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30 Teaching Behavioral Science
351
training, the utensils and materials available to them, the
season of the program, and the legacy left by those who
were in the kitchen before them. These factors will likely
change over time, and thus the behavioral medicine curriculum may necessarily shift and grow to accommodate.
It is useful to regularly survey which elements of the
behavioral medicine curriculum are being taught, when
they are being taught (PGY1, 2, 3), where the material is
disseminated (rotations, clinic precepting, didactics, etc.),
and by whom.
Keep in mind, no matter what unique avors are added by
each program, the foundational objective of the behavioral
medicine curriculum is universal. We strive to prepare family
physicians to see patients and their families through a biopsychosocial lens that magnies the inuence of culture and wellbeing on overall health; to continually seek to understand their
own impact on the health of the patient and appreciate the role
of the physician–patient relationship in the trajectory of health
and healing; and to use evidence- informed principles to treat
the mental health needs of their patients.
Appendix 1: Sample Behavioral Health Rotation (Myerholtz 2023)
Mon Tues Wed Thurs Fri
Week 1AM Psychiatry consult virtual
PM Clinic PCBH integrated
Week 2AM MOUD clinic
(medication for opioid use
disorder)
PM Child and adolescent
psychiatric consultation
clinic
Week 3AM Psychiatric collaboration
w/ BHCM at resident’s
clinic
PM Child and adolescent
psychiatric consultation
clinic
Week 4AM UNC REACH
(reverse co-location
model-primary care in
mental health center)
PM UNC REACH
(reverse co-location
model-primary care in
mental health center)
clinic (adult)
Psychiatry consult virtual
clinic (adult)
MOUD clinic community
health center (medication for
opioid use disorder)
UNC REACH (reverse
co-location model-primary
care in MH center)
UNC REACH
(reverse co-location
model-primary care in MH
center)
UNC REACH
(reverse co-location
model-primary care in mental
health center)
UNC REACH
(reverse co-location
model-primary care in mental
health center)
Didactic
conferences
behavioral health
Didactic
conferences
Tobacco treatment
program
Didactic
conferences
Formerly
incarcerated
transitions program
Didactic
conferences
Formerly
incarcerated
transitions program
Adult psychiatry
consult liaison service
Adult psychiatry
consult liaison service
PCBH integrated
behavioral health
STEP clinic
(SPMI reverse
co-location model)
Child and adolescent
weight management
program
Pediatric weight
management
Adult psychiatry
consult liaison service
Adult psychiatry
consult liaison service
General psychiatry
clinic—Latinx
emphasis
BH self-directed
learning
Psychiatric weekly
case review and
consult mtg.
Clinic
Clinic
Clinic
Child and adolescent
psychiatry consult
service
Child and adolescent
psychiatry consult
service
Appendix 2: Sample Behavioral Health Rotation (Courtesy ofBickett)
Monday Tuesday Wednesday Thursday Friday
Week 1AM Medication-Assisted
Therapy Clinic
PM BH medication
consultation clinic
Week 2AM Wellness Monday Direct observation and
PM BH didactics Psychiatry didactics Family medicine
Week 3AM Virtual behavioral
health integration
stafng
PM Outpatient clinic Direct observation and
Self-directed learning BH personal
Inpatient detox Family medicine
feedback in clinic
Inpatient detox Partial hospitalization
feedback in clinic
development
didactics
didactics
Admin half day Partial hospitalization
didactics
program
Family medicine
didactics
Medication management
rounds
BH psych consult clinic MAT curriculum/reading
program
MAT curriculum/reading Behavioral health
Medication management
rounds
Davidson inpatient clinic Professional coaching
Behavioral health
integration stafng/
consultation
Direct observation and
feedback in clinic
integration stafng/
consultation
Teen health connection
(adolescent medicine)
session
(continued)
352
A. Bickett et al.
Week 4AM Davidson inpatient
clinic
PM Professional coaching
session
Behavioral health
integration stafng/
consultation
Direct observation and
feedback in clinic
Admin half day Addiction medicine Partial hospitalization
Family medicine
didactics
References
1. Engel GL. The need for a new medical model: a challenge for
biomedicine. Science. 1977;196(4286):129–36.
2. Recommended Curriculum Guidelines for Family Medicine
Residents: Physician well-being. Published online 2020. https://
www.aafp.org/content/dam/AAFP/documents/medical_education_residency/program_directors/Physician_Well- being.pdf.
3. Accreditation Council for Graduate Medical Education. ACGME
program requirements for graduate medical education in family
medicine. Published online 2022. https://www.acgme.org/global-
assets/pfassets/programrequirements/120_familymedicine_2022.
pdf.
4. Jacobs C, Brieler JA, Salas J, Betancourt RM, Cronholm
PF.Integrated behavioral health care in family medicine residencies a CERA survey. Fam Med. 2018;50(5):380–4. https://doi.
org/10.22454/FamMed.2018.639260.
5. Dissemination of Integrated Care Within Adult Primary Care
Settings: The Collaborative Care Model. Published online
2016. https://www.psychiatry.org/File%20Library/Psychiatrists/
Practice/Professional- Topics/Integrated- Care/APA- APMDissemination- Integrated- Care- Report.pdf.
6. Reiter JT, Dobmeyer AC, Hunter CL.The primary care behavioral health (PCBH) model: an overview and operational denition. J Clin Psychol Med Settings. 2018;25(2):109–26. https://doi.
org/10.1007/s10880- 017- 9531- x.
7. Derksen F, Bensing J, Lagro-Janssen A.Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract J R
Coll Gen Pract. 2013;63(606):e76–84. https://doi.org/10.3399/
bjgp13X660814.
8. Rotenstein LS, Edwards ST, Landon BE. Adult primary care
physician visits increasingly address mental health concerns:
study examines primary care physician visits for mental health
concerns. Health Aff (Millwood). 2023;42(2):163–71. https://doi.
org/10.1377/hlthaff.2022.00705.
