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30 Teaching Behavioral Science
341
of IBH), and whether IBH development is coming from an
heirloom recipe or starting from scratch.
Depending on the variables above, programs can create
an IBH model that is aligned with one or more of the concepts below.
Integrated Care Model
• A team-based approach, whereby team members work
together to provide comprehensive care. This team may
include primary care physicians and/or Advanced Practice
Providers (APP), behavioral health specialists (e.g., psy-
chologists, social workers, or graduate students in psy-
chological training programs), pharmacists, psychiatrists,
and care managers.
• Care Coordination: There is close coordination and
communication (in-person and/or via shared electronic
medical record) among team members to ensure that
patients receive the right interventions and support. The
team may develop treatment protocols and algorithms to
determine roles for screening, assessment, and
intervention.
• Treatment Plans: Patients receive personalized treatment
plans that address both their physical and behavioral
health needs. This often includes evidence-based treat-
ments for mental health conditions like depression and
anxiety. Treatment plans are shared among interdisciplin-
ary team members.
• Measurement-Based Care: Regular assessments and mea-
surement of patient progress help guide treatment deci-
sions and adjustments.
Collaborative Care Model (CoCM)
• A patient-centered model of team-based care that engages
the PCP or APP as the cornerstone of the care team with
care management staff to provide brief behavioral inter-
ventions and a psychiatric provider as a consultant.
• In addition to regular assessment of patient progress, this
model also tracks time spent by each team member
monthly.
• Using time-based tracking and billing codes, the CoCM
payment model allows for billing through medical bene-
ts with Medicare and Medicaid, potentially ameliorating
nancial barriers for both clinics and patients in the provi-
sion of behavioral health services.
• Patient registries are utilized for population health
management.
Co-located Care/Behavioral Health Consultation
• Behavioral health consultants (BHCs), often psycholo-
gists or social workers, are embedded in primary care
clinics and receive referrals from primary care clinicians.
They work with primary care providers to offer timely
assessments and interventions for patients with behav-
ioral health concerns.
• BHCs provide brief, focused interventions that may
include counseling, psychoeducation, and recommendations for further care if needed.
• Psychiatrists also may be available through an intermittent specialty consult clinic in the primary care setting or
available for virtual consultations for diagnosis assistance
or medication management. Assess resources in the organization and the community to determine if such consultation services may be available or feasible.
• Care coordination: Co-location enhances informal communication opportunities between clinicians about shared
patients.
• Treatment Plans: Clinicians share treatment plans and
progress with referring physicians but may not share
health records/patient charts.
Coordinated Care
• The primary care ofce conducts routine behavioral
health screening and utilizes an established referral relationship with one or more external behavioral health clinicians or organizations to provide care for a patient’s
mental health needs.
• Mental health services are provided in a location other
than the primary care clinic.
• Care coordination: The primary care organization and the
mental health organization likely do not share medical
records or patient charts. However, there is a routine exchange
of information between settings to ensure cohesive care. The
communication may be facilitated by a care manager.
Other issues to consider when implementing IBH and
training family medicine residents in its utilization:
Routine Screening and Assessment. Primary care practices
routinely screen patients for behavioral health issues, such
as depression, anxiety, and substance use disorders during
regular check-ups. Screening may be performed by a clinical staff member or a physician. Forms may also be provided for patients to complete upon check-in or as part of
the rooming process. Various assessment tools and questionnaires are used to identify patients at risk or those experiencing behavioral health issues. Results of assessments
guide physicians in their treatment planning, to manage in
primary care or refer out to behavioral health services.
Care Management. Care managers or care coordinators
help patients navigate the healthcare system, schedule
appointments, and connect them to appropriate resources
and support. Patients are often educated about the connection between physical and mental health, helping
them understand the importance of integrated care. They
may have training in social work or health coaching. As
health coaches do not require graduate level professional
training, but do receive specialized training in goal setting, motivational interviewing and health behavior
change, it may be cost efcient to utilize their services.
342
A. Bickett et al.
Telehealth and Technology. Telehealth services have become
increasingly important in integrated care models, allowing
patients to access behavioral health services remotely
when needed. Services may include medication manage-
Provider Self-Awareness andReective Practice
ment with a psychiatrist, ongoing psychotherapy with a
behavioral health clinician, self-guided virtual evidenceinformed interventions such as cognitive behavior therapy,
and interventions from care management or social work.
