Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз: Предмет: Файл:
Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2725_Библиотеки_им_академика_М_И_Перельмана.pdf
Скачиваний:
0
Добавлен:
31.08.2026
Размер:
31 Мб
Скачать
320
E. T. Perryman and M. A. Dixon
cians by establishing the development of adaptive lifelong learners, as opposed to “checking the box” on skills, which is an expected outcome of CBME.
What does this mean for family physicians? Family medi-
cine physicians will be expected to learn how to adapt to a variety of settings, adjusting their level of professional devel­opment as necessary, to provide the best quality care as much and as often as possible. Equal focus on the development of knowledge and skills with teaching and evaluation, in medi­cal education, and with regards to physician leadership development, will be key to their future success in an ever­changing world with competing demands. Graduate medical education continues to remain an environment of practical balance: simultaneous critical thinking and skills mastery. Family medicine residencies are primed to teach residents how to proactively practice professionalism through the use their own inherent strengths, as well as continuously inte­grating education and experience to inform their practice, and this balanced approach will be paramount to the contin­ued success of the next generation of family medicine physicians.

References

1. ACGME: Program Requirements, Family Medicine. Professionalism. 2008. https://www.acgme.org/globalassets/
PDFs/commonguide/IVA5e_EducationalProgram_ACGME Competencies_Professionalism_Explanation.pdf
2. ACGME: Program Requirements, Family Medicine. Professionalism. 2024.
3. Albanese MA, Mitchell S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad Med. 1993;68(1):52–81.
4. American Academy of Family Physicians. The specialty of family medicine. Family Medicine: The Center of Primary Care. Leawood, Kansas; 2023.
5. American Board of Family Medicine. Guidelines for professional­ism, licensure, and personal conduct. Version 2022–2. 2022.
6. Anderson LW, Krathwohl DR, Airasian PW, Cruikshank KA, Mayer RE, Pintrich PR, Raths J, Wittrock MC, editors. A taxon­omy for learning, teaching and assessing: a revision of Bloom’s taxonomy of educational. NewYork: Longman; 2001.
7. Batalden P, Leach D, Swing S, Dreyfus H, Dreyfus S.General com­petencies and accreditation in graduate medical education. Health Aff. 2002;21(5):103–11.
8. Birden H, Glass N, Wilson I, Harrison M, Usherwood T, Nass D. Dening professionalism in medical education: a systematic review. Med Teach. 2014;36(1):47–61.
9. Bloom BS, Engelhart MD, Furst EJ, Hill WH, Krathwohl DR, (Eds). Taxonomy of educational objectives: the classication of educational goals. Handbook 1: cognitive domain. David McKay Company; 1956.
10. Caesens G, Stinglhamber F, Demoulin S, De Wilde M, Mierop A. Perceived organizational support and workplace conict: the mediating role of failure-related trust. Front Psychol. 2019;9:2704.
11. Canadian Medical Protective Association. Leadership essentials: 3 steps to creating psychological safety. 2020.
12. Castillo EG, Isom J, DeBonis KL, Jordan A, Braslow JT, Rohrbaugh R. Reconsidering systems-based practice: advancing structural
competency, health equity, and social responsibility in graduate medical education. Acad Med. 2020;95(12):1817–22.
13. Clark TR. The 4 stages of psychological safety. Berrett-Koehler Publishers: Oakland, California; 2019
14. Cooper AZ, Richards JB. Lectures for adult learners: break­ing old habits in graduate medical education. Am J Med. 2017;130(3):376–81.
15. Cross KP.Adults as learners. Increasing participation and facilitat­ing learning. San Francisco: Jossey-Bass; 1981.
16. Cruess RL, Cruess SR. Professionalism, communities of prac­tice, and medicine’s social contract. J Am Board Fam Med. 2020;33(Suppl):S50–6.
17. Deci EL, Ryan RM. Self-determination theory: a macrotheory of human motivation, development, and health. Can Psychol. 2008;49(3):182–5.
18. Dreyfus SE.The ve-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24(3):177–81.
19. Forehand M. Bloom’s taxonomy. Emerg Perspect Learn Teach Technol. 2010;41(4):47–56.
20. Frank JR, Mungroo R, Ahmad Y, Wang M, De Rossi S, Horsley T.Toward a denition of competency-based education in medi­cine: a systematic review of published denitions. Med Teach. 2010;32(8):631–7.
