INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 45(4) 311-322, 2013
TRAINING THE “ASSERTIVE PRACTITIONER OF BEHAVIORAL SCIENCE”: ADVANCING A BEHAVIORAL MEDICINE TRACK IN A FAMILY MEDICINE RESIDENCY
DENNIS J. BUTLER, PHD Medical College of Wisconsin and Columbia-St. Mary’s Family Medicine Program RICHARD L. HOLLOWAY, PHD Medical College of Wisconsin DOMINIQUE FONS, MD University of Illinois School of Medicine and Carle Foundation Hospital Family Medicine Residency Program
ABSTRACT
Objective: This article describes the development of a Behavioral Medicine track in a family medicine residency designed to train physicians to proactively and consistently apply advanced skills in psychosocial medicine, psychiatric care, and behavioral medicine. Methods: The Behavioral Medicine track emerged from a behavioral science visioning retreat, an opportunity to restructure residency training, a comparative family medicine-psychiatry model, and qualified residents with high interest in behavioral science. Training was restructured to increase rotational opportunities in core behavioral science areas and track residents were provided an intensive longitudinal counseling seminar and received advanced training in psychopharmacology, case supervision, and mindfulness. Results: The availability of a Behavioral Medicine track increased medical student interest in the
Manuscript based on material presented at the 33rd Annual Forum for Behavioral Science Education in Family Medicine, 2012. 311 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.45.4.b http://baywood.com
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residency program and four residents have completed the track. All track residents have presented medical Grand Rounds on behavioral science topics and have lead multiple workshops or research sessions at national meetings. Graduate responses indicate effective integration of behavioral medicine skills and abilities in practice, consistent use of brief counseling skills, and good confidence in treating common psychiatric disorders. Conclusion: As developed and structured, the Behavioral Medicine track has achieved the goal of producing “assertive practitioners of behavioral science in family medicine” residents with advanced behavioral science skills and abilities who globally integrate behavioral science into primary care. (Int’l. J. Psychiatry in Medicine 2013;45:311-322)
Key Words: behavioral science, medical education, primary care, counseling
INTRODUCTION: CONCEPTUAL BACKGROUND FOR A BEHAVIORAL MEDICINE TRACK Family medicine residency training requires that all trainees receive training in the behavioral sciences, a requirement that has existed since the inception of the specialty [1]. The clinical application of behavioral science includes three major domains. The first, psychosocial medicine, acknowledges the profound effect that psychosocial factors play in health and, thus, the essential reliance on a biopsychosocial model to improve health [2-4]. Next, training in the recognition and management of those psychiatric disorders which commonly present in primary care is also required due to consistent evidence that the majority of patients with psychiatric difficulties are exclusively treated in primary care [5-8]. Finally, it is well documented that family physicians are the first point of care for patients with chronic medical conditions, conditions whose onset and course are highly correlated with lifestyle. Thus, family medicine residents receive training in the principles of behavioral medicine and techniques for fostering health behavior change [9-11]. While training in the domains of psychosocial medicine, psychiatry, and behavioral medicine is required by the Accreditation Council of Graduate Medical Education (ACGME) [12], there is no clear mandate on which skills trainees must possess and to what extent they must demonstrate those skills at the completion of residency. Multiple efforts have resulted in published curricula and recommended criteria yet there are no formally recognized, universally accepted behavioral science competencies that have been used to determine if a resident has successfully completed residency requirements [13, 14]. Although most family medicine residents acknowledge the importance of attending to psychosocial factors and the behavioral aspects of care, how graduates apply the knowledge, skills, and abilities they acquire in this domain can be quite variable. And, as with most training requirements, behavioral science
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training criteria are set at baseline or minimum expectations. Insufficient attention has been devoted to identifying the qualities of graduates who are exemplary at the integration of behavioral science related abilities in practice [15, 16]. Which skills, abilities, and attitudes are associated with clinicians who proactively, consistently, and effectively address psychosocial problems, manage psychiatric disorders, and target health behavior change utilizing behavioral medicine skills? How would such a graduate proactively, efficiently, and consistently integrate these abilities? This article describes a residency-based Behavioral Medicine track designed to develop such exemplars. In this track, residents are trained to become proactive “assertive practitioners” of behavioral science in family medicine through highly structured, individualized, intensive didactic and clinical experiences. The track was first offered in 2002 at the Columbia-St. Mary’s (CSM) Family Medicine Program in Milwaukee, Wisconsin. The track continues to be offered currently. TRACK AND CURRICULUM DEVELOPMENT The creation of a specialized training track in behavioral science at CSM had four major structural influences: a departmental retreat examining behavioral science training, a strategic restructuring of the CSM residency, a co-existing Family Medicine-Psychiatry residency program, and the presence of a qualified track candidate. Behavioral Science Visioning Retreat In 2000, behavioral science and physician faculty in the Department of Family and Community Medicine at the Medical College of Wisconsin participated in a visioning retreat which examined residency behavioral science education. The workgroup did not focus on specific training provided at the department’s five residency programs but addressed the larger question, “What attributes would a family physician possess who had achieved a well-rounded set of behavioral science skills?” The participants assumed that psychosocial practice is not a matter of “if” family physicians incorporate psychosocial factors in care, but rather “how.” Participants concurred that despite national curricula for behavioral science training and educational efforts to develop psychosocial skills in family medicine trainees, significant variability in the range and quality of skills acquired by residents existed, and, consequently, there was variability in the extent to which residents applied those skills and abilities in practice. The work group identified universal attributes that define the physician who is well trained in behavioral science and described such a clinician as an “assertive practitioner of behavioral science in family medicine.” Specific skills, abilities, and attitudes were identified in communication, clinical assessment and intervention (see Table 1). Advanced competencies in self-awareness and reflection, professional relationship skills and life-long learning were also identified [17].
