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- •Preface
- •References
- •Contents
- •Author Biographies
- •About the Series Editors
- •Family Medicine Advocacy Summit
- •Robert Graham Center Workforce Studies
- •HealthLandscape
- •Residency Resources
- •Medical Education Policy Development
- •Residency Program Solutions
- •Residency Leadership Summit
- •Chief Resident Leadership Development Program
- •Educational Resources
- •Continuing Medical Education (CME) Tracking
- •Graduate Medical Education Awards
- •Summary
- •References
- •AAFP Structure
- •AAFP Governance
- •Workforce Mission
- •AAFP Workforce Advocacy
- •Residency Redesign
- •References
- •Osteopathic Recognition Requirements
- •Osteopathic Recognition Program Essential Personnel
- •Osteopathic Faculty
- •Osteopathic Recognition Resident Requirements
- •Osteopathic Educational Program Core Competencies
- •Osteopathic Program Evaluation
- •References
- •Reference
- •5: Association of Family Medicine Administration and the Key Role of the Residency Program Coordinator
- •Appendix 1
- •References
- •References
- •Membership Categories within NAPCRG
- •The AAFP Robert Graham Center
- •AAFP National Research Network (NRN)
- •Family Physicians Inquiry Network (FPIN)
- •The Family Medicine Physician-Scientist Pathway (PSP) Program
- •NAPCRG Grant Generating Project
- •Building Research Capacity (BRC)
- •Conclusion
- •References
- •Reference
- •9: Family Medicine Residency Accreditation
- •Why Accreditation Matters
- •ACGME Organizational Structure
- •The Family Medicine Review Committee (RCFM)
- •The Clinical Learning Environment Review (CLER)
- •The Site Visit
- •Initial Accreditation Period
- •Subspecialty Fellowship Application
- •The Annual Program Review
- •The Next Accreditation System Annual Review Process
- •Accreditation Data System (ADS)
- •Citations
- •Accreditation Status
- •Program Requirement Development
- •Competency-Based Medical Education (CBME)
- •References
- •10: Graduate Medical Education Funding
- •Introduction
- •Residency Operating Costs
- •Medicare GME Funding
- •Residency Caps
- •Rural Track Programs
- •Inpatient Prospective Payment System (IPPS) Subtype Hospitals
- •Rural Referral Centers
- •Sole Community Hospitals
- •Medicare-Dependent Hospital
- •Medicaid GME Funding
- •Teaching Health Center Funding
- •Veteran’s Administration GME
- •Children’s Hospital GME (CHGME)
- •State Line Item Funding
- •Hospital Supplemental Funding
- •Patient Care Revenue
- •Philanthropy
- •Conclusions
- •References
- •Introduction
- •Informed Self-Assessment
- •Faculty Development
- •Summary
- •References
- •12: Core Competencies, Milestones, and Entrustable Professional Activities
- •Entrustable Professional Activities
- •Entrustment
- •Pearls
- •Pitfalls
- •References
- •Objectives
- •Educational Strategies
- •Implementation
- •13: A Practical Approach to Curriculum Development
- •Introduction
- •Cognitive Learning Theory
- •Behavioral Learning Theory
- •Humanistic Learning Theory
- •Goals
- •Conclusion
- •References
- •Introduction
- •Preparation Phase
- •Information Technology Systems
- •Medical Student Rotations
- •Interview Season
- •Application Screening
- •Interview Day
- •Second Looks
- •Postinterview Communication
- •Ranking
- •Using R3®
- •Match® Week
- •SOAP®
- •Conclusion
- •References
- •Preboarding
- •Planning New Resident Integration
- •Baseline Assessment
- •Individual Learning Plan
- •Integration Components
- •Longitudinal Integration
- •Learner/Residency/Institutional Goal Alignment
- •Conclusion
- •References
- •Introduction
- •History
- •Residency Application
- •Conclusion
- •References
- •References
- •Introduction
- •Identifying Performance Issues
- •Medical Knowledge
- •Patient Care
- •Interpersonal Skills/Communication
- •Professionalism
- •Systems-Based Practice
- •Remediation
- •Medical Knowledge
- •Patient Care
- •Interpersonal Skills/Communication
- •Professionalism
- •Systems-Based Practice
- •Conclusions
- •References
- •19: Faculty Recruitment: Best Practices
- •Background
- •Seeking Out Suitable Candidates: Recruitment Methods
- •Unique Challenges: Faculty Who Are New Residency Graduates
- •Concluding Thoughts: Always Recruit!
- •References
- •20: Faculty Performance
- •Faculty Performance Concerns
- •Appendix 1: Sample Family Medicine Residency Program Director Job Description
- •Job Summary
- •Educational Delivery
- •Evaluation
- •Administration
- •Appendix 2: Sample Family Medicine Residency Core Faculty Job Description
- •Job Summary
- •References
- •21: Faculty Development
- •Introduction
- •Clinical Skills
- •Scholarly Work
- •Tasks that Family Medicine Residency Faculty Perform
- •Role Modeling
- •Faculty Peer Support
- •Teaching
- •Training Courses
- •Workshops
- •Learning by Doing
- •Self-Directed Learning
- •Career Development
- •Organizational Resources
- •References
- •Introduction
- •Promoting Loving Accountability
- •Clinical Setting
- •Curriculum
- •Social Connection
- •Assessment
- •Vision Forward
- •Handling Microaggressions
- •Financial Investment
- •References
- •Building Trust
- •Positionality
- •Set the Stage
- •Normalize Not Knowing
- •Probing, Not Prodding
- •Accurate
- •Addressing Implicit Bias
- •Micro-Level
- •Macro-Level
- •Conclusion
- •References
- •Introduction
- •Background
- •Risk Factors
- •Stigma
- •FSMB Recommendations Regarding Licensing Questions
- •Physician Health Programs (PHP)
- •Individual-Level Actions
- •Conclusion
- •References
- •References
- •The Clinical Learning Environment
- •Feedback
- •References
- •27: Teaching Maternal Health Care
- •ACGME Requirements
- •Obstetric Family Medicine Faculty Shortage
- •Maternity Care Curricular Elements
- •Preconception Care
- •Prenatal Care
- •Immunizations
- •Common Conditions Which Complicate Pregnancy
- •Breastfeeding
- •Intimate Partner Violence (IPV)
- •Substance Use
- •Food Insecurity
- •Inpatient Obstetrical Care
- •References
- •Introduction
- •Family Medicine Residency Advocacy Curricular Development
- •Evaluation
- •Conclusion
- •References
- •Faculty Leadership
- •Resident Leadership
- •Patient Satisfaction
- •Professional Conduct
- •Ethical Considerations
- •Curriculum Development
- •The Hidden Curriculum
- •Conclusion
- •Context Matters
- •References
- •30: Teaching Behavioral Science
- •Introduction
- •Core Mental Health Topics
- •Patient-Centered Communication Skills
- •Contextual Care
- •Integrated Behavioral Health Care
- •Master Adaptive Learner
- •Clinic-Based Learning
- •Classroom-Based Learning
- •Interprofessional Education
- •Balint Groups
- •Conclusion
- •Appendix 1: Sample Behavioral Health Rotation (Myerholtz 2023)
- •References
- •31: Teaching Evidence-Based Medicine
- •Introduction
- •Longitudinal Deep Dives
- •Journal Club
- •Family Physicians Inquiries Network
- •Case-Based Learning
- •Day-to-Day Integration
- •Curriculum Development Tips Summary
- •Institutional Involvement
- •Summary
- •References
- •32: Teaching Practice Management
- •Background
- •Current Curriculum
- •Activities
- •Quality Improvement Project
- •Virtual Practice Instructions
- •Presenters
- •Topics Covered
- •References
- •Overview
- •Why Training Is Needed
- •Stressing Communication
- •Balint Group
- •Putting It All Together
- •References
- •Introduction
- •Broad Scope
- •Primary Contact
- •Emerging Technology
- •Rural Generalism
- •Public Health Advocate
- •Rural Practice Systems
- •References
- •Introduction
- •Basic Logistics
- •Operational Considerations
- •Billing Requirements
- •Additional Funding Considerations
- •Engaged Leadership
- •The FMC-Residency Partnership
- •Scheduling
- •Data-Driven Improvement
- •Empanelment
- •Panel Weighting
- •Panel Transitions
- •Team-Based Care
- •Population Management
- •References
- •Introduction
- •Personnel Management
- •Meeting Management
- •Communication Management
- •References
- •37: Managing Change in Family Medicine Residency Programs
- •Introduction
- •What Is Change Management?
- •Change Management Case Study
- •Kotter Model
- •Step 1: Create Urgency
- •Step 4: Communicate Buy-In
- •WIFM Worksheet
- •Step 5: Empower Others
- •Step 6: Generate Quick Wins
- •Step 7: Consolidate Gains
- •Conclusion
- •References
- •Negotiating Styles
- •Collaboration
- •Summary
- •References
- •Anticipating Task Cycles
- •Residency
- •Home Life
- •Seize Control
- •Delegate
- •Delegate Residency Chores
- •Delegate Domestic Chores
- •Exercise
- •Lunch
- •Organizing
- •Summary
- •References
- •Introduction
- •References
- •Introduction
- •Anticipate Common Disasters
- •Learn About Your Regional Emergency Infrastructure
- •Learn Your Organization’s Command Center Structures
- •Here Are Some Alternative Care Site Scenarios That May Arise
- •Regional Emergency Infrastructure
- •Managing Your Program During Disaster
- •Community Recovery
- •Consolidate Your Learning
- •Author Background
- •References
- •Conclusion

