Добавил:
Sekretar
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
30 Teaching Behavioral Science
331
Fig. 30.4 Sample infographic to be used in teaching breath focused relaxation skills to family physicians [24]
332
A. Bickett et al.
about trauma to providing care (including how to appropriately refer patients for additional treatment). The 4 R’s of a
trauma-informed approach can guide the development of a
trauma-informed curriculum: (1) realizing the widespread
impact of trauma and paths for recovery; (2) recognizing the
signs and symptoms of trauma; (3) responding by integrating
knowledge of trauma into policies, procedures, and practices; and (4) resisting re-traumatization [26]. In addition to
understanding a trauma-informed approach broadly dened,
residents benet from knowledge of specic skills to help
patients manage trauma-related symptoms (for example,
age-appropriate grounding techniques) and indications for
pharmacotherapy.
A recent survey of family medicine program directors
indicated a dearth of addiction medicine training as a standard part of the residency curriculum [27]. Faculty training
(or lack thereof) has been identied as a signicant factor in
the strength of a program’s addiction medicine curriculum
[27, 28]. For programs who lack faculty expertise, online
resources are available to supplement training. For example,
the STFM Addiction Medicine Curriculum for Residents and
Faculty includes modules on principles of addiction medicine; screening, brief intervention, and referral to treatment
(SBIRT); taking a substance use history; management of opioid, alcohol, stimulant, and tobacco use disorders; and health
equity. The resource has been rated favorably by those who
have participated in it [29]. In addition to these topics, behav-
ioral science faculty also could increase resident comfort
with motivational interviewing (covered in the next section
on communication skills) and knowledge of local supports
(e.g., AA and related groups).
Part of the substance use disorder curriculum likely will
overlap with training on appropriate prescribing for chronic
pain and insomnia. Both chronic conditions have historically been treated with medications with high abuse/dependence potential, but more recently, biopsychosocial
approaches and less addictive medications have been
favored. Building a supportive, empathic patient-physician
relationship, collaborative engagement in functional goal
setting, and behavioral management of comorbid factors
(e.g., improving sleep, paced physical activity, relaxation,
and mindfulness-based practices to address mood and anxiety) should be included in training on non-pharmacologic
pain management. For insomnia, residents can learn how to
engage in brief behavioral treatment of insomnia (BBT-I)
[30] or elements of it (sleep hygiene, stimulus control, setting sleep, and wake times).
This is not an exhaustive list of ingredients to include in
a behavioral health meal but provides a starting point for its
preparation. Consult with other cooks in the kitchen
(department) and the community (departments within or
outside the organization) to nd out where residents are
nourished, and to take stock of collaboration
opportunities.
30 Teaching Behavioral Science
Patient-Centered Communication Skills
333
Source: By the author Linda Myerholtz, PhD
334
A. Bickett et al.
Patient-centered communication skills training is a principal
element of the behavioral medicine curriculum. The importance of teaching communication skills received increased
emphasis in the latest ACGME program requirements and is
specically mentioned several times in the family medicine
milestones (e.g., agenda setting—Interpersonal and
Communication Skills 1). The AAFP guidelines also highlight communication and counseling skills as a foundation of
FM behavioral science training.
There are several models that highlight the use of these
communication skills in the structure of the medical interview, including the Calgary-Cambridge model and the Four
Habits Model. These models share common elements with a
focus on rapport building, setting an agenda, gathering
information using open-ended questions, demonstrating
empathy, inviting questions, and collaboratively setting
goals for care.
The Calgary-Cambridge Guides [31] can serve as a tool to
organize a communication skills curriculum, and to highlight
the complex, co-occurring tasks that physicians aim to
accomplish in encounters with patients.
There are also patient-centered communication models
designed for specic parts of the clinical encounter. For
example, the BATHE technique [32] and the Four Habits
Model [33] are patient-centered approaches to the medical
interview. The Four Habits Model (see Fig.30.5) comprises
23 specic skills that outline physician communication tools
to effectively navigate the clinical encounter.
The acronym “BATHE” stands for Background, Affect,
Trouble, Handling, and Empathy. This technique is intended
to help healthcare professionals gather important information about a patient’s medical condition, as well as their emotional and psychological well-being.
Background—“What is going on in your life?”/ “How have
you been?”
Affect—“How is it affecting you?”/ “How do you feel about
that?”
