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Behavioral science priorities in residency education: the perspective of practicing family physicians.

Introduction: The family medicine residency behavioral science curriculum is more effective if prioritized to match what is needed in practice after graduation. Two prior studies (Kendall, Marvel, & Cruickshank, 2003; Marvel & Major, 1999) identified physician priorities for behavioral science education. The present study extends this research to include topics from more recent curriculum guidelines and examines the extent to which size of community and perceived competence correlate with prioritization of Washington state family physicians. Method: Practicing family physicians in Washington state (N = 2,270) were invited to complete the survey. Respondents provided demographic and practice information. Respondents then rated, on a scale from 1 to 4, 35 behavioral science topics on 2 different scales including (a) priority to be given in residency education and (b) perceived level of competence. Results: A total of 486 responded and 430 completed both priority and competence scales for a response rate of 19%. The top half of 35 topics of the present study included the top 13 topics found in the 2 prior studies. Priority and competence scales were moderately correlated (r = .48, n = 430, p = .001). There was a small significant correlation with size of community and priority ratings (r = .13, n = 435, p = .006). Discussion: Family physicians in Washington state prioritize behavioral science topics in residency education similar to Colorado and Mississippi. The results of this study support recent ACGME guidelines, in that training should focus on common psychiatric illnesses, including depression and anxiety, and interpersonal processes.

Keywords: behavioral science, clinical competence, curriculum, medical residency, rural health services

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Despite the importance of family medicine behavioral science training, the time devoted in 3-year residency to this topic is limited. Established resources are available for developing a behavioral science curriculum in family medicine (Accreditation Council for Graduate Medical Education [ACGME], 2014; American Academy of Family Physicians [AAFP], 2001; McCutchan, Sanders, & Vogel, 1999). However, consensus has yet to be established regarding the prioritization of behavioral science topics and expected competencies.

Family medicine residency behavioral science education should be relevant to the specific practice context of primary care. A 2001 literature review (Hodges, Inch, & Silver, 2001) highlighted differences in the expressed CME needs of psychiatrists versus primary care physicians. Curriculum design should take into account the specific context and practice needs of primary care physicians and not simply adopt curriculum objectives better suited for psychiatry.

Family physicians practicing in the community value behavioral science. In one study, more than 80% of physicians reported frequently using behavioral interventions themselves or referring to a specialist, and rated behavioral interventions highly (Oyama, Kosch, Burg, & Spruill, 2009). Exposure to behavioral science curriculum results in higher perceived competency ratings in behavioral health (Haley, Ivey, & Rollins, 2006). Prioritization of behavioral science topics, therefore, has the potential to maximize resident exposure to what is actually needed in primary care practice.

Marvel and Major (1999) led the first attempt to evaluate how practicing physicians rank the relative importance of specific topics in behavioral science residency education. Marvel and Major observed that prioritization of the vast array of behavioral science topics had not been established in residency curriculum. Marvel and Major therefore mailed a questionnaire to 663 Colorado family medicine practicing physicians and asked participants to prioritize 28 behavioral science topics in residency education. Depression and anxiety ranked the highest and female physicians and physicians with a behaviorist in their practice provided significantly higher overall average ratings. Marvel and Major's study was then replicated with 543 Mississippi physicians (Kendall, Marvel, & Cruickshank, 2003). Remarkably, the top 13 topics were identical between the two studies, differing slightly in order of importance.

The present study expands on Marvel and Major's research in several ways. First, the present study develops a more comprehensive and geographically representative priority listing of behavioral science topics, specifically assessing physician topic prioritization in Washington state. The number of primary care physicians per capita in Washington state compared with other states is "significantly higher than the national average" (Hing & Hsiao, 2014), and Washington is considered to have a strong primary care system. At the same time, Washington state is sorely lacking in adequate mental health resources (Mental Health America, 2015). This discrepancy may influence behavioral science prioritization in unknown ways. The present study aims to answer the question: How do practicing family physicians in Washington state prioritize behavioral science topics for family medicine residency education?

