Angry Encounters Can Adversely Affect Clinical Decision-Making
A patient screams and spits at the EP and ED nurse who are trying to determine if a life-threatening emergency exists. Another patient is extremely grateful, cooperative, and respectful. Assuming both patients presented with the exact same clinical situation, would ED providers treat them any differently? The authors of two recent studies examined this interesting question.
Researchers studied how emotional patient encounters affect clinical decision-making in the ED. In the first study, researchers asked 94 ED providers (50 EPs, 44 ED nurses) to write about three patient encounters: one that caused anger, irritation, or frustration; one that led to appreciation, happiness, or satisfaction; and one that involved a patient with a mental health condition.1
ED providers said their emotions affected clinical decision-making most often during angry situations (e.g., patients displaying manipulative or abusive behavior, poor self-care, or frequent ED use). Emotions during mental health and angry situations were connected to more perceived risk to patient safety. In contrast, ED visits eliciting positive emotions were associated with perceived better care quality.
In a second study, researchers conducted in-person interviews (averaging about one hour in length) with 45 EPs and 41 nurses from four academic medical centers and four community hospitals.2 ED providers indicated they were aware negative emotions could adversely affect their clinical decision-making. Many described specific ways they regulated their emotions, such as distraction, suppression, and cognitive reappraisal.
“They believed that they employ strategies that can effectively mitigate risk. But in the heat of the moment, they might still make poor judgments,” says Linda M. Isbell, PhD, lead author of both studies.
In fact, in the first study, more than 75% of EPs acknowledged they had done something that could have adversely affected at least one of the patient encounters they described because of an emotional response to that patient. ED providers acknowledged spending less time with the patient, acting less compassionately, and failing to provide a necessary exam or treatment. Survey participants offered these specific examples:
- An EP said it was possible that a full history and physical exam had not been obtained because of anger at the patient;
- An ED nurse described feeling “overcome with anger” and not wanting the patient to be seen;
- An EP recounted feeling angry at a patient and that he had “probably prematurely closed my thoughts to them having anything bad”;
- An EP stated if patients are verbally abusive and manipulative, that she “tends to not go any length to provide them with extra services, consults, etc.”
On the other hand, positive emotions affected patient care beneficially. Providers spent more time with the patient and provided extra testing, consultation, or treatment. One ED nurse put it this way: “Since she was so pleasant and appreciative of everything I did for her, I was happy to enter the room to help her.” An EP said, “In that the patient was a very kind, articulate person, I may have been more motivated to go the extra mile to make the correct diagnosis.” As a social psychologist, Isbell researches how emotions affect decision-making. The Institute of Medicine’s To Err is Human: Building a Safer Health System motivated her to consider this in a medical context.3
At first, Isbell was mainly focused on identifying disparities that put patients with mental health conditions at risk in the ED. After spending time with ED providers, her perspective evolved.
“I realized that the ED is a very difficult work environment, where people’s needs far outweigh the resources that are available. It is where all societal problems end up,” says Isbell, professor of psychology at the University of Massachusetts.
Most EPs truly appreciated the chance to explain to someone outside the healthcare field what they deal with daily. Participants displayed empathy, care, and concern. Some became emotional as they spoke about how their own negative emotions could have played a part in a patient’s poor outcome. To encourage candor, Isbell and colleagues emphasized confidentiality would be strictly respected, and that cases would be de-identified.
“These results would probably be shocking to anyone who doesn’t work in an ED, but would not surprise any ED provider,” Isbell offers.
One problem is EPs’ emotions, and the adverse effect on patient care, are unlikely to be aired during root cause analyses or morbidity and mortality conferences. “It’s really hard for an EP to say, ‘I was really angry at the patient. That’s why I discharged them early,’” Isbell notes.
Peers and administrators are likely to be unsympathetic to a statement like that. EPs also are concerned such a statement could be used against them in malpractice litigation. “From a liability perspective, that kind of admission is really bad. The attorney can say, ‘What’s wrong with your physicians? They can’t control their anger?’” Isbell suggests.
Recently, Isbell showed 82 EPs a video of an actor playing the role of an ED patient interacting with a physician while giving a medical history. Some videos included patient behaviors Isbell found to produce frustration and anger in EPs (e.g., making demands, insulting remarks, and using profanity), while other videos did not include these behaviors.
Preliminary data show EPs who saw the anger-inducing behavior did not trust the patient as much as the EPs who saw the other videos. “This has important clinical implications. It means that physicians might discount part of the history provided by the patient, which may lead to medical errors,” Isbell cautions.
Isbell says possible solutions are pop-up warnings in EHRs for patients identified as high-risk for emotional encounters, such as patients with mental health conditions and substance use disorders. EPs also could use cognitive interventions to remind themselves to process information more carefully if they feel their emotions are affecting their decision-making.
Emotions during ED encounters “are not all bad,” according to Isbell. “A long history of research demonstrates that emotions are highly adaptive and often lead us to make good decisions,” she says.
For example, the anxiety an EP feels when discharging a patient can trigger a re-evaluation on whether it might be a safer, better idea to observe the patient in the ED for a few additional hours. Isbell says it is not realistic — or even desirable — for ED providers to expect medical decision-making to be devoid of emotion.
A better, more realistic approach is to simply acknowledge emotions do play a factor. “Open communication about emotions could promote better outcomes. It could also have a downstream effect on the legal situations that emerge,” Isbell says.
Andrew Lawson, MD, FACEP, says, “any stressful encounter, angry or otherwise, has a direct effect on our decision-making in the ED.”
During an angry patient encounter, an EP’s brain functioning has been “hijacked and shut down by our primitive, survival brain functioning. With this shutdown, our decision-making suffers,” says Lawson, says director of patient satisfaction and service recovery for the ED group at Mission Hospital Mission Viejo (CA).
Lawson recommends EPs perform breathing exercises whenever they recognize they are reacting angrily to a patient. “This moves our primitive brain from ‘fight or flight’ mode to ‘rest and digest’ mode,” Lawson says. “Elite military teams such as the Navy SEALs use tactical and box breathing methods while in combat.”4
Lawson uses both methods before a stressful patient encounter, during the encounter, and afterward. “It is an easy exercise to ‘hide’ from staff and patients that you are actually doing it,” Lawson adds. “But it provides immediate calming of your body’s stress response.”
REFERENCES
- Isbell LM, Tager J, Beals K, Liu G. Emotionally evocative patients in the emergency department: A mixed methods investigation of providers’ reported emotions and implications for patient safety. BMJ Qual Saf 2020;29:1-2.
- Isbell LM, Boudreaux ED, Chimowitz H, et al. What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care. BMJ Qual Saf 2020;29:1-2.
- Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. PMID: 25077248.
- Nazish N. How to de-stress in 5 minutes or less, according to a Navy SEAL. Forbes. May 30, 2019.
A patient screams and spits at the emergency physician and nurse who are trying to determine if a life-threatening emergency exists. Another patient is extremely grateful, cooperative, and respectful. Assuming both patients presented with the exact same clinical situation, would ED providers treat them any differently? The authors of two recent studies examined this interesting question.
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