The CALMER Approach: Teaching Learners Six Steps to ... - STFM

For the Office-based Teacher of Family Medicine 

William Huang, MD 

Feature Editor 

Vol. 36, No. 7 

Editor’s Note: Encounters with “difficult” patients can be challenging and stressful to learners and even 

clinical teachers. In this month’s column, Heidi Pomm, PhD, and colleagues discuss a practical approach 

that teachers and learners can use to alleviate the stress in difficult patient encounters and better 

handle the patient’s needs. 

I welcome your comments about this feature, which is also published on the STFM Web site at 

www.stfm.org. I also encourage all predoctoral directors to make copies of this feature and distribute it 

to their preceptors (with the appropriate Family Medicine citation). Send your submissions 

to williamh@bcm.tmc.edu. William Huang, MD, Baylor College of Medicine, Department of Family 

and Community Medicine, 3701 Kirby, Suite 600, Houston, TX 77098-3915. 713-798-6271. Fax: 713- 

798-7789. Submissions should be no longer than 3–4 double-spaced pages. References can be used 

but are not required. Count each table or figure as one page of text. 

The CALMER Approach: Teaching Learners Six Steps 

to Serenity When Dealing With Difficult Patients 

Teaching learners to handle encounters 

with “difficult” patients is not 

easy since these encounters may tax 

the coping resources of even the 

most skilled or experienced physician. 

Difficult patients include those 

who are “medically challenging, 

interpersonally difficult, psychiatrically 

ill, chronically medically ill, 

or lacking in social support.” 1 Studies 

have found that they are older; 

have more acute, chronic, and psychosocial 

problems; take more 

medications; and more frequently 

are divorced or widowed and from 

a lower social class. 2,3 Specific be- 

(Fam Med 2004;36(7):467-9.) 

Heidi A. Pomm, PhD; Edward Shahady, MD; Raymond M. Pomm, MD 

From the St Vincent’s Medical Center Family 

Medicine Residency Program, Jacksonville, Fla, 

and the Department of Family Medicine and 

Community Health, University of Miami (Dr H 

Pomm); the Department of Family Medicine and 

Rural Health, Florida State University (Dr 

Shahady); and the Impaired Practitioner’s Program, 

Fernandina Beach, Fla, and the Department 

of Psychiatry, University of Florida (Dr R 

Pomm). 

haviors of patients that make the 

encounter difficult include their 

being overly dependent, demanding, 

manipulative, or noncompliant. 

4,5 One study found that family 

physicians rated approximately 

30% of their 722 patient encounters 

as troubling. 3 

However, the problems surrounding 

these encounters are often not 

solely due to the patient. Physicians 

must understand how their own attitudes 

and behavior may contribute. 

3,5-8 Reactions toward difficult 

patients can range from acquiescence 

and inward anger to more 

active scorn and disrespect. 9 These 

negative reactions may result from 

these patients being “an uncomfortable 

reminder of the doctor’s inadequacy 

and impotence.” 10 In addition, 

a physician’s failure to carefully 

listen, show empathy, or establish 

trust may result in an inadequate 

understanding of the 

patient’s history and issues. 11 

The CALMER approach assists 

physicians in reducing the affective 

467 

distress associated with interactions 

with problem patients. This approach 

combines elements from 

Prochaska and DiClemente’s 

“Stages of Change” model, 12 

Shahady’s “Rule of Five, ”8 and 

Gillette’s “Practical Approach for 

Managing Problem Patients.” 5 In 

addition, the CALMER model also 

incorporates strategies derived from 

cognitive-behavioral therapy. 13 

Office-based teachers may find 

the CALMER approach to be a 

structured, easy-to-remember 

model that is especially helpful during 

encounters where the learner 

has difficulty dealing with a 

patient’s demands, feels frustrated 

with a particular patient, makes derogatory 

remarks about a patient, 

wants to transfer care of a patient 

to someone else, and is not interested 

in helping an individual patient 

and/or even the teacher has 

difficulty dealing with a patient. 

The CALMER approach consists 

of six steps, several of which 

only take moments to complete: (1)

468 July-August 2004 Family Medicine 

Catalyst for change, (2) Alter 

thoughts to change feelings, (3) 

Listen and then make a diagnosis, 

(4) Make an agreement, (5) Education 

and follow-up, and (6) Reach 

out and discuss feelings. 

(1) Catalyst for Change 

In this step (either before, during, 

or after an interaction with a difficult 

patient), physicians should remind 

themselves of what they can 

and cannot control about the situation. 

In most cases, the responsibility 

to change behavior lies with the 

patient. Physicians cannot control 

the patient’s behavior, but they can 

control their own reaction and try 

to be helpful by offering practical 

advice. After identifying the 

patient’s current stage in the “Stages 

of Change” model, 12 (Table 1) the 

physician can serve as a catalyst for 

change by giving recommendations 

on how the patient can advance to 

the next stage of change and eventually 

overcome the problem. 

(2) Alter Thoughts 

to Change Feelings 

Cognitive-behavioral therapy 

posits that the only way individuals 

can control their reactions (feelings) 

is to alter their thoughts about 

the situation. 13 Either before, during, 

or after the doctor-patient interaction, 

physicians should identify 

which feelings they are experiencing 

in response to the patient and 

then ask how these feelings might 

be affecting the physician-patient 

relationship and the management 

plan. Physicians should remind 

themselves not to take the patient’s 

behavior personally, since this is 

likely the patient’s way of responding 

and behaving in many areas of 

his/her life (not just in interactions 

with the physician). It is also suggested 

that the physician explore 

and understand possible underlying 

reasons or answers for the patient’s 

behavior (past abuse, poor finances, 

loneliness, etc). Lastly, physicians 

should ask themselves, “What can 

I tell myself about this situation that 

will make me feel less (angry, dis- 

gusted, etc)?” In doing so, they are 

then able to alter or change their 

thoughts and therefore feel less distressed. 

