1 Sparrow/MSU Family Medicine Residency Program September 19, 2013Assembling a Behavioral Medicine Rotation: Success without re-inventing the wheel Amy M. Romain, LMSW, ACSW Amy J. Odom, DO Sparrow/MSU Family Medicine Residency Program September 19, 2013

2 We have nothing to discloseNo commercial interest/conflict of interest statement

3 Session Objectives Understand a structure for creating a behavioral medicine rotation in your own program Understand 4 key content areas in a behavioral medicine rotation and real world performance goals associated with each Identify new resources to augment behavioral medicine teaching in your program

4 How is your Behavioral Medicine Curriculum structured?

5 Behavioral Health CurriculumDidactics

6 Behavioral Health CurriculumSenior Seminar Series Behavioral Medicine Rotation Mental Health Clinic Behavioral Health Curriculum Didactics Wellness Activities FM Clinic at CMH

7 What is your Behavioral Medicine Curriculum Structure by Academic Year?Do all three levels of training have the same experience? Do you do something different for interns that upper levels do not get? On your graph, the horizontal bar represents the total behavioral medicine exposure each level of resident has in an academic year. Divide the bar into segments that represent the relative percentage they experience with each type of exposure.

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9 Why Have a Behavioral Medicine Rotation?Interns had little exposure to bm (didactics as able, intern wellness)…a little lost/at sea Core doctor-patient communication taught in 2nd - 3rd years… had to work hard to change practice patterns and stuck in the basics… unable to move to advanced level. Some interns came from strong medical schools and got this education but without an intern year teaching there was a disconnect and this education was lost. Interns Seniors

10 Our First Attempt: Psychosocial Rotation Collaboration with Internal MedicineInvitation Blessing Partnership The invitation (collaboration, grant work) The blessing (give up cardiology for this?) The partnership Collaboration (learning from their experience; new teaching partners) Scheduling Cultural differences (inpatient focus; specialist orientation)

11 Our First Attempt: Psychosocial Rotation Collaboration with Internal MedicineSomewhat successful Relationships (faculty and resident) Skill advancement (“grads” as teachers) But… This is too complicated!

12 Second Attempt: Creating our own BM RotationWhat did we like about psychosocial rotation Considering our curriculum, what belongs in 1st year (core content) Scheduling What is our destination, how are we going to get there, what do we need for the trip. How will we know when we’ve arrived. Did we take the best route? Condense to 2 rotations Faculty availability (who can help… when? Part time/full time, interview season Developmental readiness (residents think they should get it earlier… must feel a little discomfort about what you don’t know before you are ready to learn it)

13 Second Attempt: Creating our own BM RotationMeasuring our successes Creating competency-based evaluations (New Innovations) Evaluating our work Creating surveys IRB approval

14 Curriculum Planning 101

15 Curriculum Planning 101 Identify a BHAG- “Big Harry Audacious Goal”Start with the end in mind Identify real world performance goals Build tests that evaluate and measure these goals Identify specific content that is needed to meet these goals and match objectives with these goals Mine for resources that provide this content- “Don’t recreate the wheel” RWPG- concrete measurable Tests- measure the goal directly (not multiple choice test on knowledge of 5 steps, but video observation of performance) Content needs to be specific and have purpose- too much extraneous stuff and you loose your way how are they supposed to keep the focus on the goal People all over the country are teaching this- someone likely has done it the way you want to

16 Behavioral Medicine Rotation: BHAG“Residents will be compassionate, self-reflective, patient-centered physicians who have a basic understanding of behavioral medicine, its role and relevance in primary care and can apply it to their daily practice.” Designed to provide residents with a foundation in the psychosocial principles of medicine with particular reference to their application in primary care. OBJECTIVES Residents will achieve basic competency in patient-centered communication, the use of core psychiatric diagnos

17 Behavioral Medicine Rotation: 4 Content AreasPatient Centered Communication Core Psychiatric Topics and Tools Contextual Care Reflective Practices There is much overlap between these 4 content areas.

