Teaching Students How to BATHE: Behavioral skills training in a Family Medicine Clerkship Stuart MR, Lieberman JA. The Fifteen Minute Hour

Focus of Presentation Introductions The BATHE Technique Overview of our Clerkship / Behavioral Skills Training Our results with BATHE Questions and Comments Why did you choose this conference? If there is something you are really hoping to get from it…hear from you in a minute

Introductions Nancy Bushnell-Harper, MA, LPC Jan Hood, MD Tammy Baudoin, MD Joy Reger, MEDL 4th year medical students: Justin Dean Mary Eskander

Audience Experience with BATHE? Precept Students in Clinic? Design and Run Courses? What do you hope to get from this session?

FM Clerkship: Principles of Family Medicine The Biopsychosocial Model Comprehensive Care Continuity of Care Contextual Care Coordination/Complexity of Care Important topics, traditionally difficult to effectively teach and evaluate. Family Medicine Clerkship Curriculum

BATHE Objectives: Patient-Centered Communication Skills • Active listening skills and empathy for patients. • Ability to elicit and attend to patients’ specific concerns. • Validation of the patient’s feelings by naming emotions and expressing empathy. How do you cover these objectives? Family Medicine Clerkship Curriculum: The Biopsychosocial Model

Secondary Objectives: Effectively incorporate psychological issues into patient discussions and care planning. Use effective listening skills and empathy to improve patient adherence to medications and lifestyle changes. Foundation for additional acute, chronic, and preventive care competencies Ripple effect, efficacy begets efficacy Family Medicine Clerkship Curriculum

The BATHE Technique

The BATHE technique: B - background. What has been going on in your life? A - affect. How do you feel about that? T - trouble. What troubles you the most about that? H - handling. How have you been handling that so far? E - empathy. I can see how that is really hard.

The BATHE Technique It is easy to learn It takes very little time It helps the patient feel heard It improves understanding It works; patients get better It helps patients who are stuck Good for “difficult patients”

Primary Care and Mental Health Services Half of all U.S. mental health services provided by primary care sector. 50% of patients treated for major depressive disorder are treated solely by primary care physicians. 20% of psychotherapy sessions are provided in primary care. Searight, H.R. (2009).

Why Physicians avoid asking about live stresses It takes time Limited skills of the physician It is painful and not fun It isn’t “real” medicine

Asking about Feelings …..

BATHE is helpful for: Any patient; for screening and to practice Patients with any significant stress Depression, anxiety, grief Marital discord When any life situation is causing symptoms Difficult patients; to end the session without offending Sexual assault

Strategies to go beyond BATHE Homework Use the word “YET” Follow up visits Referral Stuart MR, Lieberman JA. The Fifteen Minute Hour

Questions or Comments so far?

Behavioral Skills Training in Family Medicine …basic flaw …almost no effective, reproducible, and teachable clinical methods… …unable to make real the ideal” Pollyanna: Formational material for me. Acceptance, Empathy, Conceptualization, Competence. Acceptance: Patient needful and worthy of your help. You, the doctor, have the ability to help. 1984 Cassell, Eric J. Annals of Internal Medicine. 1985

Behavioral Skills Training in Family Medicine 1st Edition 1986 4th Edition 2008 Able to make the transition. Still relevant. Effective, more evidence, newer information (Cognitive Behavioral, After BATHE, Positive Psychology)

“Realistic Approaches to Counseling in the Office Setting” Evidence Based B Recommendations Benefit Primary Care Counseling (BATHE featured) Brief Alcohol Intervention 5 A’s Technique Stages of Change Brief Motivational Interviewing Short term benefits for psychiatric symptoms Reduced ETOH use over time Smoking Cessation Adherence to HTN regime at 12 and 18 months Reduction in ETOH and marijuana use EBM Searight HR in Am Fam Physician 2009

Use of the BATHE method in the preanesthetic clinic visit. BATHE patients more satisfied than control: t(98)=5.37, P=0.001 (95% CI=0.19, 0.41). BATHE did not increase time: t(98)=0.110, P=0.912 (95% CI=-1.519, 1.359). Relevance outside Primary Care DeMaria, etal. Society for Ambulatory Anesthesiology. 2011

Behavioral Skills Training Not just a Family Medicine issue More compassionate, behaviorally savvy, and patient-centered Research and educational guidelines Tack on to “The scientific foundation” 2013: Information explosion, EMR, technology, EBM, clinical skills, procedures, competencies, numbers, outcomes, reimbursement. And be nice. And do research. 2011 Association of American Medical Colleges

Structure of LSUHSC-S 3rd Year 6 week Family Medicine Clerkship 2 week sub-blocks to allow longitudinal exposure

3rd Year Family Medicine Clerkship Inaugural Year 2011-2012 LSUHSC-Shreveport FM Primary Care Clinic Provider of first contact Continuity relationships with patients Members of a Health Care Team AHEC-facilitated Community Family Medicine National FM Clerkship Curriculum fmCASES through www.med-u.org Small group learning: Includes behavioral skills training Traditionally longitudinal program. Student ownership of patients, required to have continuity.

