Preparing residents to practice integrated behavioral health care: Multi-site feasibility study of a competency-based curriculum.

OBJECTIVE: Workforce development is essential for the dissemination of team-based integrated behavioral healthcare. There is limited literature on training family medicine residents to function within an integrated behavioral health (IBH) system. The purpose of this pilot study was to assess the feasibility and value of an IBH competency-based curriculum for family medicine residents across multiple programs. METHODS: Residency programs were recruited using professional listservs and networks to test a competency-based, multi-modal curriculum for preparing residents to practice IBH in primary care. Faculty instructors who led the workshop were invited to complete semi-structured interviews to examine the feasibility and appropriateness of the curriculum. Interview data were analyzed using thematic analysis to identify, analyze, and report patterns. Residents completed a survey of perceived IBH skill and knowledge before and after training. A paired-sample t-test was used to determine significant differences pre- and post-training. RESULTS: All five instructors completed interviews. Results suggest IBH training is valuable. Instructors gave specific feedback on online modules, implementation flexibility, and adjusting faculty development to differing levels of experience. Nineteen of forty residents (48%) completed anonymous pre-, post-, and retrospective-training surveys. Residents reported an increase in competence after training. CONCLUSION: The results of this pilot suggest that IBH training implementation is feasible, desirable, timely, and may improve resident ability to work on an IBH team. Training should accommodate variations in program structure and faculty expertise.

Interprofessional team based learning to enhance behavioral health care for Latinx patients: Results of a teleconsultation program.

Culturally sensitive behavioral health services are scarce, particularly in rural and underserved areas. To expand integrated behavioral health care training for providers, specifically those working in rural communities and federally qualified health centers, an interprofessional teleconsultation program was developed. Given the desire to focus on culturally informed care training, this was done in partnership with a nonprofit community mental health agency which focuses on behavioral health within Latinx populations. The teleconsultation sessions were provided bimonthly using Zoom and included didactic components and case-based discussion using the Multidimensional Ecosystemic Comparative Approach (MECA; Falicov, 1995; Falicov, 2017). Participants represented a diverse, interprofessional group composed of behavioral health professionals (45.2%), primary care physicians (26.8%), family medicine residents (15.3%), and others (medical students and administrative staff [12.7%]). The program evaluation demonstrates that participants valued the teleconsultation sessions and articulated specific skills that they subsequently planned to integrate into their clinical practice to enhance care. This teleconsultation model allows interprofessional training across multiple types of organizations to enhance knowledge in providing integrated behavioral health care for Latinx populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Being in the room where it happens: Leveraging behavioral scientists' strengths in leadership.

Studies of leadership have identified several key traits and skills among successful leaders, including honesty, emotional intelligence, setting a vision, effective communication, and interest in providing feedback and developing others. These attributes, in addition to specific knowledge and skills related to health care systems, medical education, and effective team dynamics can propel behavioral scientists to success in graduate medical education. Whether or not it was labeled directly as leadership development, many behavioral scientists have had specific training in these core competencies, creating a potential for them to excel in leadership positions. We outline strategies for behavioral scientists to identify their leadership strengths, areas for growth, and pathways to seek opportunities for leadership within their programs or other avenues in medical education.

Using a Delphi Technique to Define a Feedback Culture in Graduate Medical Education.

BACKGROUND AND OBJECTIVES: Experts in medical education hypothesize that programs with a robust culture of feedback foster learning and growth for learners and educators, yet the literature shows no consensus for what defines a feedback culture in graduate medical education. METHODS: Using a two-round, modified Delphi technique in summer and fall of 2019, the authors asked a panel of experts to identify essential elements to a feedback culture. The research team compiled a list of experts and a list of 29 descriptors of a highly functioning feedback culture. Experts rated the items as an essential, compatible, or not important aspect of a highly functioning culture of feedback. Researchers set a minimum threshold of 80% agreement and used comments from panelists to revise elements that did not meet agreement during round one. Experts then rerated the elements using information on their initial ratings, aggregate panelist ratings, and comments from all panelists. RESULTS: The response rates from our panel of experts were 68% (17/25) for round one and 88% (15/17) for round two. Seventeen elements were rated as essential to a feedback culture. CONCLUSIONS: An expert panel endorsed essential elements that can be used to assess feedback culture in graduate medical education programs.

A Systematic Approach to Opioid Prescribing.