(3) Listen and Then 

Make a Diagnosis 

As a result of a physician’s negative 

response to a difficult patient 

encounter, he/she may not accurately 

hear what the patient is trying 

to verbally or nonverbally communicate. 

11 This can lead to severe 

errors in diagnosis. By engaging in 

the first two steps described above, 

the physician will be better 

equipped to truly hear what patients 

are trying to communicate. This 

will improve the likelihood of making 

more-accurate diagnoses and 

will lead to better working relationships 

with patients. 

(4) Make an Agreement 

This step is focused solely on 

making an agreement with the patient 

to continue the doctor-patient 

relationship. The physician might 

say to the patient, “So, after all we 

have discussed, it is my understanding 

that you would like to continue 

to see me, and we have agreed that 

we will work together to keep you 

as healthy as possible. Is that your 

understanding too?” It is important 

to confirm that the patient understands 

and agrees with the proposal. 

Table 1 

Stages of Change 

• Precontemplation Patient denies or minimizes problem 

• Contemplation Patient acknowledges problem but not ready to change 

• Preparation/determination Patient commits to time and plan for resolving the problem 

• Action Patient makes daily efforts to overcome problem 

• Maintenance Patient has overcome problem for at least 6 months 

but must remain vigilant 

• Relapse Patient has gone back to problem behavior 

Adapted from Prochaska JO, DiClemente CC. The transtheoretical approach: crossing traditional 

boundaries of therapy. Homewood, Ill: Dow-Jones-Irwin, 1984. 12 

In addition, if the patient has insight 

into the problem behavior, the physician 

might say, “We have agreed 

to work on this problem (specify 

exactly what the problem is) together. 

Is that your understanding 

as well?” This step helps both the 

physician and the patient increase 

their awareness that they are making 

a conscious choice to continue 

their relationship and work on the 

patient’s concerns, which in turn 

increases perceived control for both 

parties. 

(5) Education and Follow-up 

After the doctor and the patient 

agree to continue their relationship 

and work together, how they will 

accomplish this needs to be addressed 

as specifically as possible. 

Physicians should temporarily let 

go of their own agenda (even 

though they feel it is more appropriate) 

and give a “doable” recommendation 

tailored to where the 

patient is in the “Stages of Change” 

model. 12 For example, for a patient 

contemplating whether to quit 

smoking, the physician may prescribe 

homework such as: “Over the 

next 2 weeks, I’d like for you to 

write down your feelings right before 

you reach for a cigarette. Think 

about the ‘pros’ and ‘cons’ of picking 

up that cigarette without judging 

yourself on the choice you ulti-

For the Office-based Teacher of Family Medicine 

mately make. We’ll talk about your 

experience with this homework assignment 

when I see you back in 2 

weeks. Is that okay?” Similarly, the 

physician can encourage a patient 

in the precontemplation stage to 

begin thinking about the issue at 

hand. The physician and patient 

should agree on the “homework assignment” 

and the time frame in 

which it is to be completed. 

(6) Reach Out and Discuss 

Your Feelings 

It is commonly believed that 

most doctors are “islands” and are 

generally reluctant to ask for help. 

Yet, as stated earlier, even the most 

skilled and competent of physicians 

will at times feel great distress following 

an interaction with a difficult 

patient. After engaging in the 

preceding steps, it is suggested that 

physicians ask themselves, “How 

do I now feel about this patient and 

his/her behaviors?” It is also important 

for physicians to identify how 

they will care for themselves the 

next time a patient elicits these 

types of feelings. Discussing these 

feelings and the difficulty of the 

experience with a trusted colleague 

or friend can be of great assistance 

since a wealth of research attests to 

the beneficial effects of social support. 

14,15 When dealing with difficult 

patients, physicians do not have to 

feel alone. 

Although numerous articles have 

been published on difficult doctorpatient 

interactions, only a few 

models have been proposed to help 

physicians decrease the distress frequently 

associated with these interactions. 

The CALMER approach 

incorporates six steps that physicians 

can utilize to feel more in control 

and less distressed during these 

types of patient encounters. By taking 

the time to guide learners 

through the individual steps of this 

approach, the office-based teacher 

may increase learners’ self-efficacy 

in handling difficult patient encounters 

since the CALMER approach 

focuses on what learners can control 

(their own reactions) and less 

on what they ultimately cannot control 

(the patient’s behavior). A 

CALMER learner results in a more 

serene learner, who is better able to 

care for patients in need. 

Corresponding Author: Address correspondence 

to Dr Heidi Pomm, Family Medicine Residency 

Program, St Vincent’s Medical Center, 2708 St 

Johns Avenue, Jacksonville, FL 32205. 904-308- 

8482. Fax: 904-308-2998. hpomm001@ 

stvincentshealth.com. 

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Vol. 36, No. 7 

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3. Crutcher JE, Bass MJ. The difficult patient 

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11. Havens LL. Taking a history from the difficult 

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12. Prochaska JO, DiClemente CC. The 

transtheoretical approach: crossing traditional 

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13. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive 

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14. Antoni MH, Cruess S, Cruess DG, et al. Cognitive-behavioral 

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