’Review article Ignorance isn’t bliss: why patients become angry Amnon Sonnenberg Patients with cognitive limitations may struggle understanding complex arguments and feel overwhelmed by the need to choose among medical options that they poorly understand. Such struggle may result in frustration and anger directed at the physician. The aim of the present study is to explain the characteristics underlying such situations. A decision tree is modeled to capture the choice that every patient has to make after receiving medical advice. Patient choices are phrased in terms of a threshold probability for accepting or rejecting advice by physicians. To a patient with poor understanding of medical exigencies all differences between present or absent disease state, prognosis, and risks of intervention may seem largely arbitrary and meaningless. With little or no guidance to make an informed decision, taking any medical action is deemed wasted and harmful, whereas inaction leaves the underlying medical problem unsolved. Both choices appear equally ineffective with respect to the patient’s symptoms and therefore unappealing. As shown by applying threshold analysis to a patient in a state of ignorance, no threshold probability for following medical advice exists. Patients with cognitive limitations will become frustrated and angry by a seemingly dismal situation without good alternatives to choose from. Eur J Gastroenterol Hepatol 27:619–622 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Why patients become angry
Because of the relatively high incidence of cancers affecting the digestive system and the frequent prevalence of multiple chronic disabling conditions, such as inflammatory bowel disease, pancreatitis, chronic liver disease and functional bowel disorders, just to name a few, gastroenterologists are frequently forced into the role of being the messenger of bad news. Many chronic illnesses of the digestive tract defy cure and can only be managed by suppressing disease activity or preventing the occurrence of complications. In a survey, about 60% of all physicians report being subject to verbal abuse by angry patients during the previous year [1]. Patients turn angry in response to psychological distress, anxiety, frustration, discomfort, pain, or feelings of vulnerability, loss of personal control, and becoming powerless [2,3]. Anger can also result from the perception of injustice, violation of rights, rejection, or compromise of beliefs and values [4]. Patients with fewer coping skills, substance abuse, personality disorders, or mental illness are more prone to develop anger [5]. The psychological substrate of anger is comprised of faulty cognitive appraisals, emotional affects, and their underlying neurophysiologic mechanisms [6]. The present perspective is limited to the occurrence of anger characterized by cognitive misappraisal of circumstances and poor decisions associated with disease management. European Journal of Gastroenterology & Hepatology 2015, 27:619–622 Keywords: anger, cognitive deficits, decision analysis, medical practice, outcome research, threshold analysis The Portland VA Medical Center and the Division of Gastroenterology/Hepatology, Oregon Health & Science University, Portland, Oregon, USA Correspondence to Amnon Sonnenberg, MD, MSc, The Portland VA Medical Center P3-GI, 3710 SW US Veterans Hospital Road, Portland, OR 97239, USA Tel: + 1 503 220 8262 x56679; fax: + 1 503 220 3426; e-mail: [email protected] Received 18 December 2014 Accepted 27 January 2015
When experiencing new gastrointestinal symptoms, a patient has to assess their severity and then decide whether to seek medical help. Dependent on the type of symptoms and clinical presentation, the physician will discuss the need for additional work-up and possible interventions, such as esophago-gastroduodenoscopy, colonoscopy, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and other medical or surgical procedures. In general, patients will also be presented with the benefits and potential adverse events of various management options. Patients with cognitive limitations may struggle in understanding complex arguments and feel overwhelmed by the need to choose among options that are only partly understood and whose varying outcomes also become weighted by different probability values. Depressed by their illness and frustrated by their inability to choose, patients may become angry with the medical system and lash out against their physicians. The present analysis serves to illustrate the factors that influence a patient’s decision in favor of following a physician’s advice or submitting to an endoscopic procedure as opposed to rejecting any intervention. The patient’s decision is phrased in terms of a decision tree where costs and decision making are analyzed exclusively from a patient’s perspective. A threshold analysis is used to model how patient knowledge or ignorance affects the decision process and potentially leads to anger in instances of seemingly unsolvable decisional dilemmas. Thresholds for taking action
Threshold analysis is a special form of decision tree that yields probability values rather than costs as outcome and guidance for decision making [7,8]. Figure 1a depicts a simple decision tree that captures the choice that every patient has to make after receiving medical advice. The tree is read from left to right. The decision tree contains two primary and four secondary branches. The small black square on the far left represents a decision node, whereas
0954-691X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/MEG.0000000000000323
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
619
620
June 2015 • Volume 27 • Number 6
European Journal of Gastroenterology & Hepatology
(a)
K+
p
a
(b) Knowledge
A+
K+
p
K−
A+
a
b
A−
c
d
b
Action
K−
1−p
K+
c
A−
K−
1−p
p≤
d
d−b a−c+d−b
pa + (1−p)b ≤ pc + (1−p)d (c)
(d) Knowledge
Knowledge K−
A+
0
w
A−
h
0
K+
K−
A+
h+w
h+w
A−
h
h
Action
Action
K+
p≤
w w+h
p≤
−w < 0 w−w
Fig. 1. Relationship between action (A) and knowledge (K) and its influence on harmful (h) or wasteful (w) medical outcomes. This relationship is presented as general decision tree (a), general game matrix (b), special case of knowledgeable patient (c), and special case of ignorant patient (d).