21. French H, Arias-Shah A, Gisondo C, Gray MM.Perspectives: the ipped classroom in graduate medical education. NeoReviews. 2020;21(3):e150–6.
22. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affect­ing physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Health Q. 2014;3(4):1.
23. Gómez-Durán EL, Vizcaíno-Rakosnik M, Martin-Fumadó C, Klamburg J, Padrós-Selma J, Arimany-Manso J.Physicians as sec­ond victims after a malpractice claim: an important issue in need of attention. J Healthc Qual Res. 2018;33:284–9.
24. Hadie SNH. The application of learning taxonomy in anatomy assessment in medical school. Educ Med J. 2018;10(1):13–23.
25. Halperin EC. Grievances against physicians: 11 years’ experi­ence of a medical society grievance committee. West J Med. 2000;173(4):235–8.
26. Hilton S, Southgate L.Professionalism in medical education. Teach Teach Educ. 2007;23(3):265–79.
27. Hyer SM, Dixon MA. Motivational interviewing and self­determination theory in suicide assessment: a practical applica­tion to aid residents’ management of suicide. Int J Psychiatr Med. 2022;57(5):413–22.
28. Johns JA, Moyer MT. The attitudes, beliefs, and norms frame­work: a tool for selecting student-centered, theory-informed affec­tive learning objectives in health education. J Health Educ Teach. 2018;9(1):14–26.
29. Kern DE, Thomas PA, Howard DM, Bass EB.Curriculum develop­ment for medical education: a six-step approach. Baltimore: Johns Hopkins University Press; 1998.
30. Kirk LM. Professionalism in medicine: denitions and consider­ations for teaching. Baylor Univ Med Cent Proc. 2007;20(1):13–6. Taylor & Francis.
31. Kotsis SV, Chung KC. Application of the “see one, do one, teach one” concept in surgical training. Plast Reconstr Surg. 2013;131(5):1194–201. https://doi.org/10.1097/PRS.
0b013e318287a0b3.
32. Krathwohl DR. A revision of Bloom’s taxonomy: an overview. Theory Pract. 2002;41(4):212–8.
33. Krathwohl DR, Bloom BS, Masia BB. Taxonomy of educational objectives: the classication of educational goals. Handbook II: affective domain. NewYork: David McKay Co; 1964.
34. Lucado M. When god whispers your name. Thomas Nelson Publishers; 2011.
29 Teaching andEvaluating Professionalism inFamily Medicine
321
35. Mackin R, Baptiste S, Niec A, Kam AJ.The hidden curriculum: a good thing? Cureus. 2019;11(12):e6305.
36. Manson H.The need for medical ethics education in family medi­cine training. Fam Med. 2008;40(9):658–64.
37. Martimianakis MAT, Michalec B, Lam J, Cartmill C, Taylor JS, Hafferty FW. Humanism, the hidden curriculum, and educa­tional reform: a scoping review and thematic analysis. Acad Med. 2015;90(11):S5–S13.
38. Mickan S, Rodger S.Characteristics of effective teams: a literature review. Aust Health Rev. 2000;23:201–8.
39. Miller GE. The assessment of clinical skills/competence/perfor­mance. Acad Med. 1990;65(9):S63–7.
40. Peña A.The Dreyfus model of clinical problem-solving skills acqui­sition: a critical perspective. Med Educ Online. 2010;15(1):4846.
41. Prakash B. Patient satisfaction. J Cutan Aesthet Surg. 2010;3(3):151–5.
42. Riley BA, Riley G.Innovation in graduate medical education–using a competency based medical education curriculum. Int J Osteopath Med. 2017;23:36–41.
43. Rohrich RJ. “See one, do one, teach one”: an old adage with a new twist. Plast Reconstr Surg. 2006;118(1):257–8.
44. Ronquillo Y, Ellis VL, Toney-Butler TJ.Conict management. In: StatPearls. Treasure Island: StatPearls Publishing; 2023.
45. Rosen MA, Diaz Granados D, Dietz AS, Benishek LE, Thompson D, Pronovost PJ, Weaver SJ.Teamwork in healthcare: key discoveries enabling safer, high-quality care. Am Psychol. 2018;73(4):433–50.
