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24 Resident andFaculty Well-Being andBurnout
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Interprofessional Education
andTeamwork
AshleyR.Wilk
25
Key Points
• Residency programs are greatly strengthened through the
integration of interprofessional teamwork with programspecic pharmacy and psychology professionals.
• Residency program psychologists and pharmacists
improve not only the patient care provided at family
medicine residency clinics but also the quality of education and training experience for resident physicians within
the program.
• Clinical pharmacists can provide immediate medication
consultations and best-t medication discussions with
residents while patients are present in the ofce.
• Having patient visits dedicated to reducing polypharmacy
or teaching the use of new medication are incredibly valuable services that clinical pharmacists can offer to residency clinic patients.
• Clinical pharmacists can provide excellent resident education on topics such as the cost of medication, prior
authorizations, and medication assistance programs,
which are generally not taught to a great extent during
medical school.
• Having a clinical psychologist on the residency program
faculty team encourages and streamlines resident efforts
to initiate therapy services or obtain psychometric assessments for their patients.
• Clinical psychologists can greatly assist resident physicians in performing risk assessments and determining the
next steps for clinic patients actively in crisis.
• Integration of a clinical psychologist within a residency
program promotes a culture of wellness and support for
resident physicians throughout their training and beyond.
A. R. Wilk (*)
Florida State University College of Medicine Residency at
BayCare Health System (Winter Haven), Winter Haven, FL, USA
e-mail: Ashley.Wilk@baycare.org
Interprofessional Education andTeamwork
Interprofessional education has been a core component of
family medicine education since the founding of the discipline. Some of the earliest residency programs included
chaplains, nutritionists, psychiatrists, social workers, medical librarians, and practice administrators as faculty members. Gayle Stephens, one of the founding fathers of family
medicine, described these professionals as critical to ensure
that family medicine could realize the “vision of the wholeness of the human organism” [1].
Today, family medicine training continues to emphasize
the importance of the health care team and has embraced
interprofessional education as central to the discipline. The
ten building blocks of primary care described by Tom
Bodenheimer and colleagues in 2014 identify team-based
care as one of the central pillars [2]. A team approach to care
is essential considering the sheer volume of work that a family physician must accomplish in one day. A study in 2009
demonstrated that a single physician caring for a panel of
2500 patients would spend more than 17hours per day providing all of the recommended acute, chronic disease, and
preventive care services recommended for that panel [3].
With such an overwhelming amount of work to do, which
has likely only increased since 2009, teams are necessary to
ensure high-quality care for patient panels. In residency programs, team members may not only assist with accomplishing the volume of recommendations but also provide a level
of continuity for patients that can be difcult to achieve with
yearly physician entry and graduation from the program.
Interprofessional teams may include advanced practice providers, nurses, pharmacists, care coordinators, social workers, or even individuals working in community-based
agencies, schools, or law enforcement [4].
Effective teamwork does not simply happen, though, by
the co-location of health care professionals trained in various
disciplines. A dedicated curriculum with clear competencies
in interprofessional teamwork to be achieved by trainees is
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_25
261
262
A. R. Wilk
essential to ensuring successful learning. Core competencies
in interprofessional teamwork have been developed by the
Interprofessional Education Collaborative (IPEC). The
IPEC, a coalition of over 20 health professions education
associations committed to developing best practices for
interprofessional education in medicine, updated their Core
Competencies for Interprofessional Collaborative Practice in
2023. The four key competencies for successful team members include:
• Ensuring that team members develop and maintain shared
values, ethical conduct, and mutual respect.
• Dening roles and responsibilities for each team member
and assessing if members understand their own and others’ roles and areas of expertise.
• Communication which focuses on ensuring responsible,
respectful, and compassionate communication among
team members, and
• Teams and teamwork wherein the scientic principles of
optimal teamwork are adapted and applied within the
team setting [5].