Behavioral Skills Topics BATHE Smoking Cessation (5 As, Stages of Change) Alcohol Screening / Interventions DAMP-DASH: Behavioral Review of Symptoms Depression, Anxiety, Mania, Psychosis, Drugs, Alcohol, Suicide, Homicide Stress Management (New for 2012-2013) Action Plan (New for 2012-2013) Ethical Dilemmas

Behavioral Skills Training Adult Learning Principles Allow choice/self-direction Integrate new concepts with current knowledge Connect teaching goals to personal goals Illustrate relevance Practical training Respectful learner-centered environment Behavioral and Social Science Foundations for Future Physicians AAMC 2011

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BATHE: Training Structure Initial Patient Visits: Establish Need Observe Effective / Ineffective Communication Patient Ownership & Responsibility Small group: Discussion circle Discover current understanding / experience Connect behavioral skill to patient care needs Practical instruction and/or supervised practice Reinforcement: Grade incentive to practice and document skill Reflect and build on what was learned

Behavioral Skills Evaluation Small group discussion and practice How could you cause harm? Student-patient visit under faculty supervision Formative and summative faculty evaluations Optional use of behavioral skill during patient visits Grade incentive for completion of behavioral skills card signed by faculty at time of patient visit Faculty review of behavioral skills cards

3rd Year Family Medicine Clerkship Grading 40%: Summative Faculty Evaluations 30% fmCASES exam 10% Observed physical exams 20% Log: Minimum = 72/100 points Min 20 Clinic Visits Min 5 Continuity Patients Min 10 Preventive Care Plans Min 6 Clinical Questions Additional activities including Behavioral Skills Cards Card = O.2% of final grade

Behavioral Skills Results: 2011-2012 118 students completed the clerkship 110 students completed at least one card Total Behavioral Skill Cards Completed: 813 405 BATHE 333 Smoking Cessation 48 Alcohol Screening / Intervention 27 DAMP-DASH Screening

Smoking Cards 2011-2012: #333

BATHE Encounters Documented in 2011-2012: Total #405 50% students performed BATHE at least three times

BATHE Card

One thing you learned about the patient… There is much more going on than I realized Family is important The patient was willing to open up to me Hx of substance abuse doesn’t mean current problem Insights into specific medical condition Patient is trying to improve health Patient is resilient She shared her wisdom

One thing you learned about the practice of medicine… Connection between stress and mental and physical health Multifacited/multicultural/Holistic Dr-Pt relationship / Patient centeredness is important to healing No quick fixes / medicines are not always necessary or helpful Talk is effective

One thing you learned about yourself… I feel effective BATHE is effective Self assessment insight (need to improve communication skills, need to understand the patient better) I am becoming more empathetic / less judgmental Better able to integrate

Warm Fuzzies I enjoyed I was inspired I identified with: fractured hand, sleep disturbance, blindness, emotional aspect of sexual dysfunction

FM Clerkship Curriculum: Teaching Students How to BATHE Benefit of Primary Care counseling: B recommendation BATHE used in Family Medicine for >25 years Applicable beyond Family Medicine BATHE in 3rd year Clerkship: Integrates practical communication skills into early clinical encounters Acceptable and effective for a wide range of students Supports therapeutic student attitudes towards patients

References AAMC: Behavioral and Social Science Foundations for Future Physicians. 2011 www.aamc.org/socialsciencesfoundation. DeMaria, S. Jr., DeMaria, A., Silvay, G., Flynn, B.C. (2011). Use of BATHE method in the preanesthetic clinic visit. Society for Ambulatory Anesthesiology. 111(5), 1020-1026. Searight, R. H. (2009). Realistic approaches to counseling in the office setting. Am Fam Physician. Feb 15;79(4):277-284 STFM: The family medicine clerkship curriculum. STFM website http://www.stfm.org/documents/fmcurriculum(v3).pdf Stuart MR, Lieberman JA. The fifteen minute hour: therapeutic talk in primary care. 4th Ed. Radcliff Publishing, Oxford, New York. ;2008. Reiser DE, Rosen DH. Medicine as a Human Experience. University Park Press. Baltimore, MD. 1984. IOM: Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Criteria. National Academy Press, 2004. Cassell, Eric J. Annals of Internal Medicine. Apr85, Vol. 102 Issue 4, p567. 2p.

STFM Student Conference 2012