the two small black circles represent chance nodes. As depicted by the small black square of the first branching point, the patient has to make a decision in favor of or against a medical intervention in managing his/her complaints. This intervention could be some type of endoscopy or any other type of diagnostic or therapeutic procedure. The outcomes following the initial decision making are governed by chance events, as symbolized by small black circles associated with the two secondary branching points. Let the letters A represent the initial action or medical intervention suggested to the patient and K the patient’s knowledge or medical understanding. A patient can decide in favor or against taking action (A + vs. A − ). The patient may or may not have knowledge about the medical situation (K + vs. K − ). Knowledge is associated with a probability p of being correct and applicable to the present medical situation or a probability of (1 − p) of being incorrect. Each combination of action and knowledge is associated with different costs or outcomes, as denoted by the small letters a through d. Expected costs correspond with costs multiplied by the probability of their occurrence. For instance, the expected cost of the top branch is pa, and of the second branch is (1 − p)b. The
overall expected cost of the upper primary branch is the sum of its two secondary branches: pa + (1 − p)b. For a decision in favor of taking action, the expected costs of the primary upper branch must be less than those of the lower branch of the decision tree or, in mathematical terms, pa + (1 − p)b ≤ pc + (1 − p)d, as shown below the decision tree. This algebraic expression can be easily solved to yield a threshold probability of p ≤ (d − b)/(a − c + d − b). For the upper primary branch of taking action to represent the preferred choice, the probability of knowledge to be correct should fall below the threshold value of p. This threshold value answers the question of how certain one needs to be about one’s knowledge to decide in favor of taking action or consenting to medical intervention. A low threshold is preferable, indicating that a low probability of correct knowledge would already be sufficient to make a decision and take action. In Fig. 1b, the relationship between action and knowledge is depicted as a two-by-two matrix or zero-sum game equivalent to the decision tree of Fig. 1a [9]. The two-bytwo matrix just serves as short-form of showing the relevant outcome parameters, which determine the outcome probability, without the need to redraw the decision trees
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Ignorance isn’t bliss Sonnenberg
for varying scenarios. The general formula for the threshold probability is again shown below the matrix. Thresholds for becoming angry
The first clinical scenario, as shown by the matrix of Fig. 1c, deals with a rational patient who commands some understanding of his/her clinical situation. A decision in favor of action leads to no cost when the knowledge is correct but wasted action (w) in case of incorrect knowledge. Inaction in case of correct knowledge leads to harm (h) associated with missed treatment, but no cost in case of no (applicable) knowledge. Since the decision is made by the patient, the terms ‘waste’ and ‘harm’ reflect the patient’s very own estimation of the relevant contributing factors. From a patient’s perspective, waste would probably include financial outlay, lost time, bodily indignity, discomfort, pain, and other adverse effects associated with the medical intervention. Similarly, harm would include the ill effects of continued disease, such as pain, discomfort, disability, and diminished capability to pursue life to its full extent. In most instances patients would assign them ranks, such as very small, small, medium, large and very large, rather than precise numeric values. To calculate the actual threshold, one applies the formula from above (and shown beneath Fig. 1b) to the matrix elements depicting the present scenario in Fig. 1c. For this first scenario, the threshold for taking action in the face of knowledge is p ≤ w/(w + h). In most instances, the cost of harm by far exceeds the cost of waste, and in light of such low threshold value, action appears to be an attractive option to the patient. Although not expressed in precise mathematical terms, the patient will nevertheless have some general understanding that there is also the possibility of incorrect knowledge and, thus, the possibility that the planned medical intervention will yield no benefit and become wasteful. The scenario depicted by Fig. 1d pertains to a patient with poor understanding of the medical exigencies. Because of the patient’s poor understanding, the resulting differentiation between present and absent knowledge, which