William Huang MDFeature EditorFor the Officebased Teacher of Family M - PDF document

1 William Huang, MDFeature EditorFor the O
William Huang, MDFeature EditorFor the Office-based Teacher of Family Medicine(Fam Med 2004;36(7):467-9.) EditorÕs Note: Encounters with ÒdifficultÓ patients can be challenging and stressful to learners and evenclinical teachers. In this monthÕs column, Heidi Pomm, PhD, and colleagues discuss a practical ap-proach that teachers and learners can use to alleviate the stress in difficult patient encounters and betterhandle the patientÕs needs.I welcome your comments about this feature, which is also published on the STFM Web site atwww.stfm.org. I also encourage all predoctoral directors to make copies of this feature and distribute itto their preceptors (with the appropriate Family Medicine citation). Send your submissionsto williamh@bcm.tmc.edu. William Huang, MD, Baylor College of Medicine, Department of Familyand Community Medicine, 3701 Kirby, Suite 600, Houston, TX 77098-3915. 713-798-6271. Fax: 713-798-7789. Submissions should be no longer than 3Ð4 double-spaced pages. References can be usedbut are not required. Count each table or figure as one page of text.Teaching learners to handle encoun-ters with ÒdifficultÓ patients is noteasy since these encounters may taxthe coping resources of even themost skilled or experienced physi-cian. Difficult patients include thosewho are Òmedically challenging,interpersonally difficult, psychiat-rically ill, chronically medically ill,or lacking in social support.Ó Stud-ies have found that they are older;have more acute, chronic, and psy-chosocial problems; take moremedications; and more frequentlyare divorced or widowed and froma lower social class.2,3 Specific be-haviors of patients that make theencounter difficult include theirbeing overly dependent, demand-ing, manipulative, or noncom-pliant.4,5 One study found that fam-ily physicians rated approximately30% of their 722 patient encountersas troubling.However, the problems surround-ing these encounters are often notsolely due to the patient. Physiciansmust understand how their own at-titudes and behavior may contrib-ute.3,5-8 Reactions toward difficultpatients can range from acquies-cence and inward anger to moreactive scorn and disrespect. Thesenegative reactions may result fromthese patients being Òan uncomfort-able reminder of the doctorÕs inad-equacy and impotence.Ó10 In addi-tion, a physicianÕs failure to care-fully listen, show empathy, or es-tablish trust may result in an inad-equate understanding of thepatientÕs history and issues.11The CALMER approach assistsphysicians in reducing the affectivedistress associated with interactionswith problem patients. This ap-proach combines elements fromProchaska and DiClementeÕsÒStages of ChangeÓ model,12ShahadyÕs ÒRule of Five,Ó8 andGilletteÕs ÒPractical Approach forManaging Problem Patients.Ó Inaddition, the CALMER model alsoincorporates strategies derived fromcognitive-behavioral therapy.13 Office-based teachers may findthe CALMER approach to be astructured, easy-to-remembermodel that is especially helpful dur-ing encounters where the learnerhas difficulty dealing with apatientÕs demands, feels frustratedwith a particular patient, makes de-rogatory remarks about a patient,wants to transfer care of a patientto someone else, and is not inter-ested in helping an individual pa-tient and/or even the teacher hasdifficulty dealing with a patient. The CALMER approach con-sists of six steps, several of whichonly take moments to complete: (1)The CALMER Approach: Teaching Learners Six Stepsto Serenity When Dealing With Difficult PatientsHeidi A. Pomm, PhD; Edward Shahady, MD; Raymond M. Pomm, MDFrom the St VincentÕs Medical Center FamilyMedicine Residency Program, Jacksonville, Fla,and the Department of Family Medicine andCommunity Health, University of Miami (Dr HPomm); the Department of Family Medicine andRural Health, Florida State University (DrShahady); and the Impaired PractitionerÕs Pro-gram, Fernandina Beach, Fla, and the Depart-ment of Psychiatry, University of Florida (Dr RPomm). 468July-August 2004Family Medicineatalyst for change, (2) lterthoughts to change feelings, (3)isten and then make a diagnosis,(4) ake an agreement, (5) du-cation and follow-up, and (6) eachout and discuss feelings.(1) Catalyst for ChangeIn this step (either before, during,or aft

