Storylines of family medicine III: core principles-primary care, systems and family.

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 'III: core principles-primary care, systems, and family', authors address the following themes: 'Continuity of care-building therapeutic relationships over time', 'Comprehensiveness-combining breadth and depth of scope', 'Coordination of care-managing multiple realities', 'Access to care-intersectional, systemic, and personal', 'Systems theory-a core value in patient-centered care', 'Family-oriented practice-supporting patients' health and well-being', 'Family physician as family member' and 'Family in the exam room'. May readers develop new understandings from these essays.

Addressing Sexual Harassment and Gender Bias: Mandatory Modules Are Not Enough.

BACKGROUND AND OBJECTIVES: Despite decades of new policy guidelines and mandatory training modules, sexual harassment (SH) and gender bias (GB) continue in academic medicine. The hierarchical structure of medical training makes it challenging to act when one experiences or witnesses SH or GB. Most trainings designed to address SH and GB are driven by external mandates and do not utilize current educational techniques. Our goal was to design training that is in-person, active, and directed toward skills development. METHODS: Our academic family medicine (FM) department began by surveying our faculty and residents about their lived experiences of SH and GB. We used these data, incorporating principles of adult learning, to deliver voluntary, experiential, interactive workshops throughout 2019. The workshops took place during faculty development meetings and an annual retreat. We used interactive techniques that included case-based and Theater of the Oppressed formats. OUTCOMES: Eighty percent of faculty and residents participated in at least one of our voluntary training sessions. In April of 2020, we administered a retrospective, pre/postsurvey on confidence in recognizing, responding to, and reporting SH and GB. We found significant improvements in all domains surveyed; many participants reported using the skills in the 6 months prior to completing the surveys. CONCLUSION: We demonstrated that voluntary, interactive training sessions using the recommendations of the National Academies of Science Engineering and Medicine Report on the Sexual Harassment of Women improve participants' reported confidence in recognizing, responding to, and reporting SH and GB in one academic FM department. This training intervention is practical and can be disseminated and implemented in many settings.

Evaluating the Uptake of Antiracism Training, Policies, and Practices in Departments of Family Medicine.

BACKGROUND: Recent attention and focus on, antiracism training in health care has potential to accelerate our path to social justice and achieve health equity on a national scale. However, theoretical frameworks and empirical data have yet to emerge that explain the uptake of antiracism trainings and their efficacy. OBJECTIVE: This goal of this study was to test hypotheses regarding uptake of antiracism training in Family Medicine departments using Diffusion of Innovation Theory. METHODS: In 2021, we incorporated 10 survey items in the Council of Academic Family Medicine Educational Research Alliance's national omnibus survey for Department of Family Medicine Chairs (n = 104). We used DOI (Diffusion of Innovation) attributes (ie, relative advantage, compatibility, complexity, trialability, and observability) as a guiding framework to assess perceived innovation of antiracism training. We also evaluated the mode of training (eg, didactic, experiential) and whether any subsequent policy or practice-level antiracist actions occurred. We used c2 tests to examine associations between DOI attributes and antiracist actions; and logistic regression to determine odds of association. RESULTS: Ninety-two percent of respondents indicated antiracism training was happening in their department. Relative advantage, compatibility and observability were positively associated with antiracist actions, P < .05. Perceived relative advantage was associated with implementation of antiracist action (OR 1.94, 1.27-2.99). Complexity and trialability were not statistically significantly associated with action. CONCLUSION: Our findings provide evidence of DOIs influence on antiracism uptake in Departments of Family Medicine. We believe our findings can facilitate the future implementation of antiracism training activities and actionable antiracist policies and practices.

Sexual Harassment and Gender Bias in Family Medicine: Divergent Experiences of Men and Women.

BACKGROUND AND OBJECTIVES: Awareness of sexual harassment (SH), gender bias (GB), and gender discrimination (GD) has spread throughout popular culture and has been highlighted at universities across the United States. More nuanced data is needed to inform policies that address these issues. However, there are currently limited qualitative studies examining the nature of SH, GB, and GD in academic medicine, particularly family medicine. METHODS: In 2018, we conducted a series of gender-specific focus groups with faculty and residents in a department of family medicine (DFM) to understand their experiences with and responses to SH, GB, and GD. The focus groups were transcribed verbatim. We used immersion-crystallization and an adapted SH Experiences model to review the transcripts and identify patterns or themes during the immersion process. RESULTS: Participants identified the potential for patients, colleagues, faculty, and themselves as perpetrators and victims of SH, GB, and GD. Results suggested that GB was often implicit. SH was experienced verbally and physically. Women participants, especially, reported that both SH and GB occurred frequently and had lasting psychological effects. Gender, age, and position (faculty vs trainee) moderated SH and GB experiences. The effects seemed to be mediated by moral distress. CONCLUSIONS: This study emphasizes the importance of recognizing differences in experiences across gender, age, and position of SH, GB, and GD in academic family medicine. Our findings can be leveraged to develop antiharassment policies and set cultural expectations.

