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

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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.


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.


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).


Application of the BREATHE OUT questionnaire before and after visits improved clinician satisfaction with difficult patient encounters.

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