18 Real World Performance GoalsCompetently & routinely use patient-centered communication skills Proficient use of screening and diagnostic tools for depression, anxiety, bipolar & ADHD Know how to gather, synthesize & use contextual information in the care of patients Develop self-awareness through reflective practice & goal setting

19 Test = All about the RWG Video Review Role PlayCorrect use of tools in clinical or case based settings Variety of reflective practice exercises that are turned in Self Management Goal written accountability and success/failures

20 Preparing for the JourneyThere are MANY ways to get to your destination… Choose your route Gather resources Time reserved at the end of session to hear your ideas and resources

21 The Roadmap

22 The Timing

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24 Administrative Tasks/TimelinePre-academic year Hospital-wide rotation planning Faculty call schedule Early academic year Faculty teaching schedule/topics Resident vacation requests Curriculum planning Room requests

25 Administrative Tasks/TimelinePre-rotation Preparation Organize rotation binders Order books Set up wellness event(s) During the Rotation Keeping track of assignments Assignment List (residents) Assignment Log (faculty) DocCom Administrator Notes Residents Curriculum

26 Administrative Tasks/TimelinePost Rotation Evaluation of residents Resident rotation evaluations Faculty Debrief Research Project

27 BM Rotation: Our Observations(View from John Hancock Observatory) Group process Relationship forming Returning “home” in the middle of their 1st year More office time this month reconnect with purpose of ambulatory medicine Wellness – intentionally in middle of year, cold, dark winter Can focus on more advanced skills in 2nd/3rd year Equipped with core tools that they may have missed previously Opportunity to develop good habits early (Nosh’s quote… already did a good job at this, why need it? The realized how much he didn’t know) Opportunity for assessment & early intervention

28 Behavioral Medicine Rotation: 4 Content AreasPatient Centered Communication Core Psychiatric Topics and Tools Contextual Care Reflective Practices There is much overlap between these 4 content areas.

29 Patient Centered CommunicationBasic patient-centered communication skills Health behavior change and self-management goals Delivering bad news Refer them to performance objectives

30 Resources: Basic Patient Centered CommunicationSee Toolbox on FMDRL Cite authors verbally

31 Resources: Basic Patient Centered CommunicationPatient Centered Observation Form PCOF on fmdrl and also on UW’s website

32 Resources: Basic Patient Centered CommunicationDocCom AACH Additional PCC topics… communicating with adolescents, elderly, delivering bad news, medical mistakes, etc.

33 Resources: Health behavior change & self-management goalsSee Resources on FMDRL

34 Additional Resource Pharmacist certified as smoking cessation counselor

35 Resources: Delivering Bad NewsSee Toolbox on FMDRL

36 Patient Centered Communication:Level 2 on PCOF form Record MI encounter Complete associated doccom modules/post tests

37 Patient Centered Communication: What’s your “go to” resource?Break into groups . You meet a brand new behavioral scientist faculty at the Forum. S/he asks for advise regarding teaching doctor-patient communication. What is your “go to” resource?

38 Behavioral Medicine Rotation: 4 Content AreasPatient Centered Communication Core Psychiatric Topics and Tools Contextual Care Reflective Practices There is much overlap between these 4 content areas.

39 Psychiatric Topics and ToolsBasic use of screening and diagnostic tools and first step prescribing Depression Bi-polar Disorder ADHD Anxiety We didn’t want to teach the basics of these core topics every year to all 3 resident groups. 2nd and 3rd need a more advance layer.

40 Psychiatric Topics & Tools: ResourcesDoc.com PHQ9, Vanderbilt, STORM (Blackman et Forum and STFM) PHQ-9, STORM, Vanderbilt, GAD-7 Karen Blackman MD’s Med Charts

41 Psychiatric Topics & Tools:1) Bring in a PHQ-9 from a patient encounter during that month that has been scored 2) Score and interpret the STORM, Vanderbilt, and GAD-7 during case-based workshop

42 Behavioral Medicine Rotation: 4 Content AreasPatient Centered Communication Core Psychiatric Topics and Tools Contextual Care Reflective Practices There is much overlap between these 4 content areas.

