INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 45(4) 299-310, 2013
ON TRACK FOR SUCCESS: AN INNOVATIVE BEHAVIORAL SCIENCE CURRICULUM MODEL
JOHN R. FREEDY, MD, PHD PETER J. CAREK, MD, MS LORI M. DICKERSON, PHARMD ROBERT M. MALLIN, MD Medical University of South Carolina, Charleston
ABSTRACT
This article describes the behavioral science curriculum currently in place at the Trident/MUSC Family Medicine Residency Program. The Trident/MUSC Program is a 10-10-10 community-based, university-affiliated program in Charleston, South Carolina. Over the years, the Trident/MUSC residency program has graduated over 400 Family Medicine physicians. The current behavioral science curriculum consists of both required core elements (didactic lectures, clinical observation, Balint groups, and Resident Grand Rounds) as well as optional elements (longitudinal patient care experiences, elective rotations, behavioral science editorial experience, and scholars project with a behavioral science focus). All Trident/MUSC residents complete core behavioral science curriculum elements and are free to participate in none, some, or all of the optional behavioral science curriculum elements. This flexibility allows resident physicians to tailor the educational program in a manner to meet individual educational needs. The behavioral science curriculum is based upon faculty interpretation of existing “best practice”
Manuscript based on material presented at the 33rd Annual Forum for Behavioral Science Education in Family Medicine, 2012. 299 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.45.4.aa http://baywood.com
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guidelines (Residency Review Committee-Family Medicine and AAFP). This article provides sufficient curriculum detail to allow the interested reader the opportunity to adapt elements of the behavioral science curriculum to other residency training programs. While this behavioral science track system is currently in an early stage of implementation, the article discusses track advantages as well as future plans to evaluate various aspects of this innovative educational approach. (Int’l. J. Psychiatry in Medicine 2013;45:299-310)
Key Words: family medicine, behavioral science, curriculum barriers, track system
This article, indeed this entire special issue of the International Journal of Psychiatry in Medicine (IJPM) is a product of the 33rd Annual Forum for Behavioral Science in Family Medicine. The Forum is an annual event that brings together hundreds of behavioral science professionals who are dedicated to educating Family Medicine residents in the science and art of the behavioral sciences as applied to primary care medicine. Over the years, many behavioral science educators from U.S. and Canadian Family Medicine residency programs have either presented work or at least attended the Forum. In producing this special issue of IJPM, invitations were extended to a broad spectrum of authors presenting work at the 33rd Forum in order to capture the scope, spirit, and quality of the 2012 Forum in Chicago, Illinois. This article reflects the current behavioral science curriculum in place at the Trident Health System/Medical University of South Carolina (Trident/MUSC) Family Medicine Residency in Charleston, South Carolina. GENERAL RESIDENCY CURRICULUM The Trident/MUSC Family Medicine Residency Program is a 10-10-10 community-based, university-affiliated program. The Family Medicine Center (FMC) associated with the program has over 18,000 annual patient care visits. In addition, inpatient training is conducted primarily at the 290 bed community hospital with the inpatient teams caring for over 2,000 patient admissions annually. Core residency curriculum elements include: patient care, didactic learning, rotations, and community service. Patient care activities involve the previously described outpatient and inpatient settings. While the resident physicians receive educational instruction from subspecialty physicians and allied health practitioners, the overall education objective is to have the vast majority of instruction and mentorship delivered by Family Medicine faculty. Didactic education occurs through morning reports, noon conferences, a scholars program, and skills seminars. The content focus in each didactic offering is balanced among the various program curricular elements. Rotation elements include a
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combination of required and elective/selective rotations (2.5 to 5 week rotation blocks) across the 36 month training cycle. The community service component includes a range of well-established opportunities for faculty and residents giving back to the local as well as international communities. National Behavioral Science Curriculum Guidelines The behavioral science curriculum is based upon local efforts to implement Residency Review Committee for Family Medicine (RRC-FM) requirements for Human Behavior and Mental Health (see Figure 1) [1]. In addition, the behavioral science curriculum is built upon the American Academy for Family Practice (AAFP) curriculum guidelines for Family Medicine Residents: Human Behavior and Mental Health [2]. Of note, the AAFP guidelines have been endorsed by numerous members of the Family Medicine education community in the United States (AAFP, Association of Family Medicine Residency Directors, Association of Departments of Family Medicine, Society of Teachers of Family Medicine, and the American Psychological Association). Going forward, the effectiveness of residency behavioral science curriculum efforts will be evaluated in relation to impact upon attainment of identified milestones (e.g., PROF-3 Demonstrates humanism and cultural proficiency, PROF-4 Maintains emotional, physical, and mental health and pursues continual personal and professional growth, C-1 Develops meaningful, therapeutic relationships with patients and families, C-2 Communicates effectively with patients, families, and the public) [3]. The program strongly recommends that comprehensive behavioral science curriculum and specific elements of behavioral science curriculum for Family Medicine residents be based on a thorough reading and understanding of available “best practices” guidelines and relevant Family Medicine milestones [1-3]. Potential Curriculum Barriers All residency training programs may face learning barriers with the potential to diminish optimal learning opportunities. Therefore, as we plan and revise our curriculum offerings (with resident and faculty input at monthly Residency Education Committee meetings and at our annual residency program educational retreat) we carefully consider whether or not any potential learning barriers have unintentionally diminished optimal learning opportunities. This culture of individual and collective self-reflection is supported by program leadership and therefore implemented by faculty responsible for the various program curricular elements. Depending on the year (state of program development) one learning barrier or another may be more salient for curriculum planning and adaptation. The salient point is that our educational culture regularly examines potential learning barriers and makes programmatic adjustments as feasible in order to
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Figure 1. ACGME Program Requirements for Graduate Medical Education in Family Medicine-Human Behavior and Mental Health.