Source: By the author Linda Myerholtz, PhD
Considering the breadth of information and practice required
to integrate all the aforementioned curricula into a 3- or
4-year residency experience, additional teaching about provider self-awareness and reective practice may feel overwhelming. Fortunately, the ingredients for a curriculum
around personal development are the same that adult learners
require for engaging productively in the family medicine
curriculum. Family medicine into a program with a variety
of skills and resiliency that will create natural opportunities
to promote professional development, personal development, and self-care. Although considerable variability will
exist within any program or any class of residents, family
medicine residents want to succeed, want to grow, and possess well-developed self-awareness.
ACGME requirements clarify the commitment to physician self-awareness and reective practice within the professionalism domain and within the subsections dedicated to
practice-based learning and improvement. Further commitment to self-awareness and personal development is reected
in the statement on physician wellness which highlights
shared responsibility to support thriving physicians.
Physician self-awareness and reective practice are integrated into the AAFP behavioral health curriculum guidelines and explicitly described in the full developmental
context in the ACGME milestones connected with Practice
Based Learning and Improvement (PBLI).
Competencies connected with professionalism and ethics
require content education and a commitment to selfawareness in broad strokes. Within the domain of professionalism (see Fig. 30.5), physicians-in-training develop
self-awareness and reective practice, vital components of a
family physician’s professional journey. They enhance a
family physician’s ability to better understand their own
biases, values, and emotions that can inuence patient inter-
30 Teaching Behavioral Science
343
actions. This awareness enables them to provide more
patient-centered care, adapting their approach to align with
the needs and preferences of diverse patients. This can, in
turn, cultivate a deeper sense of empathy for the patient
experience.
Physicians must be aware of how personal bias affects
care for patients. Licensing boards often require specic curriculum addressing implicit bias, even when employers may
not. In any case, awareness of the roots of implicit bias and
specic strategies that physicians can use to mitigate bias in
their care will be central to efforts to create a more equitable
health system. Behavioral Health Curriculum in family medicine training provides many opportunities to offer implicit
bias curriculum and to address health inequities.
Requirements for PBLI further elaborate on important
content related to self-awareness and reective practice,
including appropriate goal setting, awareness of personal
competencies and decits, and identication of appropriate
learning activities. These requirements outline learning goals
directed toward physicians’ leadership in practice and health
systems. This connects with the mission to create Master
Adaptive Learners (see below for description) who adjust
and adapt based on the ongoing feedback they receive from
the environment in which they practice and learn. Family
medicine milestones describe the aspirational developmental
trajectory of physicians who are skilled in self-reection and
committed to personal and professional growth.
Engaging in reective practice allows physicians to
review and evaluate their clinical decisions, identifying patterns of success, and areas of concern. This iterative process
enhances their critical thinking skills and leads to more
informed and evidence-based medical choices. Selfawareness helps family physicians recognize signs of burnout, compassion fatigue, and other psychological challenges.
By reecting on emotions and stress triggers, they can take
proactive steps to manage their well-being. Likewise, reective practice improves physician’s abilities to collaborate and
communicate with other healthcare professionals. By understanding their own strengths and areas for growth, they can
contribute more effectively to team-based patient care.
The ultimate goal of family medicine training is to facilitate the development of family physicians who are wellrounded, self-aware leaders, with a good fund of medical
knowledge and a high degree of cultural humility. In outlining the necessary ingredients for a curriculum that engages
residents’ personal and clinical growth, we are aware of the
signicant variability in our residency programs, learning
environments, personnel, and communities that require us to
adjust and accommodate the curriculum. Each program is
working with different ingredients, in different kitchens,
with different measuring spoons and kitchen tools. The previous section provided details on the ingredients for the BH
curriculum. The next section will describe methods of preparing and using these ingredients.
Crafting Behavioral Health Educational
Experiences: Teaching Methods
andStrategies
Much of adult learning, particularly during residency education, comes from a combination of experiential learning
and reection [61]. The cognitive apprenticeship model
[62] and other adult learning theories can help frame our
role during teaching encounters through content curation,
engaging teaching strategies, and the facilitation of reective experiences throughout the learning process. Effective
teachers will help learners orient themselves to the activity,
identify explicit learning objectives, and anticipate important elements of the experience (pre-brief) [63]. Both
intended and unintended learning happens during experiential learning (which could be anything from a team-based
learning activity, clinical encounters, patient simulation,
resident-faculty retreat, or role play during didactics as
examples). Facilitators then hold space for learners to
debrief and reect on their experience, often returning to
learning objectives to facilitate a deeper connection to the
material.
Just as a chef might employ a fusion of cuisines or cooking methods to create a cohesive dish, the program should
consider using a combination of teaching methods and strategies. Educational approaches might include principles of
Master Adaptive Learner, Behavioral Health/Science
Rotations and Electives, clinic-based learning, didactics/
classroom-based learning, interprofessional education, video
review/patient simulation, and personal development and
self-care.
