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relaxed demeanor. Complex social issues and limited
resources may also put a strain on the encounter and
may require the involvement of a social worker.
Various communication tools have been developed to guide the physician through difficult patient
encounters. The CALMER strategy is a six-step process
to serenity when dealing with difficult patients and
combines elements from Prochaska and DiClemente’s
Stages of Change model, Shahady’s Rule of Five, and
Gillette’s Practical Approach for Managing Problem
Patients, as well as principles of cognitive-behavioral
therapy (see Table 1, page 19). 23 The BREATHE OU T
approach is a similar tool and was developed for a
randomized controlled trial at six family medicine
clinics in urban, suburban, and rural locations (see
Table 2, page 20). 25 A total of 57 clinicians, including
physicians, physician assistants, nurse practitioners,
and residents, completed the Physician Satisfaction
Scale (PSS) after implementing the BREATHE OUT
technique, and those who were instructed in the use
of BREATHE OUT had improved PSS scores after
difficult encounters (p=0.02). Use of the tool took less
than three minutes. 25
Effective communication is a key skill for successful surgeons and the delivery of high-quality patient
care. The ability to communicate with your superiors
is equally important as the ability to communicate
with your peers and patients. Although these interpersonal skills are difficult to measure and standardize,
the author’s anticipate that these guidelines and techniques will prove useful in each of those encounters. ♦