promote optimal learning opportunities from that moment forward (an atmosphere of continuous quality improvement with regard to our educational offerings). Figure 2 lists common potential curriculum barriers [4-6]. As mentioned, our program faculty examine such potential barriers and make adjustments (usually minor) as needed to optimize resident learning opportunities. We will provide one complex example of how several potential barriers have required attention in order to ensure the continued optimal delivery of our behavioral science curriculum. In particular, our residency program and academic Department have experienced a number of changes (leadership, faculty, funding) over the past 18 months. With regard to the continued implementation of the behavioral science curriculum this has raised several potential barriers, including: changes in program structure, time limits (both available resident and faculty time), faculty expertise (some behavioral science oriented faculty have retired), electronic
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Figure 2. Potential curriculum barriers.
medical record (EMR) change in the FMC, and “buy-in” (from Department and residency program leadership, faculty, and resident physicians). With each of these potential barriers, the behavioral science curriculum director needed to think creatively and to work collaboratively with faculty, resident physicians, and staff in order to make adjustments to the behavioral science curriculum intended to continue to provide adequate (if not excellent) learning experiences to our residents on a sustained basis. Track System Strategy Core residency curriculum elements (patient care, didactic learning, rotations, and community service) are supplemented by a track system. All residents complete the same curricular elements. During the PGY2 and PGY3 years, residents complete a combination of required and elective rotations (2.5 to 5 week blocks) in 5 areas of interest: 1. 2. 3. 4. 5.
Academic Family Medicine; Women’s Health; Primary Care Sports Medicine; Underserved and Global Health; and Behavioral Science.
304 / FREEDY ET AL.
Our track system was implemented in 2005 with 3 initial track offerings (1-3 above). Subsequent tracks have been added based on mutual resident and faculty interest. The Behavioral Science Track was initiated in 2012. Four elements are common to all tracks: elective rotations, longitudinal patient care experiences, didactics, and scholarship. PGY2 and PGY3 residents have the opportunity to participate in none, one, or multiple curriculum tracks based upon their professional interests. Residents who chose to not formally declare interest in at least one educational track complete core program requirements and choose elective/ selective rotations to meet their unique educational needs (in a more eclectic manner). This track system provides structural flexibility that allows residents to pursue individual professional interests in greater depth while still fulfilling core curriculum requirements. Behavioral Science Track Elements All five of the curriculum tracks include both required as well as optional elements. Figure 3 presents the required and optional experiences for our behavioral science track. Among the required behavioral science elements, didactic lectures include morning reports approximately every 5 weeks (alternating between board review questions and case-based ethics discussion) and monthly noon educational sessions (focused on building essential applied behavioral science skills such as motivational interviewing, mental health screening, mental status exam skills, etc.).
Figure 3. Behavioral science track elements.