43 Contextual Care Ecomaps Family Conferences Culturally Responsive CareEcomaps: Residents will learn how to gather relevant contextual information about a patient, using patient centered interviewing skills. They will be able construct an Ecomap illustration of the patient’s context and synthesize this information (psychosocial assessment) to inform patient care. Family Conferences: Residents will know how to plan, facilitate and document (in Epic) a family conference in the inpatient or outpatient setting or home visit environment, using residency family conference resources. Cultural Competency:1) Residents will be able to identify how race, ethnicity, and social determinants of health impact access healthcare, healthcare costs and health outcomes. 2) Residents will develop an awareness of the factors that influence health disparities (socioeconomic, political, environmental and institutional). 3) Residents will explore and discuss how their own experiences, attitudes, biases, and stereotypes affect clinical encounters, decision-making, policies, and quality of care. 4) Residents will identify 1 thing that s/he will do differently in practice to minimize health disparities (Commitment to Change).

44 Contextual Care: ResourcesSee Toolbox on FMDRL

45 Contextual Care: Completing and present at least 2 Ecomaps of patients seen in the office, by the end of the rotation. DocCom test for the family conference module. (competency evaluated in 2nd year) Pre/post session quiz surveying knowledge and attitudes related to health care disparities

46 Behavioral Medicine Rotation: 4 Content AreasPatient Centered Communication Core Psychiatric Topics and Tools Contextual Care Reflective Practices There is much overlap between these 4 content areas.

47 Reflective Practices Book Club Reflective WritingPersonal Goal Setting Experiential Learning Workshops on self-awareness, resiliency and burnout Residents will learn the value and importance of reflective practice including how it relates to: 1) Identifying strengths, deficiencies and limits in one’s knowledge and expertise. 2) Developing skills and habits to be able to set learning and self- improvement goals

48 Reflective Practices: ResourcesSee toolbox on FMDRL What self- reflection resources do you use?

49 Reflective Practices: An Intern’s 55 Word Story

50 Reflection Exercise You will be seeing 3 images.For each image write down the first three words that comes to your mind

51 Reflection: So What? Your previously unrecognized responses affect your relationships with patients Change the dynamic of the interview Personal responses are normal but when the relationship is so important to medical care physicians need to know how to recognize and manage them

52 Reflective Practices:Identify, set and work toward a personal self-management goal throughout the four week rotation for which they are accountable to the group. Complete 3 Reflections and enter them into New Innovations by the end of the rotation.

53 BM Rotation: Formal EvaluationNI Competency Based Eval Pre-rotation survey Post-rotation survey End of the year survey

54 Attitudinal Survey: 30?, 5 pt likert scale, 9 ResQuestion Rot Start Rot End End of Year P value I am confident in my ability to take a social history 4 4.4 4.75 0.013 I am confident in my ability to recognize my pts strengths and weaknesses in his/her ability to manage stress and disease 3.4 4.3 4.37 0.004 I am comfortable in my ability to use information gathered during a social history to intervene for my patient’s health 3.6 4.7 4.6 0.0008 I can create therapeutic relationships with my pts 4.625 0.0139 I sustain a therapeutic relationship with my pts over time 3.7 0.014 I feel confident in my ability to deliver bad news 3.2 4.25 0.0038

55 I know how to document a family conference Question Rot Start Rot End End of Year P value I know how to document a family conference 2.4 3.7 3.125 0.0090 I feel confident in my ability to handle someone’s emotion during an encounter 3.8 4.3 4.625 0.0251 I feel confident in my ability to set an agenda at the beginning of a pt encounter 3.3 4.5 0.0025 I feel confident in my ability to diagnose depression 3.5 4.7 0.0030 I feel confident in my ability to diagnose bipolar disorder 2.8 4.1 0.0002 I feel confident in my ability to diagnose ADHD 3.1 4.6 4.375 0.0005 I am comfortable offering critique to my peers 4 3.87 0.0050 I currently engage in regular self-reflective activity 3.2 3.75 0.0651

56 Discussion

57 Contact Information Amy Romain, LMSW, ACSW Amy Odom, DO