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Table 1. Characteristic Skills of the Assertive Practitioner of Behavioral Science in Family Medicine TECHNICAL SKILLS FOR COMMUNICATION, ASSESSMENT, AND INTERVENTIONS The assertive practitioner of biopsychosocial family medicine is able to Communication 1. Communicate in a manner patients understand 2. Exhibit active listening skills 3. Demonstrate empathetic responses to patient’s experience 4. Find common ground with patients (e.g., consistently negotiates and develops effective treatment plans, solves problems, and resolves conflict) 5. Set appropriate boundaries in physician-patient relationships Assessment 6. Assess psychosocial context in more specificity than simple recognition (e.g., consistently assesses physical finding in psychosocial context) 7. Recognize and assess common psychosocial problems and diagnoses 8. Recognize important early psychosocial cues that lead to a psychosocial diagnosis. Includes diagnosis of common and not-miss psychiatric conditions and psychosocial conditions 9. Incorporate a developmental framework into patient care Intervention 10. Manage the most psychosocially challenging patients and accept cases others may not want or be able to handle 11. Intervene in crisis management situations SELF-AWARENESS, PROFESSIONAL RELATIONSHIPS, GROWTH SKILLS, AND LIFELONG SKILL DEVELOPMENT The assertive practitioner of biopsychosocial family medicine possesses the following characteristics: 1. Recognizes and accepts his or her personal and professional limitations 2. Appropriately self-discloses 3. Brings an attitude of openness and curiosity to patient care 4. Practices in an ethical and moral manner 5. Understands own feelings and life experiences and uses them to therapeutic advantage 6. Exhibits realistic sense of expectations regarding outcomes and management of psychosocial problems
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Table 1. (Cont’d.) 7. Anticipates and plans for psychosocial context of various interventions and encounters 8. Goes beyond traditional role expectations to achieve a patient outcome that is optimal. Steps forward to help a patient with a task usually performed by a nurse because this is the most immediate response to the patient. 9. Responds to patient’s needs rather than focusing on his or her own experience 10. Feels comfortable in many patient encounters and accepts a broad range of one’s own emotional responses as a natural part of daily practice 11. Is aware of boundaries between physician and patient 12. Exhibits skill in brief office-based psychosocial interventions, such as teaching basic stress management, parenting skills, and health behavior 13. Facilitates family meetings and interdisciplinary team meetings 14. Manages psychotropic medications as appropriate in primary care, seeking consultation when indicated 15. Pursues continued acquisition and implementation of psychosocial skills in practice across various practice environments COORDINATIVE SKILLS The assertive practitioner of biopsychosocial family medicine is able to 1. Collaborate with all members of the health care team, using a variety of specific skills: a. Communicating in writing, by telephone, and personally b. Communicating with all team members, nurses, office staff, psychotherapists, and physician colleagues c. Maintaining continuity in the collaboration by following up with each team member d. Actively clarifying role expectations with team members 2. Seek appropriate psychosocial consultation 3. Routinely work with psychosocial providers 4. Coordinate multiple provider involvement for patients with complex biopsychosocial issues 5. Make appropriate, well-prepared, informed referrals to psychosocial providers 6. Know the difference among various psychosocial providers and seek consultations and referrals appropriately
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Residency Program Redesign In 2002, CSM Residency Program faculty engaged in a strategic planning process to re-examine the program’s curriculum and structure. This effort was driven by recommendations in the Future of Family Medicine Report [18], the merger of two residency programs due to hospital consolidation, and feedback from medical students interested in primary care. Student applicants increasingly expressed interest in developing skills and creating more opportunities in diverse areas of family medicine including advanced obstetrics, international medicine, community and public health, sports medicine, and psychiatry. They were seeking more flexible training than that provided in the traditional family medicine curriculum. The faculty concluded that specialized tracks would allow flexibility in training, could be individually tailored, would provide advanced competencies in track areas, and still conform to ACGME requirements. The faculty catalogued training opportunities and personnel in the environment and committed to developing tracks in Obstetrics, Community Medicine, International Medicine, and Behavioral Medicine. Tracks were designed to be consistent with ACGME family medicine training requirements by allowing residents to pursue advanced training using elective rotation months. Dual Family Medicine-Psychiatry Program A 5-year Family Medicine-Psychiatry Residency program also was in place at CSM. The dual program consistently recruited high achieving residents who were attracted to practicing primary care medicine and psychiatry and who modeled advanced skills for a biopsychosocial approach to primary care. The dual residents practiced in parallel with the family medicine residents in clinic, on rotations, and on the family medicine hospital service. The integrated program provided examples of practicing assertive practitioners and offered a structural analogue for designing the track. This program continued until 2006 when an administrative decision was made to phase it out. Resident Interest The opportunity to translate the results of the visioning retreat, program restructuring, and the dual program model into a Behavioral Medicine track were actualized in 2002. A PG-2 family medicine resident with a strong interest in behavioral science, geriatrics, and rural practice expressed an interest in acquiring more advanced training in geriatric psychiatry, palliative care, and hospice care. After identifying appropriate resources, the track was implemented.