Master Adaptive Learner
Likely, BH training will occur in a variety of settings, using
a variety of methods. Depending on the context, it may be
helpful to keep the Master Adaptive Learner (MAL) approach
in mind. The MAL framework encourages self-reection and
self-directed learning in an iterative process similar to a
PDSA cycle. In the clinic, faculty may contribute to the
learner’s self-assessment by providing feedback on an
observed skill and then facilitating learning through
questioning or thinking aloud [64]. Putting MAL into action,
BH faculty may ask residents to reect and identify the communication skills to be enhanced prior to an observed clinic.
Feedback could be provided and implemented in real-time,
with the resident leading how it is to be implemented.
Alternatively, the resident could describe their approach to a
visit that was recorded and then share how they might
approach it differently with input from BH faculty. Because
MAL requires continual reection and self-assessment, it
adapts to the residents’ level of learning, always identifying
the next step of something to learn [65].
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A. Bickett et al.
Behavioral Health/Science Rotations
andElectives
Many residencies have a curriculum that is built around
block rotations, weeks, or months during residency training
that focus on a particular learning environment/clinical care
context such as inpatient care, pediatric outpatient care, and
obstetrical care. Some programs also have a rotation that
focuses on behavioral medicine/science/health care. These
terms are interchangeable and will subsequently be referred
to as a BH rotation or BH elective in this chapter.
The new ACGME program requirements state that residents must have a “dedicated experience” in the diagnosis
and management of common mental illnesses and that this
needs to include IBH in the primary care clinic, but they do
not specify that programs must have a specic BH rotation or
how long this experience should be. While BH learning
should be integrated throughout all clinical training experiences during residency rather than articially siloing BH as
a separate aspect of healthcare, a BH rotation does allow for
an immersed concentrated experience in a variety of behavioral health/mental health learning environments.
The experiences included in a BH rotation will depend on
the learning goals for the rotation and on connections the
residency program has within the larger health care system
and the community. Thus, a BH rotation could look quite
different across residency programs. There is considerable
opportunity for creativity in crafting learning experiences for
the residents. Inpatient psychiatric settings can offer easier
access to participating in care as there tends to be less emphasis on continuity of behavioral health care. Likewise, psychiatric consultation services in healthcare systems can provide
rich learning and opportunities to practice assessment skills
and consultation.
Referring back to the metaphor of behavioral science as a
culinary experience, you’ll want to check your pantry for
what is available to you. Whether your residency exists in a
community clinic or an academic institution, you may wish
to explore interdepartmental or inter-organizational collaborations. Educational partnerships frequently exist between
family medicine residencies and psychiatry, pediatrics, OB/
GYN, and community organizations. For opportunities to
practice behavior change counseling skills, one could look
for individuals in the community or partnerships with organizations who specialize in substance use treatment programs, tobacco cessation/moderation programs, behavioral
weight management programs, and other harm reduction
programs. In conjunction with, or in the absence of, such collaborations programs may wish to develop self-directed
learning opportunities for residents to explore various behavioral health topics at their own pace. For example, a rotation
schedule may include 2–4 self-directed learning half-days,
whereby the resident is provided with a list of articles,
resources, videos, and online modules to further their understanding of mental health assessment and treatment topics.
These self-directed learning times and topics can be further
tailored to the resident’s desired learning style and interests
at the beginning of the rotation.
To help residents learn about crisis management, a residency could include experiences with a mental health crisis
center or crisis hotline. Having residents rotate with a local
ACT team (Assertive Community Treatment) or a rehabilitation clubhouse program would broaden training for working
with interdisciplinary teams serving individuals with serious
and persistent mental illness. Consider incorporating poverty
simulations and shelter health opportunities to provide tangible representations of psychosocial and community
connections.
In addition, a BH rotation might offer experience in different models of IBH such as psychiatric collaborative care
models, primary care behavioral health, and reverse colocated models of care.
Given that BH is foundational to primary health care and
behavior change counseling skills are critical for residents to
learn, having the BH rotation in the intern or second year
may be ideal. With the recent expansion of time for elective
rotations during the 3years of residency (3–6months), there
is also an enhanced opportunity to craft elective BH rotations
to enhance learning for second and third-year residents.
These elective rotations could focus in more depth on particular populations such as child and adolescent mental
health or substance use treatment. For examples of BH
Rotations please see Appendixes 1 and 2.