9. ABFM National Graduate Survey for 2020. https://www.theabfm.
org/sites/default/les/PDF/NationalOnly_Report2020.pdf.
10. Baird MA, Hepworth J, Myerholtz L, Reitz R, Danner C. Fifty
years of contributions of behavioral science in family medicine.
Fam Med. 2017;49(4):296–303.
11. STFM Task Force on Behavioral Science. Core competency
objectives in behavioral science education. Published online 1986.
https://connect.stfm.org/behavioralsciencebasics/curriculum/
core- principles
12. Myerholtz L. Take a deep breath. Fam Med. 2023;55(4):284–5.
https://doi.org/10.22454/FamMed.2023.731271.
13. AAFP Reprint No. 270 Recommended Curriculum Guidelines for
Family Medicine Residents Human Behavior and Mental Health.
Published online 2020. https://www.aafp.org/content/dam/AAFP/
documents/medical_education_residency/program_directors/
Reprint270_Mental.pdf.
14. Family Medicine Milestones. Published online 2019. https://
www.acgme.org/globalassets/pdfs/milestones/familymedicinemilestones.pdf.
program
Teen health connection
(adolescent medicine)
15. Landoll RR, Cervero RM, Quinlan JD, Maggio LA. Primary
care behavioral health training in family medicine residencies: a qualitative study from a large health care system.
Fam Med. 2020;52(3):174–81. https://doi.org/10.22454/
FamMed.2020.681872.
16. Nutting R, Ofei-Dodoo S, Wipperman J, Allen AD. Assessing
family medicine physicians’ perceptions of integrated behavioral
health in a primary care residency. Fam Med. 2022;54(5):389–94.
https://doi.org/10.22454/FamMed.2022.541800.
17. Leigh H, Stewart D, Mallios R. Mental health and psychiatry
training in primary care residency programs. Part II.What skills
and diagnoses are taught, how adequate, and what affects training
directors’ satisfaction? Gen Hosp Psychiatry. 2006;28(3):195–204.
https://doi.org/10.1016/j.genhosppsych.2005.10.004.
18. Schiefer R, Levy S, Rdesinski R.A family systems curriculum:
evaluating skills and empathy. Fam Med. 2021;53(1):54–7.
https://doi.org/10.22454/FamMed.2021.391849.
19. Zubatsky M, Brieler J, Jacobs C. Training experiences of family medicine residents on behavioral health rotations. Fam Med.
2017;49(8):635–9.
20. Wu LT, McNeely J, Subramaniam GA, et al. DSM-5 substance
use disorders among adult primary care patients: results from a
multisite study. Drug Alcohol Depend. 2017;179:42–6. https://
doi.org/10.1016/j.drugalcdep.2017.05.048.
21. Substance Abuse and Mental Health Services Administration
(SAMSHA). National survey of drug use and health. 2021. https://
www.samhsa.gov/data/release/2021- national- survey- drug- useand- health- nsduh- releases.
22. Laschober R, Kelley L, Sartor Z, Johnson S, Griggs J.The Waco
guide to psychopharmacology in primary care. Published online
September 21, 2023. https://wacoguide.org/.
23. Lynch T.The skills training manual for radically open dialectical behavior therapy: a clinician’s guide for treating disorders of
overcontrol. New Harbinger; 2018.
24. Haymaker C, Leckie K, Roberts V. Innovative instruction with
infographics for clinical teaching in residency. Presented at:
43rd annual forum for behavioral science in family medicine;
September 2022; Chicago.
25. Norris DR, Clark MS.The suicidal patient: evaluation and management. Am Fam Physician. 2021;103(7):417–21. https://www.
aafp.org/pubs/afp/issues/2021/0401/p417.html. Accessed 11 Sept
2023.
26. Substance Abuse and Mental Health Services Administration.
SAMHSA’s concept of trauma and guidance for a traumainformed approach. SAMHSA; 2014. https://store.samhsa.gov/
sites/default/les/d7/priv/sma14- 4884.pdf.
27. Tong S, Sabo R, Aycock R, etal. Assessment of addiction medicine training in family medicine residency programs: a CERA
study. Fam Med. 2017;49(7):537–43.
28. Louis JS, Worringer E, Barr W. Residency setting association
with resident substance use disorder training: a CERA secondary data analysis. Fam Med. 2020;52(3):198–201. https://doi.
org/10.22454/FamMed.2020.373152.
29. Martin M, Sokol R. Evaluation of a national addiction medicine curriculum for primary care physicians. Ann Fam Med.
Behavioral health
integration stafng/
consultation
30 Teaching Behavioral Science
353
2023;21(Supplement 1). https://doi.org/10.1370/afm.21.
s1.4029.
30. Troxel WM, Germain A, Buysse DJ. Clinical management of
insomnia with brief behavioral treatment (BBTI). Behav Sleep
Med. 2012;10(4):266–79. https://doi.org/10.1080/15402002.201
1.607200.
31. Kurtz SM, Silverman JD. The Calgary-Cambridge referenced
observation guides: an aid to dening the curriculum and organizing the teaching in communication training programmes.
Med Educ. 1996;30(2):83–9. https://doi.org/10.1111/j.1365-
2923.1996.tb00724.x.
32. Mcculloch J, Ramesar S, Peterson H. Psychotherapy in primary care: the BATHE technique. Am Fam Physician.
1998;57(9):2131–4. https://www.aafp.org/pubs/afp/issues/1998/
0501/p2131.html. Accessed 21 Aug 2023
33. Frankel RM, Stein T. Getting the most out of the clinical
encounter: the four habits model. J Med Pract Manag MPM.
2001;16(4):184–91.
34. Miller WR, Rollnick S. Motivational interviewing: preparing people to change addictive behavior. The Guilford Press.
1991;xvii:348.