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Clinical observation with faculty feedback is conducted on a twice-yearly basis with all resident physicians (minimum of 6 observation points per resident across 3 years of residency training). Clinical observation is accomplished by any one of three behavioral science oriented faculty members who have instructional time dedicated to this task. Through a combination of shadowing (spending part of an FMC clinic session entering consultation rooms with the observed resident physician) and DVR review (later review of FMC patient encounters with the resident physician) our twice yearly clinical observation sessions are accomplished. A written clinical feedback form as adapted from a previously used instrument facilitates feedback and discussion with resident learners [7]. Behavioral science faculty dedicated to this core curricular task also periodically huddle (at least monthly) to discuss individual and collective learner trends (both strengths and weaknesses) in order to adjust our observational feedback/instruction as well as other required behavioral science curriculum offerings to address any areas of consistent knowledge or skill weakness or inconsistency that have been noted. The Balint groups are based on each residency class going through a 24 month curriculum cycle during their PGY2 and PGY3 years. PGY1 residents do not participate in Balint groups, but instead meet monthly with the program director and chief residents for a monthly “intern support group.” Balint groups are class-specific, meet weekly, and are co-led by a faculty dyad at least one of which has been credentialed for group leadership by the American Balint Society (ABS). At least one leader per group also has some form of graduate-level behavioral science training. Based on taking breaks for holidays and summer months, approximately 36 Balint sessions are conducted yearly. Attendance is mandatory with allowed exceptions for inpatient duties, patient urgencies, post-call, personal illness, and vacations (with these allowances each resident generally participates in 20 to 24 annual Balint sessions). The content and process of residency Balint groups is strictly confidential (not part of judging residency competency or professionalism). Upon residency graduation, resident group members are awarded an ABS-endorsed certificate of completion for a graduatelevel Balint group experience. These ABS certificates are awarded at our residency graduation dinner with the intent of emphasizing to our graduates the important role that self-reflection, peer-consultation, and openness to professional attitude and behavioral change has played in their professional growth and development [8]. Resident Grand Rounds are a fourth required component to our behavioral science curriculum. As well, Grand Rounds are based on a 24-month curriculum cycle (see Figure 4). Each PGY2 and PGY3 resident is required to present a clinical Grand Rounds annually (twice during their 3 years of residency training). These presentations (20 annually residency-wide) occur from noon to 1:00 pm approximately twice monthly. Each presentation lasts approximately 30 to 45 minutes with 5 to 10 minutes allowed for questions and discussion. Presentations
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Figure 4. Grand Rounds presentation topics past 24 months (required curriculum element).
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are developed in consultation with our residency behavioral science curriculum director. The curriculum director ensures that across the 24-month curriculum cycle a full range of relevant behavioral science topics is covered by resident Grand Rounds presentations. Each presentation focuses on an ongoing treatment relationship that is conceptualized using a biopsychosocial approach. Each presentation is evidence based to the extent that peer-reviewed evidence exists for the topic. The use of illustrative case material (including audio or video) is encouraged. The required elements of the behavioral science curriculum (didactic lectures, clinical observation, Balint groups, and Resident Grand Rounds) are supplemented with four optional elements. Program residents can be involved in none, some, or all of these optional elements. The first optional element is a longitudinal patient care experience. For this element, the resident picks one or several difficult patients for additional biweekly behavioral science supervision sessions. These sessions can be one-on-one between a behavioral science faculty member and resident or involve several interested resident physicians. The focus of these supervised sessions is to have guided discussions designed to enhance relevant behavioral science knowledge and skills. Additional instructional methods include article review/discussion, DVR review/discussion, and role play. A second optional element is the completion of one or more elective/selective rotation(s) (2.5 to 5 weeks) in a behavioral science area of interest. Though a combination residency faculty expertise, community-based, and university-based resources, our residency program is in the position to offer a wide-variety of elective/selective rotations (see Figure 5). The supplemental rotations chosen are based on the individual resident physician’s training interests.
Figure 5. Available elective (5 weeks) and selective (2.5 weeks) rotations.
