• Opinion

    Incivility in the Clinic

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    Ruth D. Williams, MD

    By Ruth D. Williams, MD, Chief Medical Editor, EyeNet

    I accelerated out of a red light a bit slowly last month, and the driver behind me erupted into erratic behavior in frustration. He honked, pulled up beside me, and nearly crashed into another car while gesticulating with his arms. His reaction was completely out of proportion to my crime. The AAA Foundation for Traffic Safety surveyed 2,705 licensed drivers, and 51% reported purposefully tailgating another vehicle, 47% reported honking the horn to express anger, and 33% reported yelling at another driver during the previous year.1 Two out of 3 of the drivers queried believe that road rage is a bigger problem today than it was 3 years ago.

    In its annual nationwide survey Civility in America, the global communications firm Weber Shandwick documents an increasing concern among Americans about incivility in our culture.2 The survey attributes this shift to the internet and social media and to the political milieu.

    Is aggressive behavior also becoming more common among our patients? Several ophthalmology colleagues have noted an increase in patients acting in a toxic manner. At my own institution this year, employees engaged the police to assist with a patient whose behavior was escalating.

    Although many ophthalmologists would agree that inappropriate patient behavior has become more common in recent years, little documentation exists. We do know, however, that health care workers are at increased risk of workplace violence compared with workers in other sectors. The Occupational Safety and Health Administration reports that incidents of serious workplace violence are 4 times more common in health care than in private industry on average.3

    Some disruptive behaviors are related to mental illness, substance abuse, and dementia, and they can be expected in health care settings. The increase, however, might be attribut­ed to burgeoning frustration with the health care system. For example, many patients have high deductibles and may not want to—or may not be able to—pay the large out-of-pocket fees that are now required. Patients may use confrontation as a negotiating tool when trying to avoid payment, or they may simply be extremely anxious when they cannot afford their care. Furthermore, patients with large out-of-pocket costs, who are paying cash up front, may have higher expectations regarding wait times, inefficiencies, and outcomes, and they may not hesitate to express dissatisfaction.

    What to do about this growing problem? First, verbal and physical aggression must not be tolerated. The safety and comfort of patients and staff are paramount. Second, enforcing high standards for respect toward our staff is critical. Workplace morale can be negatively affected if patients treat staff poorly. Managers must clearly define what behavior is not allowed—for ex­ample, any patient who curses at staff will be told to leave if such language is repeated.

    Third, staff can be taught de-escalation techniques. We invited a social worker from the county health department to train our managers. She taught techniques for effective verbal and nonverbal communi­cation. It was helpful to learn that only 1 person should verbally engage with an agitated patient, repetition of a simple message can be effective, and nonjudgmental listening is essential.

    To physicians who are overloaded—from dealing with preauthorization requirements, postpayment audits, opaque insurance ben­efits, large deductibles, MIPS reporting, Human Resources reporting requirements, and more—it may seem like yet an­other burden to suggest that we and our employees be trained in de-escalation techniques. Yet the skills required to work with agitated patients are necessary to maintain a calm, safe workplace and worth the effort required. And maybe our employees can use nonverbal de-escalation techniques to deal with road rage encountered on the drive home.


    1 www.aaafoundation.org/prevalence-self-reported-aggressive-driving-behavior-united-states-2014.

    2 www.webershandwick.com/news/article/civility-in-america-2016-us-facing-a-civility-crisis.

    3 www.osha.gov/Publications/OSHA3826.pdf.