35. Levensky ER, Forcehimes A, O’Donohue WT, Beitz
K. Motivational interviewing: an evidence-based approach to
counseling helps patients follow treatment recommendations.
AJN Am J Nurs. 2007;107(10):50. https://doi.org/10.1097/01.
NAJ.0000292202.06571.24.
36. Glasgow RE. Assessing delivery of the ve “as” for patientcentered counseling. Health Promot Int. 2006;21(3):245–55.
https://doi.org/10.1093/heapro/dal017.
37. Searight HR.Counseling patients in primary care: evidence-based
strategies. Am Fam Physician. 2018;98(12):719–28. https://www.
aafp.org/pubs/afp/issues/2018/1215/p719.html. Accessed 21 Aug
2023
38. Beck A, Rush A, Shaw B, Emery G. Cognitive therapy of depression. Guilford Press; 1987. https://www.
guilford.com/books/Cognitive- Therapy- of- Depression/
Beck- Rush- Shaw- Emery/9780898629194.
39. Butler AC, Chapman JE, Forman EM, Beck AT. The empirical
status of cognitive-behavioral therapy: a review of meta-analyses.
Clin Psychol Rev. 2006;26(1):17–31. https://doi.org/10.1016/j.
cpr.2005.07.003.
40. Berkey FJ, Wiedemer JP, Vithalani ND.Delivering bad or lifealtering news. Am Fam Physician. 2018;98(2):99–104.
41. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka
AP.SPIKES– a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–11.
https://doi.org/10.1634/theoncologist.5- 4- 302.
42. Narayanan V, Bista B, Koshy C. ‘BREAKS’ protocol for breaking bad news. Indian J Palliat Care. 2010;16(2):61–5. https://doi.
org/10.4103/0973- 1075.68401.
43. Rabow MW, McPhee SJ. Beyond breaking bad news: how to
help patients who suffer. West J Med. 1999;171(4):260–3. https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC1305864/. Accessed 21
Sept 2023
44. Kavan MG, Guck TP, Barone EJ.A practical guide to crisis management. Am Fam Physician. 2006;74(7):1159–64.
45. World Health Organization (WHO). Report of the consultation on
child abuse prevention. 1999.
46. Greene JD, Nystrom LE, Engell AD, Darley JM, Cohen JD.The
neural bases of cognitive conict and control in moral judgment. Neuron. 2004;44(2):389–400. https://doi.org/10.1016/j.
neuron.2004.09.027.
47. Doherty W, Baird M.Family therapy and family medicine: toward
the primary care of families. Guilford Press; 1983.
48. Mengel MB. Physician ineffectiveness due to family-of-origin
issues. Fam Syst Med. 1987;5(2):176–90. https://doi.org/10.1037/
h0089711.
49. Rakel DP, Hoeft TJ, Barrett BP, Chewning BA, Craig BM, Niu
M. Practitioner empathy and the duration of the common cold.
Fam Med. 2009;41(7):494–501.
50. Felix D. Improving family interviewing skills using the Family
Centered Observation Form (FCOF): an online training module
for healthcare providers. https://sites.google.com/view/fcof/home.
Accessed 27 July 2023.
51. Daaleman TP, Elder GH.Family medicine and the life course paradigm. J Am Board Fam Med JABFM. 2007;20(1):85–92. https://
doi.org/10.3122/jabfm.2007.01.060012.
52. Antonucci TC, Akiyama H.Convoys of social relations: family
and friendships within a life span context. In: Handbook of aging
and the family. Greenwood Press/Greenwood Publishing Group;
1995. p.355–71.
53. Kawachi I, Berkman L.Social cohesion, social capital, and health.
In: Kawachi I, Berkman L, editors. Social epidemiology. Oxford
University Press; 2000. p.174–90.
54. Patra BG, Sharma MM, Vekaria V, etal. Extracting social determinants of health from electronic health records using natural language processing: a systematic review. J Am Med Inform Assoc.
2021;28(12):2716–27. https://doi.org/10.1093/jamia/ocab170.
55. Felitti VJ, Anda RF, Nordenberg D, etal. Relationship of childhood abuse and household dysfunction to many of the leading
causes of death in adults. The adverse childhood experiences
(ACE) study. Am J Prev Med. 1998;14(4):245–58. https://doi.
org/10.1016/s0749- 3797(98)00017- 8.
56. Krist AH, Davidson KW, Ngo-Metzger Q, Mills J.Social determinants as a preventive service: U.S. preventive services task
force methods considerations for research. Am J Prev Med.
2019;57(6, Supplement 1):S6–S12. https://doi.org/10.1016/j.
amepre.2019.07.013.
57. Echiverri A, Parra Y, Rodríguez J. Start with individuals,
but ensure that antiracism becomes an institutional value.
Fam Med. 2023;55(1):67–8. https://doi.org/10.22454/
FamMed.55.689129.
58. Implicit Bias Resources. https://www.aafp.org/family- physician/
patient- care/the- everyone- project/toolkit/implicit- bias.html.
Accessed 21 Sept 2023.
59. Barajas MS, Bines D, Straussman J.Integrated behavioral health
and intervention models. Pediatr Clin N Am. 2021;68(3):669–83.
https://doi.org/10.1016/j.pcl.2021.02.015.
60. Butler M, Kane RL, McAlpine D, et al. Integration of mental health/substance abuse and primary care. Evid Rep Technol
Assess. 2008;173:1–362.
61. Taylor DCM, Hamdy H.Adult learning theories: implications for
learning and teaching in medical education: AMEE guide no. 83.
Med Teach. 2013;35(11):e1561–72. https://doi.org/10.3109/0142
159X.2013.828153.