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CURRICULUM GOALS AND OBJECTIVES The Behavioral Medicine track is designed around three core behavioral science domains familiar to family medicine: psychosocial medicine, psychiatric care, and behavioral medicine. Residents selected for the track are expected during their track experience to: • proactively and effectively intervene in psychosocial problems commonly seen in primary care settings (intimate partner violence, adjustment difficulties, etc.); • possess and advance skills in patient-centered communication with patients across the lifespan; • demonstrate advanced competence in psychiatric diagnosis and psychopharmacologic management of psychiatric disorders seen in primary care; • develop advanced skills in understanding and working with systems and families; • develop expertise in office-based counseling skills using multiple modalities (solution-focused, CBT, supportive, BATHE, psychodynamic), and proactively utilize counseling and psychotherapy techniques in daily practice; • acquire advanced behavioral medicine skills designed to improve the health of patients and consistently apply specific health behavior change techniques (e.g., motivational interviewing); • routinely demonstrate use of self-awareness and reflection to improve patient care; • foster collaborative relationships with mental health professionals; and • develop scholarly abilities for presentation and/or research. The primary goal of the track is to train residents to become “assertive practitioners” who integrate the above skills and abilities throughout their clinical practice in a consistent, proactive fashion. Thus, a resident interested in advancing skills in the management of depression in primary care who chooses two psychiatry electives does not fit with the assertive practitioner model due to the narrow level of focus. All track residents commit to advanced training in the three domains of psychosocial medicine, psychiatry and behavioral medicine. TRACK STRUCTURE AND INSTRUCTIONAL METHODS Resident Selection Residents in the Behavioral Medicine track begin track activities in the second year of training. Acceptance is contingent upon good academic standing, commitment to a minimum of four elective rotations to track experiences, and a demonstrated interest in behavioral science in the first year of training or prior to residency. Track residents participate in individualized didactic activities,
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clinical rotations, and case supervision during their PG-2 and PG-3 years in addition to the core behavioral science requirements for all residents. Track residents must also identify an area of clinical focus in which they will develop expertise. The clinical areas of focus chosen by the first four track graduates were dementia assessment, depression management, attention deficit disorder treatment, and management of anxiety and depression in women. Finally, track residents must present a hospital Grand Rounds on a behavioral science related topic and submit a scholarly proposal for a national or regional conference. Rotations
Residents in the track dedicate a minimum of four and up to six elective rotations related to the three core domains which form the basis of the Behavioral Medicine track. Of these, one must be with a Consultation-Liaison Psychiatry service at a regional medical center. Over 20 rotations are identified in the program catalogue and include psychosocial experiences (child abuse center, domestic violence service, sexual assault treatment center), mental health rotations (psychotherapy center, dialectic behavior program, child psychiatry), or behavioral health experiences (pain management, wellness-mindfulness center). Population-based rotations are also available (child, adolescent, geriatric). Didactics Monthly Counseling Skills Seminar
Behavioral Medicine residents participate in a monthly seminar with the track director. The seminar is structured to provide 2 years of training in officebased counseling methods, beginning with generic methods (BATHE, supportive therapy) and advancing to more theoretical models (CBT, Psychodynamic Psychotherapy, Solution-focused). Residents are also taught problem formulation and assessment methods, skills, and strategies. Training in office counseling methods is based on a primary care oriented, time limited, brief treatment model. Residents are expected to identify counseling patients from their clinic panel and discuss active treatment. Psychopharmacology Training
A dual-boarded psychiatrist-family physician is responsible for a monthly Primary Care-Psychiatry didactic lecture and provides individualized consultation for the Behavioral Medicine track resident. Case Supervision
The Behavioral Medicine track resident also works individually with the track director to process issues in the care of difficult and challenging patients. In
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addition, the resident participates in the evaluation of patients referred to the family medicine clinic’s outpatient psychiatric consult service and receives training from the PG-4 psychiatry resident responsible for the consult service. Longitudinal Integration
Track residents are encouraged to maintain a log of behavioral science related experiences for all 24 rotations during their PG-2 and PG-3 training years. In addition they are expected to research or read rotation-relevant, behaviorallyoriented articles during each rotation (e.g., psychological adjustment to amputation while they are on a surgery rotation). Teaching
Residents on the track co-teach behavioral science topics in collaboration with the Director of Behavioral Science when available and appropriate.
TRACK IMPACT Resident Graduates Four residents have successfully completed the Behavioral Medicine track. Three practice in small to medium sized communities; one practices in a large metropolitan area. Two program graduates completed “mini” track experiences focused on more specific areas of interest. They devoted fewer than the four required rotations but were highly interested in integrating depression management or drug and alcohol treatment in practice. The most recent track graduate’s transition to practice exemplifies how becoming an “assertive practitioner” is actualized. The graduate works in an outpatient family medicine clinic serving patients from a rural and mid-sized urban area. She negotiated with her employer to include one 40-minute counseling appointment each day, an appointment that is now routinely filled. She identified herself through the practice website as having a strong clinical interest in the treatment of depression, anxiety, and attention deficit disorder and routinely counsels patients using cognitive-behavioral therapy and psychodynamic approaches. As a result of advanced residency training in mindfulness and acquisition of osteopathic manipulation skills, the track graduate is utilizing mindfulness techniques in most clinical encounters (especially with pain management) as part of a mind-body practice philosophy. She has begun offering behavioral science didactics to medical students and will be co-facilitating a Balint group at a nearby family medicine residency.