would be applicable to the patient’s underlying medical condition, becomes arbitrary and largely meaningless. With little or no guidance to make an informed decision, taking any action may seem wasted and harmful irrespective of the patient’s own perceived state of knowledge. Although inaction constitutes the lesser evil with h < h + w, both choices appear equally ineffective with respect to the patient’s symptoms and therefore unappealing. As shown by applying the threshold formula to scenario depicted by the two-bytwo matrix of Fig. 1d, no real threshold for action exists, and the patient will become frustrated by a seemingly dismal situation without any good alternative to choose from. Limitations of the present approach
The present threshold analysis has been limited to patient anger resulting from the inability to make a rational decision because of faulty knowledge and compromised understanding. As indicated above, patients may also become angry with their physicians for many other reasons. Even knowledgeable patients with perfect insight may grow frustrated and angry in the face of unpleasant medical news or chronic illness, whereas other cognitively impaired patients with very limited understanding may be
www.eurojgh.com
621
highly compliant and trustfully rely on all their physician’s recommendations. Knowledge alone will not necessarily result in rational decision making, which may still remain confounded by religious, cultural, socioeconomic and other influences. Lastly, the model left unexplored how different sources of deficient understanding, such substance abuse, personality disorders, and mental illness could be potentially amendable to medical intervention. What to do
There is a subgroup of gastroenterology patients, who become angry at their gastroenterologists. Aside from the justified occasional irritation caused by malfunction of the medical system, another common source for anger is a patient’s poor understanding of his/her medical condition and the complexity of existing options for its management. A basic principle of clinical medicine relates to the fact that success cannot be guaranteed with certainty and that multiple potential outcomes associated with competing diagnoses need to be weighted by their probability of occurrence. A patient made knowledgeable by his/her physician will ultimately understand that there is some type of threshold associated with making a decision in favor or against any type of medical intervention. Such threshold is influenced, on the one hand, by the risk of performing an unnecessary procedure and, on the other hand, by the risk of passing over a beneficial procedural intervention. A less insightful patient, however, may have trouble balancing such competing options and tying them with alternative diagnostic outcomes. Gastroenterologists may try to overcome the lack of knowledge by providing lengthy explanations, draw detailed graphs, and engage their patients in extensive descriptions of the underlying pathophysiology or the intricacies of the planned endoscopic intervention. They may show pictures of the endoscopic instruments and even demonstrate their function using real instruments. Most likely, they will also explain to their patients the alternatives associated with inaction and their potential adverse outcomes. Occasionally one encounters patients with preconceived notions that seem resistant to any explanation or attempts at giving reassurance. Patients may harbor the idea, for instance, that all physicians are quacks or only pursuing their own financial benefit, that their disease can be readily cured by healthy diet or exercise alone, that all modern pharmacology is poisonous, or that their health insurance or the hospital system are conspiring to harm them. They will make demands for endoscopic procedures or treatment regimens that are unconventional, unrealistic, or unavailable. Because the healthcare system will appear inexplicable or even hostile, all suggested medical options will also appear wasteful and harmful. Frustrated and angry, these patients are more likely to end up dissatisfied by their treatment and sue their gastroenterologists for perceived negligence [10]. Several general principles have been developed for deescalating encounters with angry patients [2,3,11,12]. It is helpful, for instance, if a physician is forewarned and can mentally prepare for the encounter with an angry patient. A physician must listen to the patients tell their side of the story without interruption or any immediate attempts at correcting all misunderstandings. The patient’s knowledge and reasons for disparity should be explored while trying to find some common medical goals. Such interactions
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
622
June 2015 • Volume 27 • Number 6