Physician Communication Coaching: How Psychologists can Elevate Skills and Support Resident Education, Professionalism, and Well-being.

Many factors influence resident physician communication, including rigorous training demands that can contribute to professionalism issues or burnout. The University of Rochester Physician Communication Coaching program launched for attendings in 2011, and expanded to residency programs within 11 clinical departments of our institution. In this model, psychologists serve as coaches, drawing on their expertise in communication skills, behavior change, and wellness promotion. These coaches conduct real-time observation of patient encounters, coding communication with an expanded Cambridge-Calgary Patient-Centered Observational Checklist. Residents receive a written report with individualized feedback. From 2013 to 2020, 279 residents were coached. Since 2018, residents have been formally surveyed for feedback (n = 70 surveys completed; 61% response rate), with 97% rating the experience Very Helpful or Helpful. Of the 70 completed surveys, 54 (77%) included qualitative feedback that has also been positive. Due to the feasibility and growing demand for communication coaching from other residency and fellowship programs, in 2018 two authors (SM and LD-R) developed a 2-year, part-time program to train communication coaches.

Child Psychiatrists and Psychologists: Enhanced Collaboration in Primary Care.

Psychiatry and psychology have a long history of competition that too often interferes with the collaboration that can characterize complementary contributions to our common missions. We hope this article will inspire our disciplines to expand on this collaboration, for the sake of our children and families, our communities, our colleagues, and honestly, ourselves. We are better together than apart. This text is a blueprint for the assumptions, attitudes, skills, and advocacy that can make this partnership healthy and successful.

"Am I Making More of It Than I Should?": Reporting and Responding to Sexual Harassment.

BACKGROUND AND OBJECTIVES: Health professionals may face sexual harassment from patients, faculty, and colleagues. Medicine's hierarchy deters response to sexual harassment. Current evidence consists largely of quantitative data regarding the frequency and types of sexual harassment. More information is needed about the nature of the experience and how or why professionals choose to report or respond. METHODS: We developed and administered a semistructured interview guide to elicit family medicine faculty and residents' experiences with sexual harassment and gender bias. Facilitators led a series of focus groups divided by faculty (N=28) and residents (N=24). We ensured voluntary consent and groups were audiotaped, transcribed and deidentified. We coded the transcripts using immersion-crystallization theory to identify emergent themes. RESULTS: Sexual harassment from patients and colleagues was described as witnessed or personally experienced by faculty and resident participants in 100% of the focus groups. Respondents identified the presence of mentors, clear reporting process and follow-up, history of good organizational response to reporting, and education and training as facilitators to reporting sexual harassment. Barriers to reporting included fear of retaliation, lack of trust of the system to respond, lack of clarity about "what counts," and confusion with the reporting process. CONCLUSIONS: It is important to capitalize on facilitators to reporting sexual harassment, starting with acknowledging the frequency of sexual harassment and gender discrimination. Addressing barriers to responding through education and training for our learners and faculty is critical. Clarifying the reporting process, having clear expectations for behavior, and a continuum of responses may help increase the frequency of reporting.

Empathy and boundary turbulence in cancer communication.

OBJECTIVES: To describe and deepen our understanding of patient-centeredness, empathy, and boundary management in challenging conversations. Previous studies show frequent physician self-disclosure, while empathy and boundary management are infrequent. METHODS: Three standardized patients (SPs) portrayed cancer patients consulting a new community-based physician, resulting in 39 audio-recorded SP visits to 19 family physicians and 20 medical oncologists. Transcripts underwent qualitative iterative thematic analysis, informed by grounded theory, followed by directed content analysis. We further defined the identified communicative categories with descriptive and correlational calculations. RESULTS: We identified patient-centered physician response categories--empathy, affirmation, and acknowledgement; and physician-centered categories-transparency, self-disclosure, and projection. Acknowledgement and affirmation responses were frequent and empathy rare. Physician transparency and self-disclosure were common. Useful and not useful self-disclosures were highly correlated; empathy, useful and not useful transparency, and projection were moderately correlated. Most physicians used self-disclosure but few of these were judged patient-centered. CONCLUSIONS: Physicians expressing empathy and patient-centered transparency were also more likely to use projection and physician-centered transparency, thus engaging in communication "boundary turbulence." Patients may benefit from physicians' improved use of empathy and boundary management.