As mentioned above, primary care educational needs are distinct from psychiatry (Hodges et al., 2001). The present study aims to answer the question: How do practicing family physicians prioritize topics more akin to psychiatry for family medicine residency education?

Size of community was not assessed by Marvel and Major. Graduate medical education for rural practice has unique characteristics (AAFP, 2008), and this may be a factor contributing to topic prioritization. The present study aims to answer the question: In what ways do physicians practicing in smaller versus larger communities prioritize behavioral science residency education differently?

Curriculum guidelines published subsequent to Marvel and Major's studies (ACGME, 2014; AAFP, 2001) identify important topics not included in the original survey (e.g., bipolar/mood disorders and well child skills). Based on these more recent guidelines, additional items were added to the original survey to establish a more comprehensive priority listing in keeping with recent developments.

It is unknown what effect the level of perceived physician competence has on prioritization. Research among physicians indicates those who perceive increased value in behavioral methods are more likely to believe that lack of expertise limits the use of these methods (Astin et al., 2006). Similarly, a limitation noted by Marvel and Major in their original study, perceived lower competence in behavioral science topics may lead to lower priority ratings because of a lack of familiarity with the subject (Marvel & Major, 1999). The present study addresses this limitation and asks: What effect does physician perceived competence have on topic prioritization?

Method

The study was approved by the Spokane Institutional Review Board. The study was also approved and facilitated by the Washington Academy of Family Physicians (WAFP).

Participants

The present study included a sample of 2,270 practicing family physicians in Washington state. These physicians were identified through the WAFP as "active" members. The proportion of male respondents was 45%.

Procedure

The invitation to complete the online survey was sent via e-mail to a sample of 2,270 practicing family physicians in Washington state. Participants clicked on a link and completed the consent form before answering the survey questions. After the initial e-mail request, three additional reminders were sent out spaced at approximately 2 to 4 weeks apart. No personal identifying information was collected.

Questionnaire

The questionnaire used in the present study included all but one of the original 28 questions from the two previous studies (Marvel & Major, 1999; Kendall et al., 2003). One of the original items, unfortunately, had been changed because of a technical error where "chronic medical illness" was inadvertently substituted with "chronic mental illness." In addition to this altered question, seven new topics were added. All 35 topics are listed in Table 2 complete with wording used in the questionnaire. Time required to complete the questionnaire was approximately 5 minutes. The survey was administered electronically, whereas the two prior studies mailed out paper surveys.

Respondents provided the same demographic data as with the original survey including gender, years in practice since residency or internship, average number of patients seen in clinic per half day, presence of a behaviorist (mental health therapist, health educator, and/or social worker) in their practice, and patient payment type (percentage of practice that is fee for service, managed care, or government supplemented/indigent). They were also asked to indicate whether a psychologist or clinical pharmacist (PharmD) was present in their practice, and to indicate the size of the community in which their practice was located.

Respondents rated 35 behavioral science topics on 2 different scales including: 1) rate each topic according to the priority to be given in residency education, and, 2) rate each topic according to your current perceived level of competence. Topics were rated according to priority (Scale 1) using a scale identical to the Marvel and Major's original questionnaire's

4-point scale, with 4 assigned to topics considered highest priority (essential/core competency) and 1 assigned to topics considered lowest priority (optional/seldom needed in practice). In addition, respondents were encouraged to list other behavioral topics or skills and to rate these additional items using the same 1 to 4 scale. Finally, respondents were asked to rate their competence (Scale 2) with regard to each topic using a 4-point scale, with 4 assigned to topics at the highest level of competence (proficient, less need for training) and 1 assigned to topics at the lowest level of competence (basic capability, more need for training).

Data Analysis

Data were analyzed using both descriptive and inferential methods. SPSS statistical software was used for analyses. Ratings were listed and ranked from highest to lowest priority according to the average ratings for each topic. Additionally, comparative rankings of the 27 items common in all 3 studies appear in Table 3.

