Dennis J. Butler

Training the "assertive practitioner of behavioral science": advancing a behavioral medicine track in a family medicine residency.

Objective: This article describes the development of a Behavioral Medicine track in a family medicine residency designed to train physicians to proactively and consistently apply advanced skills in psychosocial medicine, psychiatric care, and behavioral medicine. Methods: The Behavioral Medicine track emerged from a behavioral science visioning retreat, an opportunity to restructure residency training, a comparative family medicine-psychiatry model, and qualified residents with high interest in behavioral science. Training was restructured to increase rotational opportunities in core behavioral science areas and track residents were provided an intensive longitudinal counseling seminar and received advanced training in psychopharmacology, case supervision, and mindfulness. Results: The availability of a Behavioral Medicine track increased medical student interest in the residency program and four residents have completed the track. All track residents have presented medical Grand Rounds on behavioral science topics and have lead multiple workshops or research sessions at national meetings. Graduate responses indicate effective integration of behavioral medicine skills and abilities in practice, consistent use of brief counseling skills, and good confidence in treating common psychiatric disorders. Conclusion: As developed and structured, the Behavioral Medicine track has achieved the goal of producing “assertive practitioners of behavioral science in family medicine” residents with advanced behavioral science skills and abilities who globally integrate behavioral science into primary care.

A review of the benefits and limitations of a primary care-embedded psychiatric consultation service in a medically underserved setting

A significant percentage of patients with psychiatric disorders are exclusively seen for health-care services by primary care physicians. To address the mental health needs of such patients, collaborative models of care were developed including the embedded psychiatry consult model which places a consultant psychiatrist on-site to assist the primary care physician to recognize psychiatric disorders, prescribe psychiatric medication, and develop management strategies. Outcome studies have produced ambiguous and inconsistent findings regarding the impact of this model. This review examines a primary care-embedded psychiatric consultation service in place for nine years in a family medicine residency program. Psychiatric consultants, family physicians, and residents actively involved in the service participated in structured interviews designed to identify the clinical and educational value of the service. The benefits and limitations identified were then categorized into physician, consultant, patient, and systems factors. Among the challenges identified were inconsistent patient appointment-keeping, ambiguity about appropriate referrals, consultant scope-of-practice parameters, and delayed follow-up with consultation recommendations. Improved psychiatric education for primary care physicians also appeared to shift referrals toward more complex patients. The benefits identified included the availability of psychiatric services to underserved and disenfranchised patients, increased primary care physician comfort with medication management, and improved interprofessional communication and education. The integration of the service into the clinic fostered the development of a more psychologically minded practice. While highly valued by respondents, potential benefits of the service were limited by residency-specific factors including consultant availability and the high ratio of primary care physicians to consultants.

A review of published guidance for video recording in medical education.

Introduction: Medical educators have used resident–patient video recording to verify trainee competence in interpersonal and technical skills for 50 years. Although numerous authors acknowledge that video recording can compromise patient privacy and confidentiality, no summary of potential risks is available. Method: A scoping review of the literature on resident–patient video recording in medical education from the 1960s to the present was conducted. The review examined publications that addressed ethical, policy, procedural, or legal issues affecting patients’ rights when video recording. Results: Potential risks to the rights of video recorded patients were organized into 6 categories: informed consent policies, informed consent procedures, recorded medical errors, secondary use of recordings, collateral patient information, and public trust issues. The review revealed contradictory opinions on informed consent policies, inadequate guidance for responding when medical errors are recorded, and conflicting opinions about when recordings become part of the medical record. Many reviewed publications are opinion-based, precede current confidentiality guidelines, or rely on survey results. Discussion: This review organizes potential threats to patients’ rights for those medical educators who use video recording technology. The review reveals a need for broader consensus about video recording guidelines and for research on video recording practices, especially given technological advances in video equipment and the expansion of video technology in health care settings.

Educational strategies for overcoming health care disparities

In 2002, the Institute of Medicine (IOM) released a report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care which concluded that the quality of health care in the United States varied significantly with the racial background of patients, even when insurance, income, age, and severity of conditions were comparable. The findings verified that racial and ethnic minorities were less likely to receive routine medical care and more likely to receive lower quality services which contributed to poorer quality of life and greater disease burden. There is further evidence that health care disparities affect vulnerable populations regardless of race, including the homeless, the previously incarcerated, victims of abuse and those suffering from mental illness. The 37th Forum for Behavioral Science in Family Medicine which took place in Chicago, Illinois in Fall 2016 addressed the theme of reducing health care disparities and promoting multicultural practice in medical education. This special issue of the International Journal of Psychiatry and Medicine presents 10 articles drawn from the most highly rated presentations at the conference. Within the issue are descriptions of innovative, successful efforts by medical educators to reverse the systemic and personal factors which contribute to the failure of the US health care system to meet the needs of diverse patient groups. The insights that emerge can have a measurable impact on health care disparities; the proposed solutions will resonate with those who care for displaced, disenfranchised, and underserved patients around the world. To fully understand the dynamics underling disparities, readers should begin with the article, A Commitment to Health Equity: Reflections on Why; One Journey Toward How, by Jennifer Edgoose whose personal insights help frame disparities as the outcome of racism. She notes three forms of racism, the first of which is implicit and explicit bias, prejudice, and stereotyping by the provider,