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Impact on Recruitment The creation of multiple tracks in the residency program has attracted a diverse pool of medical student applicants to the residency. All applicants are screened for track interest and most indicate they are attracted to the flexibility inherent in the tracks. In the most recent recruitment year, eight candidates indicated a primary interest in advanced behavioral science training. Some of those candidates are also interviewing at Family Medicine-Psychiatry programs and consider the Behavioral Medicine track an alternative because of time in training. Since 2004, eight matched residents have declared an intent at orientation to participate in the Behavioral Medicine track. By the time of advancement to PG-2 status, three residents were able to commit to the track. Of the residents who did not participate, attrition was due to remediation needs, commitment to a different track, or satisfaction with the quality of core behavioral science training. Scholarly Projects Every track resident presented a medical staff Grand Rounds on a behavioral science clinical topic as part of track completion requirements. Track residents have presented a total of six workshops or lectures at national meetings, two have presented original research at regional meetings, and one has co-authored a peer reviewed publication. COMPONENTS OF SUCCESS A specialized track in family medicine residency can only be implemented and succeed if there are sufficient qualified, committed residents. Despite high interest among applicants, after matching and completion of the PG-1 year, interested candidates defer for understandable reasons. Some find the core behavioral science curriculum sufficient; others use electives to strengthen their abilities in subspecialty areas, and some commit to other tracks. Participation in the track requires a significant commitment of resident time, focus, and energy and, consequently, participants must sustain a passion for behavioral science. Of note, all graduates of the behavioral medicine track had clinical or professional experience before or after medical school including teaching, military service, and/or providing mental health services. This was also true of the two “mini track” graduates who worked in mental health related positions between college and medical school. Diversity of experience and sufficient clinical exposure are essential in the track design. The CSM Program employs one full-time psychologist as Director of Behavioral Science and other faculty and staff with a strong behavioral science identity are embedded in the program. A dual-boarded family physicianpsychiatrist provides monthly lectures, a social worker-case manager is available full time, and a nurse behavioral health interventionist provides resident teaching
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and clinical intervention. The program is affiliated with the Medical College of Wisconsin and can access the medical school’s rich educational resources. In addition, track residents have access to CSM’s in-patient and out-patient mental health services, and other medical and mental health clinical services at a nearby regional medical center. Any program considering a behavioral medicine track (or any other track) must examine the nature and extent to which faculty resources will be allocated to the track and the program must attend carefully to meeting the educational needs of all residents. It is critical to create tracks such as Behavioral Medicine around a sufficient infrastructure rather than an individual faculty as faculty attrition weakens track experiences. Conversely, a track-oriented philosophy requires faculty who have a strong professional and clinical interest in the track area, mature skills, and a dedication to seeing residents succeed as assertive practitioners of behavioral science. Finally, although infrastructure considerations such as adequate resources, skilled faculty, and sufficient resident candidates are important, the success of a Behavioral Medicine track is contingent upon establishing a vision of the attributes and practice patterns of an exemplary family physician. The CSM Behavioral Medicine track is built upon a vision of an “assertive practitioner of behavioral science in family medicine,” a vision which track graduates are now advancing in practice. REFERENCES 1. Stephens GG. The behavioral sciences in family medicine. In Rosen GM, Geyman JP, Layton RH, editors. Behavioral Science in Family Medicine. New York: Appleton Century Crofts, 1980:3-14. 2. Engel GL. The need for a new medical model: A challenge for biomedicine. Science 1977;196:129-136. 3. Kern DE, Branch WT, Jackson JL, Brady DW, Feldman MD, Levinson W, Lipkin M. Teaching the psychosocial aspects of care in the clinical setting. Academic Medicine 2005;80:8-20. 4. Marvel MK, Doherty WJ, Baird MA. Levels of physician involvement with psychosocial concerns of individual patients: A developmental model. Family Medicine 1993;25:337-342. 5. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system. Archives of General Psychiatry 1978;35:685-693. 6. Schurman RA, Kramer PD, Mitchell JB. The hidden mental health network: Treatment of mental illness by nonpsychiatrist physicians. Archives of General Psychiatry 1985;42:89-94. 7. Katon W. The epidemiology of depression in primary care. International Journal of Psychiatry in Medicine 1987;17:93-112. 8. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Lowe B. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine 2007;146:317-325.
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9. Bodenheimer T, Chen E, Bennet H. Confronting the growing burden of chronic disease: Can the US health care workforce do the job? Health Affairs 2009;28:64-74. 10. Zimmerman GL, Olsen CG, Bosworth MF. A stages of change approach to helping patients change behavior. American Family Physician 2000;61:1409-1416. 11. Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Motivational interviewing. British Medical Journal 2010;340:c1900. 12. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in family medicine, 2011. Retrieved February 1, 2013 from http://www.acgme.org 13. Longlett S, Kruse J. Behavioral science education in family medicine: A survey of behavioral science educators and family physicians. Family Medicine 1992;24:28-35. 14. Marvel K, Majors G. What should we be teaching residents about behavioral science? Opinions of practicing family physicians. Family Medicine 1999;31:248-251. 15. Marvel K, Doherty W, Weiner E. Medical interviewing by exemplary family physicians. Journal of Family Practice 1998;47:343-348. 16. Prislin M, Lenahan P, Shapiro J. Family practice residency behavioral science training: Influence on graduate practice activity. Family Medicine 1997;29:483-487. 17. Holloway RL, Ambuel B, Butler DJ, Hamberger LK, Schmidt K, Ovide C, Ward R. Who is the assertive practitioner of behavioral medicine in family practice? In Holloway RL, editor. Clinics in family practice: Behavioral medicine in family practice. Philadelphia: WB Saunders, 2001;3:1-12. 18. The future of family medicine: A collaborative project of the family medicine community. Annals of Family Medicine 2004;2(suppl 1):S3-S32.