46. Ross S, Pirraglia C, Aquilina AM, Zulla R.Effective competency­based medical education requires learning environments that pro­mote a mastery goal orientation: a narrative review. Med Teach. 2022;44(5):527–34.
47. Rothenberger DA. Physician burnout and well-being: a sys­tematic review and framework for action. Dis Colon Rectum. 2017;60(6):567–76.
48. Sawyer T, White M, Zaveri P, Chang T, Ades A, French H, … Kessler D.Learn, see, practice, prove, do, maintain: an evidence-
based pedagogical framework for procedural skill training in medi­cine. Acad Med. 2015;90(8):1025–33.
49. Schneiderhan J, Guetterman TC, Dobson ML. Curriculum development: a how to primer. Fam Med Commun Health. 2019;7(2):e000046.
50. Sudak DM.Handbook of psychiatric education. Washington, DC: American Psychiatric Association Publishing; 2021.
51. Taylor DC, Hamdy H. Adult learning theories: implications for learning and teaching in medical education: AMEE guide no. 83. Med Teach. 2013;35(11):e1561–72.
52. Theard MA, Marr MC, Harrison R.The growth mindset for chang­ing medical education culture. EClinicalMedicine. 2021;37:100972.
53. van Mook WN, Gorter SL, Kieboom W, Castermans MG, de Feijter J, de Grave WS, Zwaveling JH, Schuwirth LW, van der Vleuten CP. Poor professionalism identied through investi­gation of unsolicited healthcare complaints. Postgrad Med J. 2012;88(1042):443–50.
54. Veloski J, Hojat M.Measuring specic elements of professional­ism: empathy teamwork, and lifelong learning. In: Stern DT, editor. Measuring medical professionalism. Oxford: Oxford University Press. Chapter 7; 2006. p.117–45.
55. West CP, Dyrbye LN, Shanafelt TD.Physician burnout: contributors, consequences and solutions. J Intern Med. 2018;283(6):516–29.
56. Wofford MM, Wofford JL, Bothra J, Kendrick SB, Smith A, Lichstein PR.Patient complaints about physician behaviors: a qual­itative study. Acad Med. 2004;79(2):134–8.
57. Wolfe AD, Hoang KB, Denniston SF. Teaching conict resolu­tion in medicine: lessons from business, diplomacy, and theatre. MedEdPORTAL. 2018;14:10672.
58. Yazdankhahfard M, Haghani F, Omid A. The Balint group and its application in medical education: a systematic review. J Educ Health Promot. 2019;8:124.
59. Zaidi NLB, Grob KL, Monrad SM, Kurtz JB, Tai A, Ahmed AZ, … Santen SA.Pushing critical thinking skills with multiple- choice ques­tions: does Bloom’s taxonomy work? Acad Med. 2018;93(6):856–9.

Teaching Behavioral Science

AllisonBickett, LaurenPenwell-Waines, ChristopherM.Haymaker, andLindaMyerholtz
30
Key Points
• Behavioral medicine has been an important part of the family medicine curriculum since the specialty’s inception.
• The behavioral medicine curriculum evolved in the rst 30years, without a high degree of standardization across programs.
• The Accreditation Council for Graduate Medical Education (ACGME) and American Academy of Family Physicians (AAFP) developed sets of standards and guidelines to ensure that graduate medical education pro­grams provide a high-quality educational experience that prepares family physicians to autonomously deliver safe, effective, and patient-centered care.
• The ACGME requirementsstate that a faculty member mustbe dedicated to a behavioral science curriculum.
• The ACGME requirements state that family medicine residents must experience training in integrated behav­ioral health in primary care.
• A group of behavioral scientists through the Society of Teachers of Family Medicine developed a core set of competencies necessary for the provision of a behavioral medicine curriculum.
A. Bickett (*) Department of Family Medicine, Atrium Health, Charlotte, NC, USA e-mail: Allison.Bickett@atriumhealth.org
L. Penwell-Waines Novant Health Family Medicine Residency Program, Cornelius, NC, USA e-mail: Lmpenwell-waines@novanthealth.org
C. M. Haymaker Western Michigan University Homer Stryker M.D.School of Medicine, Kalamazoo, MI, USA e-mail: chris.haymaker@wmed.edu
L. Myerholtz Department of Family Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC, USA e-mail: Linda_Myerholtz@med.unc.edu
• The operationalization of the ACGME requirements and AAFP guidelines depends on many factors, including training of faculty, availability of resources and collabora­tive partners, and the training environment of the resi­dency program.