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.
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Teaching Behavioral Science
AllisonBickett, LaurenPenwell-Waines,
ChristopherM.Haymaker, andLindaMyerholtz
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
30years, 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 requirementsstate that a faculty member
mustbe 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 inuences on health, the specialty of family medicine
reects 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 prole of the behav-
ioral medicine training will likely be inuenced 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 forGraduate Medical
Education (ACGME) andFamily Medicine
ResidencyProgram 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 10years, and there is an
increased focus on competency-based medical education,
individualized learning plans, and continuity of clinical care.

30 Teaching Behavioral Science
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There are also multiple elements within the program requirements that impact behavioral health (BH) education for family physicians.
The program requirements start with a denition of the specialty of family medicine, and here we see a strong emphasis
specically on BH that did not exist in the previous denition.
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 denition of family
physicians clearly calls for the need for strong BH training
during residency.
Within the denition 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, certied 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 dened as
care being provided in the same physical proximity and full
integration was dened 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 specic 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 species 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-

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ments that describe that residents must receive “instruction
in.”
In addition to these counseling skills, the program
requirements emphasize specic conditions to incorporate
into a BH curriculum including identication 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 identication 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 signicant 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 signicant 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 specic 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 ofaBehavioral
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 identied 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 signicant
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 50years of behavioral science contributions
in family medicine [10]. Without a recipe, or set of standards
dened 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 15years, 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,
dened 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 principlesfor
behavioral medicine
curriculadeveloped 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 specic 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 identication 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 [15–19]. A program-specic 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 specically [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
insufcient 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 18years 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

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Fig. 30.3 Sample infographic to be used in teaching behavioral activation to family physicians [24]
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