Trouble—“What troubles you most about the situation?”
Handling—“How have you been handling (coping) this so
far?”/ “What helps you handle the situation?”/“How do
you want to handle that? (slight variation).
Empathy—“That sounds very (scary, frustrating, sad, etc.)”/
“This is a tough situation to be in.”/ “Your reaction makes
sense to me.”
Motivational Interviewing (MI) is a patient-centered
counseling approach to behavior change that is designed to
help individuals explore and resolve ambivalence about
behavior change [34]. Rather than telling the patient to
stop or change a behavior, the spirit of MI encourages
practitioners to assess the patient’s values and readiness to
change, help the patient identify discrepancies between
values and behaviors, and help the patient build self-efcacy by setting specic, achievable goals based on the
patient’s values [35]. While MI is more of a spirit of patient
engagement than a script, the OARS acronym can provide
structure for engaging in behavior change discussions with
patients.
Open-ended questions: As opposed to asking “closed” ques-
tions that typically elicit a limited response such as “yes”
or “no”, open questions invite others to “tell their story”
in their own words without leading them in a specic
direction. Examples include: “What would you like to
change about your health?”/“What do you think you will
lose if you give up ___?”/“What have you tried before to
make a change?”
Afrmations: Afrmations are statements and gestures that
recognize client strengths and accomplishments in the
direction of positive change. Examples include: “You
handled yourself really well in that situation.”/“You’ve
come up with a great plan to change ___.”
Reective listening: Reective listening conveys interest,
understanding and respect for what the patient is saying.
Repeating or rephrasing: The listener repeats what the
patient said, or substitutes synonyms or phrases.
Paraphrasing: The listener restates the speaker’s
meaning in their own words.
Reection of feeling: The listener highlights the emotional aspects of communication through feeling statements. “A part of you feels scared to make this change.”
Summary reections: Summaries are another form of reec-
tive listening that helps establish clear communication
between the speaker and listener. For example: Let me see
if I understand so far… Tell me if I’ve missed anything.
The 5 A’s Model is another behavior change framework
that can be used to inform conversations about health behavior change [36, 37]. Five A’s stand for Assess, Advise, Agree,
Assist, and Arrange. Each step represents a crucial component of the process to support patients in making sustainable
changes to their health behaviors.
Assess: In this initial step, the clinician assesses the patient’s
current health behaviors and identies areas that may need
improvement. This involves gathering information about
the patient’s habits, risks, and motivations. By understand-
ing the patient’s baseline behaviors and challenges, the
clinician can tailor their approach accordingly.
Advise: After assessing the patient’s situation, the clinician
offers clear and concise advice on the benets of chang-
ing specic behaviors. This advice is evidence-based and
highlights the potential positive impact on the patient’s
health. The goal is to provide information that empowers
the patient to consider making changes.
Agree: In this step, the clinician collaborates with the patient
to set goals and develop a plan for behavior change. The
patient’s preferences, readiness, and priorities are taken
into account. Together, the clinician and the patient work
toward creating realistic and achievable goals that reso-
nate with the patient’s values and circumstances.
30 Teaching Behavioral Science
335
Fig. 30.5 The four habits/23 skills model
336
A. Bickett et al.
Assist: This step involves providing practical assistance and
support to help the patient implement the behavior change
plan. Clinicians may offer resources, tools, strategies, and
guidance to overcome obstacles and reinforce positive
behaviors. Continuous feedback and encouragement play
a signicant role in ensuring the patient’s success.
Arrange: The nal step focuses on arranging follow-up ses-
sions and ongoing support.
As previously mentioned, the ACGME requires behavioral medicine training to be interprofessionally integrated
into residency training [38]. Cognitive behavioral therapy
(CBT) is a type of psychotherapy that guides patients toward
reframing negative or unhelpful thoughts and changing maladaptive behaviors. It is an evidence-informed treatment for
a number of mental health conditions, including depression
[39], and is appropriate for use in primary care settings given
its brief, skill-based approach. While it is not necessary for
family physicians to become fully trained in all elements of
this intervention, it is important for them to understand how
they may incorporate it into patient care. They play a valuable role in describing the benets of CBT to patients, promoting engagement in therapy when appropriate. Behavioral
medicine faculty should train FM residents on the delivery of
several brief CBT interventions that they might use in the
clinic with their patients (e.g., behavioral activation, cognitive reframing, and journaling). Resources, including educational handouts, podcasts, and therapist locators, are available
for physicians to download and provide to patients.