Clinic-Based Learning
Faculty responsible for BH training may want to consider
the sites where residents engage in patient care (ambulatory, inpatient, OB, etc.) and identify partners for incorporating BH topics into those sites, or tie cases from other
sites into BH didactics at the family medicine residency
site. For example, discussions on how to perform a traumainformed well-woman exam or the importance of screening
for interpersonal violence and depression at a postpartum
visit could be covered as part of an OB/GYN rotation or in
the family medicine practice. When at the family medicine
site, BH principles can be strengthened through precepting,
curbside consults, observation, and engaging in collaborative or integrated care models (covered in a subsequent section). Behavioral co-precepting occurs with family
physicians and BH provider faculty and aims to reinforce
residents’ skills in psychosocial assessment, medication
management, and behavioral interventions. Innovations to
this approach have utilized telehealth modalities [66]. BH
preceptors may want to be aware of how much information
they convey and utilize principles of microlearning, which
emphasizes self-directed learning in small units that build
upon each other and are applied quickly (focused, “just-intime training”) [67].
30 Teaching Behavioral Science
345
Indeed, though some principles of effective patientcentered communication can be conveyed through workshops, developing strong communication skills must include
observations with coaching. Henry and colleagues [68] propose that communication skills training should be conducted
like training in procedures, with observed practice and feedback. This could take place with standardized patients, role
plays with faculty or peers, and video reviews or direct
observations of patient care [69]. Having a structured process to review patient encounters that includes clear identication of communication skills to be bolstered, ways to
improve, and strengths can improve resident satisfaction
with the process [70].
Many programs use a standardized format to provide
feedback on communication skills, such as the PatientCentered Observation Form (PCOF). The PCOF provides
linkages to family medicine milestones, aiding in both formative feedback and competency assessment [71–73].
Classroom-Based Learning
BH faculty should have an active role in directing the topics
scheduled for didactics. They may want to teach certain core
topics annually (e.g., basics of managing depression and
anxiety, communication skills workshops) and include other
topics in a rotating fashion on an 18-month schedule (e.g.,
eating disorders).
Active learning strategies should be the primary modality
of instruction. Though some may require more time to prepare or up-front investment to master the teaching style, they
result in greater engagement and retention as compared to
lecture-based formats. One example of this format is the
ipped classroom, in which residents are assigned pre-work
to identify their learning goals and prepare them to be active
participants in the classroom-based instruction. Residents
co-create the learning experience by asking questions and
reecting on their experiences or sharing their knowledge.
The faculty acts as a guide in the residents’ learning and
must be prepared to address multiple goals or competencies,
as opposed to directing all of the content that is shared with
the learners [74]. Other chapters in this book provide more
in-depth descriptions of active learning strategies.
Video Review andSimulation-Based Learning
Video review (VR) is commonly used in family medicine
residency training as a valuable educational tool that can help
residents develop their clinical skills, enhance their knowledge, and improve their patient care. Programs vary in the
number of recorded patient encounters they require for residents each year, with some choosing to increase the frequency
of video reviews for residents experiencing difculty or limitations in clinical interviewing or medical knowledge.
The process is also highly variable, depending on video
equipment and administrative support for the experience.
When implementing video review in family medicine residency training, it is important to ensure patient privacy and
condentiality by obtaining informed consent from the
patient and following ethical and legal standards, including
the use of HIPAA-compliant equipment. Additionally, creating a supportive and nonjudgmental learning environment is
crucial to encourage residents to actively engage in the
review process and seek continuous improvement in their
clinical skills and patient care. Because video review processes can invoke anxiety in learners and faculty alike, faculty should provide a thorough explanation of the purpose
and expectations for the activity, so as to lessen discomfort
and improve learner safety (e.g., Video Review | Family
Practice Residency Program (ubc.ca)). As noted previously,
the Patient Centered Observation Form (PCOF) is often used
to guide feedback sessions [73].
Faculty can request that residents present recorded cases
during didactic sessions or in small-group discussions.
Reviewing these cases allows residents to receive feedback
from attending physicians and fellow residents, helping them
rene their assessment, interviewing, clinical decisionmaking, and treatment planning skills, as well as the structure and ow of their ofce visit. Facilitating the process of
peer feedback can provide a unique perspective to the evaluation, sharpen interprofessional communication skills, and
foster a collaborative learning environment. The video
review feedback session may alternatively be held with one
or two faculty members (i.e., one attending physician and
one behavioral medicine faculty), without other residents
present.
Simulation-based medical education (SBME) experiences can also serve as mechanisms for training and
evaluation in the family medicine curriculum. This learning
environment provides residents with an opportunity to practice clinical skills and gain experience with challenging clinical scenarios in a controlled and safe environment [75, 76]
and allows for the tailoring of clinical scenarios to the developmental level of the learner [77].