Direct reprint requests to: Dennis J. Butler, PhD Columbia-St. Mary’s Family Medicine Program 1121 E. North Avenue Milwaukee, WI 53212 e-mail: [email protected]
TRAINING THE “ASSERTIVE PRACTITIONER OF BEHAVIORAL SCIENCE”: ADVANCING A BEHAVIORAL MEDICINE TRACK IN A FAMILY MEDICINE RESIDENCY
DENNIS J. BUTLER, PHD Medical College of Wisconsin and Columbia-St. Mary’s Family Medicine Program RICHARD L. HOLLOWAY, PHD Medical College of Wisconsin DOMINIQUE FONS, MD University of Illinois School of Medicine and Carle Foundation Hospital Family Medicine Residency Program
ABSTRACT
Objective: This article describes the development of a Behavioral Medicine track in a family medicine residency designed to train physicians to proactively and consistently apply advanced skills in psychosocial medicine, psychiatric care, and behavioral medicine. Methods: The Behavioral Medicine track emerged from a behavioral science visioning retreat, an opportunity to restructure residency training, a comparative family medicine-psychiatry model, and qualified residents with high interest in behavioral science. Training was restructured to increase rotational opportunities in core behavioral science areas and track residents were provided an intensive longitudinal counseling seminar and received advanced training in psychopharmacology, case supervision, and mindfulness. Results: The availability of a Behavioral Medicine track increased medical student interest in the
Manuscript based on material presented at the 33rd Annual Forum for Behavioral Science Education in Family Medicine, 2012. 311 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.45.4.b http://baywood.com
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residency program and four residents have completed the track. All track residents have presented medical Grand Rounds on behavioral science topics and have lead multiple workshops or research sessions at national meetings. Graduate responses indicate effective integration of behavioral medicine skills and abilities in practice, consistent use of brief counseling skills, and good confidence in treating common psychiatric disorders. Conclusion: As developed and structured, the Behavioral Medicine track has achieved the goal of producing “assertive practitioners of behavioral science in family medicine” residents with advanced behavioral science skills and abilities who globally integrate behavioral science into primary care. (Int’l. J. Psychiatry in Medicine 2013;45:311-322)
Key Words: behavioral science, medical education, primary care, counseling
INTRODUCTION: CONCEPTUAL BACKGROUND FOR A BEHAVIORAL MEDICINE TRACK Family medicine residency training requires that all trainees receive training in the behavioral sciences, a requirement that has existed since the inception of the specialty [1]. The clinical application of behavioral science includes three major domains. The first, psychosocial medicine, acknowledges the profound effect that psychosocial factors play in health and, thus, the essential reliance on a biopsychosocial model to improve health [2-4]. Next, training in the recognition and management of those psychiatric disorders which commonly present in primary care is also required due to consistent evidence that the majority of patients with psychiatric difficulties are exclusively treated in primary care [5-8]. Finally, it is well documented that family physicians are the first point of care for patients with chronic medical conditions, conditions whose onset and course are highly correlated with lifestyle. Thus, family medicine residents receive training in the principles of behavioral medicine and techniques for fostering health behavior change [9-11]. While training in the domains of psychosocial medicine, psychiatry, and behavioral medicine is required by the Accreditation Council of Graduate Medical Education (ACGME) [12], there is no clear mandate on which skills trainees must possess and to what extent they must demonstrate those skills at the completion of residency. Multiple efforts have resulted in published curricula and recommended criteria yet there are no formally recognized, universally accepted behavioral science competencies that have been used to determine if a resident has successfully completed residency requirements [13, 14]. Although most family medicine residents acknowledge the importance of attending to psychosocial factors and the behavioral aspects of care, how graduates apply the knowledge, skills, and abilities they acquire in this domain can be quite variable. And, as with most training requirements, behavioral science
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training criteria are set at baseline or minimum expectations. Insufficient attention has been devoted to identifying the qualities of graduates who are exemplary at the integration of behavioral science related abilities in practice [15, 16]. Which skills, abilities, and attitudes are associated with clinicians who proactively, consistently, and effectively address psychosocial problems, manage psychiatric disorders, and target health behavior change utilizing behavioral medicine skills? How would such a graduate proactively, efficiently, and consistently integrate these abilities? This article describes a residency-based Behavioral Medicine track designed to develop such exemplars. In this track, residents are trained to become proactive “assertive practitioners” of behavioral science in family medicine through highly structured, individualized, intensive didactic and clinical experiences. The track was first offered in 2002 at the Columbia-St. Mary’s (CSM) Family Medicine Program in Milwaukee, Wisconsin. The track continues to be offered currently. TRACK AND CURRICULUM DEVELOPMENT The creation of a specialized training track in behavioral science at CSM had four major structural influences: a departmental retreat examining behavioral science training, a strategic restructuring of the CSM residency, a co-existing Family Medicine-Psychiatry residency program, and the presence of a qualified track candidate. Behavioral Science Visioning Retreat In 2000, behavioral science and physician faculty in the Department of Family and Community Medicine at the Medical College of Wisconsin participated in a visioning retreat which examined residency behavioral science education. The workgroup did not focus on specific training provided at the department’s five residency programs but addressed the larger question, “What attributes would a family physician possess who had achieved a well-rounded set of behavioral science skills?” The participants assumed that psychosocial practice is not a matter of “if” family physicians incorporate psychosocial factors in care, but rather “how.” Participants concurred that despite national curricula for behavioral science training and educational efforts to develop psychosocial skills in family medicine trainees, significant variability in the range and quality of skills acquired by residents existed, and, consequently, there was variability in the extent to which residents applied those skills and abilities in practice. The work group identified universal attributes that define the physician who is well trained in behavioral science and described such a clinician as an “assertive practitioner of behavioral science in family medicine.” Specific skills, abilities, and attitudes were identified in communication, clinical assessment and intervention (see Table 1). Advanced competencies in self-awareness and reflection, professional relationship skills and life-long learning were also identified [17].
