Competencies for Those Who Coach Physicians: A Modified Delphi Study.

The rapidly evolving coaching profession has permeated the health care industry and is gaining ground as a viable solution for addressing physician burnout, turnover, and leadership crises that plague the industry. Although various coach credentialing bodies are established, the profession has no standardized competencies for physician coaching as a specialty practice area, creating a market of aspiring coaches with varying degrees of expertise. To address this gap, we employed a modified Delphi approach to arrive at expert consensus on competencies necessary for coaching physicians and physician leaders. Informed by the National Board of Medical Examiners' practice of rapid blueprinting, a group of 11 expert physician coaches generated an initial list of key thematic areas and specific competencies within them. The competency document was then distributed for agreement rating and comment to over 100 stakeholders involved in physician coaching. Our consensus threshold was defined at 70% agreement, and actual responses ranged from 80.5% to 95.6% agreement. Comments were discussed and addressed by 3 members of the original group, resulting in a final model of 129 specific competencies in the following areas: (1) physician-specific coaching, (2) understanding physician and health care context, culture, and career span, (3) coaching theory and science, (4) diversity, equity, inclusion, and other social dynamics, (5) well-being and burnout, and (6) physician leadership. This consensus on physician coaching competencies represents a critical step toward establishing standards that inform coach education, training, and certification programs, as well as guide the selection of coaches and evaluation of coaching in health care settings.

Professional Coaching in Medicine and Health Care.

Professional coaching can support individuals and organizations in four ways: (1) improving provider experience of working in health care, (2) supporting provider role and career development, (3) helping build team effectiveness, and (4) building an organizational coaching culture. There is evidence about effectiveness of coaching in business, and an increasing body of literature, including small randomized, controlled trials, supporting use of coaching in health care. This article summarizes the framework for professional coaching, describes ways professional coaching can support the four processes above, and provides case scenarios that contextualize understanding of how professional coaching can be of benefit.

Nonpharmacological Self-Management of Migraine Across Social Locations: An Equity-Oriented, Qualitative Analysis.

BACKGROUND: Migraine is a disabling neurological disorder and the sixth biggest cause of disability worldwide. The World Health Organization has declared migraine a major public health problem due to a paucity of knowledge about cause and effective treatment options. Both in incidence and severity, migraine disproportionately affects people occupying marginalized social locations (SL). Managed pharmacologically, migraine is treated with daily preventive and as-needed abortive medications. Both come with high literal and figurative costs: intolerable side effects, medication interactions, and prohibitive prices. Cost prohibitive, ineffective, and unsustainable pharmacological treatment options have contributed to high levels of interest in complementary approaches by people with migraine, but little is known about their motivations, patterns of use or access, or how these may vary by SL. METHOD: We conducted focus groups with 30 people with migraine to explore their desires and recommendations for migraine clinicians and researchers. We used qualitative content analysis to identify themes.Outcomes: We identified 4 themes: a more holistic, collaborative, long-term treatment approach; medication as a short-term solution; high personal and economic costs of medication; and desire for more information and access to natural approaches. Across SL, participants expressed keen interest in integrative approaches and wanted better access to complementary modalities. Participants in marginalized SL described reliance on traditional/folk remedies, including engagement with family and community healers, who they described as more affordable and culturally accessible. CONCLUSIONS: Holistic and integrative approaches were preferred over medication as long-term migraine management strategies. However, people in marginalized SL, while disproportionately disabled by migraine, did not feel as comfortable accessing integrative approaches through currently available channels. Engaging with these communities and using a critical lens to explore barriers to access can develop options to make complementary modalities more approachable, while also attending to systemic blind spots that may unintentionally alienate socially marginalized groups.

Perspectives on a Lifestyle Medicine Fellowship Curriculum From Interested Medical Students.

Background. Lifestyle behaviors have a significant effect on preventing and treating disease, yet there is minimal graduate medical training in lifestyle medicine (LM). LM stakeholders' perspectives regarding components of a LM fellowship have been examined. However, the student perspective has not been studied. Methods. A cross-sectional study design analyzed medical student perceptions surrounding LM domains and educational experiences. A Kruskal-Wallis analysis of variance and a Wilcoxon Rank-Sum Test were performed for each topic. Results. In all, 21 medical students completed the survey. All domains (nutrition, physical activity, behavior change, stress resiliency, and personal health), except smoking cessation, were rated as important or very important by at least 75% of the respondents (P = .002). The 4 highest-rated educational experiences, by at least 69% of respondents, included developing LM interventions and health promotion programs, clinical experiences, and teaching other health care providers about LM. Significant differences overall were found among the educational experiences (P = .005), with research and fund raising considered the least important. Conclusions. Medical students felt strongly about including nutrition, physical activity, behavior change, personal health, and stress resiliency as part of a LM fellowship curriculum. There was significantly less interest in smoking cessation. Desired experiences of students focused on delivery of LM.

Integration of Personalized Health Planning and Shared Medical Appointments for Patients with Type 2 Diabetes Mellitus.

