Identifying core curricular components for behavioral health training in internal medicine residency: Qualitative interviews with residents,faculty,and behavioral health clinicians

Abstract

Objective

Behavioral health services frequently delivered by primary care providers include care for mental health and substance abuse disorders and assistance with behavioral risk factor reduction. Internal medicine residencies in the United States lack formal expectations regarding training in behavioral health for residents. This qualitative study aimed to determine learners’ and teachers’ perceptions about appropriate behavioral health curricular components for internal medicine residents.

Method

Focus groups and interviews were conducted with the following individuals from the Duke Outpatient Clinic: residents with continuity practice (n = 27), advanced practice providers (n = 2), internal medicine attending physicians (n = 4), internal medicine/psychiatry attending physicians (n = 2), and behavioral health clinicians (n = 4). A focus group leader asked regarding residents’ successes and challenges in managing behavioral health issues and about specific learning components considered necessary to understand and manage these behavioral health conditions. Transcripts were coded using an editing analysis style to identify central themes and concordance/discordance between groups.

Results

Regarding mental health management (Theme 1), residents emphasized a need for better care coordination with specialty mental health, while attendings and behavioral health clinicians gave priority to residents’ skills in primary management of mental health. Residents, attendings, and behavioral health clinicians all emphasized advanced interviewing skills (Theme 2) with subthemes: eliciting the patient’s perspective, managing time in encounters, improving patients’ understanding, and patient counseling.

Conclusions

Internal medicine residents, attendings, and behavioral health clinicians may differ significantly in their perceptions of primary care’s role in mental health care. Future internal medicine behavioral health curricula should specifically address these attitudinal differences. Curricula should also emphasize interview skills training as an essential component of behavioral health learning.

Keywords

behavioral medicine clinical competence mental health services interpersonal relations medical education graduate

Get full access to this article

View all access options for this article.

References

Substance Abuse and Mental Health Services Administration. National behavioral health quality framework, https://www.nasmhpd.org/.../SAMHSA%20Quality%20Improvement%20Initiative.pdf (2012, accessed 13 September 2018).

Crowley

Kirschner

The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: executive summary of an American College of Physicians position paper. Ann Intern Med 2015; 163: 298–299.

Sperry

Teaching the biopsychosocial perspective: a comparison of two approaches. Psychol Rep 1991; 68: 99–102.

Merkel

Margolis

Smith

RC.

Teaching humanistic and psychosocial aspects of care: current practices and attitudes. J Gen Intern Med 1990; 5: 34–41.

Kern

Grayson

Barker

et al . Residency training in interviewing skills and the psychosocial domain of medical practice. J Gen Intern Med 1989; 4: 421–431.

Smith

Laird-Fick

D’Mello

et al . Addressing mental health issues in primary care: an initial curriculum for medical residents. Patient Educ Couns 2014; 94: 33–42.

Cohen-Cole

Boker

Bird

et al . Psychiatric education improves internists’ knowledge: a three-year randomized, controlled evaluation. Psychosom Med 1993; 55: 212–218.

Accreditation Committee for Graduate Medical Education. ACGME program requirements for graduate medical education in family medicine, https://www.acgme.org/.../0/.../ProgramRequirements/120FamilyMedicine2018.pdff (2018, accessed 13 September 2018).

Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. Policy statement—the future of pediatrics: mental health competencies for pediatric primary care. Pediatrics 2009; 124: 410–421

10.

The Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine. The Internal Medicine Milestone Project, www.acgme.org/Portals/0/PDFs/Milestones/InternalMedicineMilestones.pdf (2015, accessed 9 July 2018).

11.

Bandura

Human agency in social cognitive theory. Am Psychol 1989; 44: 1175–1184.

12.

Crabtree

Miller

(eds) Doing qualitative research. Newbury Park, CA: SAGE, 1992.

13.

Wright

Wolfe

Stewart

et al . Ethical concerns related to grateful patient philanthropy: the physician’s perspective. J Gen Intern Med 2013; 28: 645–651.

14.

Rubak

Sandbaek

Lauritzen

et al . Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract 2004; 55: 305–312.

15.

Gaufberg

Joseph

Pels

et al . Psychosocial training in U.S. internal medicine and family practice residency programs. Acad Med 2001; 76: 738–742.