European Journal of Gastroenterology & Hepatology
should be held in a private room, indicating to the patient that he/she is being paid respect and given full uninterrupted attention. The presence of a family member, a patient advocate, or some other independent broker can facilitate such interactions. As the capacity to interact with angry patients increases with experience, gastroenterologists could also seek consultation by psychologists and psychiatrists. If such attempts are to no avail, it seems advisable to refrain from developing any initiative and submit to the patients’ own erratic decision process within the range permissible by standards of practice. In light of their professional commitment to help and reduce suffering, it may become rather agonizing for the gastroenterologist having to manage such patients, because the underlying decision process and the optimal choice may appear so obvious to the physician, yet the patient selects to ignore them. Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
Mayhew C, Chappell D. Violence in the workplace. Med J Aust 2005; 183:346–347. 2 Hollinworth H, Clark C, Harland R, Johnson L, Partington G. Understanding the arousal of anger: a patient-centred approach. Nurs Stand 2005; 19:41–47. 3 Lown BA. Difficult conversations: anger in the clinician-patient/family relationship. South Med J 2000; 100:33–39. 4 Davila YR. Women and anger. J Psychosoc Nurs Ment Health Serv 1999; 37:25–29. 5 Hodgins S, Muller-Isberner R. Violence, crime and mentally disordered offenders. New York: Wiley; 2000. 6 Cox DE, Harrison DW. Models of anger: contributions from psychophysiology, neuropsychology and the cognitive behavioral perspective. Brain Struct Funct 2008; 212:371–385. 7 Pauker SG, Kassirer JP. The threshold approach to clinical decision making. N Engl J Med 1980; 302:1109–1117. 8 Sonnenberg A. Decision analysis in clinical gastroenterology. Am J Gastroenterol 2004; 99:163–169. 9 Sonnenberg A. Threshold analysis of Helicobacter pylori therapy. Pharmacoeconomics 1998; 14:423–432. 10 Ofri D. What doctors feel: how emotions affect the practice of medicine. Boston, MA. Beacon Press; 2013. pp. 173–201. 11 Fauteux K. De-escalating angry and violent clients. Am J Psychother 2010; 64:195–213. 12 Philip J, Gold M, Schwarz M, Komesaroff P. Anger in palliative care: a clinical approach. Intern Med J 2007; 37:49–55.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Why patients become angry
Because of the relatively high incidence of cancers affecting the digestive system and the frequent prevalence of multiple chronic disabling conditions, such as inflammatory bowel disease, pancreatitis, chronic liver disease and functional bowel disorders, just to name a few, gastroenterologists are frequently forced into the role of being the messenger of bad news. Many chronic illnesses of the digestive tract defy cure and can only be managed by suppressing disease activity or preventing the occurrence of complications. In a survey, about 60% of all physicians report being subject to verbal abuse by angry patients during the previous year [1]. Patients turn angry in response to psychological distress, anxiety, frustration, discomfort, pain, or feelings of vulnerability, loss of personal control, and becoming powerless [2,3]. Anger can also result from the perception of injustice, violation of rights, rejection, or compromise of beliefs and values [4]. Patients with fewer coping skills, substance abuse, personality disorders, or mental illness are more prone to develop anger [5]. The psychological substrate of anger is comprised of faulty cognitive appraisals, emotional affects, and their underlying neurophysiologic mechanisms [6]. The present perspective is limited to the occurrence of anger characterized by cognitive misappraisal of circumstances and poor decisions associated with disease management. European Journal of Gastroenterology & Hepatology 2015, 27:619–622 Keywords: anger, cognitive deficits, decision analysis, medical practice, outcome research, threshold analysis The Portland VA Medical Center and the Division of Gastroenterology/Hepatology, Oregon Health & Science University, Portland, Oregon, USA Correspondence to Amnon Sonnenberg, MD, MSc, The Portland VA Medical Center P3-GI, 3710 SW US Veterans Hospital Road, Portland, OR 97239, USA Tel: + 1 503 220 8262 x56679; fax: + 1 503 220 3426; e-mail: [email protected] Received 18 December 2014 Accepted 27 January 2015
