BREATHE OUT: A Randomized Controlled Trial of a Structured Intervention to Improve Clinician Satisfaction With "Difficult" Visits

Abstract

Purpose: Difficult patients comprise at least 15% of ambulatory visits and are associated with clinician burnout. No structured procedure has been reported to assist health care practitioners with these challenging relationships. This randomized trial evaluated whether a pre-and postvisit patient-centered and clinician-reflective technique called BREATHE OUT improved clinician satisfaction during visits with patients perceived by the clinician as difficult.Methods: Six family medicine residency clinics paired as urban, suburban, and rural sites were randomized by clinic to the BREATHE OUT intervention or usual care of difficult patients. A total of 57 physician faculty, nurse practitioners, physician assistants, and residents participated. The validated Physician Satisfaction Scale (PSS) was administered and analyzed using hierarchical linear modeling to assess differences between the intervention and control groups.Results: The BREATHE OUT intervention improved the PSS score (P ‫؍‬ .02) in the intervention group compared with the usual care group. Female practitioners reported worse PSS scores compared with their male counterparts despite whether they used BREATHE OUT (P ‫؍‬ .009).

Difficult Patient Encounters: Assessing Pediatric Residents' Communication Skills Training Needs

“…One example is the BREATHE OUT technique, which includes a structured pre-visit intervention with the mnemonic BREATHE to prompt 1) reflection on provider's Bias or assumption about the patient, 2) reflection upon why patient is difficult, 3) goals to accomplish during the visit, and 4) pause before entering the patient room, as well as a post-visit intervention mnemonic OUT to prompt 1) reflection on the outcome, 2) consideration regarding whether anything unexpected was learned, and 3) anticipation of what the provider would look forward to addressing tomorrow. This BREATHE OUT technique has been shown to improve physician satisfaction with DPEs [ 26 ]. These techniques may support residents’ resilience on an individual level, although systems interventions to optimize the learning and working environment, which go beyond the scope of a difficult encounters curriculum, remain important steps to reducing resident anxiety and burnout [ 27 ].…”

Mindfulness training for healthcare professional students: A waitlist controlled pilot study on psychological and work-relevant outcomes

“…Ecological momentary assessment may prove beneficial for designing a study to investigate cumulative effects of informal practices -this would consist of randomly paging HCPs to practice informally and then measuring the effects on patient care outcomes relative to a group of HCPs not practicing informal mindfulness. This was preliminarily investigated in a recent study with findings supported by our grounded theory model - Edgoose and colleagues (2015) found that an informal practice at work improved HCP-perceptions of difficult patient encounters (Edgoose et al, 2015). Another method for investigating informal practices may be to follow the example by Edgoose et al, 2015, and measure HCP and patient outcomes prior to and following an encounter in which the HCP practices informal mindfulness immediately before the patient encounter and immediately after the baseline outcome measurement.…”

“…This was preliminarily investigated in a recent study with findings supported by our grounded theory model - Edgoose and colleagues (2015) found that an informal practice at work improved HCP-perceptions of difficult patient encounters (Edgoose et al, 2015). Another method for investigating informal practices may be to follow the example by Edgoose et al, 2015, and measure HCP and patient outcomes prior to and following an encounter in which the HCP practices informal mindfulness immediately before the patient encounter and immediately after the baseline outcome measurement. This would provide information on the state-effects of informal practices as opposed to cumulative, or trait, effects.…”

“…Another study found conflicting results and demonstrated improvements on psychological symptoms for both intervention arms (informal practice only and seated meditation) compared to a waitlist control (Cavanagh et al, 2018). In HCPS, one study found an informal mindfulness exercise to improve state-level stress following difficult patient encounters relative a usual care group in family medicine residents (Edgoose, Regner, & Zakletskaia, 2015). Ultimately, more research on the effects of informal mindfulness is needed with careful classification of informal vs. formal practices and sophisticated monitoring of practice time, type, and quality to build upon these research questions.…”

Practical, Office-based Interventions That Improve Care Today

“…Physicians who report many of these types of patient encounters are more likely to be dissatisfied in practice. In a randomized trial across 6 offices, Edgoose et al 1 report the positive results of a structured, angstrelieving, reflective intervention used by the provider before and after these visits. "BREATHE" is the mnemonic used for the portion of the intervention before the visit, and "OUT" is the mnemonic for the portion used after the visit.…”