62. Stalmeijer RE, Dolmans DHJM, Snellen-Balendong HAM, van
Santen-Hoeufft M, Wolfhagen IHAP, Scherpbier AJJA.Clinical
teaching based on principles of cognitive apprenticeship:
views of experienced clinical teachers. Acad Med J Assoc
Am Med Coll. 2013;88(6):861–5. https://doi.org/10.1097/
ACM.0b013e31828fff12.
63. Christian D, McCarty D, Brown C.Experiential education during
the COVID-19 pandemic: a reective process. J Constr Psychol.
2021;34:264–77. https://doi.org/10.1080/10720537.2020.181366
6.
64. Edje L, Price DW.Training future family physicians to become
master adaptive learners. Fam Med. Published online June 8,
2021. https://doi.org/10.22454/FamMed.2021.192268.
65. Cutrer WB, Miller B, Pusic MV, etal. Fostering the development
of master adaptive learners: a conceptual model to guide skill
Acquisition in Medical Education. Acad Med. 2017;92(1):70–5.
https://doi.org/10.1097/ACM.0000000000001323.
66. Kowalski A, Gupta A, Pellegrino T, Petrides J, Sepede J,
Vermeulen M.Innovative family medicine and behavioral health
354
A. Bickett et al.
co-precepting via telemedicine. Ann Fam Med. 2020;18(5):467.
https://doi.org/10.1370/afm.2577.
67. De Gagne JC, Park HK, Hall K, Woodward A, Yamane S,
Kim SS. Microlearning in health professions education: scoping review. JMIR Med Educ. 2019;5(2):e13997. https://doi.
org/10.2196/13997.
68. Henry SG, Holmboe ES, Frankel RM. Evidence-based competencies for improving communication skills in graduate medical education: a review with suggestions for implementation.
Med Teach. 2013;35(5):395–403. https://doi.org/10.3109/01421
59X.2013.769677.
69. Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Health
Aff (Millwood). 2010;29(7):1310–8. https://doi.org/10.1377/
hlthaff.2009.0450.
70. Sherman MD, Nissly T, Carlson S, Wootten M.Video review process: enhancing impact and resident/faculty satisfaction. PRiMER.
2018:2. https://doi.org/10.22454/PRiMER.2018.152628.
71. Adam P, Murphy CF, Dierich M, Hager KD. Seven years of
teaching communication with the patient-centered observation
form. Fam Med. 2018;50(2):132–7. https://doi.org/10.22454/
FamMed.2018.516713.
72. Keen M, Cawse-Lucas J, Carline J, Mauksch L.Using the patient
centered observation form: evaluation of an online training program. Patient Educ Couns. 2015;98(6):753–61. https://doi.
org/10.1016/j.pec.2015.03.005.
73. Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship,
communication, and efciency in the medical encounter: creating a clinical model from a literature review. Arch
Intern Med. 2008;168(13):1387–95. https://doi.org/10.1001/
archinte.168.13.1387.
74. Hurtubise L, Hall E, Sheridan L, Han H.The ipped classroom
in medical education: engaging students to build competency. J
Med Educat Curri Develop 2015;2:JMECD.S23895. https://doi.
org/10.4137/JMECD.S23895.
75. Akaike M, Fukutomi M, Nagamune M, et al. Simulation-based
medical education in clinical skills laboratory. J Med Investig.
2012;59(1–2):28–35. https://doi.org/10.2152/jmi.59.28.
76. Singer BD, Corbridge TC, Schroedl CJ, et al. First-year residents outperform third-year residents after simulation-based
education in critical care medicine. Simul Healthc J Soc
Simul Healthc. 2013;8(2):67–71. https://doi.org/10.1097/
SIH.0b013e31827744f2.
77. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon
D, Scalese RJ. Features and uses of high-delity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27(1):10–28. https://doi.
org/10.1080/01421590500046924.
78. Tenegra JC, Hoffman MR, Mueller Luckey GS, DiLalla LF,
Ledford CJW.Simulation-based medical education in family medicine residencies: a CERA study. Fam Med. 2022;54(4):264–9.
https://doi.org/10.22454/FamMed.2022.731975.
79. Iroku-Malize T, Matson C, Freeman J, McGrew M, David
A.Interprofessional education. Ann Fam Med. 2013;11(2):188–9.
https://doi.org/10.1370/afm.1523.
80. Arenson C, Brandt BF. The importance of Interprofessional
practice in family medicine residency education. Fam
Med. 2021;53(7):548–55. https://doi.org/10.22454/
FamMed.2021.151177.
81. IPEC Core Competencies. https://www.ipecollaborative.org/ipec-
core- competencies. Accessed 21 Sept 2023.
82. Carney PA, Thayer EK, Palmer R, Galper AB, Zierler B, Eiff
MP. The benets of interprofessional learning and teamwork in
primary care ambulatory training settings. J Interprofessional
Educ Pract. 2019;15:119–26. https://doi.org/10.1016/j.
xjep.2019.03.011.
83. van Diggele C, Burgess A, Roberts C, Mellis C. Leadership in
healthcare education. BMC Med Educ. 2020;20(Suppl 2):456.
https://doi.org/10.1186/s12909- 020- 02288- x.
84. Hager KD, Merighi J, O’Donnell C, Remke S. Perceptions of
interprofessional collaboration with integrated behavioral health
providers in a family medicine clinic: insights from residents,
physicians, and pharmacists. J Interprofessional Educ Pract.
2018;13:65–72. https://doi.org/10.1016/j.xjep.2018.10.002.
85. Porcerelli JH, Fowler SL, Murdoch W, Markova T, Kimbrough
C. Training family medicine residents to practice collaboratively with psychology trainees. Int J Psychiatry Med.
2013;45(4):357–65. https://doi.org/10.2190/PM.45.4.f.
86. Thompson Buum H, Dierich M, Adam P, Hager
KD. Implementation of a direct observation and feedback tool
using an interprofessional approach: a pilot study. J Interprof
Care. 2021;35(4):641–4. https://doi.org/10.1080/13561820.2019
.1640190.