BACKGROUND AND OBJECTIVES: Opioid misuse has become a national crisis. In response to the need for improved standards of opioid prescribing within medical practices, a university-based academic family medicine practice developed, implemented, and evaluated a series of initiatives to ensure appropriate opioid prescribing and support clinicians in the practice in providing optimal care. METHODS: In 2015-2018, the University of North Carolina Family Medicine Center developed and implemented a practice-wide opioid prescribing policy, created a controlled medication advisory board (CMAB), provided regular feedback to clinicians on opioid prescribing, and trained selected providers in management of opioid use disorder. The impact of these opioid stewardship initiatives on prescribing patterns, utilization of the CMAB, and provision of medications for opioid use disorder was evaluated using electronic health record data from 2015 to 2018 and chart audits. RESULTS: Between 2014 and 2018 the opioid prescribing rate per 100 patient visits decreased by 31% and the rate of concomitant use of benzodiazepines and opioids decreased by 56%. The CMAB received 117 referrals between 2015 and 2018, 60% of which resulted in recommended revision in the treatment plan. CONCLUSIONS: Safe opioid prescribing is essential to mitigate the opioid crisis. An evidence-based standardized protocol, coupled with support for providers and patients, can reduce prescribing and improve patient safety, thereby enhancing the comprehensiveness and quality of patient care.

Utilizing the F3App to Capture Learner Feedback About Faculty Teaching.

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education requires soliciting learner feedback on faculty teaching, although gathering meaningful feedback is challenging in the medical education environment. We developed the Faculty Feedback Facilitator (F3App), a mobile application that allows for real-time capture of narrative feedback by residents. The purpose of our study was to assess efficacy, usability, and acceptability of the F3App in family medicine residency programs. METHODS: Residents, faculty, and program directors (PDs) from eight residency programs participated in a beta test of the F3App from November 2017 to May 2018; participants completed pre- and postimplementation surveys about their evaluation process and the F3App. We interviewed PDs, and analyzed responses using a thematic analysis approach. RESULTS: Survey results showed significant postimplementation increases in faculty agreement that accessing evaluations is easy (42%), evaluations are an effective way to communicate feedback (34%), feedback is actionable and meaningful (24%), and the current system provides meaningful data for promotion (33%). Among residents, agreement that the current system allows meaningful information sharing and is easy to use increased significantly, by 17% each. The proportion of residents agreeing they were comfortable providing constructive criticism increased significantly (22%). PDs generally reported that residents were receptive to using the F3App, found it quick and easy to use, and that feedback provided was meaningful. CONCLUSIONS: Participating programs reviewed the F3App positively as a tool to gather narrative feedback from learners on faculty teaching.

Content Analysis of Family Medicine Resident Peer Observations.

BACKGROUND AND OBJECTIVES: Direct observation is a critical part of assessing learners' achievement of the Accreditation Council for Graduate Medical Education (ACGME) Milestones and subcompetencies. Little research exists identifying the content of peer feedback among residents; this study explored the content of residents' peer assessments as they relate to ACGME Milestone subcompetencies in a family medicine residency program. METHODS: Using content from a mobile app-based observation tool (M3App), we examined resident peer observations recorded between June 2014 and November 2017, tabulating frequency of observation for each ACGME subcompetency and calculating the proportion of observations categorized under each subcompetency, as well as for each postgraduate year (PGY) class. We also coded each observation on three separate dimensions: "positive," "constructive," and "actionable." We used the χ2 test for independence, and estimated odds ratios and 95% confidence intervals for two-by-two comparisons to compare numbers of observations within each category. RESULTS: Our data include 886 peer observations made by 54 individual residents. The most frequently observed competencies were in patient care, communication, and professionalism (56%, 47%, and 38% of observations, respectively). Practice-based learning and improvement was observed least frequently (16% of observations). On average, 97.25% of the observations were positive, 85% were actionable, and 6% were constructive. CONCLUSIONS: When asked to review their peers, residents provide comments that are primarily positive and actionable. In addition, residents tend to provide more feedback on certain subcompetencies compared to others, suggesting that programs may rely on peer feedback for specific subcompetencies. Peers can provide perspective on the behaviors and skills of fellow residents.

Residency Faculty Teaching Evaluation: What Do Faculty, Residents, and Program Directors Want?

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education Common Residency Program Requirements stipulate that each faculty member's performance be evaluated annually. Feedback is essential to this process, yet the culture of medicine poses challenges to developing effective feedback systems. The current study explores existing and ideal characteristics of faculty teaching evaluation systems from the perspectives of key stakeholders: faculty, residents, and residency program directors (PDs). METHODS: We utilized two qualitative approaches: (1) confidential semistructured telephone interviews with PDs from a convenience sample of eight family medicine residency programs, (2) qualitative responses from an anonymous online survey of faculty and residents in the same eight programs. We used inductive thematic analysis to analyze the interviews and survey responses. Data collection occurred in the fall of 2017. RESULTS: All eight (100%) of the PDs completed interviews. Survey response rates for faculty and residents were 79% (99/126) and 70% (152/216), respectively. Both PD and faculty responses identified a desire for actionable, real-time, frequent feedback used to foster continued professional development. Themes unique to faculty included easy accessibility and feedback from peers. Residents expressed an interest in in-person feedback and a process minimizing potential retribution. Residents indicated that feedback should be based on shared understanding of what skill(s) the faculty member is trying to address. CONCLUSIONS: PDs, faculty, and residents share a desire to provide faculty with meaningful, specific, and real-time feedback. Programs should strive to provide a culture in which feedback is an integral part of the learning process for both residents and faculty.