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Table 1. Characteristic Skills of the Assertive Practitioner of Behavioral Science in Family Medicine TECHNICAL SKILLS FOR COMMUNICATION, ASSESSMENT, AND INTERVENTIONS The assertive practitioner of biopsychosocial family medicine is able to Communication 1. Communicate in a manner patients understand 2. Exhibit active listening skills 3. Demonstrate empathetic responses to patient’s experience 4. Find common ground with patients (e.g., consistently negotiates and develops effective treatment plans, solves problems, and resolves conflict) 5. Set appropriate boundaries in physician-patient relationships Assessment 6. Assess psychosocial context in more specificity than simple recognition (e.g., consistently assesses physical finding in psychosocial context) 7. Recognize and assess common psychosocial problems and diagnoses 8. Recognize important early psychosocial cues that lead to a psychosocial diagnosis. Includes diagnosis of common and not-miss psychiatric conditions and psychosocial conditions 9. Incorporate a developmental framework into patient care Intervention 10. Manage the most psychosocially challenging patients and accept cases others may not want or be able to handle 11. Intervene in crisis management situations SELF-AWARENESS, PROFESSIONAL RELATIONSHIPS, GROWTH SKILLS, AND LIFELONG SKILL DEVELOPMENT The assertive practitioner of biopsychosocial family medicine possesses the following characteristics: 1. Recognizes and accepts his or her personal and professional limitations 2. Appropriately self-discloses 3. Brings an attitude of openness and curiosity to patient care 4. Practices in an ethical and moral manner 5. Understands own feelings and life experiences and uses them to therapeutic advantage 6. Exhibits realistic sense of expectations regarding outcomes and management of psychosocial problems
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Table 1. (Cont’d.) 7. Anticipates and plans for psychosocial context of various interventions and encounters 8. Goes beyond traditional role expectations to achieve a patient outcome that is optimal. Steps forward to help a patient with a task usually performed by a nurse because this is the most immediate response to the patient. 9. Responds to patient’s needs rather than focusing on his or her own experience 10. Feels comfortable in many patient encounters and accepts a broad range of one’s own emotional responses as a natural part of daily practice 11. Is aware of boundaries between physician and patient 12. Exhibits skill in brief office-based psychosocial interventions, such as teaching basic stress management, parenting skills, and health behavior 13. Facilitates family meetings and interdisciplinary team meetings 14. Manages psychotropic medications as appropriate in primary care, seeking consultation when indicated 15. Pursues continued acquisition and implementation of psychosocial skills in practice across various practice environments COORDINATIVE SKILLS The assertive practitioner of biopsychosocial family medicine is able to 1. Collaborate with all members of the health care team, using a variety of specific skills: a. Communicating in writing, by telephone, and personally b. Communicating with all team members, nurses, office staff, psychotherapists, and physician colleagues c. Maintaining continuity in the collaboration by following up with each team member d. Actively clarifying role expectations with team members 2. Seek appropriate psychosocial consultation 3. Routinely work with psychosocial providers 4. Coordinate multiple provider involvement for patients with complex biopsychosocial issues 5. Make appropriate, well-prepared, informed referrals to psychosocial providers 6. Know the difference among various psychosocial providers and seek consultations and referrals appropriately
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Residency Program Redesign In 2002, CSM Residency Program faculty engaged in a strategic planning process to re-examine the program’s curriculum and structure. This effort was driven by recommendations in the Future of Family Medicine Report [18], the merger of two residency programs due to hospital consolidation, and feedback from medical students interested in primary care. Student applicants increasingly expressed interest in developing skills and creating more opportunities in diverse areas of family medicine including advanced obstetrics, international medicine, community and public health, sports medicine, and psychiatry. They were seeking more flexible training than that provided in the traditional family medicine curriculum. The faculty concluded that specialized tracks would allow flexibility in training, could be individually tailored, would provide advanced competencies in track areas, and still conform to ACGME requirements. The faculty catalogued training opportunities and personnel in the environment and committed to developing tracks in Obstetrics, Community Medicine, International Medicine, and Behavioral Medicine. Tracks were designed to be consistent with ACGME family medicine training requirements by allowing residents to pursue advanced training using elective rotation months. Dual Family Medicine-Psychiatry Program A 5-year Family Medicine-Psychiatry Residency program also was in place at CSM. The dual program consistently recruited high achieving residents who were attracted to practicing primary care medicine and psychiatry and who modeled advanced skills for a biopsychosocial approach to primary care. The dual residents practiced in parallel with the family medicine residents in clinic, on rotations, and on the family medicine hospital service. The integrated program provided examples of practicing assertive practitioners and offered a structural analogue for designing the track. This program continued until 2006 when an administrative decision was made to phase it out. Resident Interest The opportunity to translate the results of the visioning retreat, program restructuring, and the dual program model into a Behavioral Medicine track were actualized in 2002. A PG-2 family medicine resident with a strong interest in behavioral science, geriatrics, and rural practice expressed an interest in acquiring more advanced training in geriatric psychiatry, palliative care, and hospice care. After identifying appropriate resources, the track was implemented.