87. van Diggele C, Roberts C, Burgess A, Mellis C.Interprofessional
education: tips for design and implementation. BMC Med Educ.
2020;20(2):455. https://doi.org/10.1186/s12909- 020- 02286- z.
88. Wu D, Saint-Hilaire L, Pineda A, et al. The efcacy of
an antioppression curriculum for health professionals.
Fam Med. 2019;51(1):22–30. https://doi.org/10.22454/
FamMed.2018.227415.
89. Barreto M, Gaynor ST.A pilot randomized controlled trial of a
single-session of acceptance and commitment therapy versus
information only for promoting health-related behavior change
in collegians. J Contextual Behav Sci. 2023;27:1–10. https://doi.
org/10.1016/j.jcbs.2022.11.004.
90. Neff KD.Self-compassion: theory, method, research, and intervention. Annu Rev Psychol. 2023;74(1):193–218. https://doi.
org/10.1146/annurev- psych- 032420- 031047.
91. Winkel AF, Yingling S, Jones AA, Nicholson J.Reection as a
learning tool in graduate medical education: a systematic review.
J Grad Med Educ. 2017;9(4):430–9. https://doi.org/10.4300/
JGME- D- 16- 00500.1.
92. Aronson L.Twelve tips for teaching reection at all levels of medical education. Med Teach. 2011;33(3):200–5. https://doi.org/10.3
109/0142159X.2010.507714.
93. Walpola R, Lucas C. Reective practice: the essential competency for health systems and healthcare practitioners during the
COVID- 19 pandemic. Reective Pract. 2021;22(2):143–6. https://
doi.org/10.1080/14623943.2020.1860925.
94. Hs W.Professional identity (trans)formation in medical education:
reection, relationship, resilience. Acad Med J Assoc Am Med Coll.
2015;90(6). https://doi.org/10.1097/ACM.0000000000000731.
95. Wald HS, Borkan JM, Taylor JS, Anthony D, Reis SP.Fostering
and evaluating reective capacity in medical education: developing the REFLECT rubric for assessing reective writing.
Acad Med J Assoc Am Med Coll. 2012;87(1):41–50. https://doi.
org/10.1097/ACM.0b013e31823b55fa.
96. Mantle M.The benets of oral reection: the use of oral reective action learning sets and discussion groups with post graduate student teachers. Int J Second Educ. 2019;7(1):11. https://doi.
org/10.11648/j.ijsedu.20190701.13.
97. Diaz VA, Chessman A, Johnson AH, Brock CD, Gavin JK.Balint
groups in family medicine residency programs: a follow-up study
from 1990–2010. Fam Med. 2015;47(5):367–72.
98. Hamadeh G, Antoun J, Romani M.The effect of Balint training
on the psychological skills of residents beyond family medicine residency. Health Educ J. 2020;79(8):987–96. https://doi.
org/10.1177/0017896920930267.
99. Player M, Freedy JR, Diaz V, etal. The role of Balint group training in the professional and personal development of family medicine residents. Int J Psychiatry Med. 2018;53(1–2):24–38. https://
doi.org/10.1177/0091217417745289.
30 Teaching Behavioral Science
355
100. Edgoose JYC, Regner CJ, Zakletskaia LI. Breathe out: a
randomized controlled trial of a structured intervention to
improve clinician satisfaction with “difcult” visits. J Am
Board Fam Med. 2015;28(1):13–20. https://doi.org/10.3122/
jabfm.2015.01.130323.
101. Taub S, Morin K, Goldrich MS, Ray P, Benjamin R. Council
on ethical and judicial affairs of the American medical association. Physician health and wellness. Occup Med Oxf Engl.
2006;56(2):77–82. https://doi.org/10.1093/occmed/kqj025.
102. Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt
TD.Physician satisfaction and burnout at different career stages.
Mayo Clin Proc. 2013;88(12):1358–67. https://doi.org/10.1016/j.
mayocp.2013.07.016.
103. Candilis PJ, Kim DT, Sulmasy LS.ACP ethics, professionalism
and human rights committee. Physician impairment and rehabilitation: reintegration into medical practice while ensuring patient
safety: a position paper from the American College of Physicians.
Ann Intern Med. 2019;170(12):871–9. https://doi.org/10.7326/
M18- 3605.
104. Dyrbye LN, West CP, Sinsky CA, Goeders LE, Satele DV,
Shanafelt TD. Medical licensure questions and physician
reluctance to seek care for mental health conditions. Mayo
Clin Proc. 2017;92(10):1486–93. https://doi.org/10.1016/j.
mayocp.2017.06.020.
105. Buck K, Grace A, Runyan T, Brown-Berchtold L.Addressing mental health needs among physicians. South Med J. 2019;112(2):67–9.
https://doi.org/10.14423/SMJ.0000000000000924.
106. Samet JH, Liebschutz J. Beyond “heal thyself”: physicians as
patients– an uneasy role. Ann Intern Med. 2019;170(12):893–4.
https://doi.org/10.7326/M19- 1192.
107. Godschalx J, Van Mook W.Dismissed psychiatry residents who
appeal: exploring unprofessional behavior. Acad Psychiatry
Published online February. 2023;28. https://doi.org/10.1007/
s40596- 023- 01746- 0.
108. Kelly M, O’Flynn S, McLachlan J, Sawdon MA. The clinical
conscientiousness index: a valid tool for exploring professionalism in the clinical undergraduate setting. Acad Med J Assoc
Am Med Coll. 2012;87(9):1218–24. https://doi.org/10.1097/
ACM.0b013e3182628499.
109. Sawdon MA, Whitehouse K, Finn GM, McLachlan JC, Murray
D.Relating professionalism and conscientiousness to develop an
objective, scalar, proxy measure of professionalism in anaesthetic
trainees. BMC Med Educ. 2017;17(1):49. https://doi.org/10.1186/
s12909- 017- 0891- 6.