2 er an interaction with a diffi-cult pati
er an interaction with a diffi-cult patient), physicians should re-mind themselves of what they canand cannot control about the situa-tion. In most cases, the responsibil-ity to change behavior lies with thepatient. Physicians cannot controlthe patientÕs behavior, but they cancontrol their own reaction and tryto be helpful by offering practicaladvice. After identifying thepatientÕs current stage in the ÒStagesof ChangeÓ model,12 (Table 1) thephysician can serve as a catalyst forchange by giving recommendationson how the patient can advance tothe next stage of change and even-tually overcome the problem.(2) Alter Thoughtsto Change FeelingsCognitive-behavioral therapyposits that the only way individu-als can control their reactions (feel-ings) is to alter their thoughts aboutthe situation.13 Either before, dur-ing, or after the doctor-patient in-teraction, physicians should iden-tify which feelings they are experi-encing in response to the patient andthen ask how these feelings mightbe affecting the physician-patientrelationship and the managementplan. Physicians should remindthemselves not to take the patientÕsbehavior personally, since this islikely the patientÕs way of respond-ing and behaving in many areas ofhis/her life (not just in interactionswith the physician). It is also sug-gested that the physician exploreand understand possible underlyingreasons or answers for the patientÕsbehavior (past abuse, poor finances,loneliness, etc). Lastly, physiciansshould ask themselves, ÒWhat canI tell myself about this situation thatwill make me feel less (angry, dis-gusted, etc)?Ó In doing so, they arethen able to alter or change theirthoughts and therefore feel less dis-tressed.(3) Listen and ThenMake a DiagnosisAs a result of a physicianÕs nega-tive response to a difficult patientencounter, he/she may not accu-rately hear what the patient is try-ing to verbally or nonverbally com-municate.11 This can lead to severeerrors in diagnosis. By engaging inthe first two steps described above,the physician will be betterequipped to truly hear what patientsare trying to communicate. Thiswill improve the likelihood of mak-ing more-accurate diagnoses andwill lead to better working relation-ships with patients.(4) Make an AgreementThis step is focused solely onmaking an agreement with the pa-tient to continue the doctor-patientrelationship. The physician mightsay to the patient, ÒSo, after all wehave discussed, it is my understand-ing that you would like to continueto see me, and we have agreed thatwe will work together to keep youas healthy as possible. Is that yourunderstanding too?Ó It is importantto confirm that the patient under-stands and agrees with the proposal.In addition, if the patient has insightinto the problem behavior, the phy-sician might say, ÒWe have agreedto work on this problem (specifyexactly what the problem is) to-gether. Is that your understandingas well?Ó This step helps both thephysician and the patient increasetheir awareness that they are mak-ing a conscious choice to continuetheir relationship and work on thepatientÕs concerns, which in turnincreases perceived control for bothparties.(5) Education and Follow-upAfter the doctor and the patientagree to continue their relationshipand work together, how they willaccomplish this needs to be ad-dressed as specifically as possible.Physicians should temporarily letgo of their own agenda (eventhough they feel it is more appro-priate) and give a ÒdoableÓ recom-mendation tailored to where thepatient is in the ÒStages of ChangeÓmodel.12 For example, for a patientcontemplating whether to quitsmoking, the physician may pre-scribe homework such as: ÒOver thenext 2 weeks, IÕd like for you towrite down your feelings right be-fore you reach for a cigarette. Thinkabout the ÔprosÕ and ÔconsÕ of pick-ing up that cigarette without judg-ing yourself on the choice you ulti-Table 1Stages of Change¥PrecontemplationPatient denies or minimizes problem¥ContemplationPatient acknowledges problem but not ready to change¥Preparation/determinationPatient commits to time and plan for resolving the problem¥ActionPatient makes daily efforts to overcome problem¥MaintenancePatient has overcome problem for at least 6 monthsbut must remain vigilant¥RelapsePatient has go