Results

Of the 2,270 potential respondents, 486 replied to the request after the initial e-mail and 3 additional requests. A total of 430 respondents completed priority and competence scales. The response rate was therefore 19%. A total of 46 respondents only completed all or part of the demographic information. Demographic information about the respondents who completed both priority and competence scales, are presented in Table 1 below.

Respondent average ratings of all 35 study priority and competence questions are presented in Table 2 below. Average priority ratings of the present study ranged between 3.66 (depression) to 2.31 (enuresis/encopresis) and average competence ratings ranged between 3.6 (depression) to 2.18 (autism). Rankings of the 35 content areas incorporated 8 topics that were not included in the prior studies. Four of these topics ranked in the top half with regard to priority (1-16; i.e., well child skills, psychopharmacology, chronic mental illness, and cognitive disorders). In contrast, autism spectrum disorders, and spirituality and medicine ranked near the bottom with regard to priority (32 and 34, respectively). Common psychiatric problems like depression and anxiety ranked high (1 and 3, respectively). However, out of the 18 topics more akin to psychiatry (1, 3, 7, 11, 12, 16, 18-20, 23, 25, 26, 28, 30-33, 35), 12 topics (67%) ranked in the bottom half (17-35). Lastly, responses to the question, priority of "other topics/skills" were divided into categories and increasing physician access to psychiatry/mental health was the most frequently noted, followed by complementary and alternative medicine (CAM), interviewing skills, and team-based care.

Respondent average priority ratings of the 27 topics common between the present and past 2 studies are presented in Table 3. Average range of priority ratings ranged from a low of 2.31 in the present study and 2.40 in the past 2 studies, to a high of 3.66 in the present study, and 3.79/3.78 in 1999/2003, respectively. The top 13 topics are the same between the studies, though the order differs somewhat among them.

The proportion of respondent males versus females was compared with reported total sample characteristics as well as results of the prior 2 studies. There were 2,270 WAFP members in Washington state at the time of this study, including 1,212 males (53.4%), 1,052 females (46.3%), and 6 individuals for which no gender was specified (0.3%). The proportions of males versus females (and not reported) in the present study were significantly different from the sample proportions provided by the WAFP for Washington state, [chi square] (df = 2) = 36.33, 0.0001. Moreover, there was a significant difference in male priority ratings (M = 104.31, SD = 18.50) and female priority ratings (M = 108.08, SD = 19.15); t(425) = -2.05, p = .041).

The priority ratings and the respondents' perceived competence of each topic showed a significant, medium correlation when all 35 topics were combined (Pearson product-moment correlation coefficient r = .48, n = 430,p = .001, using Cohen's, 1988, 1992, effect size recommendations). Respondents' priority and competence ratings were found to be highly reliable (Cronbach's alphas at .96 and .95, respectively).

Correlations were examined between priority ratings and other demographic variables. Of note, larger size of community was correlated with higher priority ratings (r = .13, n = 435, p = .006). There was a significant small negative correlation between the presence of a mental health therapist and priority ratings (r = -.11, n = 435, p = .03).

No other significant correlations were found between priority ratings and other demographic variables including, years in practice, average number of patients seen per half-day, patient payment type, and the presence of a Heath/ Patient Educator, Social Worker, Psychologist, or PharmD in the practice.

Discussion

Based on the opinion of practicing family physicians, behavioral science residency education should prioritize the top half (1-13) of the 27 common topics between the 3 studies. This finding persisted despite the fact that Washington state is among the top 4 states whose number of primary care physicians per capita exceeds the national average (Hing & Hsiao, 2014), and is ranked among the bottom 4 states for overall measures of prevalence of mental illness and access to mental health care (Mental Health America, 2015). Notable shortages of psychiatry/mental health care is particularly evident in rural Washington state (Baldwin et al., 2006) and lack of access was the most frequently mentioned topic in the present survey "other topics/skills" question.

Despite strong primary care and a weak mental health system, Washington state family physicians prioritize behavioral science topics similar to physicians in Colorado (Marvel & Major, 1999) and Mississippi (Kendall et al., 2003). This lends support to the conclusion that the 13 topics common between the 3 studies represent the priorities of physicians over time (>15 years) and region, and form the basis of a physician informed practiced-based behavioral science curriculum for family medicine residency education.