Teaching Evidence-Based Medicine
J.LaneWilson
31
Key Points
• Evidence-based medicine (EBM) is a way of thinking
about clinical decision-making and the application of best
evidence to individual patients.
• Evidence-based medicine is a process, not always performed sequentially.
• The ideal, full process of evidence-based medicine practice is important to understand but often not practical during day-to-day practice.
• Teaching evidence-based medicine concepts should be
introduced during intern orientation and regularly practiced throughout residency in a variety of formats.
• Teaching evidence-based medicine is most effective
if introduced conceptually using practical clinical
examples.
• Concepts of evidence-based medicine are reinforced
when integrated into the curriculum with frequent opportunities to practice.
• Offer all evidence-based learning opportunities to faculty
as well as residents to encourage a shared mental model
and evidence-based medicine culture.
• Basic statistics about test characteristics and risk underpin key evidence-based medicine concepts and guide the
judicious application of evidence to individual patients.
• Diagnostic reasoning and medical decision-making
should not be decoupled from evidence-based medicine
education.
• Journal clubs, case-based learning, morbidity and mortality conferences, and scholarly activity projects can provide opportunities for ongoing use of evidence-based
medicine principles.
• Journal clubs are most effective when using a standardized appraisal process and when both faculty and residents are involved.
J. L. Wilson (*)
Department of Community and Family Medicine, University of
Missouri Kansas City School of Medicine, Kansas City, MO, USA
e-mail: Lane.Wilson@uhkc.org
• Short, on-the-y prompts from faculty preceptors can
encourage evidence-based medicine thinking in residents
during routine clinical encounters.
Introduction
What do you think about when you think about evidencebased medicine (EBM)? Chances are, if you’re like most
residents I ask, you think about two-by-two tables and math
you can’t quite keep straight. Many residents (and faculty!)
had a few lectures in medical school dedicated to biostatistics and/or epidemiology, memorized a few terms and equations from board study materials, and then promptly forgot
exactly what the difference between sensitivity and specicity is. If you’re reading this, you may nd that’s a description
that ts you and your faculty. You probably don’t consider
yourself an expert in EBM, and it’s not terribly unlikely that
you don’t have a faculty member you can point to as an EBM
expert. That’s okay! The rst key to teaching EBM lies not in
two-by-two tables (although they are important) but in a
small number of concepts that just happen to have some
math behind them. The second key is that you can’t teach
EBM in a few lectures—it must be integrated throughout
your curriculum. That’s it!
This chapter will help you lay out a curriculum based on
those two key features and, at times, get into some of the
nitty-gritty that seems to give so many of us heartburn. This
chapter is not intended to be an EBM glossary or to cover
each and every EBM concept in depth. What it will do is
introduce some of the most important EBM concepts, offer
suggestions for introductory sessions and ongoing workshops, provide an overall structure to the curriculum with
tips for success, and suggest resources to go to for help eshing out the details.
Before proceeding, I do feel compelled, given the subject
matter, to put in a disclaimer that there is not a lot of highquality evidence to guide what follows. The information and
© 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_31
357
358
ideas in this chapter mostly stem from established andragogic principles and my own experience, the latter of which
I have come to sadly realize will never register high on the
pyramid of evidence.
Denitions
As much as it makes me groan to hear a lecture or graduation
speech begin with the way Merriam-Webster denes a word
or a quote from the Oxford Dictionary of Quotations, we
should probably start with an idea of what exactly EBM is so
we can develop a framework for the implementation of a curriculum. Perhaps the most widely quoted denition is from
David Sackett and colleagues: EBM is “the conscientious,
explicit and judicious use of current best evidence in making
decisions about the care of individual patients [1].” In her
widely read book How to Read a Paper: The Basics of
Evidence-based Medicine and Healthcare, Trisha Greenhalgh
further species that “Evidence based medicine is the use of
mathematical estimates of the risk of benet and harm,
derived from high quality research on population samples, to
inform clinical decision making in the diagnosis, investigation or management of individual patients [2].” Lots of
others have offered their modications, criticisms, additions,
and specications that more narrowly or more broadly
explain ideas of what exactly EBM is.
My own preferred, and I think more broadly applicable,
denition is closer to Sackett’s original. It is true that quite
often EBM comes down to the application of populationbased data to individual patients, but there isn’t always highquality population-based data out there addressing a clinical
question. That doesn’t necessarily mean EBM principles
don’t apply or that “there is no evidence.” Sackett’s “best
evidence” verbiage allows for scenarios where high-quality
evidence is lacking in a way that Greenhalgh’s excludes. In
general, we are going to reach more of our learners if we
de- emphasize the math, focus more on concepts the math
explains, and demonstrate how EBM is applicable to patient
care. If residents can get excited by the concepts, they may
be more likely to explore some of the math that underlies
them.
Like the denition of EBM, there is variation in what the
idealized step-by-step process of EBM looks like in practice.
But, in general, it follows the process outlined in Fig.31.1.
Most people have some sort of idea of the process outlined
in Fig.31.1 as the ideal. But the truth is, rarely does anyone
fully complete this sequence for a single patient. Most clinicians will quickly identify the impracticality of using these
resource intensive steps during an average clinical encounter
in an average busy clinical practice. More often than not,
J. L. Wilson
Fig. 31.1 Simplied steps of the EBM process in practice
these steps occur asynchronously or in a different order. For
example, known evidence is often applied at the beginning of
a clinical encounter as part of diagnostic reasoning.