When experiencing new gastrointestinal symptoms, a patient has to assess their severity and then decide whether to seek medical help. Dependent on the type of symptoms and clinical presentation, the physician will discuss the need for additional work-up and possible interventions, such as esophago-gastroduodenoscopy, colonoscopy, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and other medical or surgical procedures. In general, patients will also be presented with the benefits and potential adverse events of various management options. Patients with cognitive limitations may struggle in understanding complex arguments and feel overwhelmed by the need to choose among options that are only partly understood and whose varying outcomes also become weighted by different probability values. Depressed by their illness and frustrated by their inability to choose, patients may become angry with the medical system and lash out against their physicians. The present analysis serves to illustrate the factors that influence a patient’s decision in favor of following a physician’s advice or submitting to an endoscopic procedure as opposed to rejecting any intervention. The patient’s decision is phrased in terms of a decision tree where costs and decision making are analyzed exclusively from a patient’s perspective. A threshold analysis is used to model how patient knowledge or ignorance affects the decision process and potentially leads to anger in instances of seemingly unsolvable decisional dilemmas. Thresholds for taking action
Threshold analysis is a special form of decision tree that yields probability values rather than costs as outcome and guidance for decision making [7,8]. Figure 1a depicts a simple decision tree that captures the choice that every patient has to make after receiving medical advice. The tree is read from left to right. The decision tree contains two primary and four secondary branches. The small black square on the far left represents a decision node, whereas
0954-691X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/MEG.0000000000000323
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
619
620
June 2015 • Volume 27 • Number 6
European Journal of Gastroenterology & Hepatology
(a)
K+
p
a
(b) Knowledge
A+
K+
p
K−
A+
a
b
A−
c
d
b
Action
K−
1−p
K+
c
A−
K−
1−p
p≤
d
d−b a−c+d−b
pa + (1−p)b ≤ pc + (1−p)d (c)
(d) Knowledge
Knowledge K−
A+
0
w
A−
h
0
K+
K−
A+
h+w
h+w
A−
h
h
Action
Action
K+
p≤
w w+h
p≤
−w < 0 w−w
Fig. 1. Relationship between action (A) and knowledge (K) and its influence on harmful (h) or wasteful (w) medical outcomes. This relationship is presented as general decision tree (a), general game matrix (b), special case of knowledgeable patient (c), and special case of ignorant patient (d).
the two small black circles represent chance nodes. As depicted by the small black square of the first branching point, the patient has to make a decision in favor of or against a medical intervention in managing his/her complaints. This intervention could be some type of endoscopy or any other type of diagnostic or therapeutic procedure. The outcomes following the initial decision making are governed by chance events, as symbolized by small black circles associated with the two secondary branching points. Let the letters A represent the initial action or medical intervention suggested to the patient and K the patient’s knowledge or medical understanding. A patient can decide in favor or against taking action (A + vs. A − ). The patient may or may not have knowledge about the medical situation (K + vs. K − ). Knowledge is associated with a probability p of being correct and applicable to the present medical situation or a probability of (1 − p) of being incorrect. Each combination of action and knowledge is associated with different costs or outcomes, as denoted by the small letters a through d. Expected costs correspond with costs multiplied by the probability of their occurrence. For instance, the expected cost of the top branch is pa, and of the second branch is (1 − p)b. The
overall expected cost of the upper primary branch is the sum of its two secondary branches: pa + (1 − p)b. For a decision in favor of taking action, the expected costs of the primary upper branch must be less than those of the lower branch of the decision tree or, in mathematical terms, pa + (1 − p)b ≤ pc + (1 − p)d, as shown below the decision tree. This algebraic expression can be easily solved to yield a threshold probability of p ≤ (d − b)/(a − c + d − b). For the upper primary branch of taking action to represent the preferred choice, the probability of knowledge to be correct should fall below the threshold value of p. This threshold value answers the question of how certain one needs to be about one’s knowledge to decide in favor of taking action or consenting to medical intervention. A low threshold is preferable, indicating that a low probability of correct knowledge would already be sufficient to make a decision and take action. In Fig. 1b, the relationship between action and knowledge is depicted as a two-by-two matrix or zero-sum game equivalent to the decision tree of Fig. 1a [9]. The two-bytwo matrix just serves as short-form of showing the relevant outcome parameters, which determine the outcome probability, without the need to redraw the decision trees