OBJECTIVES: This study describes the feasibility of implementing personalized health planning (PHP) within shared medical appointments (SMAs) for patients with type 2 diabetes mellitus. The PHP-SMA approach was designed to synergize the benefits of SMAs with those of PHP, enabling greater patient engagement focused on meeting individualized therapeutic goals in a group setting. METHODS: Patients were assigned randomly to a PHP-SMA or a standard eight-session SMA series. Standard SMAs included an interactive educational curriculum delivered in group medical encounters. The PHP-SMA included the addition of a patient self-assessment, health risk assessment, shared patient-provider goal setting, creation of a personal health plan, and follow-up on clinical progress. Clinical and patient-reported outcomes and qualitative data from focus groups with patients, providers, and administrative staff were used for evaluation. Qualitative data explored facilitators and barriers to implementation of the PHP-SMA. The Consolidated Framework for Implementation Research was used to provide insight into implementation factors. RESULTS: PHP was successfully integrated into SMAs in a primary care setting. Patients in the PHP-SMA (n = 12) were more likely to attend ≥5 sessions than patients assigned to the standard SMA (n = 7; 58% PHP, 28.5% control). Qualitative data evaluation described the advantages and barriers to PHP, the team-based approach to care, and patient participation. The PHP-SMA group experienced reductions in hemoglobin A1c, low-density lipoprotein, blood pressure, and body mass index, as well as successful attainment of health goals. CONCLUSIONS: The PHP-SMA is a proactive and participatory approach to chronic care delivery that synergizes the benefits of PHP within SMAs. This study describes the components of this intervention; collects evidence on feasibility, acceptability, and clinical outcomes; and identifies implementation barriers and facilitators. The PHP-SMA warrants further evaluation as an approach to improve health outcomes in patients with common chronic conditions.

Best Practices in Transgender Health: A Clinician's Guide.

Providing culturally competent and medically knowledgeable care to the transgender community is increasingly falling within the realms of practice for primary care providers. The purpose of this article is to provide an overview of best practices as they relate to transgender care. This article is by no means a comprehensive guide, but rather a starting point for clinicians as they provide high-quality care to their transgender patients.

Primary care multidisciplinary teams in practice: a qualitative study.

BACKGROUND: Current recommendations for strengthening the US healthcare system consider restructuring primary care into multidisciplinary teams as vital to improving quality and efficiency. Yet, approaches to the selection of team designs remain unclear. This project describes current primary care team designs, primary care professionals' perceptions of ideal team designs, and perceived facilitating factors and barriers to implementing ideal team-based care. METHODS: Qualitative study of 44 health care professionals at 6 primary care practices in North Carolina using focus group discussions and surveys. Data was analyzed using framework content analysis. RESULTS: Practices used a variety of multidisciplinary team designs with the specific design being influenced by the social and policy context in which practices were embedded. Practices overwhelmingly located barriers to adopting ideal multidisciplinary teams as being outside of their individual practices and outside of their control. Participants viewed internal organizational contexts as the major facilitators of multidisciplinary primary care teams. The majority of practices described their ideal team design as including a social worker to meet the needs of socially complex patients. CONCLUSIONS: Primary care multidisciplinary team designs vary across practices, shaped in part by contextual factors perceived as barriers outside of the practices' control. Facilitating factors within practices provide a culture of support to team members, but they are insufficient to overcome the perceived barriers. The common desire to add social workers to care teams reflects practices' struggles to meet the complex demands of patients and external agencies. Government or organizational policies should avoid one-size-fits-all approaches to multidisciplinary care teams, and instead allow primary care practices to adapt to their specific contextual circumstances.

Behavioral Health in Prevention and Chronic Illness Management: Motivational Interviewing.

This article reviews the history, methodology, and evidence related to the effective use of motivational interviewing (MI) in the primary care setting. MI has been shown to have a positive effect in promotion and modification of health habits and to increase treatment engagement. MI is also effective when used in conjunction with other treatment modalities, such as educational programs and cognitive behavioral therapy. Practical application of MI can be accomplished in a variety of primary care settings by a wide range of practitioners, incorporates nicely into new health care delivery models, and may improve the patient-provider relationship.

Associations between Difficulty Paying Medical Bills and Forgone Medical and Prescription Drug Care.

Problems paying medical bills have been reported to be associated with increased stress, bankruptcy, and forgone medical care. Using the Behavioral Model for Vulnerable Populations developed by Gelberg et al as a framework, as well as data from the 2010 Ohio Family Health Survey, this study examined the relationships between difficulty paying medical bills and forgone medical and prescription drug care. Logistic regression was used to examine associations between difficulty paying medical bills and predisposing, enabling, need (health status), and health behaviors (forgoing medical care). Difficulty paying medical bills increased the effect of lack of health insurance in predicting forgone medical care and had a conditional effect on the association between education and forgone prescription drug care. Those who had less than a bachelor's degree were more likely to forgo prescription drug care than those with a bachelor's degree, but only if they had difficulty paying medical bills. Difficulty paying medical bills also accounted for the relationships between several population characteristics (eg, age, income, home ownership, health status) in predicting forgone medical and prescription drug care. Policies to cap out-of-pocket medical expenses may mitigate health disparities by addressing the impact of difficulty paying medical bills on forgone care.