These key competencies provide a framework as family
medicine residencies begin to develop experiences aimed at
fostering and evaluating skills in interprofessional teamwork. Studies have shown that experiences ranging from
weeklong immersion to semester-long episodic learning
events can have an impact on improving interprofessional
competencies [6–8]. Rather than being a single model of best
practice for developing interprofessional teamwork competence multiple types of learning activities may promote
improved skills and effectiveness.
While all family medicine residents interact with other
health professionals on a daily basis, that interaction may or
may not constitute interprofessional teamwork. Reeves noted
that multiple types of interprofessional interactions exist [9].
For example, networks are where teams complete predictable,
minimally complex tasks that may be accomplished asynchronously. Conversely, interprofessional teamwork or collaboration may occur when individuals share responsibility for
unpredictable, urgent, and complex tasks [9]. For example, a
family medicine ofce may have systems where a nurse and
physician communicate through chart messages to convey lab
results to a patient. While this may be an example of interprofessional work, it is a different type of interaction than may
occur between a physician and psychologist who co-manages
a patient with complex physical and mental health needs.
While there is no one-size-ts-all approach to designing
interprofessional teams for family medicine residency programs, the following sections of this chapter will provide
examples of how an individual program has integrated a
clinical psychologist and pharmacist into interprofessional
teams in their residency programs.
Interprofessional Teamwork withClinical
Pharmacists
At the Winter Haven Family Medicine Residency program,
integrating a clinical pharmacist into the family medicine
residency clinic team has proven benecial for both resident
education and patient care. As part of the precepting team
during ambulatory sessions, the pharmacist is available for
tableside consultations to optimize medication treatment
choices based on patient co-existing conditions, nancial
resources, and existing medications. It is important to note
that the pharmacist does not simply provide answers, but
rather teaches the residents how to go about obtaining the
answers. Assisting the residents in navigating pharmaceutical databases and prescription resources empowers them
with the knowledge they can use during residency and
beyond in their practice following graduation.
Furthermore, pharmacists may play a critical role in the
operation of the family medicine center as a member of the
healthcare team providing essential services for patients. For
pharmacists to enjoy a robust clinical role within the practice, several elements may be needed including a
Collaborative Practice Agreement, adequate electronic
health record capabilities for the generation of accurate registries, and an understanding of the billing that may or may
not be possible in every program [10].
Depending on the scope of practice determined, a pharmacist may provide a dedicated visit for medication review
for indications such as patient polypharmacy or adverse
effects of medication. This time-intensive process can be
challenging for resident physicians to accommodate during a
busy ofce visit schedule. A pharmacist may improve the
quality of care provided by the family medicine resident by
making recommendations to simplify medication regimens
or eliminating prescriptions causing signicant side effects.
Some practices use an in-ofce referral system whereby the
family physician identies and refers patients who would
benet from a pharmacist visit whereas others have established protocols where all patients with a specic number or
class of medications are automatically referred [10]. Too,
some practices may identify patients who are initiating therapy with medications to meet with a pharmacist for additional education to improve patient adherence [10].
Similarly, pharmacists may play an important role in
providing optimal care and educating residents about
chronic disease management. For example, COPD and
asthma are commonly encountered diagnoses within family
medicine and the number of medications and inhaler types
available on the market seems to continually increase.
When a clinic patient is prescribed a new inhaled medication, it is vitally important that the patient knows how to
properly use the inhaler and receive the correct dose of
their prescribed medication. With the multitude of inhalers
25 Interprofessional Education andTeamwork
263
available, it can be benecial for the patient to have a consultation with the clinical pharmacist to learn and teach
back exactly how to use their new inhaler. Similarly, with
injectable medications such as for the treatment of diabetes, patients, and physicians have found benet in pharmacist visits or co-visits with the family medicine resident for
the patient to receive injection teaching. In addition to the
one-time visit for medication teaching, pharmacists may be
integrated into the care team to provide regularly scheduled
visits to escalate therapy when needed. Furthermore, pharmacists may play a vital role in helping to ensure that
patients have appropriate medication coverage based on
changing insurance formularies and requirements. In the
Winter Haven family medicine residency program, physicians have found increased compliance with patient medication use when the patient has received this training and
feels empowered to correctly take their medications.