Given their continuity relationships with patients, family
medicine physicians often communicate difcult news that
will result in signicant emotional and behavioral impacts for
the patient and their family [40]. There are several models to
provide guidance on navigating these challenging encounters,
including the SPIKES [41], BREAKS [42], and ABCDE [43]
protocols. Common elements involve cultivating an appropriate setting for the conversation, consideration of cultural values and health beliefs, maximizing patient autonomy, provision
of trauma-informed verbiage, and expression of authentic
empathy and support for the patient and their family.
In that vein, physicians are likely to be in the position to
help manage and stabilize a patient experiencing a mental
health crisis. While the circumstances of the crisis and
patient needs will vary widely, the AAFP provides some
practical steps for family physicians to respond effectively
to a patient’s crisis [44]. Elements of this intervention
include communication skills to establish and maintain rapport with the patient and their family, assessment, and
screening tools to evaluate risk, assist in creating a safe
physical and emotional environment, and connecting with
resources in the clinic and community. For example, the
physician may provide reassurance and develop rapport
with the patient through validation of their emotions and circumstances, and use of active listening skills. One can use
the BATHE and SPIKES protocols to engage in such. To
evaluate the patient’s psychiatric status, including risk of
suicidal and homicidal ideation, plan, and intent, the physician can use the Columbia Suicide Severity Rating Scale
(CSSRS) and/or the PHQ-9 (question 9 assesses for suicidal
ideation). To enhance the safety and stability of the patient,
physicians can utilize the National Council for Mental WellBeing, which provides information, toolkits, and resources
for practitioners in the primary care setting. Primary care
physicians may also create a safety plan with the patient,
using an evidence-based template, such as the one created
by Stanley and Brown, in 2008. There are various free mental health apps (e.g., Mood Tools and Fear Tools) that can be
used as adjunct interventions between ofce visits.
Physicians can also create a handout with local resources
that the patient can access in times of mental health crisis,
including contact information for emergency departments,
and/or psychiatry emergency departments, free- and
reduced-cost mental health providers, or organizations, that
National Suicide Prevention Lifeline (988), and online/virtual mental health resources.
The development of patient-centered communication
skills for the family physician can contribute to improved
patient rapport, increased efciency in the clinical encounter,
and improved patient outcomes. See Table30.2 for a summary of these models.
Table. 30.2 Summary of clinical interviewing skills, tools, and resources
Clinical interviewing skill(s) Training resources/models
Create visit infrastructure
Establish focus
Set the agenda
Cognitive behavioral therapy Academy of Cognitive Therapy (http://academyofct.org)
Behavior change 5 A’s
Communicating difcult news SPIKES
Crisis intervention skills CSSR-S
Calgary-Cambridge guides
Four habits model
BATHE
Association for Cognitive and Behavioral Therapies (http://www.abct.org)
Beck Institute for Cognitive Behavioral Therapy (http://www.beckinstitute.org)
Motivational interviewing
BREAKS
ABCDE
Safety planning template
Zero Suicide: Information, toolkits, and resources specically developed for medical providers
National Council for Mental Well Being
30 Teaching Behavioral Science
Contextual Care
337
Source: By the author Linda Myerholtz, PhD
While medical conditions are often understood through a biological lens, it’s essential to recognize that patients’ overall
well-being is shaped by a complex interplay of psychological,
social, and environmental factors [1, 45], which is further
informed by spiritual and cultural factors. The Future of
Family Medicine (FFM) proposes that one of the most important responsibilities of family physicians is to “humanize” the
health care experience by understanding the contextual factors contributing to the patient’s whole health [46]. This is
echoed in the ACGME Program Requirements for Family
Medicine, which lists the following as core competencies:
IV.B.1.a).(1). (a) compassion, integrity, and respect for others;
IV.B.1.a).(1). (c) cultural humility;
IV.B.1.a).(1). (f) respect and responsiveness to diverse
patient populations, including but not limited to diversity
in gender, age, culture, race, religion, disabilities, national
origin, socioeconomic status, and sexual orientation.
Family medicine curricula must provide guidance and
structure in the incorporation of contextual care into every
element of their patient care, including interviewing and
assessment, diagnosis development, and treatment planning.
