and refund for the crown. The dentist did not have reservations about contacting the police but was concerned that the patient was mid-treatment. Considering the mother’s irrational and violent behavior, the dentist asked if the mother would now allege that the patient had been abandoned. The analyst advised the dentist that in this case, the dismissal was justified despite the patient being in the middle of treatment. While the aggressive mother was not a patient, she consistently accompanied her daughter to appointments and clearly posed a threat to the safety of staff.

The analyst reminded the dentist that, as an employer, she has a responsibility to keep her staff safe and prevent exposure to this kind of hostility. The parent was angry enough to physically assault a staff member, therefore injury to patients or staff could possibly occur again in the future.

Case Study Two

In another instance, the Advice Line received a call from a dentist right in the midst of an escalating situation.

In this scenario, a large, muscular male patient who was known to be very fearful of dental treatment had presented for his appointment. The dentist and her assistant always spent time trying to comfort the patient and minimize his anxiety. During the call to the Advice Line, the dentist explained to the analyst that despite red flags and signs that the patient could get hostile when upset, she really had a desire to help him. Before treatment, the assistant expressed her concerns to the dentist and was nervous about being near the patient given his intimidating size and what seemed to be a propensity to escalate his behavior toward physical interaction. The dentist assured the assistant that they were not in danger.

The dentist proceeded with treatment, communicating to the anxious patient that she would be as gentle as possible with him. She cautioned him that he might feel slight discomfort while the anesthetic injection was administered. During the injection, the patient violently grabbed the dentist’s hand and squeezed it hard enough to cause pain. She withdrew the needle and tried to calm him down without success.

At this point, the patient jumped up, moved aggressively toward the dentist and began to angrily accuse her of intentionally causing him pain. The dentist assured the patient that she did not intentionally hurt him, but the more she talked the angrier he became. The dentist suggested that the patient leave until he was able to discuss his treatment calmly.

The patient left the treatment area, but then entered the front office area where he continued to behave in a way that upset and frightened the office staff. He eventually left the building but lingered outside the office for an extended time pacing back and forth while angrily staring in the windows, which prompted the dentist’s call to the Advice Line.

The Risk Management analyst recommended that the dentist contact law enforcement immediately given the patient’s outward expression of anger, physical interaction with the dentist and menacing behavior outside the office. Again, this was a situation that warranted immediate dismissal of the patient, so the analyst guided the dentist in the proper documentation and communication.

As a result of her experience with this patient, the dental assistant felt traumatized and later requested to open a workers’ compensation claim as she continued to experience anxiety during patient care following the incident. In hindsight, the dentist realized that downplaying the concerns of her assistant regarding this patient led to unnecessary risk for the entire office.

De-escalation and Mitigation

Patients and their accompanying family members or friends can pose a threat to dentists, staff and other patients when their emotions lead to aggressive behavior. Heightened emotions should never be taken lightly. Physical and verbal threats should be responded to with equal caution, as there is no way to anticipate how far (or fast) a situation will escalate.

Some key communication strategies are important when dealing with angry or aggressive patients.

• Set boundaries. Have clear expectations of behavior for both patients and staff, along with planned responses for when anyone crosses those boundaries.
• Remain calm. Always respond with a professional demeanor.
• Be understanding and empathetic. Listening is an essential element of communication. Let upset patients know you are willing to hear them out. “Sometimes patients just want to be heard,” Senior Risk Management Analyst Taiba Solaiman explains. “Sit down with them privately and let them know you understand they are upset and that you are willing to listen to their concerns. A compassionate ear can go a long way in diffusing a tense situation.”
• Remember documentation. Just as you make careful notes regarding treatment in a patient’s chart, you should document any conflicts that arise with a patient.
• Know when to contact law enforcement. It may not be necessary to contact police every time a patient is upset or confrontational. However, when a patient refuses to leave the office when asked to do so or engages in behavior including — but not limited to — harassing staff by calling repeatedly, making threats to show up at the office and do harm or physically interacting with anyone in the office, it is appropriate to call the police to intervene. (If you are not in immediate danger, it is advisable to seek guidance from the Risk Management Advice Line when these situations arise).

Handling unhappy patients can be an unfortunate reality of practice ownership and as these incidents demonstrate, have been on the rise in recent years. On the rare occasion anger escalates to aggression, be aware of your obligation to provide a safe working environment for your employees. Also be mindful of the anxiety you and your employees may experience after a traumatic event and provide supportive resources. Request the aid of law enforcement to assist with de-escalating the situation when needed and seek expert support from TDIC risk management analysts to assist with properly dismissing a patient from care.

TDIC’s Risk Management Advice Line is a benefit to TDIC policyholders. To schedule a consultation with an experienced risk management analyst, visit tdicinsurance.com/RMconsult or call 1.877.269.8844.