• The core behavioral medicine curriculum should include mental health diagnoses frequently seen in primary care, clinical interviewing skills, provider self-awareness/pro­fessional development, contextual care, and integrated behavioral health.
• The methods of disseminating a behavioral health curric­ulum include clinic and classroom-based learning, behav­ioral health rotations and electives, simulation, video reviews, integrated behavioral health experiences, inter­professional clinical experiences, and professional devel­opment exercises.
• Teaching methods and content should be individualized to the program and learner needs.

Introduction

The integration of behavioral science into family medicine residency education has been a hallmark of the specialty since its founding. Aligned with George Engel’s biopsychosocial framework [1], and its evolution to include cultural and spiri­tual inuences on health, the specialty of family medicine reects a recognition of the interconnectedness between physical health, mental well-being, and social factors. Family physicians are well-positioned to attend to mental health con­cerns given their continuity of relationships with patients and their families, thus providing the physician with a unique lens to understand the context of the family’s comprehensive health. Further, the American Academy of Family Physicians (AAFP) guidelines for the development of family medicine curricula explicitly recommend training residents to recog­nize the impact of medical practice on their own wellness so that they might develop coping and self- care strategies to mitigate burn out and promote well-being [2]. It is both a
© 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_30
323
324
A. Bickett et al.
privilege and a challenge for those in family medicine to understand and implement this knowledge into their practice.
Incorporation of behavioral medicine into the training curriculum is outlined by the Accreditation Council for Graduate Medical Education (ACGME) accreditation requirements for family medicine [3]. The competencies, attitudes, knowledge, and skills underscore the importance of behavioral science in this specialty. Indeed, the recent updates to the ACGME Family Medicine program require­ments require residencies to have faculty members dedicated to the interprofessional infusion of behavioral medicine training into the family medicine curriculum (II.B.2.j) (p.18). This necessitates that dedicated time, energy, scal resources, and infrastructure be invested in behavioral medi­cine training for family medicine residencies.
While the AAFP Curriculum Guidelines and the ACGME Competencies provide infrastructure for the provision of a behavioral science curriculum, its content and dissemination will be contingent on several factors and thus will vary across residency programs. In this way, behavioral medicine training in a family medicine residency is like a culinary experience. While the guiding documents suggest a list of ingredients and a standard recipe, the menus across residency programs will vary widely, based on a variety of considerations:
The chef’s training. Behavioral science faculty come from
various professional backgrounds and training programs.
They may be social workers, psychologists, marriage and
family therapists, physicians, doulas, educators, a combi-
nation of these, or none of the above. They may bring
with them experience in trauma, substance use disorders,
pediatrics, health psychology, maternal mental health, or
sports psychology. Thus, the avor prole of the behav-
ioral medicine training will likely be inuenced by pro-
fessional background, theoretical orientation, and area(s)
of specialty of the behavioral science faculty and interdis-
ciplinary team members. Who else is in the kitchen? Individuals within the residency
who are not explicitly designated as behavioral science
faculty may play a role in the dissemination of its curricu-
lum. There may be opportunities to add balance and depth
of avor by assessing strengths, talent, and desire to teach
from nonbehavioral science physicians, advanced prac-
tice providers (APPs), residency support staff, adminis-
tration, and clinical staff. Heirloom recipes. Many behavioral science faculty who are
new to the role inherit recipes, cooking styles, and avors
that are passed down from previous generations. While
incoming faculty may wish to respect these traditions, it is
also prudent and appropriate to take stock of current needs,
resources, values, and competencies to determine what’s
working well and what could be changed for the better. The availability of ingredients/cooking utensils. The loca-
tion, structure, and culture across organizations will
determine, in part, the availability of resources and per­sonnel to disseminate a behavioral science curriculum and integrate behavioral health into primary care. Common variations include interdisciplinary care team members (e.g., social work, pharmacy, care manage­ment), degree of collaboration between departments, and community resources.