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CURRICULUM GOALS AND OBJECTIVES The Behavioral Medicine track is designed around three core behavioral science domains familiar to family medicine: psychosocial medicine, psychiatric care, and behavioral medicine. Residents selected for the track are expected during their track experience to: • proactively and effectively intervene in psychosocial problems commonly seen in primary care settings (intimate partner violence, adjustment difficulties, etc.); • possess and advance skills in patient-centered communication with patients across the lifespan; • demonstrate advanced competence in psychiatric diagnosis and psychopharmacologic management of psychiatric disorders seen in primary care; • develop advanced skills in understanding and working with systems and families; • develop expertise in office-based counseling skills using multiple modalities (solution-focused, CBT, supportive, BATHE, psychodynamic), and proactively utilize counseling and psychotherapy techniques in daily practice; • acquire advanced behavioral medicine skills designed to improve the health of patients and consistently apply specific health behavior change techniques (e.g., motivational interviewing); • routinely demonstrate use of self-awareness and reflection to improve patient care; • foster collaborative relationships with mental health professionals; and • develop scholarly abilities for presentation and/or research. The primary goal of the track is to train residents to become “assertive practitioners” who integrate the above skills and abilities throughout their clinical practice in a consistent, proactive fashion. Thus, a resident interested in advancing skills in the management of depression in primary care who chooses two psychiatry electives does not fit with the assertive practitioner model due to the narrow level of focus. All track residents commit to advanced training in the three domains of psychosocial medicine, psychiatry and behavioral medicine. TRACK STRUCTURE AND INSTRUCTIONAL METHODS Resident Selection Residents in the Behavioral Medicine track begin track activities in the second year of training. Acceptance is contingent upon good academic standing, commitment to a minimum of four elective rotations to track experiences, and a demonstrated interest in behavioral science in the first year of training or prior to residency. Track residents participate in individualized didactic activities,
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clinical rotations, and case supervision during their PG-2 and PG-3 years in addition to the core behavioral science requirements for all residents. Track residents must also identify an area of clinical focus in which they will develop expertise. The clinical areas of focus chosen by the first four track graduates were dementia assessment, depression management, attention deficit disorder treatment, and management of anxiety and depression in women. Finally, track residents must present a hospital Grand Rounds on a behavioral science related topic and submit a scholarly proposal for a national or regional conference. Rotations
Residents in the track dedicate a minimum of four and up to six elective rotations related to the three core domains which form the basis of the Behavioral Medicine track. Of these, one must be with a Consultation-Liaison Psychiatry service at a regional medical center. Over 20 rotations are identified in the program catalogue and include psychosocial experiences (child abuse center, domestic violence service, sexual assault treatment center), mental health rotations (psychotherapy center, dialectic behavior program, child psychiatry), or behavioral health experiences (pain management, wellness-mindfulness center). Population-based rotations are also available (child, adolescent, geriatric). Didactics Monthly Counseling Skills Seminar
Behavioral Medicine residents participate in a monthly seminar with the track director. The seminar is structured to provide 2 years of training in officebased counseling methods, beginning with generic methods (BATHE, supportive therapy) and advancing to more theoretical models (CBT, Psychodynamic Psychotherapy, Solution-focused). Residents are also taught problem formulation and assessment methods, skills, and strategies. Training in office counseling methods is based on a primary care oriented, time limited, brief treatment model. Residents are expected to identify counseling patients from their clinic panel and discuss active treatment. Psychopharmacology Training
A dual-boarded psychiatrist-family physician is responsible for a monthly Primary Care-Psychiatry didactic lecture and provides individualized consultation for the Behavioral Medicine track resident. Case Supervision
The Behavioral Medicine track resident also works individually with the track director to process issues in the care of difficult and challenging patients. In
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addition, the resident participates in the evaluation of patients referred to the family medicine clinic’s outpatient psychiatric consult service and receives training from the PG-4 psychiatry resident responsible for the consult service. Longitudinal Integration
Track residents are encouraged to maintain a log of behavioral science related experiences for all 24 rotations during their PG-2 and PG-3 training years. In addition they are expected to research or read rotation-relevant, behaviorallyoriented articles during each rotation (e.g., psychological adjustment to amputation while they are on a surgery rotation). Teaching
Residents on the track co-teach behavioral science topics in collaboration with the Director of Behavioral Science when available and appropriate.
TRACK IMPACT Resident Graduates Four residents have successfully completed the Behavioral Medicine track. Three practice in small to medium sized communities; one practices in a large metropolitan area. Two program graduates completed “mini” track experiences focused on more specific areas of interest. They devoted fewer than the four required rotations but were highly interested in integrating depression management or drug and alcohol treatment in practice. The most recent track graduate’s transition to practice exemplifies how becoming an “assertive practitioner” is actualized. The graduate works in an outpatient family medicine clinic serving patients from a rural and mid-sized urban area. She negotiated with her employer to include one 40-minute counseling appointment each day, an appointment that is now routinely filled. She identified herself through the practice website as having a strong clinical interest in the treatment of depression, anxiety, and attention deficit disorder and routinely counsels patients using cognitive-behavioral therapy and psychodynamic approaches. As a result of advanced residency training in mindfulness and acquisition of osteopathic manipulation skills, the track graduate is utilizing mindfulness techniques in most clinical encounters (especially with pain management) as part of a mind-body practice philosophy. She has begun offering behavioral science didactics to medical students and will be co-facilitating a Balint group at a nearby family medicine residency.
