乌鸦传媒

Last week, I visited the American Museum of Natural History in New York with my kids. As I stared at one particular giant dinosaur, I thought to myself, "Hey, that's me!"

Indeed, the magnificent skeleton reminded me of a very important skill that I have honed in my years as an emergency department (ED) doctor: conflict resolution.

What kind of dinosaur was I looking at? And what exactly do dinosaurs have to do with keeping the peace in an ED? Funny you should ask...

Before we get there, let's talk about why EDs are hotbeds for conflict.

EDs Are Stressful Places. Tempers Flare.

Nobody wants to be a patient in the ED. It's stressful and often inefficient. People become increasingly impatient.

There are many coping strategies for dealing with the stress of being an ED patient. Some patients are outwardly scared. Others hide their feelings with silence, or by being over-the-top polite. There's no one "right" way.

There are some suboptimal ones, though. Some people express their fears and impatience by becoming agitated and angry, even resorting to verbal or even physical aggression.

While verbal or physical abuse towards healthcare workers is never acceptable, I have come to understand that aggressive behaviors stem from patients' discomfort with being in situations where they lack control. Confrontational behavior can be an attempt to reassert agency.

Ignoring this does not work. So, I have some go-to strategies for de-escalating tense situations with angry and even potentially dangerous patients. I've found these techniques highly effective.

We Train for This. Kind of.

Every year, all clinicians at my hospital are required to do online trainings covering a variety of topics, from infection control to unconscious bias. Some of the modules are more helpful than others. Over time the tasks have become less painful.

The training module that has helped me the most covered conflict resolution, especially involving angry patients. I often find myself applying some of the pointers. When a patient becomes angry or agitated, there are some things that I can do to de-escalate. Here are some of the pointers I have found useful:

• Posture/position. When a patient is standing up and yelling or saying something threatening, I position my body at an angle to them. Rather than looking like we are about to square off, angling my body to around 45° with respect to the patient's torso looks less confrontational.
• Avoid eye contact. Normally, eye contact is a good thing. But in a heated confrontation, I spend most of my time looking downwards. I'll aim my gaze (and face), a couple of feet to the side of the patient, occasionally looking up to make sure they know I am listening. Eye contact should be intermittent and brief.
• Allow lots of silence. After a patient finishes speaking, I do not immediately respond. I wait a few seconds. This slows down the pace of the interaction. Time is our friend. More is better. Over time, emotions simmer.
• Lots of nodding. If the patient is saying something I don't like, but is not patently offensive, I'll nod my head a bunch as they speak. That's my way of saying, "I'm listening. I hear you. I get it." If the patient is saying something genuinely offensive, I may nod a bit less. Stopping nodding along is akin to me shaking my head no in disagreement, but it's less overt.
• When all else fails, show of force. Sometimes none of this works. At that point, if I am concerned for the safety of others in the area, I'll reverse some of these tactics. When that happens, it's usually headed towards a situation in which I have regrettably concluded that temporary restraint will be needed, both to protect the patient and others.

But Wait, Weren't We Talking About Dinosaurs?

So, what dinosaur was I looking at that reminded me of conflict resolution? A Brontosaurus. (Apparently they are .)

It reminded me of a life-changing article I once read in Slate (where I was a regular contributor for years).

Folks, may I introduce you to "The Kindly Brontosaurus."

I love , and have for over a decade. The upshot is this: when you want something, don't make the mistake of being pushy. People think that others bend when they sense entitlement from another person. . This often leads to push back -- territory protection.

Instead, try the "Kindly Brontosaurus" posture. This "pose" -- unlike the "power pose" -- can help you get whatever you want. At least that's how the lore goes (and my personal experience aligns). Here's how Slate's Jessica Winter describes it, as applied to the task of getting a seat on a plane.

"You must stand quietly and lean forward slightly, hands loosely clasped in a faintly prayerful arrangement. You will be in the gate agent's peripheral vision -- close enough that he can't escape your presence, not so close that you're crowding him -- but you must keep your eyes fixed placidly on the agent's face at all times. Assemble your features in an understanding, even beatific expression. Do not speak unless asked a question. Whenever the gate agent says anything, whether to you or other would-be passengers, you must nod empathically." -- Jessica Winter, Slate.

I use this all the time in the ED, but not quite for conflict resolution/de-escalation. I use it when I am trying to change a patient's mind, turning an adversarial moment into one of alliance.

A classic example is patients who wish to leave against medical advice (AMA). Any patient who has the cognitive capacity to weigh the risks and benefits of a medical choice can leave whenever they want to (unless there is some other legal situation.) Frequently, I'll admit a patient to the hospital, only to find out a few minutes later that they want to leave AMA. In many cases, I have a brief conversation (and document it in the chart) and they leave. But sometimes, I feel very strongly that the patient would be much better served (i.e., far safer) by staying. I can't prevent them from leaving. But I can deploy the Kindly Brontosaurus. And it works remarkably well.

A Teachable Skill

A couple years ago, I was working with an excellent senior resident in the ED. She was close to graduation. While I always have something to teach even the senior residents, I often focus on things they won't learn elsewhere. Less medical trivia, more "soft skills." On this day, the senior resident knew what a certain patient needed, medically. But she couldn't get the patient to stay. The patient was about to leave AMA. I was worried. So, I decided to see if my luck would be better. I went over to the room and spoke with the patient. At first, I got the same response the resident had. But then I remembered the Kindly Brontosaurus. I could feel the tide turning. I slowly and gently rocked up and down, head slightly bowed, hands together, looking up towards them from my "KB" posture. It was working. I kept it gently rocking. By the time the conversation was nearing its completion, I probably looked like a Hasidic Jewish guy praying in synagogue. Whatever. It worked. When I told the resident that I'd convinced the patient to stay, she looked at me like I was some kind of wizard. I let her in on my secret weapon strategy.

For some time after that, this resident would tell me when she'd successfully employed the Kindly Brontosaurus to help navigate some difficult conversation with a patient. I couldn't be prouder.

In medicine, knowing what to do gets easier with time and experience. Getting those things to actually happen, though, is an entirely different skill. The Brontosaurus may be extinct. Heck, it isn't even a Brontosaurus anymore; it's an Apatosaurus.

But its memory lives on...and may even save a life now and then!

What are your tricks of the trade for de-escalation...or just getting what you want? Please share your thoughts in the comments section.

This post originally appeared in .

Comment