A physician communication coaching program: Developing a supportive culture of feedback to sustain and reinvigorate faculty physicians.

INTRODUCTION: Physician-patient communication involves complex skills that affect quality, outcome, and satisfaction for patients, families, and health care teams. Yet, institutional, regulatory, and scientific demands compete for physicians' attention. A framework is needed to support physicians continued development of communication skills: Coaching is 1 such evidence-based practice, and we assessed the feasibility of implementing such a program. METHOD: Participants were 12 physicians, representing high and low scorers on the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) survey. We added items to capture empathy and family experience to the Calgary-Cambridge Observation Guide for the Medical Interview. Coaches observed communication associated with patient satisfaction and quality measures: introductions (I), asking about concerns (C), and check for understanding (U), or ICU. Participants received a report describing their communication behaviors, emphasizing strengths, and identifying areas for improvement. RESULTS: Scores on the ICU significantly discriminated between low and high HCAHPS scorers, physicians from surgical and cognitive specialties, men and women. We collected anonymous feedback regarding the value of this training; participants recommended expanding the program. DISCUSSION: Based on physician endorsement, experienced coaches are expanding the coaching program to physicians throughout our institution. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Nomination of John S. Rolland, MD, MPH for the 2018 CFHA Don Bloch Award.

Article provides the nomination of John S. Rolland, MD, MPH for the 2018 CFHA Don Bloch Award. John Rolland is the author of 70 journal articles and book chapters, and three books, translated into multiple languages, all focused on understanding the intersection of family function, illness, and health care. Google Scholar shows that his publications have been cited several thousand times, placing his intellectual contributions above 95% of all academic health care authors. John brought us an understanding of the psychosocial aspects of various diseases, their developmental course, and the potential for skew in relationships because of illness. He is a strong theoretician who brings his ideas to life through sharing his clinical experience as well as his own profound family experience to illustrate his points. John has supported service, training, and research through participation in grants focused on support for victims of ethnic cleansing, families and substance abuse, genetic testing and family involvement, and the impact of chronic and terminal illness on families. He is on the editorial board of three journals, all focused on families and health, and reviews submissions for many other journals. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A Curriculum for an Interprofessional Seminar on Integrated Primary Care: Developing Competencies for Interprofessional Collaborative Practice.

Health care is increasingly delivered through team-based, collaborative strategies with interprofessional education as an important mechanism for building interprofessional practice competencies. This paper describes an Interprofessional Seminar on Integrated Primary Care (IS-IPC) designed to meet this educational need with interprofessional team-based learning as the foundation of an iterative process such that education and practice inform one another. The IS-IPC can be used to educate an interprofessional group of learners about key topics relevant to working together in integrated primary care. The IS-IPC describes steps in developing an interprofessional seminar, common challenges, and their solutions in creating interprofessional learning experiences, and eight foundational content modules containing an outline and curricular resources. The IS-IPC facilitates interprofessional educator partnerships at the local level and can be customized to fit the local environment, pedagogical philosophy, and learning objectives.

The science of teamwork: Introduction to the special issue.

Provides an introduction to this special issue which explores the Science of Teamwork-what psychological science in 2018 tells us about the process and outcomes of teamwork in a variety of contexts. This work draws from and affects all areas of psychology. The science and practice of teamwork is now an interdisciplinary activity. Teamwork is a complex phenomenon requiring multiple lenses and approaches. What follows is a description of our process in putting together the issue and a brief description of the articles that compose it. (PsycINFO Database Record

The complexity, diversity, and science of primary care teams.

This article examines the past, present and future of primary care and teamwork. It begins with a definition and description of primary care-its uniqueness, diversity and complexity, including the historical role of teams within primary care. The article then reviews the emergence of innovative primary care teams, including those grounded in new processes such as the Patient-Centered Medical Home and interprofessional teams that include new types of health professionals, particularly psychologists and other integrated behavioral health clinicians. The article describes key factors that support or hinder primary care teamwork, as well as evidence of the impact of these team-based models on patient outcomes, costs, and team members. It also discusses the role of primary care teams within multiteam systems (or 'teams of teams'), which are organized around the needs of patients and families, and the unique challenges these systems pose to coordinating care. The article concludes with recommendations for advancing teams in primary care, including changes in payment, descriptions of team competencies, models for primary care team training, and research necessary to inform the gaps in scientific knowledge. (PsycINFO Database Record

The science of teamwork: Progress, reflections, and the road ahead.