Improving the spiritual dimension of whole person care: reaching national and international consensus.

Two conferences, Creating More Compassionate Systems of Care (November 2012) and On Improving the Spiritual Dimension of Whole Person Care: The Transformational Role of Compassion, Love and Forgiveness in Health Care (January 2013), were convened with the goals of reaching consensus on approaches to the integration of spirituality into health care structures at all levels and development of strategies to create more compassionate systems of care. The conferences built on the work of a 2009 consensus conference, Improving the Quality of Spiritual Care as a Dimension of Palliative Care. Conference organizers in 2012 and 2013 aimed to identify consensus-derived care standards and recommendations for implementing them by building and expanding on the 2009 conference model of interprofessional spiritual care and its recommendations for palliative care. The 2013 conference built on the 2012 conference to produce a set of standards and recommended strategies for integrating spiritual care across the entire health care continuum, not just palliative care. Deliberations were based on evidence that spiritual care is a fundamental component of high-quality compassionate health care and it is most effective when it is recognized and reflected in the attitudes and actions of both patients and health care providers.

Teaching population health: a competency map approach to education.

A 2012 Institute of Medicine report is the latest in the growing number of calls to incorporate a population health approach in health professionals' training. Over the last decade, Duke University, particularly its Department of Community and Family Medicine, has been heavily involved with community partners in Durham, North Carolina, to improve the local community's health. On the basis of these initiatives, a group of interprofessional faculty began tackling the need to fill the curriculum gap to train future health professionals in public health practice, community engagement, critical thinking, and team skills to improve population health effectively in Durham and elsewhere. The Department of Community and Family Medicine has spent years in care delivery redesign and curriculum experimentation, design, and evaluation to distinguish the skills trainees and faculty need for population health improvement and to integrate them into educational programs. These clinical and educational experiences have led to a set of competencies that form an organizational framework for curricular planning and training. This framework delineates which learning objectives are appropriate and necessary for each learning level, from novice through expert, across multiple disciplines and domains. The resulting competency map has guided Duke's efforts to develop, implement, and assess training in population health for learners and faculty. In this article, the authors describe the competency map development process as well as examples of its application and evaluation at Duke and limitations to its use with the hope that other institutions will apply it in different settings.

Commentary: Knowing it when we see it: reflections on pornography.

This commentary asks, of what contemporary use is the excavation of a specific incident of sexually intimidating and otherwise inappropriate behavior in medical education's history? The question is posed in response to the accompanying article by Halperin detailing the publication and critical reception of an anatomy textbook that adopted a demeaning attitude toward women and featured pinup style photographs of nude women. The author contends that the generational context of feminist response to this incident and others like it is critical in shaping the current discussion. Today's third-generation feminists recognize the injustice of exploitative or offensive behaviors, but because of a fear of retaliation or negative consequence, they may nonetheless decline to respond in an official or whistle-blowing capacity-despite efforts to normalize appropriate faculty-learner interactions and to provide safe reception for those affected by abuses of power or authority. Revisiting an incident such as the one Halperin recounts reminds readers of both genders and all career stages that violations of professional mores between teacher and learner still occur and that the price of speaking up remains high.

Role of the social milieu in health and wellness.

Can "we" be modified? The impact of the social milieu on health and wellness is not a new concept. Before the invention of an effective pharmacopoeia, manipulation of the social environment was one of the few tools available to physicians. Modern medicine continues to focus on individual rather than community efforts at risk reduction. To understand health and wellness, we must look not only at bodies and illnesses but also at communities and social structure. This article discusses the impact of spirituality and religion, education, economics, and politics on health and wellness. The impact of these issues on health will drive system-level change in global health.

Prevalence of health-related behaviors among physicians and medical trainees.

OBJECTIVE: The authors studied the prevalence of health-promoting and health-risking behaviors among physicians and physicians-in-training. Given the significant potential for negative outcomes to physicians' own health as well as the health and safety of their patients, examination of the natural history of this acculturation process about physician self-care and wellness is critical to the improvement of the western health care delivery system. METHODS: 963 matriculating medical students, residents, or attending physicians completed the Empathy, Spirituality, and Wellness in Medicine (ESWIM) survey between the years 2000 and 2004. Items specific to physician wellness were analyzed. These included healthy behaviors as well as risk behaviors. RESULTS: Both medical students and attending physicians scored higher in overall wellness than did residents. Residents were the lowest scoring group for getting enough sleep, using seatbelts, and exercising. Medical students were more likely to smoke tobacco and drink alcohol. Medical students reported less depression and anxiety and more social contacts. CONCLUSION: Medical school training may prevent students from maintaining healthy behaviors, so that by the time they are residents they exercise less, sleep less, and spend less time in organizational activities outside of medical school. If physicians do not engage in these healthy behaviors, they are less likely to encourage such behaviors in their patients and patients are less likely to listen to them even if they do talk about it.