4 steps to de-escalate hostile people [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

“The boundaries of unacceptable behavior have eroded in the past few years. Politicians, law enforcement, movie stars, health care providers, the health care system, and society, in general, are all acting badly occasionally. I’m amazed but no longer surprised every time it happens. Patients and family members behaving badly have captured headlines lately. I’m sad that in addition to Code Blue and Code Red, my hospital now has a Code Purple, indicating out-of-control parents. And I’m saddened that now, teaching residents how to deal with unruly people is a routine part of my curriculum.”

Ann F. Beach is a pediatric hospitalist.

She shares her story and discusses her KevinMD article, “People behaving badly: 4 steps to de-escalate hostile people.”

This episode is sponsored by the Stanford Physician Leadership Certificate Program.

For the aspiring physician leader, leadership skills are one of the most important and influential traits that will elevate your overall success. 

Leadership impacts nearly every aspect of your career in a complex and diverse health care system. Including how you effectively communicate and influence those around you, how you respond to conflict and make important key decisions, how you develop your team, and even how you navigate social dynamics in your workplace.

Stanford Medicine recognizes the need to foster physician leaders in health care. That is why they developed the physician leadership certificate program. This 6-month cohort-based program includes live virtual sessions, self-paced learning modules, professional coaching, a capstone project, and much more: Providing C-suite education for the non-C-suite physician leader.

They encourage all early career and aspiring physician leaders to apply. To find out more about the program or apply, visit physicianleadership.stanford.edu.

Did you enjoy today’s episode?

Rate and review the show so more audiences can find The Podcast by KevinMD.

Subscribe on your favorite podcast app to get notified when a new episode comes out.

Click here to earn 1.0 AMA PRA Category 1 CME for this episode.

Also available in Category 1 CME bundles.

Powered by CMEfy – a seamless way for busy clinician learners to discover Internet Point-of-Care Learning opportunities that reward AMA PRA Category 1 Credit(s)™. Learn more at about.cmefy.com/cme-info

Do you know someone who might enjoy this episode? Share this episode with anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today we welcome back to the show Ann Beach. She’s a pediatric hospitalist, and her KevinMD article is titled “People behaving badly: 4 steps to de-escalate hostile people.” Ann, welcome back to the show.

Ann F. Beach: Thanks. It’s nice to be here.

Kevin Pho: So for those of you who get a chance to listen to our other episode together, just briefly share your story and journey to where you are today.

Ann F. Beach: I’ve been a practicing pediatrician for almost 40 years. I went to school at Wake Forest and practiced small-town pediatrics in Georgia for several years. In my 39-year career, I’ve been a small-town general practice pediatrician, I’ve been an HMO pediatrician, I’ve been a hospital administrator, and I’ve been an expert witness in child abuse and started a child abuse clinic. I’ve spent time creating capacity for quality improvement programs in pediatric hospitals. For the last 20 years of my practice, I’ve been a hospitalist in an urban tertiary care pediatric hospital.

Kevin Pho: All right. And before we talk about your article, “People behaving badly: 4 steps to de-escalate hostile people,” tell me some of the hostile interactions that you’ve had in the past that drove you to write something like this.

Ann F. Beach: Mostly it’s been frazzled parents who were just on their last nerve. I’ve certainly had, a few times every year, parents who yelled, who threatened, who told me exactly what I was going to do in no uncertain terms, who said they were going to have me fired, who said they were going to sue me. It became obvious that we all need to be slick at how we handle those sorts of things. It needs to be something in our toolbox.

Kevin Pho: And during these times where you had to deal with a hostile party, someone who was threatening you, for instance, do you ever feel that you were in danger, that you were in fear for your personal safety?

Ann F. Beach: I can think of one time when I thought I was going to get slugged, but I didn’t. Mostly I’ve just been angry that people tried to intimidate me. I believe this is an issue that happens more to women physicians than men, although it happens to all of us, and certainly it’s getting worse over time. But mostly I just got mad that somebody was trying to boss me around, and I realized that response is not productive.

I worry a lot about what’s happening now, because it seems like it’s escalating. It’s getting worse. People are getting shot, terrible things are happening, and I feel for everybody who’s on the front lines.

Kevin Pho: Have you had any hostile interactions not with a patient or their family? Have you had any hostile interactions with, say, administration or your fellow physician colleagues?

Ann F. Beach: Oh, I can think of one physician who was pretty unreasonable, and these tactics, modified a little bit, work pretty well with doctors who were also behaving badly. But that’s the minority.

Kevin Pho: All right, so let’s talk about some of these techniques. Like you said, I think they come in very handy, because we do live in such a polarized society, and more and more of these instances, unfortunately, are being encountered by health care professionals. So what led you to write this article?