Additionally, most EBM didactic instruction tends to focus
on step 2 (in particular, math), less so step 1, and often overlooks step 3. The combination of presenting EBM as this
three-step process and largely neglecting step 3 runs the real
danger of a major loss of relevance to your learners. Therefore,
it’s a good idea to be upfront about the fact that this nice-andneat process is not how it works in the real world. At the same
time, it is a useful framework for philosophically thinking
about how EBM can be used in the practice setting.
Do IHave toUse Math?
Yes, I’m sorry, you do. But the good news is you don’t have
to use math in the way you learned (or didn’t learn) it! The
goal is to teach EBM in a way that math does not seem like a
barrier to understanding.
Demystifying the concepts of EBM before any introduction to math is vital to getting learner buy-in. The concepts of
EBM are more important than the math and are what most
physicians are going to carry forward in clinical settings. No
one is drawing out two-by-two tables or plotting on a Fagan
nomogram in the exam room. Very few of us probably have
any idea how a p-value is actually calculated. Instead, what
good evidence-based physicians do is use good clinical reasoning, a foundational knowledge of the mathematical formulas, and practical estimates of baseline rates and clinical
probabilities. Unfortunately, the fact of the matter is that
before learning some of the math, a lot of learners have quite
31 Teaching Evidence-Based Medicine
359
unrealistic estimates of test accuracy and treatment
effectiveness.
What traditional instruction about EBM gets wrong, in
my opinion, is introducing the math rst. Residents may nd
the math daunting and difcult to keep straight. If they
attempt application only after introduction of the math—
without a clinical context—it may lead learners to believe
that real-world application is too difcult to remember or
perform.
Let’s start with a practical example of how to introduce
EBM to residents. First, offer them the following two medical scenarios:
• A healthy 23-year-old woman presents to the ofce for
preventive healthcare. She is previously healthy, up-to-
date on immunizations, had a normal Pap smear at age 21,
and has no complaints. She is not sexually active but has
been with two male partners in the last year. Physical
examination is normal. You suggest she undergo chla-
mydia screening and nuclear stress testing to rule out
coronary artery disease.
• A 65-year-old woman with a history of poorly controlled
hypertension, type 2 diabetes mellitus, and a 40-pack-
year history of smoking presents to the ofce with exer-
tional substernal chest pressure if she walks more than
15 feet. The pain is relieved by rest. A month ago she
could go 50 feet before experiencing these symptoms.
You suggest she undergo chlamydia screening and nuclear
stress testing to rule out coronary artery disease.
Having gone through this exercise with hundreds of medical students and residents, they tend to all immediately
understand that in scenario 1 the chlamydia screening is reasonable. After all, it’s a Grade B recommendation from the
United States Preventive Services Task Force (USPSTF) [3].
They also immediately understand that a stress test is not
indicated. They will explain their understanding in terms of
pretest probability, though they may not use the exact words.
They may say something like, “we don’t have any reason to
believe she has coronary artery disease,” which is your
chance to tell them they are describing pretest probability. It
is also an invitation to describe prevalence and incidence, as
these are foundational starting points for understanding pretest probabilities. They may also think neither test is warranted given she is asymptomatic. This is a chance to
introduce basic concepts of screening tests.
Scenario 2 is then where the residents usually trip up.
They sense you’re playing a heavy-handed game and conclude that this time the chlamydia is not a reasonable suggestion but the stress test is. At this point, you concede that
chlamydia screening is indeed not indicated, even if it were
revealed that she had high-risk behavior given the more
pressing cardiac concerns. But they’ve fallen into the trap
you’ve laid—would they believe it if this patient’s stress test
was negative? Probably not. This patient has classic unstable
angina and should proceed directly to the catheterization lab
due to her high pretest probability. You can subsequently
help them conclude that tests are best utilized when pretest
probabilities are intermediate.
Next ask the residents what the possible results from a test
are. Most will answer either positive or negative. If you follow that up by asking, more specically, what the possible
test results are for one of the patients in the scenarios they
will usually realize that a false negative is possible, and, conversely, a false positive. Now you can draw out a two-by-two
table showing four possible test outcomes: true positive,
false positive, false negative, and true negative. And when I
say draw, I do mean draw it out in front of them (Fig.31.2).
By drawing it you give the residents time to categorize the
possible test outcomes and construct the two-by-two table in
their heads along with you. Popping up a PowerPoint presentation slide with a completed table robs them of this chance.
Now the groundwork has been laid to introduce the concepts
of sensitivity, specicity, and predictive values.
So let’s reect on what we’ve done. Without using the
EBM terminology or math, we have introduced the concept
of pretest probability and prevalence, posttest probability
(predictive value), and determined that testing is most helpful if a patient has an intermediate pretest probability. We’ve
divided test results into four categories that depend on baseline rates (prevalence) and test characteristics (sensitivity
and specicity). These are concepts the residents already
understand, facilitated by extreme examples. Now you have
the opportunity to label those concepts. Once you have them
labeled, the math can be introduced. A similar process should
be used to introduce other mathematical concepts of EBM
(Fig.31.3).
Barratt etal. outlined a similar process for workshops on
risk [4]. First, learners are shown a graphic representation of
risks in two groups, a control group and an intervention
group, with a high baseline event rate (i.e., high-risk
patients). Next, they are given the same information but
with a much smaller baseline event rate (i.e., low-risk
Fig. 31.2 Standard 2×2 table used to calculate sensitivity, specicity,
and predictive values
360
Fig. 31.3 Process for
introduction of EBM math
Fig. 31.4 Example of a
Cates plot generated from
https://www.nntonline.net/
visualrx/. This example shows
a baseline incidence of 16%
and an absolute risk reduction
of 5%. Relative risk and
number needed to treat can be
calculated from these values.