In addition to clinical work, the pharmacist perspective
can provide an important addition to residency didactics.
Clinical pharmacists may partner with family medicine faculty to discuss topics such as guidelines on goal-directed
therapy for heart failure and optimization of controlling type
2 diabetes. Also, lecture presentations on topics such as the
cost of medications or understanding types of insurance coverage plans may be important contributions from faculty
pharmacists.
Interprofessional Teamwork withClinical
Psychologists
An estimated 75% of primary care ofce visits include components of mental or behavioral health. This not only includes
diagnosis and management of mood disorders such as anxiety, depression, and bipolar disorder, but also behavioral
aspects of chronic disease management. Best practices in the
treatment of medical conditions including hypertension, diabetes, and obesity include lifestyle and behavioral modication approaches. The importance of behavioral science
faculty in family medicine residencies cannot be overstated.
In addition to the dedicated chapter for teaching behavioral
science concepts to residents that is included in this book, the
following provides one residency program’s description of
how interprofessional teamwork with a clinical psychologist
has enriched resident training.
At the Winter Haven family medicine residency program
interprofessional teamwork of family physicians and clinical
psychologists has resulted in numerous benets both in
patient care and in comprehensive residency training. In the
primary care setting, psychologists can utilize strategies such
as motivational interviewing to assist patients in making positive lifestyle changes like smoking cessation, increasing
physical activity, improving medication compliance, and
modifying their diet when facing a new diagnosis such as
diabetes. Psychologists can also assist physicians and
patients in troubleshooting barriers to making these lifestyle
changes. When patients do successfully make these changes,
disease control improves and the physician-patient relationship improves.
Family physicians are often the rst providers that patients
turn to with concerns regarding their mental health. Diagnosis
and management of anxiety, depression, and other mood disorders is well within the scope of family medicine and most
often includes both pharmacologic and non-pharmacologic
components. The non-pharmacologic services that clinical
psychologists are able to offer patients are extensive and
include Cognitive Behavioral Therapy (CBT), Acceptance
and Commitment Therapy (ACT), Dialectical Behavioral
Therapy (DBT), and Interpersonal Process Therapy (IPT).
Psychologists can use their expertise to tailor the therapy format to best t an individual patient’s needs [11]. Unfortunately,
there tend to be barriers to patients obtaining psychological
services in many communities including nding an appropriate provider and, occasionally, patients’ concern for the
stigma of obtaining mental health services. Psychologist
presence in the family physician ofce setting allows the family physician to refer their patient to a known, skilled behavioral health colleague. It also offers patients access to mental
health services in a familiar setting which can ease the trepidation that may come with starting therapy.
At the Winter Haven family medicine residency program’s ofce, when feasible, patients being referred to establish with the psychology team for therapy are introduced to
their future therapist during a routine ofce visit with their
PCP.This warm handoff has improved the chances that the
patient will follow through with coming in for their initial
therapy appointment and receiving those important services.
Throughout the patient’s course of therapy, it is easy and
convenient for the psychologist to discuss the patient’s progress with their PCP, and all visit notes can be viewed within
the shared EMR.If any concerns arise regarding the patient’s
pharmacotherapy, the psychologist can easily discuss them
with the patient’s PCP as well. Residents spend time with the
clinical psychologist during their behavioral health rotation
and have the opportunity to observe therapy sessions. This
provides the residents with a deeper insight into different
therapy modalities that go beyond simply referring a patient
for counseling.
Behavioral health emergencies, including management of
an actively suicidal patient in the outpatient setting, are challenging even for the most experienced family physician.
These crisis interventions are incredibly time-consuming,
high-risk situations. Having a psychologist to accompany a
family physician, particularly a resident physician, in this
type of encounter helps in performing risk assessments and
developing a safety plan.