The “season”. Attitudes of the department and leadership
toward behavioral medicine integration and training will often determine the amount of time and effort allotted to faculty and curriculum space. Some programs may be in the nascent stages of development when it comes to incor­porating behavioral health into family medicine training and practice, and the behavioral science faculty must advocate for its meaningful inclusion. Other programs may prioritize reimbursable patient activities over teach­ing responsibilities or have adopted a culture that focuses on biomedical aspects of training. Even when attitudes toward behavioral medicine are positive, the availability of faculty to devote time to behavioral health training and integration will depend on other roles and responsibilities they play within and outside the department.
In summary, as there are various iterations of a successful culinary product, there are multiple ways to successfully integrate behavioral medicine into a family medicine train­ing program. It is important for those teaching behavioral medicine to understand the staple ingredients as they prepare to create a meal. The next section explores the recently updated behavioral medicine program requirements for fam­ily medicine residency programs.
Accreditation Council forGraduate Medical Education (ACGME) andFamily Medicine ResidencyProgram Requirements
Overall, the purpose of the Accreditation Council for Graduate Medical Education (ACGME) is to ensure that graduate medical education programs provide a high-quality educational experience that prepares physicians to autono­mously deliver safe, effective, and patient-centered care. By setting standards, accrediting programs, promoting innova­tion, and supporting quality improvement, the ACGME plays a vital role in shaping the future of medical education and the healthcare system.
The ACGME undertook a comprehensive update of the program requirements for family medicine (FM) residency programs which went into effect July 1, 2023 [3]. The pro­gram requirements outline standards that all residency pro­grams must meet in order to maintain accreditation. This was the ACGME’s rst major update of program requirements for FM residency training in over 10years, and there is an increased focus on competency-based medical education, individualized learning plans, and continuity of clinical care.
30 Teaching Behavioral Science
325
There are also multiple elements within the program require­ments that impact behavioral health (BH) education for fam­ily physicians.
The program requirements start with a denition of the spe­cialty of family medicine, and here we see a strong emphasis specically on BH that did not exist in the previous denition.
Family physicians are skilled in behavioral health. Recognizing
the interrelationship of mental and physical health, they work to
address the barriers and challenges of accessing behavioral
health care in our complex society. (pg. 4)
Including behavioral health in the denition of family physicians clearly calls for the need for strong BH training during residency.
Within the denition of the specialty, we also see an emphasis on interprofessional team-based care.
Family physicians excel at coordinated team-based care and
advocate for high-value care in their partnership with diverse,
interprofessional teams. (pg. 4)
This emphasis is interwoven throughout the new require­ments demonstrating an appreciation for the critical role that interprofessional education and practice have within FM.The bold within the quotes below indicates language new in the program requirements.
There must be faculty members dedicated to the interprofes-
sional integration of behavioral health into the educational pro-
gram. (II.B.2.j) (p.18)
Clinical experiences…should include integration of multiple
non-physician professionals (e.g., behavioral health special-
ists, certied nurse midwives, clinical nurse specialists, lab
technicians, nurse practitioners, pharmacists, physician
assistants) to augment education, as well as interprofessional
team clinical services. IV.C.1.d).(1) (p.33)
Another important change with the revised program requirements is that residents are now required to train in family medicine practices that have integrated behavioral health (IBH) services.
The curriculum must incorporate behavioral health into all
aspects of patient care, including experience in integrated
interprofessional behavioral health care in the FMP.
IV.C.3.p) (p.37)
Prior ACGME program requirements emphasized clini­cal knowledge and training in behavioral health, but not a clear focus on IBH within the family medicine practice itself. While many residency programs already are meeting this requirement with well-developed fully integrated behavioral healthcare services, in some programs, inte­grated care may be in its infancy. A 2018 survey of program directors showed that almost half of FM residency pro­grams have either co- located care or fully integrated behav­ioral health services [4], where co-location was dened as care being provided in the same physical proximity and full integration was dened as multidisciplinary coordinated
team care utilizing warm handoffs and shared records. Other programs will need support in developing IBH ser­vices. There is likely to be diversity in training in IBH across residency programs as the requirements do not spec­ify the degree or level of integration for behavioral health care within the practices. For example, some programs may have one BH faculty member engaged in part-time co­located traditional therapy care within the clinic. Other pro­grams may have comprehensive, team- based, stepped care models such as the Psychiatric Collaborative Care Model [5] or the Patient Centered Medical Home Model [6].
