It's 5:15 p.m. on a Friday as you enter the exam room to see your last patient of a very long and busy day. The appointment was scheduled for 4:45, but your office has been running behind because of an EHR problem and an employee who called in sick. Your child's soccer game starts at 6:00, so you're hoping this last visit will be quick. You skipped lunch to try to catch up, and you plan to finish your charting later tonight, if you have any energy left.

When you enter the exam room, you find Ms. Carter, a generally healthy, established patient in her 30s, sitting with her arms and ankles crossed. She won't look you in the eye. You take a deep breath and begin to apologize for running behind, even though it's not your fault. But she cuts you off: “I'm going to be late for a dinner date, so I just need you to write me a prescription,” she says.

You're taken aback, but try to reply calmly, “Well, let's see what the problem is, and I'm sure we can get you out of here in no time.”

You begin to ask about her symptoms, which suggest a urinary tract infection, but Ms. Carter is terse with her replies and insists again that she just needs a prescription. So, after several attempts to engage her, you give up.

“Fine,” you say, as you open the EHR and order the prescription, typing furiously. “You're all set.”

She quickly gathers her things and exits the room. Although she didn't thank you for helping her, you call out, “You're welcome! Have a great weekend.”

THE NEED FOR EMOTIONAL INTELLIGENCE IN MEDICINE

Most everyone has had an interaction at work that they regret, but for physicians the stakes and professional expectations are higher. Accepting partial responsibility for the health of another human being is a tremendous undertaking. As a physician, you see people at their emotional worst and most vulnerable, and you share space with people who have demanding jobs that do not always offer immediate results or rewards. You are often asked to do more work in less time and with fewer staff, and the work is becoming more demanding as the severity and prevalence of chronic disease continues to increase. It is challenging enough to do good work when you feel you are at your best. It is even more challenging when you are not in control of your emotions.

So how can physicians navigate tense and even hostile situations, transform their interactions, and achieve successful resolutions? The answer is emotional intelligence.

In his book Working With Emotional Intelligence, Daniel Goleman popularized the research on emotional intelligence, which he described as the ability to “recognize, understand, and manage your own emotions” and to “recognize, understand, and influence the emotions of others.” He coined the term “emotional hijacking” to describe situations in which the amygdala — the brain's emotional processing center — takes over your normal reasoning process.

You may recognize an emotional hijack by some trademarks of the experience: Have you ever frozen during a difficult conversation, and then hours or days later thought of a great response? Have you ever set out to say “no” to someone, but found yourself saying “yes” instead? Have you ever sworn that you wouldn't fall into previous patterns of interaction, only to find yourself squarely back in your old habits? When you are emotionally hijacked, you don't think things through. You don't make careful and thoughtful decisions. You respond by instinct, and the results are typically not ideal.

One of the things I find most fascinating about emotional hijacking is that when you are emotionally hijacked you tend to have less perspective and poorer judgment, while making more errors. At the same time, you feel more certain you are right. Let's review that again. You are in an emotional state in which you are likely to perceive the situation inaccurately, but you are certain you are right. That's not a winning combination.

Can you see how this might be relevant to your work as a healer? Have you faced an urgent medical situation and made decisions that seemed rash and foolish later? Have you seen patients who were so angry that they could not see clearly what was in their own best interest? Have you tried to give feedback to a team member who responded with defensiveness? Has a patient ever tried to tell you why your proposed treatment plan would not work, and you just didn't want to hear it? Have angry patients or family members caused you to think things about them that you later felt ashamed of? If so, you're not alone.

FIVE TOOLS TO BATTLE EMOTIONAL HIJACKS

There will always be times when we are not our best selves. There will always be emotional hijacks. There is no way to completely avoid these experiences. However, there are several things we can do to manage them and improve our responses. I refer to these tools as “YOur BAG” of tricks:

• Your feelings,

• Others' feelings,

• Breathe,

• Appreciate,

• Get curious.

1. Your feelings. The most powerful tool you have during an emotional hijack is awareness of your own feelings. This requires everyday mindfulness — the ability to recognize that you are in the midst of an emotional hijack, and therefore your assessment of the situation is likely to be overly negative or inaccurate, and your “gut” response is probably not trustworthy. Physical hallmarks of an emotional hijack are increased heart rate, shallow breathing, muscle tension, clenched jaw, and chest tightness. Mental hallmarks are thoughts that include the words “always,” “everyone,” “never,” “only,” and “these.” For example, “These residents are always complaining,” “I will never be able to please these demanding patients,” or “These administrators only care about money.” When you start thinking in absolutes and overgeneralizations, stop and take note of your feelings.

To process your feelings, you might need to step away from the situation. You can say to the other person, “I want to have the best possible conversation about this, but I am not in a place where I can do that right now. Could we talk about this later/in an hour/after I have a good night's sleep/after I am finished with my call weekend/after I take a quick break?” If you can't step away from the situation, at least pause, and then pay close attention to the words and tone you are using so that you avoid unnecessary defensiveness or hostility.

2. Others' feelings. Being emotionally intelligent provides another helpful tool in tense situations: awareness of other people's feelings, which in turn gives you the ability to influence their emotional reactions. Imagine that you are presenting your care plan to a patient who has a heart condition, and the patient's spouse is immediately critical of your plan because she has researched the condition online. She wants you to prescribe various supplements that her friend recommended.