3 ne back to problem behaviorAdapted from
ne back to problem behaviorAdapted from Prochaska JO, DiClemente CC. The transtheoretical approach: crossing traditionalboundaries of therapy. Homewood, Ill: Dow-Jones-Irwin, 1984.12 469Vol. 36, No. 7mately make. WeÕll talk about yourexperience with this homework as-signment when I see you back in 2weeks. Is that okay?Ó Similarly, thephysician can encourage a patientin the precontemplation stage tobegin thinking about the issue athand. The physician and patientshould agree on the Òhomework as-signmentÓ and the time frame inwhich it is to be completed.(6) Reach Out and DiscussYour FeelingsIt is commonly believed thatmost doctors are ÒislandsÓ and aregenerally reluctant to ask for help.Yet, as stated earlier, even the mostskilled and competent of physicianswill at times feel great distress fol-lowing an interaction with a diffi-cult patient. After engaging in thepreceding steps, it is suggested thatphysicians ask themselves, ÒHowdo I now feel about this patient andhis/her behaviors?Ó It is also impor-tant for physicians to identify howthey will care for themselves thenext time a patient elicits thesetypes of feelings. Discussing thesefeelings and the difficulty of theexperience with a trusted colleagueor friend can be of great assistancesince a wealth of research attests tothe beneficial effects of social sup-port.14,15 When dealing with difficultpatients, physicians do not have tofeel alone.Although numerous articles havebeen published on difficult doctor-patient interactions, only a fewmodels have been proposed to helpphysicians decrease the distress fre-quently associated with these inter-actions. The CALMER approachincorporates six steps that physi-cians can utilize to feel more in con-trol and less distressed during thesetypes of patient encounters. By tak-ing the time to guide learnersthrough the individual steps of thisapproach, the office-based teachermay increase learnersÕ self-efficacyin handling difficult patient encoun-ters since the CALMER approachfocuses on what learners can con-trol (their own reactions) and lesson what they ultimately cannot con-trol (the patientÕs behavior). ACALMER learner results in a moreserene learner, who is better able tocare for patients in need.Corresponding Author: Address correspondenceto Dr Heidi Pomm, Family Medicine ResidencyProgram, St VincentÕs Medical Center, 2708 StJohns Avenue, Jacksonville, FL 32205. 904-308-8482. Fax: 904-308-2998. hpomm001@stvincentshealth.com.EFERENCES1.Adams J, Murray R. The general approachto the difficult patient. Emerg Med ClinNorth Am 1998;16:689-700.2.John C, Schwenk TL, Roi LD, Cohen M.Medical care and demographic characteris-tics of ÒdifficultÓ patients. J Fam Pract1987;24:607-10.3.Crutcher JE, Bass MJ. The difficult patientand the troubled physician. J Fam Pract1980;11:933-8.4.Groves JE. Taking care of the hateful patient.N Engl J Med 1978;298:883-7.5.Gillette RD. ÒProblem patients:Ó a fresh lookat an old vexation. Fam Pract Manage2000;7:57-62.6.Mathers N, Jones N, Hannay D. Heartsinkpatients: a study of their general practitio-ners. Br J Gen Pract 1995;45:293-6.7.OÕBoyle M. Reactions to difficult patients.Psychosomatics 1988;29:368.8.Shahady E. Difficult patients: uncovering thereal problems of ÒcrocksÓ and Ògomers.ÓConsultant 1990;Oct:49-56.9.Simon JR, Dwyer J, Goldfrank LR. Ethicalissues in emergency medicine: the difficultpatient. Emerg Med Clin North Am1999;17:353-70.10.Corney RH, Strathdee G, Higgs R, et al.Managing the difficult patient: practical sug-gestions from a study day. J R Coll Gen Pract1988;38:349-52.11.Havens LL. Taking a history from the diffi-cult patient. Lancet 1978;1:138-40.12.Prochaska JO, DiClemente CC. Thetranstheoretical approach: crossing tradi-tional boundaries of therapy. Homewood, Ill:Dow-Jones-Irwin, 1984.13.Beck AT, Rush AJ, Shaw BF, Emery G. Cog-nitive therapy of depression. New York:Guilford Press, 1979.14.Antoni MH, Cruess S, Cruess DG, et al. Cog-nitive-behavioral stress management reducesdistress and 24-hour urinary free cortisoloutput among symptomatic HIV-infectedgay men. Ann Behav Med 2000;22:29-37.15.Gottlieb BH. Social networks and social sup-port: an overview of research, practice, andpolicy implications. Health Educ Q 1985;12:5-22.For the Office-based Teacher of Family Medicine