In addition to an emphasis on interprofessional education and IBH as key components of residency education, the new ACGME requirements delineate specic knowledge domains that were not in the previous requirements. For example, under the competency domain of Medical Knowledge there is increased emphasis on the impact of social inequities and trauma.
Residents must recognize the impact of the intersection of social
and governmental contexts, including community resources,
family structure, trauma, racial inequities, mental illness, and
addiction on health and health care received. IV.B.1.c).(2)
(p.28)
This emphasis is also evident under the domain of Patient Care and Procedural Skills which species that resi­dents need to be competent to provide whole-person care from a family medicine framework that includes under­standing of allostatic load, social determinants of health, family dynamics, and the impact of adverse childhood events on health.
…whole person care, family-centeredness, community-focused
care, prioritizing continuity of care, rst-contact access to care,
coordination of complex care, and understanding allostatic
load and the structural determinants of health IV.B.1.b).(1).
(a). (i). (a) (p.25)
…understanding family dynamics, to include impact of
adverse childhood experiences IV.B.1.b).(1). (a). (i). (b)
(p.26)
addressing behavioral health and inequities in health and
health care. IV.B.1.b).(1). (a). (i). (c) (p.26)
The foundation of a BH curriculum in family medicine has typically included training on screening, diagnosing, and management of common mental health conditions that pres­ent in primary care. The new ACGME Program Requirements specify that residents must have “a dedicated experience” that focuses on mental illness and that this should include interprofessional training in skills of cognitive behavioral therapy and motivational interviewing.
Residents must have a dedicated experience in the diagnosis
and management of common mental illnesses, including inter-
professional training in cognitive behavioral therapy, moti-
vational interviewing, and psychopharmacology IV.C.3.p).
(1) (p.37)
The ACGME does not specify what a “dedicated experi­ence” is, but this language is different from other require-
326
A. Bickett et al.
ments that describe that residents must receive “instruction in.”
In addition to these counseling skills, the program requirements emphasize specic conditions to incorporate into a BH curriculum including identication and treatment of substance use disorders and holistic pain management. In both domains, residents need to be able to utilize phar­macological and non-pharmacological treatment approaches and work within the context of an interprofes­sional team.
This experience should include identication and treatment of
substance use disorders, including alcohol use disorder and
Opioid Use Disorder. IV.C.3.p).(2) (p.37)
The program must provide instruction in a holistic pain manage-
ment approach that includes pharmacologic and non-
pharmacologic methods and an interprofessional team. IV.C.2.a)
(p.33)
Finally, there is also a new emphasis on caring for patients through signicant life transitions from a biopsychosocial and spiritual dimension. Prior program requirements focused on end-of-life transitions and the new requirements have added transitions related to births and transitions to parenthood.
identify and address signicant life transitions in their full
biopsychosocial and spiritual dimensions, including birth,
the transition to parenthood, and end-of-life, for patients
and patients’ families; and, address suffering in all its
dimensions for patients and patients’ families. IV.B.1.b).
(1). (a).(xv)
Thus, in order to meet the new ACGME Program Requirements BH training for family physicians needs to be integrated throughout the curriculum and include dedicated experience in interprofessional, team-based IBH. The cur­riculum should focus on recognizing social and life span issues that impact the health and well-being of individuals, families, and communities. The curriculum needs to inte­grate specic behavior change and BH counseling skills and build competence in the treatment of individuals from a holistic perspective. The remainder of the chapter will pro­vide guidance on how the behavioral health “chef” might create a behavioral health curriculum and support resident development with the ACGME requirements and AAFP guidelines as a base.
The Staples: Core Elements ofaBehavioral Health Curriculum
The recipe for crafting a behavioral health curriculum will involve a set of key ingredients that are staples in any chef’s pantry and other “avors” to add based on the needs and preferences of the consumers. Where and how to implement the curriculum (the culinary style) will be informed by the
chef’s background and training, as well as the resources available to them.