Ann F. Beach: I’m a writer as well as a physician, and I’m in a writer’s group, so a shout-out to the Fearless Writers. I’m the only physician in that group. We were meeting sometime recently, when a doctor had just been shot by a patient, and they were horrified by all of that. We were having a conversation about it, and they were amazed that aggressive patients or parents were something that doctors have to confront and have to know how to deal with. They were shocked that people actually behave badly to doctors. So I started explaining to them how I handled this and my experience, and that’s how I ended up writing the article.

Kevin Pho: So this article did gain some traction on KevinMD, over 100 shares. What were some of the reactions to your article?

Ann F. Beach: What was most interesting to me, sadly, was that my emergency room colleagues said, “Yes, this is a tool we use every day, multiple times,” which made me sad and scared for my ER colleagues. I think they’re the point of the spear. They’re seeing the most of the frazzled, wound-up, inappropriate people. So it really resonated among ER physicians.

My pediatric colleagues all felt, yes, this is something they see in the office, and this was helpful. I work closely with people who teach residents, and they said, “Perfect, I need this.” I actually had a colleague from another metropolitan children’s hospital, in Arizona, who said, “Can I please use this? I’m teaching residents. Can I use it in my slideshow pack to help teach residents?” So I think it struck a nerve.

Kevin Pho: So for those of you who get a chance to read your article, just walk my audience through it.

Ann F. Beach: So imagine that you walk into a room to see a patient for the first time. I’m a hospitalist, so I think about walking into an exam room to see a child who’s just been admitted, and a parent, usually a dad. Imagine that they get in your face, they point their fingers, they tell you what you’re going to do in no uncertain terms, and they start to yell at you.

So the first step is to ignore the behavior. They know they’re behaving badly. It doesn’t help to point it out. It doesn’t help to be right. The whole point is your job is to take care of the patient. So what I say is, “Hello, I’m Dr. Beach. I’m the doctor who’s going to be taking care of your child. I’d like to ask you some questions so I can figure out what’s going on with your child.” And I just try to immediately refocus on the patient and ignore the fact that they’re behaving badly. I stand very erectly, I act very professional, I happen to wear white coats, and I just focus on the child. So that’s step one: Ignore the bad behavior.

Step two, if that doesn’t work, if they’re still yelling, is sympathy. Most people, by the time I see them, have been up a bunch of sleepless nights with their sick child. They may have been to several emergency rooms. They’re worried. They don’t know what’s going on with their child. And so I say, “You know, I’ve been doing this for a long time, and I’ve pretty much figured out that when people are acting angry, it’s really because they’re scared. I know you’re scared about what’s going on with your child, and you don’t know what’s wrong. My job is to help figure that out. So let’s focus on your child. I’d like to ask you some questions, and let’s go ahead and do that as quickly as possible. I want to help your child.” And most people at that point will say, “Yes, we’ve been to seven doctors, and nobody knows what’s wrong,” and they are scared. So just opening the door for them to be scared and feel vulnerable, lots of times, takes care of the problem.

So in most cases, step one and step two handle the issue. But every once in a while, somebody is still wound up, and so you have to go to step three. Step three is what I call the teamwork step. I say, “Listen, your job as a parent is to do what’s best for your child.” And usually people go, “You’re damn right it is.” And then I say, “My job as a pediatrician is to do what’s best for your child. We have the same job. It’s not you against me. We are on the same team. So let’s you and I work together to figure out how we can help your child.” So then I press on with taking the history. Usually that works.

A small percent of the time, people are still unreasonable. They’re still yelling. And all of this has just taken 30 seconds, 45 seconds. It’s not a long process. But if they’re still acting scary, acting unreasonable, maybe they have a psychiatric problem, maybe they have a drug problem, maybe they have anger issues, I don’t know. But if they still cannot be reasonable, I go, “You know what? I’m going to leave this room for five minutes, and I’m going to give you a chance to calm down. When I come back in five minutes, I’m going to treat you with a great deal of respect. You, sir, are going to treat me with a great deal of respect. That is what we do at this hospital. If you’re not able to treat me with respect, I will call security and have them remove you so that I can take care of your child.”

And then, no matter what they say, I leave. Sometimes people go, “OK, I’m going to calm down.” I leave anyway. I call security, I put them on standby, I go do something else for five minutes, and then I come back. I would say about half the time, that person is no longer in the room. They’ve gone, and my guess is that whoever the other adult in the room is kicked him out and said, “You’re just being a jerk. You leave.” I don’t mention it. I don’t talk about anything that went on. I just take care of the child.