In this example, relative risk
would be 0.69 (percentage of
red faces divided by the
percentage of red plus yellow
faces), and the number needed
to treat would be 20 (one
divided by the absolute risk
reduction of 0.05)
J. L. Wilson
Key
Good outcome
Bad outcome
Better with treatment
patients). The exact numbers used don’t matter but should
be something easy to demonstrate with some simple math. I
like to use more extreme variations than Barratt et al.
because I think extreme examples are most effective in illustrating the concepts. For example, the high-risk patients
could have a baseline event rate of 50% in the controls and
40% for those treated, and the low-risk patients could have
event rates of 5% and 4%, respectively. Once these graphs
are presented to the residents, you ask them how the relationships between the control groups and treatment groups
could be represented. What generally follows are descriptions, often without labels, that equate to relative risk (RR),
relative risk reduction (RRR), and absolute risk reduction
(ARR).
While Barratt etal. go on to describe in detail helpful ways
to introduce these concepts and others (Number Needed to
Treat), one big point to emphasize is how little math is actually
required. Once one nds risk in two groups, something that is
generally intuitive for most learners, there are only a few
things one can do with those two rates: divide them (RR) or
nd the difference (ARR or AR). The RRR and NNT/NNH
are simply additional ways to represent these same concepts.
Using the extreme examples to contrast high- risk and low-risk
patients, the differences between relative differences and absolute differences become starkly apparent. Working through the
concepts of a real-life—and exaggerated—clinical problem is
generally an easier way to introduce risk calculations than
introduction of formulas from a two-by-two table. Like test
characteristics, drawing out the two-by-two table only after
the residents identify ways to express risk allows the math to
clarify their thinking rather than overwhelm it.
The article by Barratt etal. is one of ve in a series from
the Canadian Medical Association Journal (CMAJ) titled
“Tips for Learners of Evidence-Based Medicine” that generally follow a similar premise of concept introduction. This
series serves as a useful guide for additional workshops,
though for most residency programs probably only the rst
two articles are at the level of depth most will need.
Another helpful tool for your residents when it comes to
risk and risk representation is the Cates plot. These are visual
representations of a population of patients that are colorcoded to indicate different outcomes. In Fig. 31.4, green
31 Teaching Evidence-Based Medicine
361
indicates patients with a good outcome who would have had
a good outcome regardless of intervention, red indicates
patients with a bad outcome regardless of intervention, and
the Cates plot, even if they don’t label those values as such.
You can view many Cates plots at https://www.nntonline.net/
visualrx/ and even create your own [5].
yellow indicates patients who had a better outcome because
of intervention. Similar to the exercise outlined previously
from the “Tips for Learners of Evidence-Based Medicine,”
What Should YouTeach?
start by showing your residents the plot and provide the denitions of the colors. From there you may ask what information can be ascertained and how the data could be represented
mathematically. Baseline risk (prevalence), RR, ARR, and
their derivatives may be ascertained fairly intuitively with
Table 31.1 EBM concepts that should be taught in family medicine residency programswith a list ofhelpful resources
Concepts all family physicians should know Suggested resources
Clinical diagnostic reasoning and medical decision-making
Type 1 vs type 2 (intuitive vs analytical) decision-making
Problem representation and matching to illness scripts
Test characteristics: sensitivity, specicity, positive predictive
value, negative predictive value, likelihood ratios
Development of a clinical question: background versus
foreground questions, PICO, MeSH
Study design
Pyramid of evidence: expert opinion, case reports and case
series, case control studies, cohort studies (retrospective and
prospective), randomized controlled trials, systematic reviews,
meta-analyses
Blinding and randomization
Intention-to-treat, per-protocol, and as-treated analyses
Superiority and non-inferiority trial design
Evidence grading
Grading of Recommendations Assessment, Development, and
Evaluation (GRADE)
Strength of Recommendation Taxonomy (SORT)
United States Preventive Services Task Force (USPSTF)
Outcomes
Patient-oriented versus disease-oriented outcomes
Math: prevalence, incidence, odds ratio, relative risk, relative
risk reduction, absolute risk reduction, attributable risk, number
needed to treat, number needed to harm
Statistical concepts/representations (do not need to know the
calculation but understand the meaning): condence interval, p
value, null hypothesis, hazard ratio, all-cause mortality, Cates plot,
Forest plot, survival curve, confounding, types of bias
Abbreviations: PICO, Population/Patient/Problem Intervention Comparison Outcome. MeSH, Medical Subject Headings. NEJM, New England
Journal of Medicine. AFP, American Family Physician. CEBM, Centre for Evidence-Based Medicine. ABFM, American Board of Family
Medicine. FPIN, Family Physicians Inquiries Network
a
Subscription-based service
There are some fundamental concepts and basic statistical
values that all family physicians should be familiar with. I’ve
broken these down into categories below along with some
suggested resources (Table31.1).
A Universal Model of Diagnostic Reasoning [6], Educational Strategies
to Promote Clinical Diagnostic Reasoning [7], The Clinical Problem
Solvers [8], NEJM Resident 360a [9], NEJM Healera [10]
How to Read a Paper [2], Visual Rx [5], AFP Evidence- based Medicine
Toolkit [11], CEBM [12], Users’ Guides to the Medical Literature: A
Manual for Evidence-Based Clinical Practice [13], Odds ratios and risk
ratios: what’s the difference and why does it matter? [14]
CEBM Finding the evidence: a how-to guide [15], Family Medicine
Residency Curriculum Resourcea [16]
AFP Evidence-based Medicine Toolkit [11], CEBM [12], Users’ Guides
to the Medical Literature: A Manual for Evidence-Based Clinical
Practice [13], ABFM National Journal Club activity [17], FPINa [18]
Family Medicine Residency Curriculum Resourcea [16]
Visual Rx [5], NEJM Resident 360a [9], AFP Evidence-based Medicine
Toolkit [11], Tips for Learners of Evidence-Based Medicine, CEBM
[12], Users’ Guides to the Medical Literature: A Manual for Evidence-
Based Clinical Practice [13], ABFM National Journal Club activity
[17], FPINa [18],