Storylines of family medicine VI: ways of being-in the office with patients.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VI: ways of being-in the office with patients', authors address the following themes: 'Patient-centred care-cultivating deep listening skills', 'Doctor as witness', 'Words matter', 'Understanding others-metaphor and its use in medicine', 'Communicating with patients-making good use of time', 'The patient-centred medical home-aspirations for the future', 'Routine, ceremony or drama?' and 'The life course'. May readers better appreciate the nuances of patient care through these essays.

Resident wellness behaviors: relationship to stress, depression, and burnout.

BACKGROUND AND OBJECTIVES: Stress in medical education has been well documented, often with the primary focus on negative factors such as depression and burnout. Few studies have attempted to assess well-being mediating behaviors. This study describes the relationship between wellness behaviors and measures of well-being at the start of family medicine residency. METHODS: Using an online questionnaire, first-year family medicine residents (n=168) completed standardized measures exploring perceived stress, depression, satisfaction with life, and burnout. A lifestyle wellness behavior measure was developed for the study. RESULTS: Average reported perceived stress levels were consistent with ranges found for medical students and residents. Twenty-three percent of residents scored in a range consistent with depression risk. In terms of burnout risk, 13.7% scored in the high emotional exhaustion range and 23.8% in the high depersonalization range. Two thirds reported high life satisfaction. Higher depersonalization and less time in nurturing relationships were associated with greater likelihood of medication use for sleep, mood, and anxiety in females. Higher alcohol use was associated with increased levels of perceived stress, burnout, and depression. The two wellness behaviors most associated with higher well-being were restful sleep and exercise. CONCLUSIONS: At the start of residency, well-being measures are consistent with findings in medical school. Restful sleep and exercise were associated with more positive well-being. Future longitudinal data analysis will help clarify the effect of residency training in well-being and lifestyle behaviors. Identification of protective factors and coping mechanisms could guide residencies in incorporating support services for residents.

Multidisciplinary team approach to improved chronic care management for diabetic patients in an urban safety net ambulatory care clinic.

Since the care of patients with multiple chronic diseases such as diabetes and depression accounts for the majority of health care costs, effective team approaches to managing such complex care in primary care are needed, particularly since psychosocial and physical disorders coexist. Uncontrolled diabetes is a leading health risk for morbidity, disability and premature mortality with between 18-31% of patients also having undiagnosed or undertreated depression. Here we describe a team driven approach that initially focused on patients with poorly controlled diabetes (A1c > 9) that took place at a family medicare office. The team included: resident and faculty physicians, a pharmacist, social worker, nurses, behavioral medicine interns, office scheduler, and an information technologist. The team developed immediate integrative care for diabetic patients during routine office visits.

Integrative medicine in residency education: developing competency through online curriculum training.

INTRODUCTION: The Integrative Medicine in Residency (IMR) program, a 200-hour Internet-based, collaborative educational initiative was implemented in 8 family medicine residency programs and has shown a potential to serve as a national model for incorporating training in integrative/complementary/alternative medicine in graduate medical education. INTERVENTION: The curriculum content was designed based on a needs assessment and a set of competencies for graduate medical education developed following the Accreditation Council for Graduate Medical Education outcome project guidelines. The content was delivered through distributed online learning and included onsite activities. A modular format allowed for a flexible implementation in different residency settings. EVALUATION: TO ASSESS THE FEASIBILITY OF IMPLEMENTING THE CURRICULUM, A MULTIMODAL EVALUATION WAS UTILIZED, INCLUDING: (1) residents' evaluation of the curriculum; (2) residents' competencies evaluation through medical knowledge testing, self-assessment, direct observations, and reflections; and (3) residents' wellness and well-being through behavioral assessments. RESULTS: The class of 2011 (n  =  61) had a high rate of curriculum completion in the first and second year (98.7% and 84.2%) and course evaluations on meeting objectives, clinical utility, and functioning of the technology were highly rated. There was a statistically significant improvement in medical knowledge test scores for questions aligned with content for both the PGY-1 and PGY-2 courses. CONCLUSIONS: The IMR program is an advance in the national effort to make training in integrative medicine available to physicians on a broad scale and is a success in terms of online education. Evaluation suggests that this program is feasible for implementation and acceptable to residents despite the many pressures of residency.

Interviewing when family members are present.

The presence of family members at an office visit creates unique opportunities and challenges for the physician while interviewing the patient. The physician must address issues of confidentiality, privacy, and agency. Special skills are required to respectfully and efficiently involve family members, while keeping the patient at the center of the visit. A core set of interviewing skills exists for office visit interviews with family members present. These skills include building rapport with each participant by identifying their individual issues and perspectives, and encouraging participation by listening to and addressing the concerns of all persons. Physicians should also avoid triangulation, maintain confidentiality, and verify agreement with the plan. It may be necessary to use more advanced family interviewing skills, including providing direction despite problematic communications; managing conflict; negotiating common ground; and referring members to family therapy.