Synchronizing the patient-centered model and health behavior change

This issue of The International Journal of Psychiatry in Medicine contains a diverse collection of manuscripts that provide compelling support for the integration of a patient-centered medical model in order to foster substantive health behavior change. The issue encourages readers to rethink many aspects of health behavior change as the contributions take on a variety of challenges to improving health. The insights by the contributing authors extend to a broad range of topics that coalesce around three very distinct areas of investigation and clinical practice. One perspective focuses on preparing physicians to understand and incorporate a patient-centered approach to specific clinical problems for which health behavior change is critical but very often unrealized. These include obesity, managing chronic non-cancer pain, and addressing health changes and decisions associated with life-threatening diagnoses. A second set of contributions examine how differences in provider and patients’ racial and cultural identity and sexual orientation can thwart the development of a patient-centered approach to care through a lack of awareness or bias. The final grouping provides the reader with an enhanced awareness of systems-based factors that interfere with the physician’s ability to engage in patient-centered dialogues with patients such as the electronic medical record and the difficulties associated with implementing patient-centered and motivational interviewing strategies with complex, ‘‘stuck’’ patients. Each of the articles in this issue were originally presented at the 37th Forum for Behavioral Science in Family Medicine, a national conference for behavioral science educators held in Chicago, Illinois, in September 2015. The authors

Training models for enhancing psychiatric care in primary care

Worldwide, the burden of care for patients with psychiatric disorders often falls to primary care physicians. Family physicians take responsibility for treating psychiatric disorders or address them as comorbid conditions on a daily basis. For other patients with psychiatric disorders, the only professional they will ever see is a primary care physicians and usually for biomedical problems. Primary care physicians are both the ‘‘de facto mental health delivery system,’’ and providers by default. For some patients, the family physician is the only professional they trust; for others, financial and logistical barriers prevent access to mental health services. For many patients, the personal and social stigma leads to the avoidance of mental healthcare. Addressing psychiatric disorders in primary care is complex. It is timeconsuming to accurately diagnose and document essential symptoms, to determine the degree of impairment, and to discuss findings with frightened, defensive, embarrassed, resistant, or demoralized patients. Moving on to treatment is equally challenging. Which disorders can a family physician manage and which methods are appropriate in a busy practice? Referral to the mental health providers often end up in a quagmire of miscommunication, duplication of treatment, iatrogenic complications, and dual systems of care due to confidentiality requirements and poor integration. This issue of the International Journal of Psychiatry in Medicine focuses on successful family medicine residency training efforts that prepare future family physicians in the United States to acquire essential skills and abilities for psychiatric care. For the third consecutive year, this special issue is based on noteworthy presentations from ‘‘The Forum for Behavioral Science in

Editorial: Special Issue

It is with great pleasure that I introduce this specia l i s sue of Aging Successfully that focuses on Preventive Gerontology. Aging successfully is dependent on the individual himself or herself. While health professionals can act as a guide through life’s journey, it is only through one’s own efforts that the best outcomes can be assured. This issue provides tools that all of us can use to age successfully. Aging is 25% genes and 75% sweat. Preventive gerontology needs to begin as a child where adequate calcium, a good diet, and exercise build our basic bone and muscle mass that will stand SUCCESSFULLY ging A A newsletter of the Division of Geriatric Medicine, Department of Internal Medicine, Saint Louis University School of Medicine; Geriatric Research, Education and Clinical Center, St. Louis Veterans Administration Medical Center; and the Gateway Geriatric Education Center of Missouri and Illinois

Physicians Stalked by Patients: Implications for Family Medicine Resident Education and Practice

Background and Objectives Health care professionals are at increased risk for harassment and stalking compared with the general population. This report examines the problem of family physician stalking and recommends strategies for family medicine residency training about harassment.

The Challenge of Extended, Continuous Collaboration From Stress Management to Coping With Terminal Illness

Most collaborative relationships between psychologists and physicians are of a time-limited, episodic nature because they focus on specific clinical problems. This article describes a longitudinal clinical collaboration that transcended the traditional model because of shifting clinical needs over a continuous, extended period. The collaboration progressed through phases, and because the purpose of treatment changed, it was necessary for the collaborating clinicians to redefine goals, responsibilities, and boundaries. At times, the focus was on medical developments, and at times, treatment was primarily psychological. What began as a routine consultation about stress management developed into a complex collaborative approach that required a biopsychosocial orientation. This article delineates the phases of treatment and identifies factors that facilitated, challenged, and created dilemmas in the collaborative process.