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A third optional element is editorial experience under faculty supervision. In particular, the behavioral science curriculum director (JRF) also serves as the editor for the International Journal of Psychiatry in Medicine (IJPM) [9]. Interested resident physicians are invited to co-review one or more peer-reviewed papers in areas of interest that have been submitted to IJPM. Interested Family Medicine residents are also encouraged to submit a manuscript for peer-review and possible publication in IJPM. During the past several years, four resident physicians in collaboration with residency faculty have co-published papers in areas of interest in IJPM. The fourth and final optional element is for the Family Medicine resident to focus their resident’s scholars project (a program requirement for all PGY2 and PGY3 residents) on a topic in some area of behavioral science/behavioral medicine with relevance to primary care medicine. Residents choosing any scholarship focus (including behavioral science/behavioral medicine) can be mentored by a faculty content-expert in presenting or publishing their scholarship topic at an appropriate peer-reviewed meeting or in a peer-reviewed journal including but not exclusively limited to IJPM. Behavioral Science Track System Advantages (and Future Directions) Within the program’s pedagogical context, the faculty remain strongly committed to sustained offering and continued improvement of “best practices” ideas for behavioral science education for the Family Medicine residents. The core behavioral science curriculum elements (didactic lectures, clinical observation, Balint groups, and Resident Grand Rounds) are required elements that are completed by all resident learners. These core behavioral science educational offerings are the long-standing features of residency educational offerings. The track system within the residency program is a newer innovation designed to provide curricular flexibility to adapt educational offerings to the specific needs of resident physicians. Optional behavioral science track offerings include longitudinal patient care experience (bimonthly supervision to build behavioral science knowledge and skills relevant to the management of particular continuity patients), elective/selective rotations, behavioral science editorial experience, and choosing a scholars project with a behavioral science focus. A number of advantages to the track system approach to residency education exist (across all track areas, including behavioral science). For example, all resident physicians are required to complete core curricular elements providing educational consistency to ensure that our graduates possess a solid core of Family Medicine (including behavioral science) knowledge and skill. Consistent with an active, engaged adult-learner model the track system allows interested residents the flexibility and opportunities necessary to explore (and even master) one or more optional track offerings. Synergistic combinations of different tracks are
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possible based upon individual resident physician interests and training needs. Over time our faculty have been able to offer additional tracks (including behavioral science) to remain sufficiently diverse in our offerings so as to be able to tailor residency learning to individual needs and interests. The flexibility and choice inherent within the track system serves to mitigate (at least in part) some potential barriers to depth and breadth of learning. The track system has become a point of discussion with medical students during residency recruitment season. In terms of future directions, the behavioral science track offering is in an early stage of implementation (behavioral science track was established in 2012). Therefore, the current focus is on continuing to offer this track opportunity to our resident physicians among their other choices of optional educational tracks. Revision in the behavioral science track will be undertaken in an ongoing basis based on monthly (Residency Education Committee meetings) and annual (annual residency educational retreat) feedback from both resident and faculty physicians. In addition to this qualitative feedback used for quality improvement purposes, future efforts will include scholarship by both residents (perhaps as a residency scholars project) and core behavioral science faculty to determine the impact of both elements and the entirety of our behavioral science curricular offerings. A key focus of behavioral science curriculum evaluation will be to determine the relationship between the curriculum and obtaining of emerging Family Medicine milestones (competency-based evaluation model) [3]. Other outcomes of interest include resident and faculty satisfaction, engagement (e.g., number of resident physicians selecting the optional behavioral science track, number of faculty participating in teaching within the behavioral science track and/or undertaking behavioral science related faculty development activities), as well as possible impact on resident career choices/trajectory (e.g., resident participation in various behavioral science-related career activities such as pain management, substance abuse assessment and treatment, assessment and treatment of other mental health problems). REFERENCES 1. Accreditation Council for Graduate Medical Education (ACGME). (2007, July 1). ACGME program requirements for graduate medical education in Family Medicine. Retrieved July 13, 2013 from www.acgme.org/Portals/o/PFAssetts/ProgramRequirments/ 120pr07012007.pdf 2. American Academy of Family Physicians (AAFP). Recommended curriculum guidelines for Family Medicine residents: Human behavior and mental health. AAFP reprint no. 270. Retrieved July 13, 2013 from www.aafp.org/dam/AAFP/docments/ medical_education_residency_program/Reprint270_Mental.pdf 3. Accreditation Council for Graduate Medical Education and American Board of Family Medicine (Authors). The Family Medicine Milestone Project, unpublished paper, April 2013. Retrieved July 13, 2013 from www.acgme_nas.org/assets/pdf/Milestones/ FamilyMedicineMildstones.pdf
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4. Astin JA, Sierpina VS, Forys K, Clarridge B. Integration of the Biopsychosocial Model: Perspectives of Medical Students and Residents. Academic Medicine 2008; 83(1):20-27. 5. Benbassat, J, Baumal, R, Borkan, JM, & Ber, R. Overcoming barriers to teaching the behavioral and social sciences to medical students. Academic Medicine 2003;78(4): 372-380. 6. DaRosa DA, Skeff K, Friedland JA, Corburn M, Cox S, Pollart S, O’Connell M, Smith S. Barriers to effective teaching. Academic Medicine 2011;86(4):453-459. 7. Muench J, Sanchez D, Garvin R. A review of video review: New processes for the 21st century. International Journal of Psychiatry in Medicine 2013;45(4):413-422. 8. American Balint Society website. Retrieved July 13, 2013 from www.american balintsociety.org 9. International Journal of Psychiatry in Medicine website. Retrieved July 13, 2013 from www.baywood.com/journals/previewJournals.asp?ID=091-2174
Direct reprint requests to: John R. Freedy, MD, PhD Associate Professor of Family Medicine Associate Dean for Student Affairs College of Medicine Medical University of South Carolina 96 Jonathan Lucas St., Suite 601 Charleston, SC 29425 e-mail: [email protected]