16.

Gunther

Bingham

RL.

A continuous quality improvement cycle for teaching the identification of psychosocial problems to general internal medicine residents. Acad Med 1993; 68: 308–310.

17.

Smith

Marshall

Cohen-Cole

SA.

The efficacy of intensive biopsychosocial teaching programs for residents: a review of the literature and guidelines for teaching. J Gen Intern Med 1994; 9: 390–396.

18.

Hemming

Hewitt

Gallo

et al . Residents’ confidence providing primary care with behavioral health integration. Family Medicine 2017; 49: 361–368.

19.

Hemming

Levine

Gallo

JJ.

“ Conversational advice”: a mixed-methods analysis of medical residents’ experiences co-managing primary care patients with behavioral health providers. Patient Educ Couns 2018; 101: 85–91.

20.

Jay

Gillespie

Schlair

et al . The impact of primary care resident physician training on patient weight loss at 12 months. Obesity (Silver Spring) 2013; 21: 45–50.

21.

Duke

Griffith

III, Haist

et al . A clinical performance exercise for medicine—pediatrics residents emphasizing complex psychosocial skills. Acad Med 2001; 76: 1153–1157.

22.

Fluker

Whalen

Schneider

et al . Incorporating performance improvement methods into a needs assessment: experience with a nutrition and exercise curriculum. J Gen Intern Med 2010; 25: S627–S633.

23.

Rosenberg

Hoffman-Wilde

Teaching behavioral medicine in a primary care setting: an integrated approach. Gen Hosp Psychiatry 1989; 11: 59–62.

24.

Chou

Lee

Improving residents’ interviewing skills by group videotape review. Acad Med 2002; 77: 744.

25.

Smith

Lyles

Mettler

et al . The effectiveness of intensive training for residents in interviewing. A randomized, controlled study. Ann Intern Med 1998; 128: 118–126.

26.

Jerant

Kravitz

Azari

et al . Training residents to employ self-efficacy-enhancing interviewing techniques: randomized controlled trial of a standardized patient intervention. J Gen Intern Med 2009; 24: 606–613.

27.

Childers

Bost

Kraemer

et al . Giving residents tools to talk about behavior change: a motivational interviewing curriculum description and evaluation. Patient Educ Couns 2012; 89: 281–287.

28.

Katz

Shuval

Comerford

et al . Impact of an educational intervention on internal medicine residents’ physical activity counselling: the Pressure System Model. J Eval Clin Pract 2008; 14: 294–299.

29.

Maatouk-Bürmann

Ringel

Spang

et al . Improving patient-centered communication: results of a randomized controlled trial. Patient Educ Couns 2016; 99: 117–124.

30.

Smith

Marshall-Dorsey

Osborn

et al . Evidence-based guidelines for teaching patient-centered interviewing. Patient Educ Couns 2000; 39: 27–36.

31.

Mauksch

Dugdale

Dodson

et al . Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Arch Intern Med 2008; 168: 1387–1395.

32.

Gulbrandsen

Østbye

Lyna

et al . The influence of physician communication style on overweight patients’ perceptions of length of encounter and physician being rushed. Fam Med 2012; 44: 183–188.

33.

Deuster

Christopher

Donovan

et al . A method to quantify residents’ jargon use during counseling of standardized patients about cancer screening. J Gen Intern Med 2008; 23: 1947–1952.

34.

Kripalani

Osborn

Vaccarino

et al . Development and evaluation of a medication counseling workshop for physicians: can we improve on “take two pills and call me in the morning”? Med Educ Online. Epub ahead of print 8 September 2011. DOI: 10.3402/meo.v16i0.7133.

35.

Cornuz

Humair

Seematter

et al . Efficacy of resident training in smoking cessation: a randomized, controlled trial of a program based on application of behavioral theory and practice with standardized patients. Ann Intern Med 2002; 136: 429–437.

36.

Burton

Brezausek

Agne

et al . Evaluation of a workshop to improve residents’ patient-centred obesity counselling skills. Postgrad Med J 2016; 92: 455–459.

37.

Burton

Agne

Lehr

et al . Training residents in obesity counseling: incorporating principles of motivational interviewing to enhance patient centeredness. J Grad Med Educ 2011; 3: 408–411.