The content and frequency of simulation-based learning
will vary by program, depending on availability of SBME
resources and nancial feasibility of engaging in this type of
learning platform. A 2019 survey of Program Directors across
a diverse sample of family medicine residency training programs indicated the majority of programs utilized simulation
as an educational tool for education and assessment of clinical skills and medical knowledge competencies [78].
Before the encounter, residents and faculty set specic
learning objectives and goals for the simulation. These
objectives can vary widely and may include tasks such as
taking a patient history, conducting a physical examination,
making a diagnosis, formulating a treatment plan, and effectively communicating with patients and their families.
Faculty or simulation experts create realistic patient scenar-
346
A. Bickett et al.
ios that mimic common or challenging clinical situations
encountered in family medicine. Scenarios can range from
routine primary care visits to complex cases like managing
chronic illnesses or addressing end-of-life care issues.
Simulated encounters can also be used for interdisciplinary
training, allowing residents to work with other healthcare
professionals, such as nurses, pharmacists, or social workers,
in a team-based approach to patient care.
Family medicine residency programs often have dedicated
simulation facilities equipped with examination rooms, medical equipment, and audio-visual recording capabilities. These
facilities mimic real clinical settings as closely as possible.
Trained actors or standardized patients (SPs) are used to portray the role of patients or family members. SPs are coached to
provide consistent and realistic responses to residents’ questions and actions during the encounter. Residents participate in
scheduled simulation sessions, either individually or in small
groups. In some training scenarios, residents take turns interacting with the simulated patient while others observe and
subsequently provide feedback. Faculty members may also
observe remotely or from behind one-way mirrors.
Interprofessional Education
Given the new emphasis in ACGME requirements on interprofessional learning, it is important to consider how to
effectively implement interprofessional education (IPE).
Prior to this update, many family medicine educators recognized the need for specic training in interprofessional practice, including dening who is on the team, understanding
scopes of practice, communicating effectively with other
professionals (e.g., developing a shared language, conict
resolution), and overcoming siloed care to work as a team.
[79, 80] Further, the Interprofessional Education
Collaborative has outlined core competencies for interprofessional collaborative practice [81]. The ability to provide
interprofessional care can enhance patient safety and quality,
as well as provider satisfaction [82].
Successful implementation of IPE in the clinic or classroom will follow certain principles. In family medicine,
interprofessional team members may include nursing, pharmacy, social work, behavioral health, and other medical professionals. The learning environment must be supportive of
each individual and clearly model respect and value for each
profession [83]. In the clinic setting, ensuring availability of
team members, role clarication, open communication, and
shared decision making enhances the relationship building
that is vital to interprofessional practice [84]. Thus, these
behaviors must be modeled in the clinic. Other strategies to
teach collaborative BH care in the clinic may include huddles, warm handoffs, shadowing, and co-counseling [85]. An
interprofessional approach also could be taken with providing feedback on direct observations of patient care to demonstrate patient-centered communication skills to multiple
types of learners [86]. In the classroom, learners from differ-
ent professions may be grouped together for team-based
learning, with an invitation to each to participate in the discussion. For example, each could be asked to describe how
they would contribute to the care of a person with uncontrolled diabetes with multiple psychosocial barriers to adhering to their treatment plan. Ideally, facilitators representing
the different professions will be present to help guide activities [87].
Regardless of the IBH model utilized by a program, there
are several competencies in interprofessional collaboration
to be addressed in a family medicine training curriculum
[81].
Competency 1: Work with individuals of other professions to
maintain a climate of mutual respect and shared values.
(Values/Ethics for Interprofessional Practice).
Competency 2: Use the knowledge of one’s own role and
those of other professions to appropriately assess and
address the health care needs of patients and to promote
and advance the health of populations. (Roles/
Responsibilities).
Competency 3: Communicate with patients, families, com-
munities, and professionals in health and other elds in a
responsive and responsible manner that supports a team
approach to the promotion and maintenance of health and
the prevention and treatment of disease. (Interprofessional
Communication).
Competency 4: Apply relationship-building values and the
principles of team dynamics to perform effectively in dif-
ferent team roles to plan, deliver, and evaluate patient/
population-centered care and population health programs
and policies that are safe, timely, efcient, effective, and
equitable (Teams and Teamwork).
Personal Development andSelf-Care
It is with great clarity that the ACGME milestones focus on
recommendations for self-awareness and well-being, quoted
here [14]:
Psychological, emotional, and physical well-being are critical in
the development of the competent, caring, and resilient physi-
cian and require proactive attention to life inside and outside of
medicine. Well-being requires that physicians retain the joy in
medicine while managing their own real-life stresses. Self-care
and responsibility to support other members of the health care
team are important components of professionalism; they are also
skills that must be modeled, learned, and nurtured in the context
of other aspects of residency training.
