Angry Medicine: Why Anger is a Healthcare Issue

Written by on August 1, 2014 in Insight - No comments

Angry-DocWEBWhile anger is a completely normal emotion, the way a doctor expresses it—as well as the intensity and frequency with which it erupts—can have a dramatic impact on several factors.

According to Vanderbilt University research, unprofessional behaviors are associated with everything from poor adherence to practice guidelines, loss of patients, low staff morale and turnover to medical errors, adverse outcomes and malpractice suits.

The Hidden Costs of Physician Anger

Another reason for concern about physicians with anger issues is that they’re putting a valuable asset (their own health) at risk:

  • In addition to being associated with habits that increase the likelihood of developing heart disease (including smoking, low levels of physical activity and excessive use of alcohol), anger also produces direct biological effects on the heart and arteries by triggering the release of adrenaline, cortisol and other stress hormones associated with the body’s ”fight or flight” response.
  • High levels of stress hormones contribute to cardiovascular disease in several ways.  Not only do they constrict blood vessels and boost blood pressure, they also enhance the clotting potential of the blood, increasing the likelihood that blockages will form in the heart’s arteries.
  • In a 10-year study of healthy veterans at Duke University, men who reported higher levels of anger, hostility and depression showed a steady increase in their levels of C3, a marker of the inflammatory process thought to contribute to the development and progression of heart disease.

What Causes Anger?

Anger is one of the most complex human emotions.  Many times anger is an appropriate response to a situational trigger—which can be expressed in either an appropriate or inappropriate manner.  Physiological changes associated with anger include elevated heart rate, blood pressure and adrenaline.

Some people anger more easily than others, some are born that way and some develop it over time.  There’s evidence that some children are born irritable and touchy and are perceived that way from an early age.  Family background can also play a role—people who are easily angered often come from families that are disruptive, chaotic and not skilled at emotional communications.

Common mental or behavioral health issues that may result in increased irritability or difficulty managing anger include:

  • Untreated depression or anxiety
  • Bipolar disorder
  • Chemical dependency
  • ADD or ADHD

Less common and more serious psychiatric disorders associated with anger include borderline, oppositional defiant or antisocial personality disorders, and schizophrenia.

In cases where anger is a manifestation of more serious underlying mental health issues such as depression, anxiety and personality styles, exploring opportunities for assessment and support is key in addressing these situations effectively.

Normal Versus Pathological Anger

Typically, “normal” anger and “pathological” anger are differentiated by a variety of factors and the relative degree to which those factors come into play, including:

  • Pervasiveness:  Is it a single, isolated incident or is there anger about a great many things and with a great many people?
  • Duration:  Is the anger over once expressed, or is there brooding after the fact about the person or event that triggered the anger?
  • Communication:  Is the anger expressed constructively or does it involve sarcasm, insults, threats or shouting?
  • Physicality:  Is there an attempt to physically intimidate or injure the person perceived as triggering the anger?  Are things thrown or broken in a rage?

“For the most part, anger disorders cannot be blamed on bad neurology, genes or biochemistry.  They arise from a failure to recognize and consciously address anger as it arises, before it becomes pathological and dangerous,” said Dr. Stephen A. Diamond, PhD in a 2009 article on anger disorders published in Psychology Today.

What Makes Physicians Angry?

With physicians, the most common “triggers” for anger include:

  • Getting behind schedule
  • Medical complications
  • Unexpected additions to the schedule
  • Nurses or other staff who are not as driven as they are — or who can’t seem to “read their minds”
  • Perceived obstacles to providing patient care — “hoops they have to jump through” to get treatments approved
  • Outdated or inefficient systems and processes
  • Charting in general, and electronic records in recent years
  • Uncooperative patients
  • Hurt or resentment over real or perceived slights

Regardless of the trigger, a doctor who responds with verbal or physical attacks has an anger management problem and so, by extension, does the organization employing him or her.

Change Contributes to Anger, Too

It’s hard to ignore that many doctors are angry, frustrated and apprehensive about the future of their medical practices.  In fact, the majority of the 2400 physicians who responded to a 2010 survey by Merritt Hawkins on behalf of The Physicians Foundation expressed fairly high levels of concern about healthcare reform, and subsequent studies have echoed those results.