Your immediate thoughts might be, “This person is angry” or “No wonder my patient has a heart condition.” You may feel defensive, given your experience and expertise, and the time and effort you have put into the patient's treatment plan. None of these thoughts is the beginning of a productive conversation. I often remind health professionals that anger is fear in disguise. If you look at the patient's spouse and see an angry person, you will become defensive and want to prove you are right. If you look at her and see a woman who is terrified and trying to do everything she can to help her husband, you will feel empathetic and compassionate. This is the start of an excellent conversation.

In a tense situation with co-workers, being aware of their feelings might reveal fears that, although they are working hard and want the best outcomes for patients, they don't feel they can succeed. It might reveal that individuals' life circumstances are distracting them from work. They might feel intimidated by you or hear your “constructive criticism” of their work as criticism of their ability, character, or work ethic. Just as you may need to ask for time to recover from a hijacked state, be generous in offering that time to others when you recognize they may be feeling hijacked. Encourage them to take a walk or step away from the situation. Give them time to recover, and when they are ready, you can engage in a more productive conversation.

3. Breathe. This is a particularly useful tool if you cannot step away from a situation. The amazing thing about a deep, relaxing breath is that it signals to the brain that everything is OK. You can be surrounded by chaos, but if your breath is steady, your body does not respond with the typical stress hormones.

There are two key qualities of a good breath: First, your inhale should be deep enough to allow the belly to rise, and your exhale should allow the belly to fall. This deep abdominal breath is much more effective than the shallow chest respirations most of us survive on unconsciously. Second, your exhales should be longer than your inhales. Ideally, they should be twice as long. This technique initiates a relaxation response in the body that can de-escalate emotional hijacks.

4. Appreciate. During times of stress, take a moment to think about some of the good things in your work and life, instead of allowing yourself to be swept up in what's wrong. Think about a person, place, or thing you appreciate on a deeply emotional level. It could be a relative, a friend, your pet, your family cabin, the beach, your bed, or a favorite dessert. It doesn't really matter, as long as the thought of it brings you a lot of happiness. Take a moment to experience that person, place, or thing in your mind. How does it look, feel, smell, and sound? This is your secret weapon against emotional hijacks.

The amygdala is a terrible multitasker. It prefers to process one strong emotion at a time. This means it is very difficult to think about how much you appreciate eating ice cream on the beach in Mexico while also being angry with the person in front of you. Next time you feel emotionally hijacked, try to call to mind the thing you appreciate. No one has to know what you are doing, but the mind is a powerful tool, and these emotional connections can quickly bring you back to a more reasonable and effective state.

5. Get curious. Everyone has good reasons — or what they perceive to be good reasons — for doing the things they do. Most people don't do and say things purely to make your life difficult. Their actions may have that result at times, but it is rarely intentional. In social psychology, fundamental attribution error is the tendency to attribute others' behavior to personality traits instead of social and environmental factors. For example, if someone avoids eye contact with you, you might perceive that the person is being disrespectful or dishonest. However, the real explanation might be that, in that person's culture, it is considered rude to look directly at an elder or someone you respect. You can see how fundamental attribution error can lead to misunderstandings.

Similarly, if a patient says he takes his hypertension medication only when he feels that his blood pressure might be elevated, you may become frustrated and consider the patient naive, lazy, or noncom-pliant. A better approach is to get curious and ask the patient a few more questions about what else might be going on. You might discover that he misunderstood the proper use of the medication, watched a talk show recently where they discussed the risks associated with these kinds of medications, is interpreting unpleasant symptoms as a side effect of the medication, or is not doing well financially and is trying to make the medication last longer. Getting curious about a patient's behavior can help you resolve the actual problem, rather than leaving an encounter feeling frustrated and ineffective.

Here are some useful questions to ask in these situations:

• What else could it be?

• What could the other person's goal be?

• What fears or misunderstandings might be guiding this person?

• Did the person misunderstand or mis-interpret something I said or did?

• What goals do we have in common, and how can I use those common goals to improve this interaction?

A WORD ON SELF-CARE

Practicing each of these skills requires a certain level of mindfulness and emotional discipline. You have to recognize when you are in an emotional hijack and choose to act against what your instincts may be telling you. It requires mental energy to pull yourself out of anger and frustration, and positive self-care makes that easier. This includes getting a reasonable amount of sleep, fueling your body and mind with healthy foods, practicing relaxation in less emotionally charged times (through breathing, yoga, meditation, etc.), and allowing yourself some downtime to disconnect from work and other demands. It also includes working in an environment that is supportive and makes you feel valued, and allows you some autonomy and control over your work life.

As health care professionals, the work we do can be stressful and demanding. We guide people through some of the most vulnerable and terrifying times of their lives. Rarely can we control the number of patients we see, the overwhelming documentation, the multiple comorbidities, or the administrative demands. What we can control is how we treat ourselves and how we treat others. The tools described in this article can help you improve your interactions and transform your work environment to one that is fueled by compassion and understanding. This is the kind of practice we all deserve.