Vancouver, April rd Annual STFM Annual Spring Conference Vancouver, April 2010 Where is the Family in Family Medicine? Identifying Best Practices Among Family Medicine Programs Eliana C. Korin, Dipl.Psic. Victoria Gorski M.D. Nancy Newman, M.D. Amy Odom, D.O.

GOALS Promote a dialogue about where is the family in FM teaching Use a strategic and systemic framework to identify challenges and opportunities to teach family in our programs Identify useful strategies – “best practices” – to promote family teaching

Defining “Family” in Family Medicine Teaching Family as a way to promote a contextual and systemic approach to clinical care Family not simply as a discrete topic (family dynamics, etc) or curricular component

PLAN Introduction: Presenters, Audience, Goals, Plan Our Theme: Why a focus on family? Dialogue (Small Groups and Larger Group Discussion) Reflecting on Challenges and Opportunities Sharing “Best” Practices: Strategies and Methods Examples of “Best” Practices Presenters Invited Speakers and Senior Faculty

Introductions Who are We Who are You “Green”- 5 years or less in the field “Red” years in the field “Gold”- > 20 years in the field

Where is the Family in FM? “Family” as a central value in Family Medicine: contextual and relationship-centered care Influential contributions to the field: family scholars, publications, professional groups, etc Challenge: Be both a scientifically-based specialty and a champion of humanistic medicine Last decades: changes in the practice and teaching environments

Family and community? HIPPA REGULATIONS ACGME REQUIREMENTS PAYMENT SYSTEM EMR MEDICAL HOME FAMILY IN FAMILY MEDICINE Competencies evals Productivity demands Disease and financial focus Best Practices No family charts Family “Believers”

REFLECTIVE QUESTIONS: Considering your position and the context where you teach, What are some factors that facilitate or hinder the teaching of a “family” model in your residency program? What are some emerging opportunities– both in your program and in the field - that have facilitated (or could facilitate) the teaching of “family”? What are some strategies you have used to become influential and to promote “family”? Any “pearls”?

SMALL GROUP DIALOGUE Form groups by mixing recent, mid-career and senior faculty Identify yourselves: discipline, time teaching in FM, position, role re: family teaching Identify program: teaching context re: family teaching Share your experiences as per previous questions

SMALL GROUP ACTIVITY Identify yourselves and your program Questions- Factors that facilitate or hinder the teaching of a “family” model in your residency program? Emerging opportunities– both in your program and in the field - that have facilitated (or could facilitate) the teaching of “family”? Strategies you have used to become influential and to promote “family”? Any “pearls”?

LARGE GROUP DISCUSSION CHALLENGES/ OPPORTUNITIES STRATEGIES

Strategies for bringing Family into Family Medicine Residency Teaching

WORK CONTEXT Fatigue Residency Culture Systems thinking Creative thinking Sharing experiences Supervisor structure/ access Work/ non work balance Time Self - reflection Habit of inquiry Workload Resident’s Competencies 1.Professionalism 2.Patient-Centered Care 3.Medical Knowledge 4.Practice-Based Leadership and Improvement 5.Interpersonal and Communication Skills 6.Systems-Based Practice Shared vision Trust Flexibility/ adaptability Team Functioning Adapted from Hoff J T., Pohl H. and Bartfield J. Creating a Learning Environment to Produce Competent Residents: The Roles of Culture and Context. Academic Medicine Vol 79, No. 6 June 2004

A “GREEN” PERSPECTIVE 1. Be a Champion 2. Permeate the Educational Environment 3. Lead By Example 4. Build a Concrete Curriculum 5. Utilize the Resources of Others

1. Become a Champion Identify needs and opportunities for family teaching in your context Find collaborators Activate involvement of interested but busy medical faculty Build partnerships with behavioral science faculty Enlist all faculty to create a culture change: Faculty development Co-teaching of didactic material Co-precepting

2. Permeate the Educational Environment Family is generally not lecture material Resident Wellness Doctor-Patient Communication Precepting Highlight obvious family opportunities Hospital care, home visits, ECF care, group visits Leading by example

3. Lead by Example Attendings need to practice side by side with residents and be examples of “family-oriented” physicians When sharing patients tell the patient’s “story” give them the family context to enrich the experience Routinely see family members together Ask pt to speak to spouse, parent, child etc. Invite residents to family conferences for your patients

4. Have Concrete Curricular Elements Specific curriculum elements are necessary to keep the concept of family tangible Curriculum establishes a place for family Guards against “institutional memory loss”

5. Utilize the Resources of Others Family-Oriented Primary Care. Susan McDaniel et al. New York: Springer, Working with Families: Case- based Modules on Common Problems in Family Medicine. Toronto: The Working with Families Institute (2003).

A GOLDEN PERSPECTIVE The “culture”: Family as a value The organizational structure re: behavioral science

THE CULTURE The Culture: “Family” as a Value Commitment to social medicine Strong legacy of a family systems orientation Interdisciplinary collaboration Family “champions” among faculty

THE ORGANIZATIONAL STRUCTURE The Organizational Structure: Director of behavioral science part of the leadership Support and partnership with residency director Medical and behavioral science faculty collaboration Integrated medical-psychosocial curriculum

CHALLENGES Complacency re: legacy of family oriented-care; behaviors not necessarily congruent w/ values Practice changes: Poor incentives to involve families or family members (less time/ reimbursement, HIPPA,etc) Fewer faculty trained in family systems Competition with other themes or curricular initiatives EMR

STRATEGIES Emphasis on oriented precepting: use of genogram (faculty “reminders”) Family systems electives (residents as “champions”) Balance between curriculum integration and “stand alone” topic Ongoing faculty development and orientation re: family issues and systems thinking Chronic care management initiatives Competencies: Family “everywhere”

Towards A Family-Centered Medical Home RESIDENCY TRAINING In the context of practice transformation ELECTRONIC HEALTH RECORD MENTAL HEALTH COLLABORATIVE CHRONIC CARE MANAGEMENT HEALTH PROMOTION INITIATIVES PT/FAMILY PARTICIPATION

Other Examples and Perspectives