ON TRACK FOR SUCCESS: AN INNOVATIVE BEHAVIORAL SCIENCE CURRICULUM MODEL
JOHN R. FREEDY, MD, PHD PETER J. CAREK, MD, MS LORI M. DICKERSON, PHARMD ROBERT M. MALLIN, MD Medical University of South Carolina, Charleston
ABSTRACT
This article describes the behavioral science curriculum currently in place at the Trident/MUSC Family Medicine Residency Program. The Trident/MUSC Program is a 10-10-10 community-based, university-affiliated program in Charleston, South Carolina. Over the years, the Trident/MUSC residency program has graduated over 400 Family Medicine physicians. The current behavioral science curriculum consists of both required core elements (didactic lectures, clinical observation, Balint groups, and Resident Grand Rounds) as well as optional elements (longitudinal patient care experiences, elective rotations, behavioral science editorial experience, and scholars project with a behavioral science focus). All Trident/MUSC residents complete core behavioral science curriculum elements and are free to participate in none, some, or all of the optional behavioral science curriculum elements. This flexibility allows resident physicians to tailor the educational program in a manner to meet individual educational needs. The behavioral science curriculum is based upon faculty interpretation of existing “best practice”
Manuscript based on material presented at the 33rd Annual Forum for Behavioral Science Education in Family Medicine, 2012. 299 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.45.4.aa http://baywood.com
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guidelines (Residency Review Committee-Family Medicine and AAFP). This article provides sufficient curriculum detail to allow the interested reader the opportunity to adapt elements of the behavioral science curriculum to other residency training programs. While this behavioral science track system is currently in an early stage of implementation, the article discusses track advantages as well as future plans to evaluate various aspects of this innovative educational approach. (Int’l. J. Psychiatry in Medicine 2013;45:299-310)
Key Words: family medicine, behavioral science, curriculum barriers, track system
This article, indeed this entire special issue of the International Journal of Psychiatry in Medicine (IJPM) is a product of the 33rd Annual Forum for Behavioral Science in Family Medicine. The Forum is an annual event that brings together hundreds of behavioral science professionals who are dedicated to educating Family Medicine residents in the science and art of the behavioral sciences as applied to primary care medicine. Over the years, many behavioral science educators from U.S. and Canadian Family Medicine residency programs have either presented work or at least attended the Forum. In producing this special issue of IJPM, invitations were extended to a broad spectrum of authors presenting work at the 33rd Forum in order to capture the scope, spirit, and quality of the 2012 Forum in Chicago, Illinois. This article reflects the current behavioral science curriculum in place at the Trident Health System/Medical University of South Carolina (Trident/MUSC) Family Medicine Residency in Charleston, South Carolina. GENERAL RESIDENCY CURRICULUM The Trident/MUSC Family Medicine Residency Program is a 10-10-10 community-based, university-affiliated program. The Family Medicine Center (FMC) associated with the program has over 18,000 annual patient care visits. In addition, inpatient training is conducted primarily at the 290 bed community hospital with the inpatient teams caring for over 2,000 patient admissions annually. Core residency curriculum elements include: patient care, didactic learning, rotations, and community service. Patient care activities involve the previously described outpatient and inpatient settings. While the resident physicians receive educational instruction from subspecialty physicians and allied health practitioners, the overall education objective is to have the vast majority of instruction and mentorship delivered by Family Medicine faculty. Didactic education occurs through morning reports, noon conferences, a scholars program, and skills seminars. The content focus in each didactic offering is balanced among the various program curricular elements. Rotation elements include a
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combination of required and elective/selective rotations (2.5 to 5 week rotation blocks) across the 36 month training cycle. The community service component includes a range of well-established opportunities for faculty and residents giving back to the local as well as international communities. National Behavioral Science Curriculum Guidelines The behavioral science curriculum is based upon local efforts to implement Residency Review Committee for Family Medicine (RRC-FM) requirements for Human Behavior and Mental Health (see Figure 1) [1]. In addition, the behavioral science curriculum is built upon the American Academy for Family Practice (AAFP) curriculum guidelines for Family Medicine Residents: Human Behavior and Mental Health [2]. Of note, the AAFP guidelines have been endorsed by numerous members of the Family Medicine education community in the United States (AAFP, Association of Family Medicine Residency Directors, Association of Departments of Family Medicine, Society of Teachers of Family Medicine, and the American Psychological Association). Going forward, the effectiveness of residency behavioral science curriculum efforts will be evaluated in relation to impact upon attainment of identified milestones (e.g., PROF-3 Demonstrates humanism and cultural proficiency, PROF-4 Maintains emotional, physical, and mental health and pursues continual personal and professional growth, C-1 Develops meaningful, therapeutic relationships with patients and families, C-2 Communicates effectively with patients, families, and the public) [3]. The program strongly recommends that comprehensive behavioral science curriculum and specific elements of behavioral science curriculum for Family Medicine residents be based on a thorough reading and understanding of available “best practices” guidelines and relevant Family Medicine milestones [1-3]. Potential Curriculum Barriers All residency training programs may face learning barriers with the potential to diminish optimal learning opportunities. Therefore, as we plan and revise our curriculum offerings (with resident and faculty input at monthly Residency Education Committee meetings and at our annual residency program educational retreat) we carefully consider whether or not any potential learning barriers have unintentionally diminished optimal learning opportunities. This culture of individual and collective self-reflection is supported by program leadership and therefore implemented by faculty responsible for the various program curricular elements. Depending on the year (state of program development) one learning barrier or another may be more salient for curriculum planning and adaptation. The salient point is that our educational culture regularly examines potential learning barriers and makes programmatic adjustments as feasible in order to
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Figure 1. ACGME Program Requirements for Graduate Medical Education in Family Medicine-Human Behavior and Mental Health.