Whether in a formalized behavioral health rotation, lectures, or other learning contexts, a core set of behav­ioral medicine knowledge, skills, and attitudes must be taught. Family physicians must be prepared to utilize interventions and counseling skills to address the increas­ing burden of health behaviors that contribute to illness and that also contribute to the development and mainte­nance of rapport between patients and physicians. The lit­erature robustly correlates the therapeutic alliance, often found in long-term relationships between patients and physicians, to positive treatment outcomes within the physical and mental health spectrum [7]. Additionally, the AAFP has identied the family physician as a key player in addressing mental health. Primary care visits that address mental health have been steadily increasing, with the majority of these related to depression, anxiety, and related disorders [8]. Surveys of FM graduates indicate that a majority identify behavioral health as a signicant part of their practice and generally feel well- prepared to manage such [9].
These are promising data but, on their own, are not enough to illuminate the active ingredients that would lead to an effective behavioral medicine learning experience in family medicine. Indeed, while behavioral science was incorporated into the earliest versions of family medicine residency train­ing, it varied widely in form and function (for a more com­prehensive description of this curricular evolution see the article outlining 50years of behavioral science contributions in family medicine [10]. Without a recipe, or set of standards dened by the literature or accrediting bodies, each program developed their own set of teaching objectives, depending on who was in the kitchen, and what utensils they had to work with. This left family physicians without a uniform approach and response to the biopsychosocial needs of their patients. In an effort to protect patients and enhance training for fam­ily physicians the AAFP and the Society for Teachers of Family Medicine (STFM) Task Force began developing a set of behavioral medicine core competencies in the late 1980s [11]. These evolved over the next 15years, under the pur­view of several entities (e.g., STFM, AAFP, ACGME, AHRQ). In 2008, a cohort of behavioral science faculty members, the Group on Behavioral Science, within STFM, dened a set of critically important elements for behavioral science curricula. These “Core Principles” were approved by the STFM Board of Directors in November 2008 and pub­lished in the STFM Messenger in February 2009 (See Fig.30.1).
If we expand this list to include current requirements from the AAFP and ACGME a comprehensive representation of the behavioral science curriculum emerges [12] (See Fig.30.2). As depicted by the overlapping circles, there will
Core Principles for Behavioral Medicine Curricula
Fig. 30.1 Core principlesfor behavioral medicine curriculadeveloped by the 2008 group of behavioral science through the Society of Teachers of Family Medicine (STFM)
use biopsychosocial and relationship-centered approaches to care;
promote patient self-efficacy and behavior change as primary factors in health
promotion, disease prevention, and chronic disease management;
integrate mental health and substance abuse care into primary health care services;
integrate psychological and behavioral knowledge into the care of physical
symptoms and diseases;
promote the integration of sociocultural factors within the organization and delivery of health care services;
demonstrate the importance to health of familial, social, cultural, spiritual,
and environmental contexts in patient care to improve health outcomes;
practice a developmental and life-cycle perspective with learners and clients; and
encourage and support provider self-awareness, empathy, and well-being.
Fig. 30.2 Key ingredients in a behavioral health curriculum. Source: By the author Linda Myerholtz, PhD
328
A. Bickett et al.
be connections among the topics covered. When these domains are well integrated into learning for family medi-
Core Mental Health Topics
cine residents, it strengthens the physician-patient relation­ship, the core of family medicine.
Source: By the author Linda Myerholtz, PhD
The AAFP (2020) has outlined a comprehensive curricu­lum guideline for Behavioral Health (BH) topics [13]. The list is organized into practice competencies tied to ACGME milestones, attitudes, skills, and medical knowledge. The medical knowledge competencies encourage the develop­ment of an understanding of human behavior, assessment and treatment of common psychiatric diagnoses, family systems and their associations with mental health, ethical issues, systems of care, and resources for behavioral health support. Attitudes of inclusivity, respect, and compassion should be created and fostered through training, exercises, protocols, and instruction. Residents must be taught meth­ods of evaluation (mental status exam, clinical interview-
ing, assessments and screens, and imaging), and behavioral and pharmacologic management of various mental health diagnoses and symptom presentations.
Parallel to these guidelines, new ACGME program requirements emphasize the need for training in behavioral strategies for pain management, family dynamics, lifespan issues, psychosocial issues, health equity, psychopharma­cology, and substance use disorders. The Family Medicine Milestones [14] also include specic BH skills. For exam­ple, residents are expected to integrate psychosocial fac­tors into their assessment and plan (Patient Care 1) and utilize behavioral strategies to improve health (Medical Knowledge 1).