We need teams in nearly every aspect of our lives (e.g., hospitals, schools, flight decks, nuclear power plants, oil rigs, the military, and corporate offices). Nearly a century of psychological science has uncovered extensive knowledge about team-related processes and outcomes. In this article, we draw from the reviews and articles of this special issue to identify 10 key reflections that have arisen in the team literature, briefly summarized here. Team researchers have developed many theories surrounding the multilayered aspects of teams, such that now we have a solid theoretical basis for teams. We have recognized that the collective is often stronger than the individual, initiating the shift from individual tasks to team tasks. All teams are not created equal, so it is important to consider the context to understand relevant team dynamics and outcomes, but sometimes teams performing in different contexts are more similar than not. It is critical to have teamwork-supportive organizational conditions and environments where psychological safety can flourish and be a mechanism to resolve conflicts, ensure safety, mitigate errors, learn, and improve performance. There are also helpful teamwork competencies that can increase effectiveness across teams or tasks that have been identified (e.g., coordination, communication, and adaptability). Even if a team is made up of experts, it can still fail if they do not know how to cooperate, coordinate, and communicate well together. To ensure the improvement and maintenance of effective team functioning, the organization must implement team development interventions and evaluate relevant team outcomes with robust diagnostic measurement. We conclude with 3 main directions for scientists to expand upon in the future: (a) address issues with technology to make further improvements in team assessment, (b) learn more about multiteam systems, and (c) bridge the gap between theory and practice. In summary, the science of teams has made substantial progress but still has plenty of room for advancement. (PsycINFO Database Record

Twenty-five years of education in psychology and psychology in education.

This article is part of a special issue of the American Psychologist celebrating the American Psychological Association's (APA's) 125th anniversary. The article reviews the last quarter century (1991-2016) of accomplishments by psychology's education and training community and APA's Education Directorate. The purpose is to highlight key trends and developments over the past quarter century that illustrate ways the Directorate sought to advance education in psychology and psychology in education, as the Directorate's mission statement says. The focus of the Directorate has been on building a cooperative culture across psychology's broad education and training community. Specifically APA has (a) promoted quality education-from prekindergarten through lifelong learning, (b) encouraged accountability through guidelines and standards for education and training, and (c) supported the discovery and dissemination of new knowledge to enhance health, education, and well-being. After identifying challenges and progress, the article discusses the future of the field of psychology and the preparation of its workforce of tomorrow. (PsycINFO Database Record

Relative prospects of children as they age: Canadians and Americans in midlife in the great recession frame future generations.

Studies of intergenerational relations in aging and changing families often focus on the present, how generations interact, relate or depend on each other in families. Less often is the focus on the prospective, on projected perceptions of life course prospects for future generations as they age. In this paper, part of a large multi-method project, we adopt this focus. We rely on interviews conducted in 2013 with midlife respondents in two socioeconomic classes in comparable cities in the United States and Canada, We specifically explore whether and how Canadians and Americans in midlife discuss life course prospects for their children (or younger relatives) in ways that map onto wider discursive frames of aging. Through a combined discourse and frame analysis of our interview data, we find that frames of "The Dream" and "Intergenerational Contract" construct and reflect competing models of intergenerational shifts in life course spaces as well as suggest intergenerational changes in mobility and opportunities.

A New Foundation for the Delivery and Financing of American Health Care.

BACKGROUND AND OBJECTIVES: For the past decade, primary care practices across America have worked to implement a practice model called the Patient-Centered Medical Home (PCMH) to revitalize practice, better support clinicians and patients, improve efficiency, and facilitate growth in primary care capacity. In spite of substantial progress, this work has not been matched by sufficient change in the payment system to allow these goals to be accomplished. Nevertheless, improving the quality and availability of primary care remains essential to achieving the goals of the Triple Aim (better health care, better population health, and containment of health care costs). For this to occur, the PCMH model of care must be further refined, and the payment system for primary care must be completely restructured. The need for these changes is urgent. In October 2014, the discipline of family medicine announced a comprehensive strategic plan called Family Medicine for America's Health (FMAHealth). FMAHealth proposes to expand the PCMH care model by fully integrating our nation's behavioral/mental health, public health, and primary care systems to create a new foundation for American health care. Accomplishing these ambitious goals will require a broad coalition of private and public interests across the health care disciplines as well as patients, communities, government, and businesses. These changes require additional infrastructure that existing financing systems do not adequately support, so comprehensive payment reform is essential for large-scale dissemination and sustainability of this model. The new payment model must reward value rather than volume of service and must provide a secure financial foundation for practices designed to care for patients and communities at affordable costs.