In the present and prior two studies, female physicians had higher average priority ratings than males (Marvel & Major, 1999; Kendall et al., 2003). This finding persisted despite a lower proportion of male respondents in the present study (45%, 2014; 76%, 2003; 72%, 1999). It may be, as Kendall has suggested, that this gender difference represents a higher priority given by females to behavioral science (Kendall et al., 2003). However, it is unclear from the current data the reason for this difference.

Interpersonal processes are at the core of this curriculum and make up nearly half of the top 13 topics common between the 3 studies (e.g., interviewing, lifestyle counseling, patient education, death and dying, difficult patients, and physician well-being). Similarly, the ACGME competencies of Patient Care, Interpersonal Communication and Professionalism and the recently published Milestones (ACGME, 2013) reflect the importance of relationship skills in physician development and evaluation. Teaching residents these nondiscrete, "soft skills" can be challenging for behavioral science educators given the pervasiveness of biomedical culture. It is significant, therefore, that practicing family physicians recognize the critical importance of these skills and behavioral science educators might use this finding to advocate for maintaining a high priority of teaching interpersonal processes in residency education.

Present study results are in line with recent ACGME recommendations that behavioral science family medicine residency education should focus on "common mental illnesses" (ACGME, 2014, p. 18)--emphasizing more general mental health knowledge and skills needed in primary care. Depression, anxiety, and substance abuse ranked among the top 13 topics common to all 3 studies and psychopharmacology in the current study ranked high as well (#7). In contrast, lower priority was given to less common psychiatric illnesses (e.g., autism and psychotic disorders). Across all 3 studies, two thirds of topics in psychiatry ranked in the bottom half. This is consistent with findings that up to 93% of psychiatric illness treated in family medicine falls in the mild-to-moderate range of severity (Fraser & Oyama, 2013).

The high priority practicing physicians gave to common psychiatric conditions is also reflected in the reality that primary care has become the de facto mental health system in the United States (Norquist & Regier, 1996). Although only 5% of outpatient visits address mental health conditions directly (Center for

Disease Control and Prevention, 2010), 25% meet criteria for a behavioral health diagnosis (World Health Organization and World Organization of Family Doctors, 2008), and more than 50% of patients have at least a subthreshold psychiatric condition (Cwikel, Zilber, Feinson, & Lemer, 2008). Moreover, primary care physicians prescribe almost four out of every five prescriptions for antidepressant medications (Mark, Levit, & Buck, 2009), despite the fact that the typical primary care visit is about 10 minutes shorter than a typical psychiatry visit (20.6 vs. 31.6 minutes, respectively; AAFP, 2014).

Despite the high volume of psychiatric care delivered in primary care, physician education lags behind. As many as 73% of visits at which antidepressants are prescribed do not have associated psychiatric diagnoses (Mojtabai & Olfson, 2011). Moreover, a recent study found family medicine residents and faculty reported their "knowledge of psychotropics as absent or marginal" (Fraser & Oyama, 2013, pp. 325-238). Accordingly, this suggests an opportunity to improve behavioral science residency training by devoting more time and greater priority to diagnosis and pharmacological treatment of common psychiatric conditions. Conversely, less focus should be given to less common psychiatric conditions better suited for specialty care.

Rural versus urban practice setting may have an effect on topic prioritization. Smaller size of community correlates with decreased behavioral science prioritization and vice versa. In rural communities two thirds of primary care providers report they are unable to obtain mental health services for their patients--a rate that is twice as high as for referrals to other specialists (Cunningham, 2009). In Washington state, urban communities have more than 3 times the number of psychiatrists than rural areas (Baldwin et al., 2006). Mental health clinicians working in rural primary care report more difficulties collaborating with PCPs than their urban counterparts (Williams, Eckstrom, Avery, & Untitzer, 2015). It is likely that in rural, underserved communities with limited behavioral health services, physicians have fewer resources to rely on and less exposure to behavioral science. Therefore, these factors may account for the lower overall prioritization of behavioral science topics. However, study effect size was small and these conclusions should be considered provisional.