promote optimal learning opportunities from that moment forward (an atmosphere of continuous quality improvement with regard to our educational offerings). Figure 2 lists common potential curriculum barriers [4-6]. As mentioned, our program faculty examine such potential barriers and make adjustments (usually minor) as needed to optimize resident learning opportunities. We will provide one complex example of how several potential barriers have required attention in order to ensure the continued optimal delivery of our behavioral science curriculum. In particular, our residency program and academic Department have experienced a number of changes (leadership, faculty, funding) over the past 18 months. With regard to the continued implementation of the behavioral science curriculum this has raised several potential barriers, including: changes in program structure, time limits (both available resident and faculty time), faculty expertise (some behavioral science oriented faculty have retired), electronic
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Figure 2. Potential curriculum barriers.
medical record (EMR) change in the FMC, and “buy-in” (from Department and residency program leadership, faculty, and resident physicians). With each of these potential barriers, the behavioral science curriculum director needed to think creatively and to work collaboratively with faculty, resident physicians, and staff in order to make adjustments to the behavioral science curriculum intended to continue to provide adequate (if not excellent) learning experiences to our residents on a sustained basis. Track System Strategy Core residency curriculum elements (patient care, didactic learning, rotations, and community service) are supplemented by a track system. All residents complete the same curricular elements. During the PGY2 and PGY3 years, residents complete a combination of required and elective rotations (2.5 to 5 week blocks) in 5 areas of interest: 1. 2. 3. 4. 5.
Academic Family Medicine; Women’s Health; Primary Care Sports Medicine; Underserved and Global Health; and Behavioral Science.
304 / FREEDY ET AL.
Our track system was implemented in 2005 with 3 initial track offerings (1-3 above). Subsequent tracks have been added based on mutual resident and faculty interest. The Behavioral Science Track was initiated in 2012. Four elements are common to all tracks: elective rotations, longitudinal patient care experiences, didactics, and scholarship. PGY2 and PGY3 residents have the opportunity to participate in none, one, or multiple curriculum tracks based upon their professional interests. Residents who chose to not formally declare interest in at least one educational track complete core program requirements and choose elective/ selective rotations to meet their unique educational needs (in a more eclectic manner). This track system provides structural flexibility that allows residents to pursue individual professional interests in greater depth while still fulfilling core curriculum requirements. Behavioral Science Track Elements All five of the curriculum tracks include both required as well as optional elements. Figure 3 presents the required and optional experiences for our behavioral science track. Among the required behavioral science elements, didactic lectures include morning reports approximately every 5 weeks (alternating between board review questions and case-based ethics discussion) and monthly noon educational sessions (focused on building essential applied behavioral science skills such as motivational interviewing, mental health screening, mental status exam skills, etc.).
Figure 3. Behavioral science track elements.
