The angry portal message arrives at 9:47 PM. The clinician is home, maybe halfway through dinner, and there it is: A patient who was pleasant enough in the exam room that afternoon, now typing things they would never say to anyone’s face.

Brian Clark, BSN, certified registered nurse anesthetist who spent more than 15 years working in cardiac environments before founding United Medical Education, an online resource for emergency medical certification, has watched this pattern play out too many times to count.

“People sit behind their screens and type things they would never dare say in a doctor’s office while sitting in a chair,” Clark says. He calls what follows — the mental replay, the ambient irritation, the subtle shift in how you walk into the next patient encounter — a slow leak. “Eventually,” he says, “the clinician is running on empty.”

This part of the job rarely makes the news. Not the dramatic blow-ups or the physical threats, but the steady accumulation of side-eye and blame, passive-aggressive comments, and hostile digital missives that wear on clinicians the way water wears on stone. It’s quieter than violence. It’s also, for most healthcare workers, far more common.

Surveys tracking workplace incivility over the past two decades suggest a substantial increase in reported rude behavior. And healthcare is no exception. A 2024 meta-analysis published in the Journal of Advanced Nursing found that one in four healthcare providers directly experiences workplace incivility, and nearly 1 in 3 have witnessed it.

And the damage isn’t just hurt feelings. Teams exposed to rude patients performed worse across every measure researchers tracked — rather important ones, too — including how accurately they diagnosed, how well they communicated, and how freely they shared information, according to a University of Florida study.

Rudeness, it turns out, isn’t just an unpleasant experience. It’s a clinical variable.

The Corrosiveness of ‘Secondary Disregard’

None of this surprises Nick Bach, PsyD, a clinical psychologist who works specifically with medical professionals dealing with this kind of chronic low-grade friction. “A single confrontation triggers an acute stress response that eventually resolves,” he explains. “But repeated low-level disrespect creates a sustained stress load. It keeps clinicians in a low-grade state of vigilance, which is neurologically and emotionally exhausting.”

The insidious part, he adds, is the mismatch between the actual harm and the perceived legitimacy of complaining about it. “It doesn’t feel dramatic enough to warrant formal intervention,” he says, “yet it accumulates in ways that are psychologically corrosive.”

The first signs tend to be internal. “Clinicians may notice lingering irritation after work, increased emotional reactivity to minor comments, or a subtle sense of dread when opening the patient portal,” Bach says. “There may also be cognitive changes — more self-doubt, second-guessing decisions, or interpreting neutral messages more defensively.”

Psychiatric nurse practitioner Shebna Osanmoh has a name for the cumulative weight of it: “Secondary Disregard.” “It is the mental weight of being treated like a vending machine instead of a person,” he says. “You stop seeing a person who needs help and start seeing a problem you have to deal with. That’s how the best nurses and doctors lose their spark.”

Welcome to the Impatient Portal

The patient portal has added an entirely new dimension to the problem, one that doesn’t clock out when the clinician does.

Those hostile messages arrive on personal phones or home computers. Without eye contact, tone of voice, or physical presence, patients lose the social feedback that keeps most of us civil. “The computer eliminates the social cues that remind us we are talking to another human being,” Clark says.

Annegret Friederike Hannawa, president of the European Institute for Safe Communication, a healthcare communication research center in Lugano, Switzerland, isn’t so sure patients are simply meaner online than in person. The real problem, she argues, is what the digital environment takes away.

“In direct face-to-face interaction, communication helps us regulate each other’s emotions,” she says. “Tone, pacing, facial expression, immediacy, and responsiveness all contribute to a process that moves us toward shared understanding. When strong emotions arise, those emotions may travel into written language without the moderating effect of one another’s communicative presence.” 

And then there are those that are geographically online but unquestionably in-your-face. Carolyn Keyes, PA-C, physician assistant in endocrinology, wrote about a patient portal interaction that included the screaming-caps subject line, “I HATE MY ENDOCRINOLOGIST.”

Indeed, Bach adds that written messages compound the problem by feeling permanent. “Clinicians may reread them, mentally replay them, or worry about how they’re documented,” he says. “Because the hostility is visible and archived, it can linger longer in memory compared to a tense but transient in-person exchange.”

Michael Chichak, MD, general practitioner with over a decade in primary care, urgent care, and mental health settings, puts it in terms any clinician will recognize: “There are months,” he says, “where I felt like a customer service representative rather than a doctor.”

He’s found one counterintuitive tool that helps: the nonresponse. “When angry portal messages are not given emotional fuel but are simply clear and clinical responses, the tone will often change with time,” he says. The goal isn’t to match the patient’s emotional register — it’s to quietly refuse to participate in it.

Is the Customer Always Right?

