First year medical intern Kgothatso Legong explores the importance of managing difficult conversations in all clinical settings - when emotions run high.
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Recently I was in Accident and Emergency department when a family member of a patient was frustrated with the health care services his family member was receiving from the hospital. I thought it to be vital for all clinicians to equip themselves with the necessary skills to calm the situation in such kinds of settings.
Difficult consultations are an inevitable part of medical practice. They may arise in outpatient clinics, consultation rooms, or high-pressure environments such as Accident and Emergency (A&E) departments. These encounters often involve heightened emotions, unmet expectations, fear, grief, anger, or mistrust from patients and their family members. De-escalation is therefore a core clinical skill that every medical doctor and medical student must develop to ensure patient safety, effective communication, and professional integrity.
A difficult consultation is not defined solely by aggressive behaviour. It may include a distressed relative demanding immediate answers, a patient refusing care, a family questioning clinical decisions, or an emotionally charged discussion around prognosis or death. In emergency settings, the combination of time pressure, overcrowding, pain, and uncertainty can easily escalate tensions. Without effective de-escalation, such situations may progress to verbal abuse, threats, or even physical violence, compromising both patient care and staff wellbeing.
De-escalation refers to a set of communication and behavioural strategies aimed at reducing emotional intensity and preventing conflict from escalating. The foundation of de-escalation is emotional self-regulation. A clinician who remains calm, composed, and respectful sets the tone for the interaction. Reacting defensively or dismissively may reinforce hostility. Maintaining a neutral posture, open body language, and appropriate eye contact helps convey attentiveness and respect, even in tense situations.
Active listening is central to successful de-escalation. Patients and relatives often escalate when they feel unheard or invalidated. Allowing them to speak without interruption, acknowledging their emotions, and summarising their concerns can significantly reduce distress. Simple statements such as, “I can see that you’re very worried,” or “I understand this is frustrating,” do not imply agreement but demonstrate empathy. Validation of emotions helps shift the interaction from confrontation to collaboration.
Clear, honest, and structured communication is equally important. Medical jargon, vague explanations, or rushed answers can worsen anxiety. Information should be delivered in simple language, with pauses to allow questions. In emergency settings, where outcomes may be uncertain, it is better to acknowledge uncertainty than to provide false reassurance. Transparency builds trust and reduces suspicion, which is often a driver of conflict.
Setting boundaries is a critical but often overlooked component of de-escalation. Empathy does not require tolerating abusive behaviour. Calmly stating acceptable behaviour—for example, “I want to help you, but I cannot do so while being shouted at”—protects both the clinician and the therapeutic relationship. In A&E, early involvement of senior staff, nursing colleagues, or security may be necessary if safety is at risk. Seeking help should be viewed as good clinical judgment, not failure.
Cultural sensitivity also plays an important role in difficult consultations. Differences in language, health beliefs, and expectations of care can contribute to misunderstanding. Where possible, interpreters should be used, and assumptions avoided. Respect for cultural and family dynamics can prevent unnecessary escalation.
For medical students, observing experienced clinicians handle difficult consultations provides invaluable learning. Reflection after such encounters helps identify what strategies were effective and where improvement is needed. Institutions should actively teach de-escalation skills, recognising them as essential clinical competencies rather than optional “soft skills.”
In conclusion, de-escalation is a vital skill in managing difficult consultations across all clinical settings. By combining emotional awareness, active listening, clear communication, boundary setting, and teamwork, medical professionals can transform potentially volatile encounters into constructive interactions. Effective de-escalation not only improves patient and family satisfaction but also enhances safety, professionalism, and the quality of care delivered.
Kgothatso Legong – First year medical intern.
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