Residents and faculty members are at risk for burnout and
depression. Programs, in partnership with their Sponsoring
Institutions, have the same responsibility to address well-being
as other aspects of resident competence. Physicians and all
members of the health care team share responsibility for the
well-being of each other. A positive culture in a clinical learning
environment models constructive behaviors, and prepares resi-
dents with the skills and attitudes needed to thrive throughout
their careers.
30 Teaching Behavioral Science
347
While the BH curriculum focus should not neglect physician vulnerability, including burnout, depression, and compassion fatigue, it should also nd a way to support well-being
and intentional connection to purpose in their role. This aspiration underlines the expectation that physicians will know
about burnout, stress management, and nd an approach to
integrate their personal well-being and their professional
identity.
When introducing resident well-being and self- awareness,
activities that encourage systems thinking will develop residents’ skill in understanding and navigating social systems
of which health systems are an important and relevant subtype. Introduction of these concepts, and health system
impacts on physicians can help reduce reactance when residents are presented with personal development exercises and
individual coping strategies for physician wellness. By framing a discussion of physician burnout in the context of health
systems at various levels, residents connect with the challenges that they might face as participants in a system that
creates vulnerability to burnout. Using these personal connections to systems introduces residents to important systems level concepts, including family systems [18] and
systems of oppression [88] that impact patients they will see
throughout their careers.
It is also important to consider, as family medicine residents are engaged in activities to promote self-care and
reection, that some will be facing important developmental
milestones (e.g., partnering, caring for parents or children,
living apart from family support), and often in the middle of
life stressors outside of medicine. This developmental trajectory, so central to the practice of family medicine, is unfolding for our residents as we teach about human development,
coping with stress, caregiving, and identity. It may be benecial to incorporate opportunities for learners to reect on
their own developmental trajectory and developmental
stressors as they develop compassion for human development across the lifespan in the context of family and
community.
Finally, the implementation of a personal development
and self-care curriculum should be incrementally implemented throughout the course of residency, through retreats,
workshops, mentorship, and didactic encounters, to maximize skill development and performance across environments. Strategies for longitudinal integration will require
signicant adaptation for local contexts, but several examples may serve to illustrate common tactics. The task of integrating behavioral health conversations, personal
development, and self-reection is given the weight it
deserves when there is longitudinal didactic time dedicated
to reection and connection with others. Similarly, designing
a didactic curriculum that readily connects with outpatient
clinical experiences facilitates an ongoing ow from didactics to clinic, and back again. This seems especially important for the skills that improve clinic ow, the skills that
allow physicians to navigate challenging encounters, and the
in-the-moment adjustments that can be made during an
encounter based on feedback from patients or competing
clinical demands. Without protected time during didactics
and rotations, most residents will nd it difcult to practice
self-reection consistently.
On the inpatient side, where residents have intense clinical experiences, regularly dedicated discussions of challenging encounters, new experiences, and personal reactions
boost reective capacity and develop residents’ skills in
communicating bad news, handling the death of patients, and
making adjustments to facilitate better team-based care.
Bringing these conversations into the milieu where residents
are actively encountering intense experiences can facilitate
the importance of self-reection, application, and skill
development.
Having multiple faculty other than the behavioral medicine educator(s) lead personal development and self- reection
exercises can increase resident buy-in and engagement. For
example, the Chair of the department may lead a “connection
to purpose” moment at the beginning of resident/faculty
meetings. The Program Director could incorporate a breathing exercise into the beginning of Resident Business Meetings.
Perhaps the Sports Medicine Division lead could lead a yoga
or tai chi session at the beginning of a didactic session. The
more residents see their faculty role model engagement in
self-care and personal development, the more it will be
engrained in their own practice.
Specic Wellness Techniques andPersonal
Development
There are opportunities for experiential learning and
rehearsal of skills represented by various behavioral health
interventions, including breathing techniques, behavioral
activation, and self-compassion. Acceptance and commitment therapy (ACT) has shown promise in single session
design [89] and provides a potential opportunity for FM residents to participate and to develop their clinical acumen in a
single session. For many residents, the addition of selfcompassion [90] can be a welcome tool to reduce vulnerability to burnout and to encourage in patients with a variety of
behavioral health concerns. In addition to adding to their
clinical wisdom, residents can often add skills to their own
coping repertoire when these techniques are a steady element
of the curriculum.