338
A. Bickett et al.
Failing to account for these elements may lead to incomplete
and incorrect diagnoses, inadequate treatment plans, and
diminished patient outcomes. If we consider contextual care
in the metaphor of culinary experience, the elements might
be considered the carbohydrates, protein, sugars, minerals,
and vitamins in the ingredients themselves. It is not left to
the chef’s discretion whether to add or leave out from a recipe, but inherent, inevitable, and engrained in the raw foods,
contributing form, avor, and nutrients. The development of
a family medicine curriculum should consider the foundational impact of contextual care.
Training in family dynamics and family systems will prepare family medicine physicians to care for patients and their
families in the context of their social and emotional environment [47]. while guiding physicians to explore the impact of
their own family on clinical interactions and decision- making
[48]. Family systems concepts are often incorporated into
the behavioral medicine curriculum, with the goal of helping
residents understand that their patient is the family, rather
than focusing on the individual. The curriculum should
explain key concepts of family systems, like boundaries,
roles, communication patterns, and subsystems within families. Doherty and Baird’s development levels for familycentered care provide a general framework for this curriculum
[47]. Family physicians will also benet from the incorporation of cultural humility training as it relates to family
dynamics, as cultures may have unique family structures,
values, and communication styles that can inuence healthcare decisions and outcomes. The curriculum may utilize
structured exercises like genograms to prompt residents to
consider how their own family’s health, beliefs, and values
have affected their own patterns of assessment, engagement
and treatment of their patients [49]. Residents can be evaluated on family-oriented interviewing skills with the FamilyCentered Observation Form [50].
Family medicine prides itself on knowing patients across
the lifespan, and across generations meaning family physicians must seek to understand patients and their families
within the context of the life course, social pathways and
change, and developmental trajectories of health and illness.
Five core principles dene the life course as a paradigmatic
framework: (1) human development and aging as lifelong
processes, (2) human agency, (3) historical time and place,
(4) the timing of events in life, and (5) linked lives [51]. The
rst principle highlights the context of expected patterns or
sequences inherent in health, family relationships, and sense
of purpose, as well as “turning points” (i.e., sentinel moments
that may result in a deviation from that expected life course).
Human agency identies individuals as active participants in
life span development, constructing their own course through
choices and behavior, given constraints of time, place, and
social circumstances. Linked lives refer to the interdependence and network of shared relationships that surround
individual lives. The concept of “social convoy,” refers to a
grouping of signicant others (e.g., important family members, friends, faith leaders, mentors, and even physicians)
across different life periods [52]. Those constraints may
include local unemployment rates, housing and transportation, socioeconomic distribution throughout a region, population density, availability and cost of healthy foods and
health services [53]. Indeed, there is robust evidence that
50% of one’s health can be attributed to one’s zip code, while
20% of health is determined by time spent accessing health
care [54]. These statistics reinforce the importance of introducing contextual factors into family medicine residents
training.
Adverse childhood experiences (ACEs) are dened as
childhood exposure to various forms of abuse and household dysfunction, including psychological abuse, physical
abuse, sexual abuse, substance abuse, mental illness,
domestic violence, and criminal behavior. A landmark
study [55] compared health outcomes for those who had no
adverse childhood experiences, to individuals who experienced four or more adverse childhood experiences. Those
with adverse events were more likely to engage in unhealthy
and risk behavior. Exposure to adverse childhood experiences was associated with greater rates of ischemic heart
disease, cancer, chronic lung disease, skeletal fractures,
and liver disease [55]. While the US Preventive Services
Task Force does not have a recommendation about screening for adverse childhood experiences, it does recommend
screening for adverse childhood experience-related
sequelae such as intimate partner violence, depression, sexually transmitted infections, unhealthy alcohol use, drug
use, poor diet, and sedentary lifestyle [56]. A behavioral
health curriculum (1) should emphasize the link between
ACEs and health outcomes, (2) should know how to utilize
patient-centered and trauma- informed interviewing skills
30 Teaching Behavioral Science
339
to navigate these sensitive discussions, and (3) should work
with an interdisciplinary team to recommend and activate
appropriate treatment.