Sometimes when I go back in the room, that person is still in the room, and they’re behaving. Rarely, I go back in the room and they’re not behaving, and then I have security on standby. They come and escort them out of the facility. And so that’s my four steps: Ignore the behavior, be sympathetic, talk about teamwork, and treat them with respect and get security involved. That is fairly quick and works pretty well.

Kevin Pho: How did you come up with these steps? Is this something that someone taught to you? Is this something that you have?

Ann F. Beach: Through the years, everybody has their own style, but this is what, over the years, I’ve ended up doing, and this is what I teach residents. Because the first time you walk into the room with a resident or a medical student and a parent goes ballistic, the resident’s eyes get this big, and they don’t know what to do. But they need to have it in their toolkit. They need to know what to do. So again, I think it’s just trial and error.

But to me, the big thing is it’s really hard to be a parent of a sick child. It is really hard to be a sick patient. And those of us in health care who’ve been there know it, but a lot of us haven’t been there. And if you can just emphasize the sympathy, “Yes, you’re sleep-deprived. Yes, you’re frazzled. Yes, I know you’re really worried. I want to help you,” that’s the direction I want to go in. It never helps to go in the direction of “Look, I’m the boss here,” or “I know way more than you do,” or “You just need to behave yourself.” None of that ever works.

Kevin Pho: I want to talk about the primary care setting and see whether we can use some of these techniques in a typical, say, primary care setting. I do primary care, and I’m sure a lot of pediatricians see children and their families who get a lot of misinformation from, say, social media. A lot of these patients and their families are openly challenging medical professionals and openly doubting the advice that they give, and they’re saying that whatever they read or heard from their friends, that’s what they should do, and they should be demanding that our pediatricians also do that as well. Now, let’s say in that typical setting, where the patient or the family is steeped in misinformation, what are some ways we can use some of your techniques to help address something like this?

Ann F. Beach: A large part of my practice was before Google, and so I would say about half my practice has been since Google, and it’s been radically different. When I get the idea that I’m going to get a laundry list of “Here are the tests I want because I read this on Google,” I try to be extra nice, and I try to disarm them with humor. I very often will say, “Have you had a chance to scare yourself with Dr. Google yet? Have you got your list of what you think I might be doing?” just to say, “I know everybody’s reading Google, and I know you probably scared yourself.”

And on the occasion that people have a list, or “We need an MRI,” I sit down and just start at the beginning and go, “OK, maybe you do, but I’ve got some questions I have to ask first,” and I ask all the questions I was going to ask anyway. I try to back up a few steps from the “I need, I want” to ask more questions.

I also do a lot of thinking out loud. My style is just to say, “Let me just tell you how doctors think. We make a mental list of all the things that could possibly be going on, and then we ask questions, we do a physical exam, we do tests, and one by one, we’re able to knock things off the list. So I’m going to start out by asking you a bunch of questions so I can make my mental list.” Nobody has any idea how we think or what a differential diagnosis is, so I just try to be very open, very conversational, and up front.

Kevin Pho: Now, what about scenarios where patients and their families bring up things that are actively harmful, refusing vaccines, for instance?

Ann F. Beach: Sure. I had years of that in my private practice. Now, this will be controversial, but in my private practice, if people refused vaccines, I just always said, “Listen, I’ll be your pediatrician for the next two weeks to give you a chance to find another pediatrician, because that is not the kind of pediatrics I practice.” And they would go, “Oh, we really like you.” “You know what? This is Pediatrics 101. If you can’t trust me on Pediatrics 101, we’re not going to have a good trust relationship if something really difficult comes up. So you need to find somebody you can trust, and it’s not me.”

I’ve had parents where I knew their child had meningitis, and they refused a spinal tap. I tell them how very worried I am, how very scared I know they are, how crucial this test is, and how the law allows me to take custody of their child if I feel like their child’s life is in danger. I’ve done that a few times: meningitis, needed a spinal tap. I had a newborn baby with hemolysis who needed a blood exchange transfusion, and they were Jehovah’s Witnesses and were not consenting to that, so I got a quick judge order for consent. Those sorts of things. And certainly I’ve taken care of lots of children who have been physically abused, and so you have those issues as well.

Kevin Pho: We’re talking to Ann Beach. She’s a pediatric hospitalist, and we’re talking about her KevinMD article, “People behaving badly: 4 steps to de-escalate hostile people.” What are some of your take-home messages that you want to leave with the KevinMD audience?

Ann F. Beach: First of all, be really sympathetic. Try really hard to understand where people are coming from. Second, don’t let yourself be abused. Have a plan. Know what you’re going to do with the unruly or scary patient. Practice it. Be ready to execute it.

Kevin Pho: Ann, thank you so much for sharing your time and insight. Thanks again for being on the show.

Ann F. Beach: Thank you.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes