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.

Optimal training in communication model (OPTiCOM): A programmatic roadmap.

OBJECTIVES: Teaching primary care residents patient communication skills is essential, complex, and impeded by barriers. We find no models guiding faculty how to train residents in the workplace that integrate necessary system components, the science of physician-patient communication training and competency-based medical education. The aim of this project is to create such a model. METHODS: We created OPTiCOM using four steps: (1) communication educator interviews, analysis and theme development; (2) initial model construction; (3) model refinement using expert feedback; (4) structured literature review to validate, refine and finalize the model. RESULTS: Our model contains ten interdependent building blocks organized into four developmental tiers. The Foundational value tier has one building block Naming relationship as a core value. The Expertize and resources tier includes four building blocks addressing: Curricular expertize, Curricular content, Leadership, and Time. The four building blocks in the Application and development tier are Observation form, Faculty development, Technology, and Formative assessment. The Language and culture tier identifies the final building block, Culture promoting continuous improvement in teaching communication. CONCLUSIONS: OPTiCOM organizes ten interdependent systems building blocks to maximize and sustain resident learning of communication skills. Practice Implications Residency faculty can use OPTiCOM for self-assessment, program creation and revision.

Effectiveness of intensive physician training in upfront agenda setting.

BACKGROUND: Patients want all their concerns heard, but physicians fear losing control of time and interrupt patients before all concerns are raised. OBJECTIVE: We hypothesized that when physicians were trained to use collaborative upfront agenda setting, visits would be no longer, more concerns would be identified, fewer concerns would surface late in the visit, and patients would report greater satisfaction and improved functional status. DESIGN AND PARTICIPANTS: Post-only randomized controlled trial using qualitative and quantitative methods. Six months after training (March 2004-March 2005) physician-patient encounters in two large primary care organizations were audio taped and patients (1460) and physicians (48) were surveyed. INTERVENTION: Experimental physicians received training in upfront agenda setting through the Establishing Focus Protocol, including two hours of training and two hours of coaching per week for four consecutive weeks. MAIN MEASURES: Outcomes included agenda setting behaviors demonstrated during the early, middle, and late encounter phases, visit length, number of raised concerns, patient and physician satisfaction, trust and functional status. KEY RESULTS: Experimental physicians were more likely to make additional elicitations (p < 0.01) and their patients were more likely to indicate agenda completion in the early phase of the encounter (p < 0.01). Experimental group patients and physicians raised fewer concerns in the late encounter phase (p < 0.01). There were no significant differences in visit length, total concerns addressed, patient or provider satisfaction, or patient trust and functional status CONCLUSION: Collaborative upfront agenda setting did not increase visit length or the number of problems addressed per visit but may reduce the likelihood of "oh by the way" concerns surfacing late in the encounter. However, upfront agenda setting is not sufficient to enhance patient satisfaction, trust or functional status. Training focused on physicians instead of teams and without regular reinforcement may have limited impact in changing visit content and time use.

Lexicon creation to promote faculty development in medical communication.

OBJECTIVE: Most medical educators have little or no training in teaching and assessing medical communication, and they are not consistent in what they teach. The authors set out to reach consensus in our educational community on a lexicon of communication terms for use in teaching physician-patient communication skills to second-year medical students. METHODS: An interdisciplinary medical school physician-patient communication committee assembled 23 important terms and agreed on definitions for each term. Thirty core preclinical faculty representing nine medical specialties reviewed the lexicon. Faculty were surveyed about lexicon definitions, barriers to use, and methods of using during educational encounters. RESULTS: All preclinical faculty members agreed on 19 out of 23 definitions and most respondents agreed on the definitions of the remaining four terms. Sixty-nine percent of respondents said they used the terms during their teaching encounters. CONCLUSION: Implementing a process to create a shared language around physician-patient communication may help unify and enhance faculty educational efforts. We were able to establish that medical educators can agree on the content of a medical communication lexicon for use with students. The use of defined and consistently used terms in multiple venues may reduce ambiguity, standardize teaching, enhance recognition of communication skills, and promote effective reinforcement and remediation by faculty. PRACTICE IMPLICATIONS: Evidence suggests that most medical educators have little or no training in teaching and assessing medical communication and that they are not consistent in what they teach. Asking a community of faculty to share responsibility for creating a communication lexicon may be an efficient and effective way to educate faculty and unify their educational effort.

"Imagine a clinical world without family systems thinking": Response.

Replies to comments made by B. J. Jacobs (see record 2018-27937-015) on the authors' original editorial (see record 2017-56601-001). While Fogarty and Mauksch agree with Dr. Jacobs that reviving the Doherty and Baird Levels of family involvement would be helpful, as would training clinicians to engage family members as partners in care, Fogarty and Mauksch want to reemphasize that helping trainees recognize systemic thinking and learn systemic problem solving is a necessary precursor to any form of family focused action. Clinicians should pursue shared decision-making partnerships with patients and their family members. (PsycINFO Database Record

Improving quality of care for mental illness in an uninsured, low-income primary care population.

OBJECTIVE: We assessed if an ongoing, multifaceted quality improvement program improved mental health care in a low-income, uninsured primary care clinic. METHODS: We reviewed the charts of 500 consecutive patients in 1999 and 500 consecutive patients in 2004 to compare the number of mental health visits; the percentage of patients with more than three follow-up visits; the percentage with > or = 1 visit with a prescribing provider and the percentage with a psychiatric medication prescribed. We also assessed whether patients with more than one charted mental illness received more care than patients with one mental illness. RESULTS: Compared to 1999, patients in 2004 had significantly more visits in the first 120 days (acute phase) of treatment (3.16 vs. 4.81, P<.001) and more visits in up to 9 months post acute phase (3.76 vs. 4.88, P>.012). A higher percentage of patients in the acute phase (28.9% vs. 49.5%, P<.001) had three follow-up visits, saw a medical provider and received a prescription. Patients with multiple charted mental illnesses had more visits than patients with one mental illness in 2004 but not in 1999 (P<.001). CONCLUSIONS: An ongoing, multifaceted intervention improved the quality of mental health care in a primary care population with a high prevalence of mental illness.

"Imagine a clinical world without family systems thinking."

Collaborative family health care acknowledges the importance of family and social context to yield a comprehensive understanding of health. In this editorial, we return to the concept of family systems thinking. (PsycINFO Database Record

Collaborative family health care, civil rights, and social determinants of health.

Social and economic disadvantage and civil rights infringement, worsens overall health (Adler, Glymour, & Fielding, 2016; McGowan, Lee, Meneses, Perkins, & Youdelman, 2016; Teitelbaum, 2005). While addressing these challenges is not new, there is reason to believe that the administration of Donald Trump and a republican majority in congress will exacerbate these challenges and their effects. How can collaborative family health care (CFHC) practitioners and our field help? The editors pondered this question and also asked a selection of leaders in the field. The editors will first share their ideas about the potential of CFHC to make a difference in daily interactions with patients. Next, they will identify key areas of risk and vulnerability. Finally, using the contributions of respected colleagues, they will propose a partial agenda for CFHC clinicians and the field. (PsycINFO Database Record

Modeling the mental health workforce in Washington State: using state licensing data to examine provider supply in rural and urban areas.

CONTEXT: Ensuring an adequate mental health provider supply in rural and urban areas requires accessible methods of identifying provider types, practice locations, and practice productivity. PURPOSE: To identify mental health shortage areas using existing licensing and survey data. METHODS: The 1998-1999 Washington State Department of Health files on credentialed health professionals linked with results of a licensure renewal survey, 1990 US Census data, and the results of the 1990-1992 National Comorbidity Survey were used to calculate supply and requirements for mental health services in 2 types of geographic units in Washington state-61 rural and urban core health service areas and 13 larger mental health regions. Both the number of 9 types of mental health professionals and their full-time equivalents (FTEs) per 100,000 population measured supply in the health service areas and mental health regions. FINDINGS: Notable shortages of mental health providers existed throughout the state, especially in rural areas. Urban areas had 3 times the psychiatrist FTEs per 100,000 and more than 1.5 times the nonpsychiatrist mental health provider FTEs per 100,000 as rural areas. More than 80% of rural health service areas had at least 10% fewer psychiatrist FTEs and nonpsychiatrist mental health provider FTEs than the state ratio (10.4 FTEs per 100,000 and 306.5 FTEs per 100,000, respectively). Ten of the 13 mental health regions were more than 10% below the state ratio of psychiatrist FTEs per 100,000. CONCLUSIONS: States gathering a minimum database at licensure renewal can identify area-specific mental health care shortages for use in program planning.

In search of a perennial philosophy for behavioral health integration in primary care.

The "perennial philosophy," a concept religious scholars have studied for centuries, represents a search for the values, themes, and constructs that transcend individual religions. Can we who develop and disseminate behavioral health integration in primary care step back from individual models to identify our perennial philosophy? If so, what are the components? What does the evidence tell us? What do we need to learn? Four case examples are presented which represent many patients seen by both of us-a family therapist and a family physician-over our combined 55 years of collaborative practice within integrated primary care settings. Can these patients be cared for in a primary care setting? Our experience provides a simple answer-yes. However, providing care for this range of patients requires variability in team configurations, frequency of visits, lengths of relationships, and interventional strategies. Is there a perennial philosophy of how to design and implement the integration of behavioral health in primary care? We think there should be. we highlight a recent publication from the Eugene S. Farley, Jr. Health Policy Center, entitled "Core Competencies For Behavioral Health Providers Working In Primary Care." The authors purposefully transcend models in delineating eight core competencies. Embedded within these competencies are common or perennial factors. These factors may guide our field going forward, helping us avoid "religious" divisions, seek to understand diverse designs, and embrace integration of models to meet the needs of the populations and teams we serve. (PsycINFO Database Record

The Tri-Optic II: Embracing the family voice.

In June, 2015, for the issue marking the passing of Donald Bloch, the intellectual founder of the collaborative health care movement, we wrote an editorial called, "The Tri-Optic: Next step for Collaborative Family Healthcare" (Mauksch & Fogarty, 2015). Bloch had famously proposed the "dual optic": the partnership of Dr. Biomedicine and Dr. Psychosocial (Bloch, 1988). Our readers, including many Collaborative Family Healthcare Association (CFHA) members, understand the value of a family perspective and are grappling with the next steps to truly integrate family and systems thinking into all levels of health care. A current exploration about the last 10 years of articles published in the journal by Tai Mendenhall, a member or our editorial board (personal communication, 2015), has found that the most common topic of focus is family health and functioning in 28% of the articles. This focus was also evident to varying degrees in all the plenaries at the 2015 CFHA conference held in Portland, Oregon. we pose the following questions to the FSH readership and CFHA community: Where are we, individually and collectively, with our knowledge about families as resources in and influences on health care? How are we teaching our learners about family-oriented care? How do we integrate family thinking into our various models of care? How do models of behavioral health integration include the family context in patient care?

Families, Systems, & Health: The past and present help determine the Journal's future.

This editorial introduces the current special issue of Families, Systems, & Health. This special issue on "Integrated Care Strategies in the Real World," guest edited by Jennifer Funderburk and Jodi Polaha, will offer rigorous studies and provide practical recommendations for others to apply scholarly knowledge in real practices.

Our continuing exploration of medically unexplained symptoms.

In this issue, the reader will find three articles examining different but converging perspectives on medically unexplained symptoms (MUS). In the first article, Gates, Petterson, Wingrove, Miller, and Klink (2016) examined 110,000 office visits to primary care providers between 2002 and 2010. In the second article, Clarke (2016), an internist and gastroenterologist, presents a model for diagnosing and treating MUS. The person most referenced in the first two articles and author of the landmark study-Kroenke (2016) writes the third article, an invited commentary. Kroenke eloquently reviews the major issues confronting health care clinicians dealing with MUS. We hope that readers of the three articles on MUS in this issue will reflect on their own practice, share these articles and their impressions with colleagues, and consider ways to improve the service and consultation designs in their practice settings. Those who teach behavioral health clinicians and physicians will surely be reinforced or reinvigorated to focus on ways to help patients and colleagues. (PsycINFO Database Record

Teaching inpatient communication skills to medical students: an innovative strategy.

At the University of Washington, a group of medical educators defined a set of communication skills, or "benchmarks," that are expected of second-year medical students conducting history and physical examinations on hospitalized patients. In order to teach the skills listed in the communication benchmarks, an educational strategy was devised that included training sessions for 30 medical teachers and the development of an innovative videotape tool used to train the teachers and their students. The benchmarks were designed in 2003 for the developmental level of the students and were based on key communication concepts and essential elements of medical communication. A set of five short videotaped scenarios was developed that illustrated various segments of a student history and physical examination. Each scenario consisted of an "OK" version of communication and a "better" version of the same scenario. The video scenarios were used in teaching sessions to help students identify effective communication techniques and to stimulate discussion about the communication benchmarks. After the training sessions, teachers and students were surveyed to assess the effectiveness of the educational methods. The majority of students felt that the educational design stimulated discussion and improved their understanding of communication skills. Faculty found the educational design useful and 95% felt that the curriculum and videotape contributed to their own education. The development of communication benchmarks illustrated with short videotaped scenarios contrasting "OK" with "better" communication skills is a useful technique that is transferable to other institutions.

Empiric and creative: Are these opposed?

We feel proud that Families, Systems, and Health disseminates different ways of knowing, and different ways of influencing thought: empiric work such as research papers and conceptual papers in contrast to creative work such as personal narrative, poetry, and 55-word stories. In this issue, we feature an interview with Dr. Julie Phillips, a family physician, scholar, and poet, who has contributed both research papers and creative manuscripts to the medical literature. Our commitment to publishing creative writing is balanced by our longstanding pursuit of scientific knowledge, which also requires creative thinking. In this issue, three knowledgeable scholars and members of our discipline set forth a call for papers for a special issue. Jodi Polaha, Ph.D., Jennifer S. Funderburk, Ph.D., and Deborah Cohen, Ph.D. will be the guest editors of a future issue blending two goals. We want to help our readers learn how to study their innovations and describe their learning so others can benefit. This special issue of Families, Systems, and Health seeks contributions from authors willing to help others learn to generate generalizable learning. In the process of doing this, we hope they will share the results of their studies to improve, implement, and disseminate integrated health care. (PsycINFO Database Record

The tri-optic: Next step for Collaborative Family Health Care.

C. J. Peek, PhD, is a descriptive psychologist, someone trained to organize and define the implicit structure of a discipline. Dr. Peek applies his training to name and organize the content of Collaborative Family Health Care (CFHC) and to examine our next developmental steps. In Dr. Peek's article (see record 2015-25290-002), the reader will find a clear examination of the CFHC organizing principles, visionary components, 20 years of planning, CFHC core competencies, and outcomes. According to Seaburn (see record 2015-10057-002), the impetus for Peek's work comes with the passing last year of Donald A. Bloch, MD, the principle person who envisioned our discipline, founded our organization, and launched this journal.

Reflections.

Times that prompt reflection include anniversaries, deaths, and birthday celebrations. September 2014, Donald A. Bloch, MD died. He started this Journal (formerly Family Systems Medicine) and the Collaborative Family Health Care Association (formerly Coalition). Don's death occurred just one month before CFHA celebrated its 20th year. In this issue and our June issue, Families, Systems and Health devotes space for reflection. We begin with a remembrance of Don, written by his friend, mentee, and colleague, David Seaburn, PhD, LMFT. We also reflect on the 20th annual CFHA meeting, where we could see Don's vision at work in the plenaries. In our June issue we will publish a second article written by CJ Peek, PhD, about Don's vision of the field, the organization (CFHA), and this Journal. The article will ask readers to reflect.