Instruction in self-calming breath techniques has application for residents and patients alike. By training our residents
in this evidence-based treatment for anxiety and panic, residents may learn to manage their own symptoms, and provide
them with the scaffolding and motivation to engage their
patients in this practice. As breathing techniques will impact
individuals in various ways, it may be helpful to provide residents with several scripts and methods of breath training
throughout their education, giving them a menu of options to
practice and disseminate with their patients. A sample infographic for breathing techniques, developed for clinical
teaching by Haymaker, Leckie and Roberts and presented at
The Forum for Behavioral Science in 2022, is included in
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A. Bickett et al.
section “Core Mental Health Topics” of this chapter [24]
When developing residents’ skills in behavior change to
address major depression, behavioral activation (see
Fig.30.3) can often be more readily implemented by learners with limited counseling experience, and often has immediate impact for patients.
Reection
Self-reection is a critical element of a curriculum to develop
self-aware, effective, resilient physicians [61, 91]. It is vital
giving and receiving feedback, skill renement, and the integration of new knowledge. This dovetails with the Master
Adaptive Learner approach discussed earlier [65], and when
our learners integrate reection into their repertoire, there
are clear benets [64].
Self-reection can be a challenging process, and thus it
may be useful to start with a basic reection exercise that can
be introduced regularly into various parts of the curriculum
and tailored to experiences and learning environments. The
‘What? So What? Now What?’ approach can serve as a basic
example (see Fig.30.6).
In response to “What?” learners include a description of a
situation or event. In response to “So What?” learners
describe their reaction to the event or situation, stating its
perceived importance. In response to “Now What?” learners
could briey identify implications or prospective changes
they might make based on experience [92, 93]. During didac-
tics this series of questions might be modied to signpost
prior learning opportunities so that the residents can integrate foundational principles with new medical knowledge.
For example, faculty can ask residents “How can you incorporate that into your clinical practice?” or, “How does this
activity connect with your purpose and values as a physician?”. Learners might be asked to react to specic learning
activities, identify important experiences, or process difcult
encounters using simple queries to structure self-reection
in the moment. In the same vein, providing explicit opportunities for residents to name and process emotional reactions
supports physician self-reection and humanizes the education process.
While the majority of family medicine residents will demonstrate some level of receptiveness to self-reection, not
everyone will show the same interest. Resistance may be
linked to the perception that reection takes time that could be
spent in other learning domains. Response to this sort of resistance can often be handled by incorporating reection into the
curriculum (i.e., no writing assignments outside of work) and
by clearly delineating objectives for self- reection as they
connect to well-being and professional identity [92, 94].
Family medicine residents often benet from time to collect their thoughts, and for some (i.e., introverts), this contemplation seems more natural, necessary, and protable.
Writing assignments and written tasks give learners the time
they need to react to content and integrate their thoughts and
feelings. Preceding group discussion with a written “quick
think” can boost engagement for those more introverted and
develop under-utilized techniques for more extraverted
learners. During a lecture or workshop, a quick think provides a moment, usually less than 5minutes, sometimes less
than a minute, for learners to sit quietly and digest material,
often by writing to a prompt. Quick think prompts can be
used early in a lecture or workshop to activate prior learning
or experience (e.g., “Take a moment to reect and write
about a time when you got useful feedback…”). Prompts
should be used to connect with emotional reactions to case
material (e.g., “Take a moment to reect on how you feel
about this case so far. How do you think you would feel in
the room with this patient?”) Similar prompts support effective planning for behavior change (e.g., “How do you plan to
implement key practices for discussion today?”). There are
multiple examples of strategies for developing and accessing
written practice. The work of Wald and colleagues [95] is a
useful starting point.
In addition to written reection, some learners benet
from social and communal opportunities to reect [96]. The
pairing of a “quick think” with a dyadic or small group “pair
and share” may be most useful since having someone to bear
witness to their thoughts can be powerful. Pair and share
activities provide a moment for learners to reect with colleagues. Learners take turns talking about their reaction to a
quick think in a pair or small group. Verbal reection with
colleagues creates opportunities for vulnerability and connection, facilitates development of culture, and maintains a
public space in which appreciation for the perspectives of
peers can be appreciated (and learned from).
Balint Groups
Perhaps the quintessential practice for reection, support
and well-being of physicians, Balint has been used to good
effect in family medicine education for decades [97]. Balint
groups incorporate many of the elements of personal development and self-awareness curriculum. When physicians
come together to reveal their personal reactions and challenges with their peers, Balint groups help facilitate empathy, connection, social support, vulnerability, compassion,
and self- compassion [98]. It also provides a unique space for
cognitive exibility, through the exploration of multiple perspectives related to the physician experience, the patient
experience, and the dynamics of their relationship. During
Balint residents are offered the opportunity to practice
trauma-informed care, as the group hypothesizes about what
might be going on for a patient, instead of what is wrong
with a patient. Consider, for example, a resident presenting a
case of a patient who exhibited anger and aggression in the
clinic space. Residents imagine what circumstances or psychosocial elements may have played a role in the patient’s
experience, rather than the physician assuming that the
patient is angry toward them. Balint groups also offer space
to practice the toleration of ambiguity and the exploration
and acceptance of multiple perspectives.