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Impact on Recruitment The creation of multiple tracks in the residency program has attracted a diverse pool of medical student applicants to the residency. All applicants are screened for track interest and most indicate they are attracted to the flexibility inherent in the tracks. In the most recent recruitment year, eight candidates indicated a primary interest in advanced behavioral science training. Some of those candidates are also interviewing at Family Medicine-Psychiatry programs and consider the Behavioral Medicine track an alternative because of time in training. Since 2004, eight matched residents have declared an intent at orientation to participate in the Behavioral Medicine track. By the time of advancement to PG-2 status, three residents were able to commit to the track. Of the residents who did not participate, attrition was due to remediation needs, commitment to a different track, or satisfaction with the quality of core behavioral science training. Scholarly Projects Every track resident presented a medical staff Grand Rounds on a behavioral science clinical topic as part of track completion requirements. Track residents have presented a total of six workshops or lectures at national meetings, two have presented original research at regional meetings, and one has co-authored a peer reviewed publication. COMPONENTS OF SUCCESS A specialized track in family medicine residency can only be implemented and succeed if there are sufficient qualified, committed residents. Despite high interest among applicants, after matching and completion of the PG-1 year, interested candidates defer for understandable reasons. Some find the core behavioral science curriculum sufficient; others use electives to strengthen their abilities in subspecialty areas, and some commit to other tracks. Participation in the track requires a significant commitment of resident time, focus, and energy and, consequently, participants must sustain a passion for behavioral science. Of note, all graduates of the behavioral medicine track had clinical or professional experience before or after medical school including teaching, military service, and/or providing mental health services. This was also true of the two “mini track” graduates who worked in mental health related positions between college and medical school. Diversity of experience and sufficient clinical exposure are essential in the track design. The CSM Program employs one full-time psychologist as Director of Behavioral Science and other faculty and staff with a strong behavioral science identity are embedded in the program. A dual-boarded family physicianpsychiatrist provides monthly lectures, a social worker-case manager is available full time, and a nurse behavioral health interventionist provides resident teaching
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and clinical intervention. The program is affiliated with the Medical College of Wisconsin and can access the medical school’s rich educational resources. In addition, track residents have access to CSM’s in-patient and out-patient mental health services, and other medical and mental health clinical services at a nearby regional medical center. Any program considering a behavioral medicine track (or any other track) must examine the nature and extent to which faculty resources will be allocated to the track and the program must attend carefully to meeting the educational needs of all residents. It is critical to create tracks such as Behavioral Medicine around a sufficient infrastructure rather than an individual faculty as faculty attrition weakens track experiences. Conversely, a track-oriented philosophy requires faculty who have a strong professional and clinical interest in the track area, mature skills, and a dedication to seeing residents succeed as assertive practitioners of behavioral science. Finally, although infrastructure considerations such as adequate resources, skilled faculty, and sufficient resident candidates are important, the success of a Behavioral Medicine track is contingent upon establishing a vision of the attributes and practice patterns of an exemplary family physician. The CSM Behavioral Medicine track is built upon a vision of an “assertive practitioner of behavioral science in family medicine,” a vision which track graduates are now advancing in practice. REFERENCES 1. Stephens GG. The behavioral sciences in family medicine. In Rosen GM, Geyman JP, Layton RH, editors. Behavioral Science in Family Medicine. New York: Appleton Century Crofts, 1980:3-14. 2. Engel GL. The need for a new medical model: A challenge for biomedicine. Science 1977;196:129-136. 3. Kern DE, Branch WT, Jackson JL, Brady DW, Feldman MD, Levinson W, Lipkin M. Teaching the psychosocial aspects of care in the clinical setting. Academic Medicine 2005;80:8-20. 4. Marvel MK, Doherty WJ, Baird MA. Levels of physician involvement with psychosocial concerns of individual patients: A developmental model. Family Medicine 1993;25:337-342. 5. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system. Archives of General Psychiatry 1978;35:685-693. 6. Schurman RA, Kramer PD, Mitchell JB. The hidden mental health network: Treatment of mental illness by nonpsychiatrist physicians. Archives of General Psychiatry 1985;42:89-94. 7. Katon W. The epidemiology of depression in primary care. International Journal of Psychiatry in Medicine 1987;17:93-112. 8. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Lowe B. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine 2007;146:317-325.
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9. Bodenheimer T, Chen E, Bennet H. Confronting the growing burden of chronic disease: Can the US health care workforce do the job? Health Affairs 2009;28:64-74. 10. Zimmerman GL, Olsen CG, Bosworth MF. A stages of change approach to helping patients change behavior. American Family Physician 2000;61:1409-1416. 11. Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Motivational interviewing. British Medical Journal 2010;340:c1900. 12. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in family medicine, 2011. Retrieved February 1, 2013 from http://www.acgme.org 13. Longlett S, Kruse J. Behavioral science education in family medicine: A survey of behavioral science educators and family physicians. Family Medicine 1992;24:28-35. 14. Marvel K, Majors G. What should we be teaching residents about behavioral science? Opinions of practicing family physicians. Family Medicine 1999;31:248-251. 15. Marvel K, Doherty W, Weiner E. Medical interviewing by exemplary family physicians. Journal of Family Practice 1998;47:343-348. 16. Prislin M, Lenahan P, Shapiro J. Family practice residency behavioral science training: Influence on graduate practice activity. Family Medicine 1997;29:483-487. 17. Holloway RL, Ambuel B, Butler DJ, Hamberger LK, Schmidt K, Ovide C, Ward R. Who is the assertive practitioner of behavioral medicine in family practice? In Holloway RL, editor. Clinics in family practice: Behavioral medicine in family practice. Philadelphia: WB Saunders, 2001;3:1-12. 18. The future of family medicine: A collaborative project of the family medicine community. Annals of Family Medicine 2004;2(suppl 1):S3-S32.
Direct reprint requests to: Dennis J. Butler, PhD Columbia-St. Mary’s Family Medicine Program 1121 E. North Avenue Milwaukee, WI 53212 e-mail: [email protected]