The prioritized ranking of the present study gives behavioral science residency educators a more comprehensive list of 35 topics. Four of the eight topics that were not part of the past two studies ranked in the top half of the present study. The highest ranked of the additional items was well child skills that ranked at number 5/35. This may reflect the reality that 16% to 26% of health visits for children are provided by family medicine physicians, not pediatricians (Phillips, Bazemore, Dodoo, Shipman, & Green, 2006).

Physicians with higher competence in behavioral science are likely to value behavioral science more. Priority and competence scales were moderately correlated. Physicians, perhaps, rated topics higher or lower priority in part based on their perceived competence in the topic and vice versa. This should be considered an important factor to be examined in greater detail in future research.

The perspective of practicing physicians is only one measure among many and has limitations in determining the prioritization of behavioral science residency curriculum. As Marvel and Major (1999) noted, topics that fit into the biomedical model tend to be rated high and the less "medicalized" topics are rated lower. In addition, physician priorities of the future may shift as health care reform progresses-potentially resulting in the expansion of integrated behavioral care. Similar to the prior two studies, the lowest rated topic in the present study was 2.31 (scale of 1-4) and therefore differences of priority between topics should not be overstated.

In a similar vein, the overlap between topics is a notable feature of behavioral science content. For example, family skills ranked low at #29/35 but is a necessary component of interviewing that ranked high at #2/35. The prioritized topic listings of the present and prior studies should not be used to eliminate topics so much as to identify practice-informed core topics. Maintaining the breadth of curriculum that includes topics that ranked low such as autism, family skills, and spirituality and medicine promotes an educational environment that encourages innovation and exploration of individual interests.

Finally, the development of outcome-based "entrustable professional activities" (EPAs) in family medicine (Society of Teachers of Family Medicine, 2015) is designed to translate the competencies into medical practice (ten Cate, 2013). In addition to reliance on research informed expert opinion, it may be instructive to elicit the priorities of practicing physicians in the development of the EPAs.

This study has several limitations. The response rate was low (19%) and not likely representative when compared to the total sample of male/female WAFP physicians in Washington state. This suggests a possible selection bias. Respondents who completed the survey may have answered differently from those who elected not to enroll in the study. Moreover, the two prior studies differed in various ways, which might reduce the comparability of findings [that is, paper versus e-mailed survey, one original survey question not being included in the present study instrument, and greater number of years between the present study and the 2003 study (11 years) versus 4 years between the 1999 study and the 2003 study]. Finally, comparability may have been affected by the addition of a second scale to each question (i.e., competence scale) and adding additional questions to the survey may have affected respondent behavior in unknown ways.

Conclusions

Behavioral science educators in family medicine residencies can utilize physician topic prioritization to better align curriculum with practice needs. The core 13 topics identified emphasize interpersonal processes and common psychiatric conditions. Although a practice-informed curriculum is important to guard against training residents in a vacuum, it is only one component among many for designing a comprehensive family medicine behavioral science curriculum. Future research should focus on other geographical areas (e.g., Eastern United States). Moreover, practicing physician prioritization should be included in ongoing curriculum development as an iterative process in keeping with a continuously evolving health care delivery system.

http://dx.doi.org/10.1037/fsh0000144

Richard L. Brandt-Kreutz, MA, MSW, Kyle E. Ferguson, PhD, and Devin Sawyer, MD

Providence St. Peter Family Medicine, Olympia, Washington

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Fraser, K., & Oyama, O. (2013). Knowledge of psychotropics and prescribing preferences of family physicians: A preliminary study. Academic Psychiatry, 37, 325-328. http://dx.doi.org/10.1176/appi.ap.12090160

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Received January 5, 2015

Revision received May 8, 2015

Accepted May 17, 2015

This article was published Online First June 29, 2015.