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Ignorance isn’t bliss Sonnenberg
for varying scenarios. The general formula for the threshold probability is again shown below the matrix. Thresholds for becoming angry
The first clinical scenario, as shown by the matrix of Fig. 1c, deals with a rational patient who commands some understanding of his/her clinical situation. A decision in favor of action leads to no cost when the knowledge is correct but wasted action (w) in case of incorrect knowledge. Inaction in case of correct knowledge leads to harm (h) associated with missed treatment, but no cost in case of no (applicable) knowledge. Since the decision is made by the patient, the terms ‘waste’ and ‘harm’ reflect the patient’s very own estimation of the relevant contributing factors. From a patient’s perspective, waste would probably include financial outlay, lost time, bodily indignity, discomfort, pain, and other adverse effects associated with the medical intervention. Similarly, harm would include the ill effects of continued disease, such as pain, discomfort, disability, and diminished capability to pursue life to its full extent. In most instances patients would assign them ranks, such as very small, small, medium, large and very large, rather than precise numeric values. To calculate the actual threshold, one applies the formula from above (and shown beneath Fig. 1b) to the matrix elements depicting the present scenario in Fig. 1c. For this first scenario, the threshold for taking action in the face of knowledge is p ≤ w/(w + h). In most instances, the cost of harm by far exceeds the cost of waste, and in light of such low threshold value, action appears to be an attractive option to the patient. Although not expressed in precise mathematical terms, the patient will nevertheless have some general understanding that there is also the possibility of incorrect knowledge and, thus, the possibility that the planned medical intervention will yield no benefit and become wasteful. The scenario depicted by Fig. 1d pertains to a patient with poor understanding of the medical exigencies. Because of the patient’s poor understanding, the resulting differentiation between present and absent knowledge, which would be applicable to the patient’s underlying medical condition, becomes arbitrary and largely meaningless. With little or no guidance to make an informed decision, taking any action may seem wasted and harmful irrespective of the patient’s own perceived state of knowledge. Although inaction constitutes the lesser evil with h < h + w, both choices appear equally ineffective with respect to the patient’s symptoms and therefore unappealing. As shown by applying the threshold formula to scenario depicted by the two-bytwo matrix of Fig. 1d, no real threshold for action exists, and the patient will become frustrated by a seemingly dismal situation without any good alternative to choose from. Limitations of the present approach
The present threshold analysis has been limited to patient anger resulting from the inability to make a rational decision because of faulty knowledge and compromised understanding. As indicated above, patients may also become angry with their physicians for many other reasons. Even knowledgeable patients with perfect insight may grow frustrated and angry in the face of unpleasant medical news or chronic illness, whereas other cognitively impaired patients with very limited understanding may be
www.eurojgh.com
621
highly compliant and trustfully rely on all their physician’s recommendations. Knowledge alone will not necessarily result in rational decision making, which may still remain confounded by religious, cultural, socioeconomic and other influences. Lastly, the model left unexplored how different sources of deficient understanding, such substance abuse, personality disorders, and mental illness could be potentially amendable to medical intervention. What to do