Sarah Doyle, DPT, physical therapist who worked 6 years in hospital critical care settings, watched the dynamic shift when patient satisfaction surveys became a central institutional metric. Administrators would walk the floors with clipboards, she recalls, measuring patient experience in real time.

“It was as if coddling the patient, catering towards their volatile emotions, was more important than giving the best clinical care,” she says.

In her work in critical care, where patients must comply with physical therapists to avoid falls and adverse events during mobilization, the stakes were not abstract. “Patients would argue with me in the middle of a transfer where they were physically dependent on my support,” she says. “It was a huge safety risk, but I was forced to coddle them.”

The institutional incentive structure Doyle describes is real and financially significant. Under the federal Hospital Value-Based Purchasing program, HCAHPS patient satisfaction scores made up 25% of a hospital’s overall score for fiscal year 2024, and a low score can trigger up to a 2% loss in Medicare payments. That’s a powerful financial incentive to prioritize patient happiness, which is not always the same thing as patient health, and which can place clinicians in an impossible position when those two things diverge.

Coping, in the Moment and After

Osanmoh’s in-the-moment strategy — he calls it the “Clinical Third” — is to treat the rudeness as a separate “third” object in the room, neither his nor the patient’s. “It isn’t about me, and it isn’t really about them,” he says. “It’s just a symptom of how scared or frustrated they are.”

Before he responds to a hostile onscreen message, he walks away from the computer. “If I reply while I’m still upset, I’ve already lost.” When he does respond, he names what’s happening directly: “I know you’re upset,” Osanmoh tells patients, “but it’s hard for me to help you when you speak to me this way. Can we try again?”

Cherelle Palmer, LMHC, founder of The Palmer Wellness Institute, works with therapists who face similar dynamics. Cynicism, she says, is often misread as a character problem when it’s a physiological one. “When clinicians are repeatedly exposed to emotional intensity without enough recovery time, the brain naturally shifts into a protective mode,” Palmer says.

She recommends identifying exactly where the overextension is happening — too many clients, too much availability, too much emotional labor with nowhere to put it — before trying to counteract the brain’s negativity bias. “Our brains are wired to remember negative interactions more strongly,” she says, “so we have to intentionally recall the clients who are growing and the impact we’re making.”

For Bach, the end-of-day ritual matters more than most clinicians realize. “Rumination is common because unresolved interactions activate our threat-detection systems,” he says.

His recommendation is structured mental closure: Recreate what happened (writing it down is best), identify what was within your control, and deliberately name what you’re choosing to set aside until the next shift. “Physical grounding exercises — slow breathing, sensory awareness, brief movement — can also interrupt replay cycles,” Bach says. “Over time, a consistent end-of-day ritual helps signal to the brain that work stress does not need to follow you home.”

Jennifer McKean, UK-based psychotherapeutic counsellor who specializes in late-diagnosed autistic and ADHD clients, adds a dimension that often gets overlooked entirely: not all behavior that reads as rude actually is.

“Our culture expects a specific social script, like eye contact, small talk, and a deferential tone,” she says. “When someone skips all of that to focus on the facts or their immediate needs, it’s frequently misread as bluntness or rudeness.” Politeness, she notes, is often a luxury of cognitive spare capacity. “That’s something many neurodivergent patients have already spent just trying to self-advocate in a stressful, sensory-overwhelming environment,” she says.

Before labeling an interaction difficult, she asks clinicians to consider whether they’re seeing hostility or a person communicating the only way they can right now.

What Institutions Owe Their Clinicians

Individual coping strategies matter (take, for example, that of Jason Wilt, MD, emergency and sports medicine physician who draws on his past experience working retail for how to handle rude patients: “Reach a place where people stomp us, but can’t leave a footprint.”) But no amount of structured journaling or breathing exercises fixes what is, at its core, a systems failure.

Bach recommends that hospital leadership implement a clear digital civility policy with automatic filtering of abusive language in patient portals, paired with cultural acknowledgment from the top that the emotional toll of routine incivility is real.

Clark goes even further. “Hospitals should stop treating medicine like a retail shop, with the customer always right, even when they are abusive,” he says. “Leaders need to support their employees when a patient crosses the line. Standing up for staff keeps them in the profession longer.”

Hannawa frames the institutional challenge in terms of communication culture rather than individual policy. “Communication does not unfold inside isolated minds,” she says. “It unfolds between people. What each of us contributes to that space becomes the lived culture of the system.”

Safety culture, she argues, isn’t something you install. It’s something that gets built or eroded in every interaction, every day. The goal isn’t to eliminate hostility by suppressing it. It’s to build communicative competence robust enough that hostility, when it surfaces, can be met with something more useful than absorption or shutdown.

Osanmoh’s prescription is the simplest and perhaps the most radical. “Respect has to go both ways,” he says. “When you take the human out of the doctor’s office, everyone loses.”