264
A. R. Wilk
The behavioral health team also provides psychometric
assessment for a multitude of behavioral conditions including autism, ADHD, intellectual disabilities, dementia, and
mood disorders. While within the scope of primary care,
thorough evaluations and objective workups for these conditions can be quite time-consuming for busy physicians and
an integrated psychologist can perform this assessment and
workup. Given that the behavior health team is integrated
into the residency ofce, communication of results is streamlined and the next steps in patient care can be efciently
developed in a collaborative manner between the psychologist and family physician.
With respect to the professional development of residents,
the psychologist is able to co-lead Balint groups with family
medicine physician faculty members in which residents can
present and discuss the doctor-patient relationship aspect of
patient cases. The goal for Balint group is to ensure that
members have a forum for a facilitated discussion focused on
understanding both different perspectives (patient, family
members, etc.) of care and how thoughts and feelings impact
the doctor-patient relationship. Ultimately, these groups
expand the physicians’ capacities to manage difcult patient
interactions and are incredibly benecial to integrate into
family medicine residency programs to allow new physicians
to explore these important behavioral aspects of practicing
medicine. Our monthly Balint groups are conducted with
each resident class and are co-facilitated by a family physician and clinical psychologist with consistent facilitators for
each class throughout the duration of the program. This has
improved trust and cohesion within each Balint group.
Clinical psychologist faculty members have also facilitated assistance for individual residents who may be struggling with increased stress or difcult situations in training.
For example, debrieng after a difcult patient encounter or
the loss of a patient or discussing personal stressors that are
impacting the resident’s clinical performance have been
areas where the psychologist has played a particularly important faculty role. Having a behavioral health professional onsite has, undoubtedly, improved the culture of support within
our program and emphasized the importance of wellness
within residency programs and for all physicians, at large.
References
1. Stephens GG. The intellectual basis of family practice. Tucson:
Winter Publishing Co; 1982.
2. Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K.The 10
building blocks of high-performing primary care. Ann Fam Med.
2014;12(2):166–71. https://doi.org/10.1370/afm.1616.
3. Yarnall KS, Østbye T, Krause KM, etal. Family physicians as team
leaders: “time” to share the care. Prev Chronic Dis. 2009;6(2):A59.
4. Arenson C, Brandt BF. The importance of interprofessional practice in family medicine residency education.
Fam Med. 2021;53(7):548–55. https://doi.org/10.22454/
FamMed.2021.151177.
5. Interprofessional Education Collaborative. IPEC core competencies
for interprofessional collaborative practice: version 3. Washington,
DC: Interprofessional Education Collaborative; 2023. Accessed 18
Mar 2024.
6. Zeien J, Hanna J, Yee S, De Castro A, Puracan J, Ervin B, Kang P,
Harrell S, Hartmark-Hill J.Education without walls: using a street
medicine program to provide real-world interprofessional learning.
J Interprof Care. 2023;37(1):91–9. https://doi.org/10.1080/135618
20.2021.2016663. Epub 2022 Jan 11. PMID: 35015588.
7. Boland DH, Scott MA, Kim H, White T, Adams E.Interprofessional
immersion: use of interprofessional education collaborative competencies in side-by-side training of family medicine, pharmacy,
nursing, and counselling psychology trainees. J Interprof Care.
2016;30(6):739–46. https://doi.org/10.1080/13561820.2016.12279
63. PMID: 27797630.
8. Linn BS, Smith BEY, Cassel T. Impact of collaborative inpatient
pairing between pharmacy students and family medicine residents
on perceptions of interprofessional care. PRiMER. 2022;6:14.
https://doi.org/10.22454/PRiMER.2022.661338. PMID: 35801194;
PMCID: PMC9256298.
9. Reeves S, Xyrichis A, Zwarenstein M. Teamwork, collaboration, coordination, and networking: why we need to distinguish
between different types of interprofessional practice. J Interprof
Care. 2018;32(1):1–3. https://doi.org/10.1080/13561820.2017.14
00150.
