The resident workroom landline rang, and as I spotted the number my stomach dropped. The number I now recognized belonged to a friend of an inpatient I was treating in my role as a medical intern. This particular patient had spent the past few days so distraught by his declining health that my early morning pre-rounds with him had morphed into a 45 minute-long ritual in which he simultaneously pleaded for my help while berating me for the failings of the medical system. His friend had called our team several times already and had spent similar lengths of time accusing us of neglecting the patient. Keeping up with an overflowing to-do list I could barely fit into a 13-hour workday was enough to overwhelm me; this situation had me at my wit’s end.
“Let me get it,” our covering senior resident for the day chimed in, but I insisted on handling the call out of a sense of obligation to the patient and resident. What the latter had probably recognized before I could was that I had exhausted my emotional resources and was set up to fail before the interaction had even begun. It was time for a different approach.
Patients and their doctors hit impasses for lots of reasons, from miscommunication, to cultural or value-based disagreements, to gaps between patient expectations and the reality of how our medical system functions. For some inpatients facing acute illness, the sudden loss of basic bodily function and the powerlessness and dependence it brings can be too much to bear. These patients may exhibit emotional dysregulation, hostility, or attempts to take back control from their care team. While clinicians often intellectually understand that such behaviors come from a place of vulnerability, in action we often feel perplexed, de-skilled, and attacked. This only makes it harder to identify and address the underlying issues. And while difficult interactions with distressed inpatients are commonplace, there is little formal training on how to navigate them.
While I am far from an expert, time spent working through these conflicts with my own patients and as a psychiatric consultant to medical and surgical teams has allowed me to develop a basic approach. I call it “The Three B’s”:
Breathe: It is distressing to be around a distressed person, not to mention to be tasked with reassuring and treating them. Managing our own distress takes work, but is necessary to protect our powers of attention and clinical reasoning in charged interactions. Breathwork activates parasympathetic tone (i.e., calms us down), and mindfulness practices cultivate an attentive, observant state of mind that makes it easier to analyze rather than automatically react to emotionally intense content. Both are core skills for improving emotion regulation, and their application to medical training is beginning to be formally studied.
My personal favorite tool is a three-part breath paced out like a box breath. Before I enter a conversation with a distressed patient, I take a few cycles of the box breath and observe my body relaxing and mind clearing. If I unexpectedly find myself in a charged interaction with a distressed patient, I’ll initiate a few cycles (no one can tell!) while allowing the patient to vent. And if I am with a patient who is too distressed to let me finish a sentence, I will point it out and invite the patient to do some cycles with me. After all, if the patient’s nervous system is so revved up that they cannot process your words, this direct de-escalation strategy can help them calm down enough to hear and respond to your verbal intervention.
Like any skill, the more you practice when you’re calm, the more effectively you can use it in a crisis. The Insight Timer meditation app is one of many great options; I encourage you to find your favorite breathing exercise and start practicing it before the next situation that calls for it arises.
Befriend: When faced with patients who are expressing hostility or making unrealistic demands, there is an impulse to immediately defend ourselves by highlighting hospital rules or justifying our medical recommendations. When I notice myself acting defensive, I remember that people tend to lash out when they are feeling misunderstood and disempowered. This helps me shift focus to better understanding them and empowering them to engage in their own care.
In these situations, I try to bridge the divide by explicitly stating that the patient is at the center of and in control of their care. I highlight shared goals that unite us; some version of “I can see how important caring for your health is to you; we are here because we care about your health, too” nearly always applies. I frame the care team’s role as that of a partner who provides the information needed for the patient to meet their own needs, and am direct about what each party needs to do to allow the partnership to function. For example, if a patient has not clearly expressed why they are upset, I will say, “We can only help if we understand your specific concerns” before trying to figure it out with them. If they are expressing suspicion or dissatisfaction around my intent to help them, I may say, “Once we understand your goals and concerns, it is my job to find out and clearly communicate what we can realistically do in the hospital to address them. It’s your job to hear our recommendations, bring your own ideas and questions, and ultimately decide what next step is best for you.”
Sometimes this is enough to get patients expressing themselves clearly and processing the information you have to provide. Sometimes it’s met with increasing escalation. If the latter happens, name that and ask if another approach might facilitate more productive conversation. If the patient still can’t engage, perhaps a connection isn’t possible at that moment and it’s time to step back from the conversation.
Be Honest: This one may seem obvious, but when feeling pressure to deviate from our typical medical recommendations or ways of operating in our roles it can be easy to lose sight of what we know. For me, the best guardrail is being transparent about everything surrounding a difficult interaction, from our role in the care team, to how much time we have available for our conversation with the patient, to what we know about their medical condition and realistic treatment options and with what degree of certainty. If possible, I like to think through how I would express these concepts in plain language ahead of time. If caught off guard and uncertain about the answers, I try to be honest about what I don’t know and what steps I will take to get an answer. In the rare case that a situation is so risky and emergent that a patient’s objections to treatment cannot be ethically honored, this principle reminds me to be honest about that fact and about what the process of treatment will entail.
This framework is a starting point to help reduce anxiety and cue basic techniques. In practice, every interaction is different, and working effectively with distressed patients is a skill to be refined through real-world practice, supervision, and debriefing. To facilitate skill-building, medical schools can increase instruction on and access to practices that enhance emotion regulation, design simulated patient encounters for direct practice and feedback, and emphasize the importance of de-escalation skills when designing how students are trained and evaluated on their real-world clinical rotations.
Returning to the patient’s friend above, the next time I received a call from him, I prepared myself with a paced breath. I was honest from the start about the time I had available, and set an alarm to help me stick to it. When my attempts to empathize with his concerns were met with increasingly intense accusations, I named this pattern out loud and gave him an opportunity to regroup. When he was unable to do so, I suggested we talk when he felt ready to listen and respond calmly; shared the next time a team member would be available; and ended our call. Not the ideal outcome, but with closer attention to my three B’s I was able to recognize the limits of what this friend could process in that moment and offer him a list of options for more effectively partnering with the team in the future. I see this as a big step forward.
How do you handle difficult patient interactions? Share your coping strategies in the comments.
Sarah Keltz is a resident psychiatrist in New York City. She enjoys gathering with friends over home cooked meals in the city, and escaping to the mountains by foot or by bicycle when she can. Dr. Keltz is a 2024–2025 Doximity Op-Med Fellow.
Illustration by April Brust