30 Teaching Behavioral Science
349
Fig. 30.6 Elements of self-reection
350
A. Bickett et al.
Consensus, commitment, and support from faculty and residents are critical to achieve a successful Balint experience
within a residency program. Facilitation skills ensure that inexperienced participants are well-supported as they participate
and help maintain a Balint program over time. Behavioral science faculty who become stewards of a Balint initiative may
also need to attend to power dynamics between faculty and
learners, perceived control and autonomy of learners, and advocacy for learners’ perspective about Balint curriculum [99].
Connections Between thePersonal
andProfessional
For learners to develop self-awareness that will keep them
thriving, the behavioral health curriculum should provide
explicit tools to connect personal reactions to professional
experiences in ways that help learners uncover bias and
develop effective tools for handling professional challenges.
Within the behavioral health curriculum, conversations about
challenging patient encounters represent opportunities to
reect on health care systems, health equity, personal bias,
and communication skill. While some of these conversations
will occur on the y during clinic, or within the context of
relevant didactic content, utilization of a dedicated curriculum to help process challenging patient encounters represents useful scaffolding for learners. BREATHE OUT, the
curriculum developed by Edgoose and colleagues [100] represents such a system and addresses the need for anticipating
such encounters, for communication best practices, and for
processing reactions to challenging encounters afterward.
The explicit inclusion of reection about personal bias within
the curriculum dovetails with required material around
implicit bias and normalizes human reactions that can be
handled with compassion (as opposed to avoided).
Physicians inNeed ofAssistance
While much of the behavioral science curriculum will be
aimed at developing and maintaining a learning community
of healthy, vibrant physician learners, given what we know
about how our medical system impacts physician well-being
[101, 102], and what we know about the prevalence of
depression, anxiety, substance use, and suicide among physicians [103], the behavioral science curriculum around personal development and self-awareness must address how
physicians can identify and address their distress and burnout [104]. This might include frank conversations about risk,
skillful rehearsal of self-monitoring strategies, and clear
identication of resources designated for physicians in need.
Resident education should include state requirements for
reporting physicians in need of assistance and accessing physician assistance from state agencies. Physician Health
Programs (PHPs) vary in their implementation from state to
state, and there is limited scholarship about best practices for
reducing physician vulnerability to burnout, substance use,
depression, and suicide [105]. Most states have a mechanism
for engaging physicians who are struggling, and whose performance has been affected. Some states encourage reporting and engagement through “safe haven” rules and direct
provision of services, while many others continue to use a
more restrictive approach and physicians may incur a signicant personal cost for evaluation and treatment.
Within the residency, the development and maintenance of
a variety of resources for physicians who express need normalize help-seeking and encourages self-care. Learners should
be encouraged to procure resources and support via regular
conversations with the program director, advisors, and from
various faculty members [106]. Cultivating spaces in which
psychological safety can be maintained, and where privacy
can be respected increases the likelihood that learners who
need help will seek it; this is especially true if core faculty can
model vulnerability and model positive attitudes toward personal development and self-care. Programs should incorporate
protected time in resident schedules to attend healthcare
appointments and may want to explicitly identify time for residents to engage in self-care. Some programs also may wish to
establish pathways for mental health care for all residents, giving individuals the option to opt out if they wish.
Even in the best of circumstances, there will be learners
who may not reveal personal concerns until they begin to
impact their professional behavior [107]. The personal development and self-awareness curriculum should address these
situations with predictability, clarity, and compassion where
possible. While beyond the scope of this chapter, early intervention and remediation for professionalism lapses can be
thought of as a backstop for the personal development and
self-awareness curriculum, identifying learners who may be
at higher risk for licensure complaints and suspensions postgraduation [108, 109].
Attending to self-care, self-awareness, and well-being of
Family Medicine residents enhances the learning environment.
Adult learners thrive when residencies prioritize well- being, and
by explicitly addressing self-reection, emotional reactions,
stress management, and burnout, we provide a framework for
Family Medicine residents to enhance their self-awareness and
develop the tools they will need throughout their career as a
Family Medicine physician and lifelong learner.
Conclusion
The integration of behavioral science into a family medicine residency program is an important part of the history
of our eld and will be vital to our future. The ACGME
has requirementsand theAAFP has provided guidelines
for the “staple ingredients” for behavioral medicine
programming, but each residency program will add their
own avors and unique ingredients based on the chef’s