10. Teichman P, Wan S.How to integrate clinical pharmacists into primary care. Fam Pract Manag. 2021;28(3):12–7.
11. Siev J, Cambless DL. Specicity of treatment effects: cognitive
therapy and relaxation for generalized anxiety and panic disorders.
J Consult Clin Psychol. 2007;75(4):513–22.
Part VII
Teaching Skills and Challenging Curricular Elements
Practical Didactic, Bedside, andOffice
Teaching Skills
W.FredMiser
26
Key Points
• Learning is facilitated when the clinical environment is
perceived as safe and encourages active participation and
autonomy.
• Residents learn best when they are active participants and
understand the practical nature of the material.
• Excellent clinical teachers act as professional role models, effective clinical supervisors, dynamic instructional
leaders and scholars, and supportive individuals.
• Feedback should be safe, respectful, and nonjudgmental
with the goal of guiding future performance.
• For a lecture to be effective it must be focused with a few
key teaching points that actively involve the audience.
• Seeing the patient together at the bedside provides a great
learning opportunity for residents and enhances patient
satisfaction.
• Use of the One-Minute Preceptor model in the ofce
enhances teaching and patient care.
• Training residents on how to teach facilitates their own
learning and those of other learners.
Clinical teaching in the patient care environment is a critical
task required of all family medicine (FM) faculty in a residency program, with the goal of transforming novice rstyear residents into practicing family physicians capable of
providing competent care autonomously [1]. Faculty have
the important responsibility for teaching both the art and science of clinical medicine to residents [2]. As noted by Irby,
this often presents several challenges [1]. Faculty often will
simultaneously teach learners at various levels of experience,
from beginning medical students to senior residents. Patients
often present issues that are complex, undifferentiated, and
W. F. Miser (*)
Department of Family and Community Medicine, The Ohio State
University, Columbus, OH, USA
e-mail: Fred.Miser@osumc.edu
unpredictable which precludes preparation for teaching.
Faculty require a wide variety of teaching styles from providing a lecture to a large audience to bedside teaching in a
small group setting to Socratic dialogue in a one-to-one
teaching encounter [2]. Finally, faculty have the responsibility for not only teaching but also ensuring excellent, safe,
quality patient care occurs.
In this chapter we will rst lay the groundwork for learning in the clinical environment, characteristics of residents as
adult learners, traits of outstanding clinical teachers, various
teaching styles, and the skill of providing feedback. We will
then focus on three major teaching environments: (1) large
group (delivering a dynamic presentation), (2) small group
(team rounding in the hospital setting), and (3) one-on-one
(ambulatory precepting in the ofce).
The Clinical Learning Environment
In clinical education, the learning environment consists of
the patient, the resident, and the faculty member, with the
focus being on providing safe quality care for the patient.
Interactions in this environment include the resident with the
patient, the faculty member with the patient, and the resident
with the faculty member. It is here that the patient presents
learning opportunities for the resident and teaching opportunities for the faculty member. Faculty have the important
responsibility of promoting learning and helping the residents acquire the knowledge, clinical skills, behaviors, and
attitudes necessary to deliver quality health care. Faculty
also have the responsibility to ensure the patient receives
safe, high-quality health care. To enhance learning the environment should be interactive, safe, nonthreatening, and
nonjudgmental.
David Kolb, Ph.D., a psychologist and educational theorist, studied experiential learning [3]. He proposed that learning is “the process whereby knowledge is created through
the transformation of experience.” That is, learning is princi-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_26
267
268
W. F. Miser
pally accomplished through doing [1]. Kolb further noted
that learning is a continuous process grounded in that experience. The stages of experiential learning involve active rather
than passive learning and are the framework for clinical
teaching.
