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Family medicine residency programs have long had behaviorists as part of the educational experience for physicians-in-training, but the role has not kept up with the many changes in training and healthcare over the last few decades. And so you have behavioral science faculty with unclear and often conflicting mandates for their work, or worse yet, vague and undefined roles that leave them feeling lost in their departments.
Now with the new ACGME guidelines promoting integrated care training as a standard portion of the resident curriculum we have an opportunity to redefine the role of the behaviorist in family medicine residency training, but I’m concerned we may get it wrong without acknowledging the needed investments.
Here’s the fundamental problem: the breadth of the traditional aspects of the role do not allow for enough resource allocation to the emerging aspect of the role, namely integrated care program development. The solution is clear: separate out the roles of behaviorists working on resident training/ curricula development and the roles of the integrated care program developers and clinical service providers. In other words, residency programs, in order to meet ACGME guidelines need to invest in more behavioral health staffing and in particular a shared leadership role with one individual focused on the resident training and departmental administration components and the other focused on building the integrated care service.
I know this is not what you want to hear if you are an administrator of a residency program that already struggles to make its budget. But it is the truth. The traditional behaviorist activities, including participation on departmental committees, wellness program development, curriculum development and resident observations take up too much time to then also dedicate time to patient care, let alone develop a full-fledged integrated care program. And therein lies the rub – to provide residents with a full experience in integrated care, meaning the work environments they are likely to work in their future employment, the residency itself has to invest in developing its own integrated care program. Residents need the experience of working alongside a Behavioral Health Consultant (BHC) and learn how to consult with a care manager and consulting psychiatrist as part of their care team. This is not just the future of the modern primary care team, it is already the present at a growing number of clinical sites around the country. There really is no way for the traditional behaviorist to fulfill both the program development/ clinical responsibilities of integrated care and the resident education components.
There are some who worry about the resident educational experience, claiming that residents need to learn how to manage behavioral health issues independently. While this is a well-meaning concern, it is also outdated. The notion that having an integrated care program turfs mental health issues to the behavioral health staff is a fundamental misunderstanding of integrated care. In fact, the prevailing models of integrated care, Primary Care Behavioral Health (PCBH) and the Collaborative Care Model (CoCM), have at their core the expansion of medical provider knowledge and ability to intervene with patients with behavioral health conditions. In other words, you can’t get a better education than working alongside BHCs, care managers and consulting psychiatrists.
In PCBH the intention of the model is to facilitate cross-pollination of learning between the BHC and primary care provider such that the primary care provider becomes more effective at doing many of the things the BHC does clinically. In CoCM the primary care provider is educated by the consulting psychiatrist on prescribing patterns for behavioral health conditions. Teaching and learning is at the core of each model as a vehicle for impacting a larger swath of the population than traditional “turfing” behavior.
So, if we really want to train the future workforce in the spirit of the new ACGME guidelines, there needs to be a commensurate investment in behavioral health staff for the integrated care programs at residency sites. At a minimum this should include a peer for the traditional behaviorist who focuses on integrated care program development and oversees enough clinical staff (BHCs, care managers, consulting psychiatrist) to support clinical service delivery for all open clinic hours. This is the only way to train the physician workforce to be prepared to work in the modern care team.
The Collaborative Family Healthcare Association, in collaboration with the Society of Teachers in Family Medicine, is developing a workgroup for behaviorists in these roles that we hope will support these professionals in building out their professional roles as well as the clinical and educational components of their programs to bring family residency training into alignment with the current state of integrated care. For more information, keep an eye on the CFHA calendar for future events or contact CFHA at info@CFHA.net.
Behaviorists in family medicine residency deserve an upgrade and so do our residents.