Richard L. Brandt-Kreutz, MA, MSW, Kyle E. Ferguson, PhD, and Devin Sawyer, MD, Providence St. Peter Family Medicine, Olympia, Washington.

The authors acknowledge the generous contribution by Kim Marvel, PhD, who shared his original 1999 behavioral medicine survey instrument and graciously consulted on the project. We also acknowledge the support of the Washington Academy of Family Physicians (WAFP) staff. Public Health committee and past president Kevin B. Martin, MD, for essential collaboration that made this study possible.

Correspondence concerning this article should be addressed to Richard L. Brandt-Kreutz, MA, MSW, Providence St. Peter Family Medicine Residency, 525 Lilly Road Northeast, MS: PBP09, Olympia, WA 98506. E-mail: richard.brandt-kreutz@providence.org
Table 1
Demographic Information About the
Respondents Who Completed Both Surveys

              Respondent characteristic                 Mean (N = 438)

Gender (male)                                               45.24%
Years in practice (post-intemship/residency)            18.30 (11.00)
Average number of patients seen per 'h day of clinic:    10.0 (4.12)
Behaviorist/Pharmacist present in your practice
  Health/Patient educator                                   26.90%
  Mental health therapist                                   37.11%
  Social worker                                             34.82%
  Psychologist                                              21.22%
  PharmD                                                    33.33%
Patient payment type
  Fee-for-service (indemnity plan)                      29.70% (25.03)
  Manage care (HMOs, PPOs, capitated contracts)         31.10% (27.05)
  Other (medicaid, medicare, self-pay, indigent)        43.45% (26.46)
Size of community
  Less than 30,000                                          21.83%
  30,000 to 75,000                                          16.55%
  75,000 to 150,000                                         19.31%
  150,000 to 500,000                                        22.07%
  500,000 to 1 million                                      12.64%
  More than 1 million                                       7.59%

Table 2
2014 Present Study (Items Added to 1999/2003 Instrument Are Italicized)

                                                       Priority

                                                          Mean rating
           Behavioral science topics              Rank     (1 = Lo,
  (including definition as worded in survey)      order     4 = Hi)

 1. Depression (recognizing, counseling,            1        3.66
    medication management, when to refer)
 2. Interviewing (building rapport, soliciting      2        3.61
    patient's agenda, efficiency)
 3. Anxiety (interviewing, common health            3        3.49
    concerns, confidentiality)
 4. Lifestyle counseling (for diet, exercise,       4        3.47
    smoking cessation, weight loss)
 5. Well child skills (child development and       5*        3.45*
    surveillance, child safety)*
 6. Geriatrics (assessment; e.g. Mini-Mental        6        3.36
    Status Exam, psychosocial issues, family)
 7. Psychopharmacology (medication management,     7*        3.34*
    side effects, referring)*
 8. Chronic pain (psychosocial issues,              8        3.33
    medications, multidisciplinary treatment)
 9. Patient education (integrating into office      9        3.32
    visit, giving information)
10. Death and dying (discussing with patients      10        3.30
    and families, advance directives)
11. Chronic mental illness (psychosocial           11*       3.27*
    effects, effect on family) (a)*
12. Substance abuse (recognizing, negotiating      12        3.26
    a treatment plan, referring)
13. Difficult patients (personality                13        3.23
    disorders, demanding/manipulating patients)
14. Headaches (assessment, behavioral              14        3.22
    treatments)
15. Stress-related disorders (behavioral           14        3.22
    interventions, medications)
16. Cognitive disorders (dementia,                 16        3.21
    concussion, referring)
17. Physician well-being (balance of               17        3.20
    work/home, recognizing one's limits)
18. Mood disorders (bipolar, medical               17*       3.2*
    management, when to refer)*
19. Mental status (assessing changes,              19*       3.12*
    management, referring)*
20. Sleep problems (behavioral interventions,      20        3.07
    medical management)
21. Culture/Diversity (sensitivity to              21        3.01
    ethnicity, gender, sexual orientation)
22. Community resources (knowledge                 22        3.00
    of/involvement with agencies, groups for
    patients)
23. Psychiatric emergencies (handling              23        2.99
    suicidal patient, aggressive/combative
    patient)
24. Adolescent care (interviewing, common          24        2.97
    health concerns, confidentiality)
25. Child behavior problems (parenting             25        2.93
    advice, how to assess/refer)
26. Somatoform disorders (assessment,              26        2.88
    managing symptoms)
27. Family violence (recognition, reporting        27        2.86
    requirements, accessing agencies)
28. ADHD (clinical assessment, school              28        2.78
    involvement, medication)
29. Family skills (conducting family               29        2.77
    meetings, helping families in crisis)
30. Psychotic disorders (identifying, medical      30        2.75
    management, referring)
31. Sexual problems (counseling, medical           31        2.58
    management, when to refer)
32. Autism spectrum disorders (screening,          32*       2.56*
    management, referring)*
33. Eating disorders (identifying, medical         33        2.43
    management, referring)
34. Spirituality and medicine (promoting           34*       2.38*
    patient and physician spiritual health)*
35. Enuresis/Encopresis (behavioral and            35        2.31
    medical treatments)