Culture and spirituality are key factors in every patient
encounter, whether or not they are explicitly addressed by a
clinician. The onus is on the family physician to exercise cultural and spiritual humility by asking about their roles in a
patient’s life/health story using open-ended questions, active
listening, and a nonjudgmental stance. Cultural humility and
understanding of spirituality can enhance communication,
build trust, and improve the overall quality of care. Behavioral
Medicine curricula should include language and terminology
that are respectful and culturally sensitive. Ethical dilemmas
involving conicts between medical recommendations and
cultural or religious beliefs should be discussed using a
nonjudgmental stance and culturally sensitive language, with
the goal of providing the patient and their family with cultural and spiritual autonomy. Residents should be guided
through opportunities to assess their own implicit biases and
cultural assumptions, as self-reection is the rst step in providing culturally competent care. Both AAFP and STFM
[57] provide resources to facilitate such reection and
encourage action toward anti-racism and health equity
(Implicit Bias Resources | AAFP) [58]. Behavioral medicine
faculty should become familiar with the history and current
context of their community, developing ways to assess and
incorporate the preferences, rituals, beliefs, help-seeking
behaviors, and health practices of their patient population.
Patients’ cultural and spiritual beliefs should be incorporated
into the care plan when feasible and appropriate. If the
resources are available, consider using chaplains, religious
and tribal leaders, or other spiritual support resources when
patients express a need for spiritual guidance or support.
These individuals may also serve as adjunct educators, providing education to the residents and faculty about various
cultures and spiritual practices.
The behavioral medicine curriculum for family medicine
residency programs should integrate a health equity curriculum that focuses on the root causes of health disparities, such
as structural racism, income inequality, and healthcare access
issues, including the inequities in access and utilization of
community mental health resources. This curriculum helps
residents recognize and address these disparities in clinical
practice. The American Medical Association (AMA)
Accelerating Change in Medical Education Consortium aims
to provide structure and guidance to family medicine residency training programs in the development and maintenance of a health equities curriculum. They advise programs
that there is no scripted curriculum that will apply to all residencies. Rather they encourage the development of a framework and supporting resources that address the needs of the
local population.
The University of Rochester Medical Center created a
three-phase approach to health equity in its KEE curriculum
(Knowledge, Empathy, and Equity) (Teresa Green, University
of Rochester Medical Center, 2023). Phase 1 teaches basic
science related to social determinants and healthcare outcomes. Phase 2 infuses that knowledge into the clinical care
of patients, preferably in connection with a local community
organization or partnership, and Phase 3 parlays information
gained through didactics and clinical care into quality
improvement, systems and organizational change, and advocacy. Residency programs should provide mentorship and
support systems for residents from underrepresented backgrounds to help them succeed in their training and overcome
barriers they may face. This may take the form of residents
conducting or participating in research on health disparities
and outcomes among their patient populations to identify
areas where improvements are needed, as data collection and
analysis can inform programmatic changes and interventions. Family medicine residency programs, in collaboration
with professional organizations, can advocate for policies
and funding that support health equity initiatives, such as
expanding access to healthcare in underserved areas.
Additionally, the ACGME mandate for a patient advisory
committee that is representative of the community can
inform residents about the health care needs of the
community.
Taking the psychosocial context into account demonstrates a patient-centered approach, which fosters trust,
empathy, and open communication between the physician
and the patient.
340
Integrated Behavioral Health Care
A. Bickett et al.
Source: By the author Linda Myerholtz, PhD
Integrated behavioral healthcare models aim to combine medical and behavioral health services, typically in a primary care
setting. These models recognize that mental health and physical health are interconnected and that addressing both aspects
of a patient’s health can lead to better overall outcomes.
Integrated behavioral health (IBH) models improve patient
outcomes, increase access to BH services, and reduce stigma
that sometimes prevents people from seeking mental health
treatment [59]. IBH addresses concerns frequently seen in primary care settings, where many patients rst seek help for
behavioral health issues, such as depression and anxiety [60].
As stated previously, ACGME requirements now
explicitly mandate that FM residents receive training in
family medicine practices that have IBH services.
However, it does not provide specic guidelines for structure or implementation. As such, this element of the
behavioral science curriculum will likely be informed by
the chef’s training (social work, psychologist, pharmacists, care managers, family systems therapists, etc.), the
availability of ingredients/cooking utensils (the location,
structure, and culture of the organization and the nancial
resources devoted to the development and sustainability