30 Teaching Behavioral Science
Table 30.1 Screening and assessment tools for commonly seen conditions in primary care
Mental health issue Sample screening tools for primary care Mood disorders Patient health questionnaire (PHQ)-9; mood disorder questionnaire (MDQ); geriatric depression scale (GDS)-short
form; Edinburgh postnatal depression scale Anxiety disorders Generalized anxiety disorder (GAD)-7 Substance use Alcohol use disorders identication test (AUDIT); drug abuse screening test (DAST)-10 ADHD Vanderbilt; Conners; adult ADHD self-report screen (ASRS); Wender Utah rating scales Suicidal ideation Columbia suicide severity rating scale (CSSRS); ask suicide screening questions (ASQ) Cognitive impairment Montreal cognitive assessment (MoCA); St Louis university mental status exam (SLUMs); mini mental status exam
(MMSE); MiniCog Insomnia Insomnia severity index (ISI); Epworth sleepiness scale (ESS) Trauma PTSD checklist for DSM 5 (PCL-5); primary care PTSD screen for DSM 5 (PC-PTSD-5) Pediatric screeners Pediatric symptom checklist (PSC)-17; PHQ- adolescent; screen for child anxiety related disorders (SCARED); MChat
329
Deciding how to prioritize BH topics also can be informed by studies of BH training in residency. Residents report excellent value in learning how to work with an interdisciplinary team to manage behavioral health care, building knowledge on psychotropic medications, learning about counseling techniques, and learning how to work with families. They identify a need for greater depth of training in some BH skills, particularly in assessment, med­ication management, and counseling skills [1519]. A pro­gram-specic needs assessment or community mental health needs assessment can be used to inform the inclu­sion of other topics.
Given the prevalence of substance use, depression, sui­cidal ideation, and anxiety-related disorders nationally and in primary care settings specically [20, 21], residents must have a strong foundation in identifying, evaluating, and man­aging these diagnoses. The rst step often is familiarizing residents with the screening tools available. A selection of commonly used tools, many of them freely available and integrated into major electronic medical records, is outlined in Table 30.1. Current USPSTF recommendations support routine screening (when appropriate supports are in place for follow-up) for depression in individuals between the ages of 12 and 65 (including postpartum women), anxiety in indi­viduals between ages 8 and 64, and substance use in adults over 18 (all Grade B recommendations). At this time, there is insufcient evidence to suggest routine screening for trauma, suicide risk, depression in children younger than 11, anxiety in children younger than 7 or adults older than 65, and drug and alcohol use in anyone under 18years old; however, resi­dents should still know how to screen when appropriate (for example, screening for suicide risk in individuals with co­morbid psychiatric diagnoses and known risk factors). Residents should be instructed that screening is one part of making a clinical diagnosis and that the information gathered
from the tools must be integrated with other relevant clinical data and patient history.
Following screening and diagnosis, residents should be comfortable with basic pharmacologic and behavioral man­agement of common psychiatric presentations. Behavioral scientists may want to partner with pharmacist or physician colleagues on education about psychotropic medication management. Part of the psychopharmacology education should ensure residents know how to nd evidence-based prescribing algorithms and resources [22], including those for use in special populations (e.g., children, pregnant and lactating individuals, older adults). The behavioral science curriculum should include instruction in non-pharmaco­logic treatment options for common mental health issues, including behavioral activation for depression (see Fig.30.3), breathing techniques (see Fig. 30.4), and other distress tolerance and emotion regulation strategies (found in Dialectical Behavior Therapy training manuals) [23].
Family physicians encounter patients in crisis and must develop evidence-based skills to guide them safely and effectively when patients experience suicidal ideation. A behaviorally informed safety plan is a collaborative endeavor in which the clinician and patient work together to identify warning signs for suicide risk, outline coping strategies and professional and social supports, and agree on how to make the home environment safe by removing access to lethal means. This strategy should be used over “contracting for safety” [25].
Though not every patient will be screened for symptoms of PTSD, residents should be able to recognize signs of trauma and know how to provide trauma-informed care. There is a range of exposure to trauma that patients may experience and that physicians should be prepared to address, from understanding the impact of adverse childhood events (ACEs) on health and well-being to knowing how to ask
330
A. Bickett et al.
Fig. 30.3 Sample infographic to be used in teaching behavioral activation to family physicians [24]