Essential Skills for Family Medicine Residents Practicing Integrated Behavioral Health A Delphi Study.

BACKGROUND AND OBJECTIVES: There are several trends compelling physicians to acquire team-based skills for interprofessional care. One underdeveloped area of team-based skills for physicians is integrated behavioral health (IBH) in primary care. We used a Delphi method to explore what skills were needed for residents to practice integrated behavioral health. METHODS: We conducted a literature review of IBH competencies and found 41 competencies across seven domains unique to physicians. Using a modified Delphi technique, we recruited family medicine educators to rate each competency as "essential," "compatible," or "irrelevant." We also shared findings from the Delphi study with a focus group for additional feedback. RESULTS: Twenty-one participants (12 physicians, nine behavioral health providers) completed all three rounds of the Delphi survey resulting in a list of 21 competencies. The focus group gave additional feedback. CONCLUSIONS: Participants chose skills that required physicians to share responsibilities across the entire care team, were not redundant with standard primary care, and necessitated strong communication ability. Many items were revised to reflect team-based care and a prescribed physician role as a team facilitator. Next steps include determining how these competencies fit with a variety of medical providers and creating effective training programs that develop competency in IBH.

Sailing smoothly across the cultural divide: Constructing effective behavioral science presentations for medical audiences.

Beginning behavioral science faculty, who are critical residency program contributors, face significant immediate challenges that often diminish their effectiveness and increase the time it takes to translate and reformat their expertise into relevant and meaningful educational presentations. Residency program culture and competency-based learning are quite different from the educational objectives and teaching environments found in most behavioral health training programs. The goal of this article is to provide beginning behavior science faculty, who are typically on their own and learning on the job, with a guide to the core educational perspectives and skills required as well as key resources that are available to them. Since a significant portion of behavioral science faculty's teaching time revolves around small and large group presentations, our guide focuses on how to incorporate key strategies and resources into relevant, evidenced-based and, most importantly, effective behavioral health presentations for the program's resident physicians. Specifically, our recommendations include selection of content, methods of content organization, techniques for actively engaging resident physicians in discussing the significance of the topics, and descriptions of numerous Internet resources for the primary mental health topics that concern family medicine trainees. Finally, it is emphasized that the relevant and effective use of these recommendations is dependent upon the behavioral science faculty educator's first understanding and appreciating how physicians' think, speak, and prioritize information while caring for their patients.

Measuring general surgery residents' communication skills from the patient's perspective using the Communication Assessment Tool (CAT).

OBJECTIVE: The Communication Assessment Tool (CAT) has been used and validated to assess Family and Emergency Medicine resident communication skills from the patient's perspective. However, it has not been previously reported as an outcome measure for general surgery residents. The purpose of this study is to establish initial benchmarking data for the use of the CAT as an evaluation tool in an osteopathic general surgery residency program. Results are analyzed quarterly and used by the program director to provide meaningful feedback and targeted goal setting for residents to demonstrate progressive achievement of interpersonal and communication skills with patients. DESIGN: The 14-item paper version of the CAT (developed by Makoul et al. for residency programs) asks patients to anonymously rate surgery residents on discrete communication skills using a 5-point rating scale immediately after the clinical encounter. Results are reported as the percentage of items rated as "excellent" (5) by the patient. SETTING: The setting is a hospital-affiliated ambulatory urban surgery office staffed by the residency program. PARTICIPANTS: Participants are representative of adult patients of both sexes across all ages with diverse ethnic backgrounds. They include preoperative and postoperative patients, as well as those needing diagnostic testing and follow-up. RESULTS: Data have been collected on 17 general surgery residents from a single residency program representing 5 postgraduate year levels and 448 patient encounters since March 2012. The reliability (Cronbach α) of the tool for surgery residents was 0.98. The overall mean percentage of items rated as excellent was 70% (standard deviations = 42%), with a median of 100%. CONCLUSIONS: The CAT is a useful tool for measuring 1 facet of resident communication skills-the patient's perception of the physician-patient encounter. The tool provides a unique and personalized outcome measure for identifying communication strengths and improvement opportunities, allowing residents to receive specific feedback and mentoring by program directors.