                                                  Competence

                                                          Mean rating
           Behavioral science topics              Rank     (1 = Lo,
  (including definition as worded in survey)      order     4 = Hi)

 1. Depression (recognizing, counseling,            1        3.61
    medication management, when to refer)
 2. Interviewing (building rapport, soliciting      2        3.49
    patient's agenda, efficiency)
 3. Anxiety (interviewing, common health            3        3.37
    concerns, confidentiality)
 4. Lifestyle counseling (for diet, exercise,       4        3.33
    smoking cessation, weight loss)
 5. Well child skills (child development and       6*        3.27*
    surveillance, child safety)*
 6. Geriatrics (assessment; e.g. Mini-Mental       12        3.07
    Status Exam, psychosocial issues, family)
 7. Psychopharmacology (medication management,     10*       3.08*
    side effects, referring)*
 8. Chronic pain (psychosocial issues,             10        3.08
    medications, multidisciplinary treatment)
 9. Patient education (integrating into office      5        3.31
    visit, giving information)
10. Death and dying (discussing with patients       7        3.26
    and families, advance directives)
11. Chronic mental illness (psychosocial           15*       2.99*
    effects, effect on family) (a)*
12. Substance abuse (recognizing, negotiating      19        2.92
    a treatment plan, referring)
13. Difficult patients (personality                21        2.88
    disorders, demanding/manipulating patients)
14. Headaches (assessment, behavioral               8        3.13
    treatments)
15. Stress-related disorders (behavioral           12        3.07
    interventions, medications)
16. Cognitive disorders (dementia,                 18        2.93
    concussion, referring)
17. Physician well-being (balance of               22        2.86
    work/home, recognizing one's limits)
18. Mood disorders (bipolar, medical               19*       2.92*
    management, when to refer)*
19. Mental status (assessing changes,              12*       3.07*
    management, referring)*
20. Sleep problems (behavioral interventions,      15        2.99
    medical management)
21. Culture/Diversity (sensitivity to               9        3.09
    ethnicity, gender, sexual orientation)
22. Community resources (knowledge                 27        2.61
    of/involvement with agencies, groups for
    patients)
23. Psychiatric emergencies (handling              23        2.76
    suicidal patient, aggressive/combative
    patient)
24. Adolescent care (interviewing, common          17        2.94
    health concerns, confidentiality)
25. Child behavior problems (parenting             27        2.61
    advice, how to assess/refer)
26. Somatoform disorders (assessment,              25        2.65
    managing symptoms)
27. Family violence (recognition, reporting        30        2.53
    requirements, accessing agencies)
28. ADHD (clinical assessment, school              32        2.51
    involvement, medication)
29. Family skills (conducting family               24        2.67
    meetings, helping families in crisis)
30. Psychotic disorders (identifying, medical      26        2.63
    management, referring)
31. Sexual problems (counseling, medical           31        2.52
    management, when to refer)
32. Autism spectrum disorders (screening,          35*       2.18*
    management, referring)*
33. Eating disorders (identifying, medical         34        2.20
    management, referring)
34. Spirituality and medicine (promoting           27*       2.61*
    patient and physician spiritual health)*
35. Enuresis/Encopresis (behavioral and            33        2.28
    medical treatments)

(a) Because of a technical error item #12, "Chronic Mental
Illness," was included in the present study instead of the item
"Chronic Medical Illness," The latter was among the 28 original
topics of the prior 2 studies.

