Brian has been a difficult patient from the outset of his treatment. He is the son of 2 busy attorneys, who appear to prioritize their careers over family obligations. An ambivalent 13-year-old, Brian has displaced multiple brackets since he began comprehensive correction almost 3 years ago. You’ve met repeatedly with his father to discuss the need for more prudent eating habits and to request that he refrain from chewing on pencils. Another problem is his home care. Apparently, it doesn’t exist. His teeth, as well as the loose brackets that dangle on the distorted archwires, are coated with a biofilm that is as dense as cottage cheese. And now his visit frequency is becoming increasingly erratic.

This morning, Brian’s mother has brought him to the appointment, and your assessment shows that his status remains unchanged. He is the first patient of the day, and you perceive this as a chance to rediscuss the issues that are delaying his treatment, as well as an opportunity to avoid maleficence. You begin by reviewing photos of inflamed gingival tissues and decalcified teeth and mention his irregular visit frequency. Brian’s mother curtly interrupts you. She tells you that his absence is your staff’s fault because they never contacted her to reappoint Brian after his last appointment. She contends that she cannot be considered responsible for his appointment scheduling because Brian best knows his own after-school activity schedule. Her voice begins to intensify as she irately reminds you that you are the doctor, and therefore you, not her, are responsible for his oral hygiene. Reaching a heated crescendo, she tells you that he is always careful when eating, and she therefore demands to know “why the braces keep falling off.” Finally, she concludes her diatribe by stating, “This is his show. He’s now old enough to run it himself!”

You are attempting to prevent damage to Brian’s dentition, but obviously his parent’s interpretation of your good intention is channeled as anger toward you and your staff. She rejects any responsibility for his predicament and, worse, has identified you as the focus of his shortcomings.

Psychologists tell us that anger is a natural defense that is precipitated by an internal desire to avoid emotional injury. Anger is rarely an emotion unto itself but, rather, is initiated by fear of guilt, insignificance, uselessness, rejection, and more. Anger is also a defense against vulnerability. Similar to all psychological defenses, anger insulates us from anxiety, distress, and humiliation potentially caused by the realization that we have failed in some capacity. Often, angry people have no understanding that the genesis of their behavior is self-preservation. And when coupled with the distraction and additional burdens of juggling a successful career with parenting, there is an increased need to protect vulnerability.

When a person perceives that he or she has failed, a common reaction is to retaliate by identifying a reason to counterattack the accuser. Brian’s mother blames your staff for failing to appoint him in a timely way, thus diverting her responsibility for his irregularity in continuing care. She holds you culpable for Brian’s inadequate home care and bracket failures. Rather than directly assuming responsibility herself or by failing to engage Brian in developing a solution, she uses anger as a defense to repel her own guilt and her son’s ambivalence. Your immediate inclination is to retaliate with your own anger in defense of her assault. If you do so, a perfect storm for confrontation has developed.

Ultimately, anger rarely resolves conflict. It often leads to escalating protective emotions that might supersede a simple exchange of words—and a viable solution—in the operatory. This can be especially dangerous when 1 combatant is a prominent attorney.

It is critical to not only avoid escalation to a verbal slugfest, but also understand the etiology of situational anger and resolve its cause before it becomes mutually destructive. In our specialty, sometimes that means parting amicably—even if Brian’s mom finds another source of care—and even if it means a refund is in order.