There is a subgroup of gastroenterology patients, who become angry at their gastroenterologists. Aside from the justified occasional irritation caused by malfunction of the medical system, another common source for anger is a patient’s poor understanding of his/her medical condition and the complexity of existing options for its management. A basic principle of clinical medicine relates to the fact that success cannot be guaranteed with certainty and that multiple potential outcomes associated with competing diagnoses need to be weighted by their probability of occurrence. A patient made knowledgeable by his/her physician will ultimately understand that there is some type of threshold associated with making a decision in favor or against any type of medical intervention. Such threshold is influenced, on the one hand, by the risk of performing an unnecessary procedure and, on the other hand, by the risk of passing over a beneficial procedural intervention. A less insightful patient, however, may have trouble balancing such competing options and tying them with alternative diagnostic outcomes. Gastroenterologists may try to overcome the lack of knowledge by providing lengthy explanations, draw detailed graphs, and engage their patients in extensive descriptions of the underlying pathophysiology or the intricacies of the planned endoscopic intervention. They may show pictures of the endoscopic instruments and even demonstrate their function using real instruments. Most likely, they will also explain to their patients the alternatives associated with inaction and their potential adverse outcomes. Occasionally one encounters patients with preconceived notions that seem resistant to any explanation or attempts at giving reassurance. Patients may harbor the idea, for instance, that all physicians are quacks or only pursuing their own financial benefit, that their disease can be readily cured by healthy diet or exercise alone, that all modern pharmacology is poisonous, or that their health insurance or the hospital system are conspiring to harm them. They will make demands for endoscopic procedures or treatment regimens that are unconventional, unrealistic, or unavailable. Because the healthcare system will appear inexplicable or even hostile, all suggested medical options will also appear wasteful and harmful. Frustrated and angry, these patients are more likely to end up dissatisfied by their treatment and sue their gastroenterologists for perceived negligence [10]. Several general principles have been developed for deescalating encounters with angry patients [2,3,11,12]. It is helpful, for instance, if a physician is forewarned and can mentally prepare for the encounter with an angry patient. A physician must listen to the patients tell their side of the story without interruption or any immediate attempts at correcting all misunderstandings. The patient’s knowledge and reasons for disparity should be explored while trying to find some common medical goals. Such interactions
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
622
June 2015 • Volume 27 • Number 6
European Journal of Gastroenterology & Hepatology
should be held in a private room, indicating to the patient that he/she is being paid respect and given full uninterrupted attention. The presence of a family member, a patient advocate, or some other independent broker can facilitate such interactions. As the capacity to interact with angry patients increases with experience, gastroenterologists could also seek consultation by psychologists and psychiatrists. If such attempts are to no avail, it seems advisable to refrain from developing any initiative and submit to the patients’ own erratic decision process within the range permissible by standards of practice. In light of their professional commitment to help and reduce suffering, it may become rather agonizing for the gastroenterologist having to manage such patients, because the underlying decision process and the optimal choice may appear so obvious to the physician, yet the patient selects to ignore them. Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
Mayhew C, Chappell D. Violence in the workplace. Med J Aust 2005; 183:346–347. 2 Hollinworth H, Clark C, Harland R, Johnson L, Partington G. Understanding the arousal of anger: a patient-centred approach. Nurs Stand 2005; 19:41–47. 3 Lown BA. Difficult conversations: anger in the clinician-patient/family relationship. South Med J 2000; 100:33–39. 4 Davila YR. Women and anger. J Psychosoc Nurs Ment Health Serv 1999; 37:25–29. 5 Hodgins S, Muller-Isberner R. Violence, crime and mentally disordered offenders. New York: Wiley; 2000. 6 Cox DE, Harrison DW. Models of anger: contributions from psychophysiology, neuropsychology and the cognitive behavioral perspective. Brain Struct Funct 2008; 212:371–385. 7 Pauker SG, Kassirer JP. The threshold approach to clinical decision making. N Engl J Med 1980; 302:1109–1117. 8 Sonnenberg A. Decision analysis in clinical gastroenterology. Am J Gastroenterol 2004; 99:163–169. 9 Sonnenberg A. Threshold analysis of Helicobacter pylori therapy. Pharmacoeconomics 1998; 14:423–432. 10 Ofri D. What doctors feel: how emotions affect the practice of medicine. Boston, MA. Beacon Press; 2013. pp. 173–201. 11 Fauteux K. De-escalating angry and violent clients. Am J Psychother 2010; 64:195–213. 12 Philip J, Gold M, Schwarz M, Komesaroff P. Anger in palliative care: a clinical approach. Intern Med J 2007; 37:49–55.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