Uncertainty about the future is adding stress to already stressful careers.  Many physicians are experiencing genuine emotional pain about the direction their careers are taking, perceived ingratitude and a diminished level of respect either for themselves specifically or physicians in general.  While many have turned to employment by health systems to eliminate at least some of this uncertainty, some challenges remain—and new ones have been added.

While physicians are typically more gifted than the general population at managing their emotional responses to extremely challenging work situations, the passage of the reform law after years of declining income and autonomy has resulted in a perfect storm of physician discontent and “organizational toxicity” in many healthcare settings.

Organizational Toxicity:
Healthcare Organizations Aren’t Immune

When the majority of physicians in a healthcare organization are experiencing widespread, intense and energy-sapping negative emotions at the same time, healthcare organizations may start to see their physicians distancing themselves from their patients, co-workers and the healthcare organizations who employ them.  Feeling that nobody cares about them, they’re less inclined to care about their work.

While administrators don’t have to agree or sympathize with all of their physicians’ concerns, it’s important to address the emotional overload before productivity and patient safety suffer.  The goal is not just to retain physicians, but also to keep them engaged and healthy.

Who’s Handling the Toxicity?
Don’t Overload Your Circuit Breakers

Despite training them to treat every conceivable disease during medical school, very little time is spent teaching physicians how to self-soothe or manage their anger.

Chances are most organizations have several physicians who not only lend a sympathetic ear to their colleagues, but are naturally inclined to see the positive side of an issue, e.g., “More people will have insurance and get care” than the negative “The newly insured will overwhelm our capacity.”  They enjoy practicing medicine and serve as a reminder to others why they entered the profession.  In leadership research by Peter J. Frost, PhD, they’re called “toxin handlers.”

In his book “Toxic Emotions at Work and What You Can Do About Them,” Frost delves into how toxin handlers alleviate organizational pain in a variety of ways.  In formal and informal meetings with individuals and groups, they:

  • Listen empathetically
  • Suggest solutions
  • Work behind the scenes to prevent pain
  • Carry the confidences shared by others
  • Reframe difficult messages

While toxin handlers often act as circuit breakers, over time and without organizational assistance they can be overwhelmed and develop toxic attitudes themselves.  That’s why it’s sometimes good for organizations to look externally for more resources.  Physician peer coaches can take on the role of circuit breakers—and also sidestep the collegiality and confidentiality concerns that some physicians might have regarding sharing their thoughts with someone that they might work with side by side in other contexts.

Preventive Medicine:
Relaxation Techniques and Practicing Self-Care

There are other steps that physicians can take to stop anger before it escalates into something toxic that affects their career and patient safety.

Even though making time for meditation and other relaxation techniques may seem like adding another item to an already overloaded to-do list, most physicians find the time they invest in self-care actually makes them more productive throughout the day.  Here are a few highly effective relaxation techniques:

  • Deep breathing engages the abdominal muscles.  Breathe in through your nose and let your abdomen expand fully.  Push in your abdomen to expel your breath.  Release your abdomen and let the air rush back in.

The belly, lower ribcage and lower back all expand on inhalation, drawing the diaphragm down deeper into the abdomen, and retract on exhalation, allowing the diaphragm to move fully upward toward the heart.

  • Progressive Calming:  Using the breathing technique described above, in a seated position or lying down, start at the top of your head and work your way down your body, concentrating on one part at the time and consciously let go of tension in your scalp, eyes, cheeks, chin, neck, shoulders, arms, chest, back, pelvis, hips, thighs, calves, ankles, feet and toes.
  • Guided Imagery & Meditation:  Using either a CD or your own imagery, imagine yourself in a favorite, peaceful place.  This is usually most effective if you begin with deep breathing or progressive calming and then let yourself go into a meditative state.
  • Group Meditation:  Joining or starting a meditation group ensures you’ll make time for meditation on a regular basis and actually sit still long enough (10 to 20 minutes) to experience some of the benefits.  Getting started is hard for almost everyone — you can often learn useful techniques from more experienced practitioners.

There’s no one right way to relax.  Find the method that works for you—and if that method stops working over time, try something new.

By Deb Wood, PhD, senior consultant, Physician Wellness Services (a division of Workplace Behavioral Solutions, Inc.), Minneapolis, MN.

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