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Clinical observation with faculty feedback is conducted on a twice-yearly basis with all resident physicians (minimum of 6 observation points per resident across 3 years of residency training). Clinical observation is accomplished by any one of three behavioral science oriented faculty members who have instructional time dedicated to this task. Through a combination of shadowing (spending part of an FMC clinic session entering consultation rooms with the observed resident physician) and DVR review (later review of FMC patient encounters with the resident physician) our twice yearly clinical observation sessions are accomplished. A written clinical feedback form as adapted from a previously used instrument facilitates feedback and discussion with resident learners [7]. Behavioral science faculty dedicated to this core curricular task also periodically huddle (at least monthly) to discuss individual and collective learner trends (both strengths and weaknesses) in order to adjust our observational feedback/instruction as well as other required behavioral science curriculum offerings to address any areas of consistent knowledge or skill weakness or inconsistency that have been noted. The Balint groups are based on each residency class going through a 24 month curriculum cycle during their PGY2 and PGY3 years. PGY1 residents do not participate in Balint groups, but instead meet monthly with the program director and chief residents for a monthly “intern support group.” Balint groups are class-specific, meet weekly, and are co-led by a faculty dyad at least one of which has been credentialed for group leadership by the American Balint Society (ABS). At least one leader per group also has some form of graduate-level behavioral science training. Based on taking breaks for holidays and summer months, approximately 36 Balint sessions are conducted yearly. Attendance is mandatory with allowed exceptions for inpatient duties, patient urgencies, post-call, personal illness, and vacations (with these allowances each resident generally participates in 20 to 24 annual Balint sessions). The content and process of residency Balint groups is strictly confidential (not part of judging residency competency or professionalism). Upon residency graduation, resident group members are awarded an ABS-endorsed certificate of completion for a graduatelevel Balint group experience. These ABS certificates are awarded at our residency graduation dinner with the intent of emphasizing to our graduates the important role that self-reflection, peer-consultation, and openness to professional attitude and behavioral change has played in their professional growth and development [8]. Resident Grand Rounds are a fourth required component to our behavioral science curriculum. As well, Grand Rounds are based on a 24-month curriculum cycle (see Figure 4). Each PGY2 and PGY3 resident is required to present a clinical Grand Rounds annually (twice during their 3 years of residency training). These presentations (20 annually residency-wide) occur from noon to 1:00 pm approximately twice monthly. Each presentation lasts approximately 30 to 45 minutes with 5 to 10 minutes allowed for questions and discussion. Presentations
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Figure 4. Grand Rounds presentation topics past 24 months (required curriculum element).
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are developed in consultation with our residency behavioral science curriculum director. The curriculum director ensures that across the 24-month curriculum cycle a full range of relevant behavioral science topics is covered by resident Grand Rounds presentations. Each presentation focuses on an ongoing treatment relationship that is conceptualized using a biopsychosocial approach. Each presentation is evidence based to the extent that peer-reviewed evidence exists for the topic. The use of illustrative case material (including audio or video) is encouraged. The required elements of the behavioral science curriculum (didactic lectures, clinical observation, Balint groups, and Resident Grand Rounds) are supplemented with four optional elements. Program residents can be involved in none, some, or all of these optional elements. The first optional element is a longitudinal patient care experience. For this element, the resident picks one or several difficult patients for additional biweekly behavioral science supervision sessions. These sessions can be one-on-one between a behavioral science faculty member and resident or involve several interested resident physicians. The focus of these supervised sessions is to have guided discussions designed to enhance relevant behavioral science knowledge and skills. Additional instructional methods include article review/discussion, DVR review/discussion, and role play. A second optional element is the completion of one or more elective/selective rotation(s) (2.5 to 5 weeks) in a behavioral science area of interest. Though a combination residency faculty expertise, community-based, and university-based resources, our residency program is in the position to offer a wide-variety of elective/selective rotations (see Figure 5). The supplemental rotations chosen are based on the individual resident physician’s training interests.
Figure 5. Available elective (5 weeks) and selective (2.5 weeks) rotations.
