When attempting to de-escalate tense situations, surgeons and other staff should maintain a calm tone and use respectful and clear language, while setting boundaries and avoiding power struggles.
Explore This Issue
April 2026Dr. Carter suggested telling the patient that you will not tolerate the behavior and may have to end the visit. “Involve office management and security early in an escalating interaction. Ask to take a break from the clinic visit so that they can calm themselves.”
Dr. Pandian, who highlighted the need for listening actively, offering validation without reinforcing harmful behavior, and offering choices when appropriate, suggested that it is important to recognize when de-escalation is no longer effective and to promptly shift to safety protocols.
A useful conceptual framework comes from Never Split the Difference, a book by Chris Voss, a former FBI hostage negotiator, Dr. Brenner said. “The book emphasizes tactical empathy, labeling emotions, and finding common ground to prevent escalation (https://www.blackswanltd.com/never-split-the-difference). That said, surgeons do not receive training in these areas, and the threshold for calling security is low. De-escalating potentially volatile situations should be done by professionals with these specialized skills.”
Duty and Ethics
Duty to treat exists within ethical and practical boundaries. “When personal or staff safety is threatened, the obligation shifts toward risk mitigation and alternative care arrangements,” Dr. Brenner explained. “This is not a failure of professionalism but an affirmation that safe systems are essential for ethical medical practice. Usually, the threat of violence can be defused and the duty to treat addressed under calmer and safer conditions.”
“Ethical guidance supports terminating a physician–patient relationship when behavior becomes threatening, if termination is conducted with appropriate notice, documentation, and assistance in identifying alternative care. Boundary setting is an expression of respect, not rejection, and helps ensure safety for everyone involved,” he added.
Physicians should never risk their own safety, but ethically, they should help the patient find another person to care for their condition. “However, this needs to be done in conjunction with law enforcement if physical violence has been threatened, because the next provider should not be placed at risk either,” Dr. Carter said, adding that involvement from patient advocacy may be necessary, as may referral for psychiatric care.
Dr. Wei noted that every hospital and their legal team has a policy that defines criteria to terminate a patient from the practice. “This is important to discuss and review; such decisions should not be made lightly, particularly when the patient is not at fault.”
A marvelous review with excellent suggestions.
To relate a brief episode: I was the only ENT in my county. We were 150 Miles N of Portland Maine with no oral surgeons (although I had been doing all the fractured jaws for years). We had a patient on whom I was very familiar, having done a mastoidectomy on him several years previously. He was in the ER having suffered a (well deserved) fractured jaw. He was yelling at the nurses and grossly threatening. I stepped in and having reviewed his Xrays demonstrating a simple jaw fracture. I met with him, rubbing my jaw and explaining that his fracsture was QUITE SEVERE and WAY BEYOND MY EXPERTISE!! (which it was not). So instead of referring him to the oral surgeons 45 miles South, there was no way that I would send him to some of my friends, So I sent him the the EXPERTS in PORTLAND, MAINE 120 miles south. So thus he could have all the expertiese of the residents on call.