Another important aspect of teaching for faculty is the
ability to assess a resident’s competency in preparation for
future autonomous practice. Dr. George E.Miller in 1990
introduced a new model for the assessment of clinical competency, known as the Miller Pyramid [4]. This model has
four, hierarchical levels of development of clinical competence. At the base is “knowledge” which is often tested by
written exams, such as the American Board of Family
Medicine In-Training Examination. The next level Miller
dened as “knows how” which is the skill that the resident
is able to acquire data from the patient, to analyze and
interpret the data, and translate the ndings into a rational
management plan. The third tier in the pyramid is the ability of the resident to “show how” they have incorporated
the knowledge and competency to perform patient care on
the hospital ward or in the ofce. The top skill of this pyramid is the resident actually demonstrating these skills with
patient care, which can be assessed by directly observing
the resident in the examination room with the patient.
A necessary skill for faculty is to provide professional
support and encouragement in dealing with the stresses of
the clinical environment [5]. Showing empathy, warmth, and
acceptance allows residents to be more willing to acknowledge their limitations, any confusion, and mistakes they may
have made. To enhance learning residents must have freedom from fear and feel empathy, warmth, and genuineness
of their faculty.
Learning is facilitated when the environment encourages
active participation, encourages autonomy, and promotes
adaptation rather than defensiveness. Differences should be
viewed as good and desirable as they promote collaborative
learning. Individuals involved in the learning process should
feel respected.
Characteristics ofResidents asAdult
Learners
It is important to understand that residents as adults learn
differently than do children. In 1968 Malcolm Knowles,
PhD, an educator, coined the term “andragogy” to differentiate how adults learn compared to how children learn (“pedagogy”) [6, 7]. Although there are many theories of adult
learning, key characteristics exist of the adult learner.
Keeping these characteristics in mind while teaching will
enhance residents’ learning. The goal of adult learning is to
build new knowledge, skills, and attitudes in relation to prior
experiences and knowledge.
Adults are self-directed, feel a need to learn, and have a
sense of responsibility for their own learning [8]. Adults
learn best when they assume responsibility for their own
education, with an emphasis on being active, rather than passive, participants in the process. Adults need to understand
why they need to learn something and that it is practical [9].
Adults want to apply what they learn soon after they learn it.
Adults like to solve problems and not just learn facts. To
improve problem-solving skills, residents must actively participate in the learning process [1].
The human brain can process only a nite amount of
material at one given time, creating a “bottleneck effect” for
learning [10]. To avoid this cognitive overload it is best to be
selective about relevant teaching pearls. Learning is best
when residents can process at their own pace. Motivation
increases when adult learners help set learning objectives—
motivation is highest when the subject matter relates to the
immediate interests and concerns of adult learners. Adults
like to know how well they are doing; feedback helps them
assess their own progress. Adults like to be actively involved
in teaching others what they have learned.
Traits ofOutstanding Clinical Teachers
The four key characteristics of excellent clinical teachers are
physician role model, effective clinical supervisor, dynamic
instructional leader/scholar, and supportive individual [1, 11,
12]. Outstanding clinical educators demonstrate competence
and caring. They delegate responsibility for patient care, provide opportunity for residents to do procedures, and provide
direction and constructive feedback. They are enthusiastic
about teaching, available and accessible to residents, engaged
in dialogue with residents, and provide answers and clear
explanations. They are friendly, helpful, caring, and supportive,
establish rapport with residents, show a positive attitude toward
teaching, and facilitate learning. The best clinical teachers are
not only knowledgeable about the clinical content of medicine,
but also knowledgeable about their learners, with the ability to
connect them with the subject matter, and knowledgeable about
the general principles of teaching and learning [13, 14].
In a large random sample of medical school faculty, residents, and students, Irby identied and subsequently veried
seven attributes of outstanding clinical teachers [5, 13].
Excellent teachers have a good breadth of medical knowledge with the ability to discuss current developments, reveal
broad reading, discuss divergent points of view, and are able
to share useful and relevant evidence-based medical literature with the resident. They are enthusiastic in their teaching
by being dynamic and energetic—one can easily see that
they enjoy teaching. Outstanding teachers present in an organized and clear manner, emphasizing what is important and
communicating expectations as to what is to be learned.