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A third optional element is editorial experience under faculty supervision. In particular, the behavioral science curriculum director (JRF) also serves as the editor for the International Journal of Psychiatry in Medicine (IJPM) [9]. Interested resident physicians are invited to co-review one or more peer-reviewed papers in areas of interest that have been submitted to IJPM. Interested Family Medicine residents are also encouraged to submit a manuscript for peer-review and possible publication in IJPM. During the past several years, four resident physicians in collaboration with residency faculty have co-published papers in areas of interest in IJPM. The fourth and final optional element is for the Family Medicine resident to focus their resident’s scholars project (a program requirement for all PGY2 and PGY3 residents) on a topic in some area of behavioral science/behavioral medicine with relevance to primary care medicine. Residents choosing any scholarship focus (including behavioral science/behavioral medicine) can be mentored by a faculty content-expert in presenting or publishing their scholarship topic at an appropriate peer-reviewed meeting or in a peer-reviewed journal including but not exclusively limited to IJPM. Behavioral Science Track System Advantages (and Future Directions) Within the program’s pedagogical context, the faculty remain strongly committed to sustained offering and continued improvement of “best practices” ideas for behavioral science education for the Family Medicine residents. The core behavioral science curriculum elements (didactic lectures, clinical observation, Balint groups, and Resident Grand Rounds) are required elements that are completed by all resident learners. These core behavioral science educational offerings are the long-standing features of residency educational offerings. The track system within the residency program is a newer innovation designed to provide curricular flexibility to adapt educational offerings to the specific needs of resident physicians. Optional behavioral science track offerings include longitudinal patient care experience (bimonthly supervision to build behavioral science knowledge and skills relevant to the management of particular continuity patients), elective/selective rotations, behavioral science editorial experience, and choosing a scholars project with a behavioral science focus. A number of advantages to the track system approach to residency education exist (across all track areas, including behavioral science). For example, all resident physicians are required to complete core curricular elements providing educational consistency to ensure that our graduates possess a solid core of Family Medicine (including behavioral science) knowledge and skill. Consistent with an active, engaged adult-learner model the track system allows interested residents the flexibility and opportunities necessary to explore (and even master) one or more optional track offerings. Synergistic combinations of different tracks are
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possible based upon individual resident physician interests and training needs. Over time our faculty have been able to offer additional tracks (including behavioral science) to remain sufficiently diverse in our offerings so as to be able to tailor residency learning to individual needs and interests. The flexibility and choice inherent within the track system serves to mitigate (at least in part) some potential barriers to depth and breadth of learning. The track system has become a point of discussion with medical students during residency recruitment season. In terms of future directions, the behavioral science track offering is in an early stage of implementation (behavioral science track was established in 2012). Therefore, the current focus is on continuing to offer this track opportunity to our resident physicians among their other choices of optional educational tracks. Revision in the behavioral science track will be undertaken in an ongoing basis based on monthly (Residency Education Committee meetings) and annual (annual residency educational retreat) feedback from both resident and faculty physicians. In addition to this qualitative feedback used for quality improvement purposes, future efforts will include scholarship by both residents (perhaps as a residency scholars project) and core behavioral science faculty to determine the impact of both elements and the entirety of our behavioral science curricular offerings. A key focus of behavioral science curriculum evaluation will be to determine the relationship between the curriculum and obtaining of emerging Family Medicine milestones (competency-based evaluation model) [3]. Other outcomes of interest include resident and faculty satisfaction, engagement (e.g., number of resident physicians selecting the optional behavioral science track, number of faculty participating in teaching within the behavioral science track and/or undertaking behavioral science related faculty development activities), as well as possible impact on resident career choices/trajectory (e.g., resident participation in various behavioral science-related career activities such as pain management, substance abuse assessment and treatment, assessment and treatment of other mental health problems). REFERENCES 1. Accreditation Council for Graduate Medical Education (ACGME). (2007, July 1). ACGME program requirements for graduate medical education in Family Medicine. Retrieved July 13, 2013 from www.acgme.org/Portals/o/PFAssetts/ProgramRequirments/ 120pr07012007.pdf 2. American Academy of Family Physicians (AAFP). Recommended curriculum guidelines for Family Medicine residents: Human behavior and mental health. AAFP reprint no. 270. Retrieved July 13, 2013 from www.aafp.org/dam/AAFP/docments/ medical_education_residency_program/Reprint270_Mental.pdf 3. Accreditation Council for Graduate Medical Education and American Board of Family Medicine (Authors). The Family Medicine Milestone Project, unpublished paper, April 2013. Retrieved July 13, 2013 from www.acgme_nas.org/assets/pdf/Milestones/ FamilyMedicineMildstones.pdf
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4. Astin JA, Sierpina VS, Forys K, Clarridge B. Integration of the Biopsychosocial Model: Perspectives of Medical Students and Residents. Academic Medicine 2008; 83(1):20-27. 5. Benbassat, J, Baumal, R, Borkan, JM, & Ber, R. Overcoming barriers to teaching the behavioral and social sciences to medical students. Academic Medicine 2003;78(4): 372-380. 6. DaRosa DA, Skeff K, Friedland JA, Corburn M, Cox S, Pollart S, O’Connell M, Smith S. Barriers to effective teaching. Academic Medicine 2011;86(4):453-459. 7. Muench J, Sanchez D, Garvin R. A review of video review: New processes for the 21st century. International Journal of Psychiatry in Medicine 2013;45(4):413-422. 8. American Balint Society website. Retrieved July 13, 2013 from www.american balintsociety.org 9. International Journal of Psychiatry in Medicine website. Retrieved July 13, 2013 from www.baywood.com/journals/previewJournals.asp?ID=091-2174
Direct reprint requests to: John R. Freedy, MD, PhD Associate Professor of Family Medicine Associate Dean for Student Affairs College of Medicine Medical University of South Carolina 96 Jonathan Lucas St., Suite 601 Charleston, SC 29425 e-mail: [email protected]