Note: Items added to 1999/2003 instrument are indicated with *.

Table 3
Ranked Comparisons of 27 Items Common
to All 3 Studies Priority Scales (a)

                                 Marvel &        Kendall, et
                                Major, 1999       al., 2003

                                                          Mean
                                                         rating
                               Rank     Mean    Rank    (1 = Lo,
 Behavioral science topics     order   rating   order   4 = Hi)

 1. Depression                   1      3.79      1       3.78
 2. Anxiety                      2      3.53      2       3.61
 3. Lifestyle counseling         3      3.48      6       3.42
 4. Headaches                    4      3.39      4       3.54
 5. Difficult patients           5      3.37      7       3.36
 6. Interviewing                 5      3.37      5       3.43
 7. Stress-related disorders     5      3.37      9       3.30
 8. Geriatrics                   8      3.36      3       3.59
 9. Physician well-being         9      3.27     12       3.26
10. Patient education           10      3.26     13       3.22
11. Chronic pain                11      3.24      7       3.36
12. Substance abuse             12      3.16     10       3.29
13. Death and dying             13      3.15     10       3.29
14. Child behavior problems     14      3.06     16       2.91
15. Adolescent care             15      3.05     14       3.18
16. Somatoform disorders        16      2.91     16       2.91
17. ADHD                        17      2.90     16       2.91
18. Psychiatric emergencies     18      2.89     15       3.17
19. Sleep problems              19      2.88     19       2.90
20. Family violence             20      2.86     23       2.79
21. Community resources         21      2.78     21       2.85
22. Sexual problems             22      2.75     20       2.89
23. Family skills               23      2.64     24       2.77
24. Eating disorders            24      2.51     25       2.63
25. Psychotic disorders         25      2.48     22       2.84
26. Culture/Diversity           26      2.42     27       2.40
27. Enuresis/Encopresis         27      2.40     26       2.52

                                Present study

                                         Mean
                                        rating
                               Rank    (1 = Lo,
 Behavioral science topics     order   4 = Hi)

 1. Depression                   1       3.66
 2. Anxiety                      3       3.49
 3. Lifestyle counseling         4       3.47
 4. Headaches                   11       3.22
 5. Difficult patients          10       3.23
 6. Interviewing                 2       3.61
 7. Stress-related disorders    11       3.22
 8. Geriatrics                   5       3.36
 9. Physician well-being        13       3.20
10. Patient education            7       3.32
11. Chronic pain                 6       3.33
12. Substance abuse              9       3.26
13. Death and dying              8       3.30
14. Child behavior problems     19       2.93
15. Adolescent care             18       2.97
16. Somatoform disorders        20       2.88
17. ADHD                        22       2.78
18. Psychiatric emergencies     17       2.99
19. Sleep problems              14       3.07
20. Family violence             21       2.86
21. Community resources         16       3.0
22. Sexual problems             25       2.58
23. Family skills               23       2.77
24. Eating disorders            26       2.43
25. Psychotic disorders         24       2.75
26. Culture/Diversity           15       3.01
27. Enuresis/Encopresis         27       2.31

(a) Because of a technical error the item "Chronic Medical
Illness" that was included in the 1999 and 2003 studies and
ranked #16/28 was not included in the present study and therefore
was left out of the comparative analysis.
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Author:Brandt-Kreutz, Richard L.; Ferguson, Kyle E.; Sawyer, Devin
Publication:Families, Systems & Health
Geographic Code:1USA
Date:Dec 1, 2015
Words:6322
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