Training Primary Care Residents In Integrated Settings Tailoring Behavioral Health to Residency Programs in Family Medicine and Beyond   Patrick Hemming, MD, MPH, Division of General Internal Medicine, Duke University Amber Hewitt, PsyD, Department of Community and Family Medicine, University of Massachusetts Rodger Kessler, PhD, Senior Scientist, American Academy of Family Physicians

Financial disclosure none

Outline Why focus on residency education? Research questions and survey findings Co-management and confidence Attitudes: Internal Medicine vs. Family Medicine Perceived learning Synthesis and next steps Questions

Why research residency education in BHI? Lack of evaluative reports

Why research residency education in BHI?

Why research residency education in BHI?

Research questions Is BH Co-management associated with residents’ confidence in managing BH? How do residents co-manage patients and perceive impact on their learning? What differences do FM and IM residents have in their perceptions of BHI? What learning topics are residents getting from co-management?

Methods Multi-site multi-specialty online survey 47 items, closed and open-ended questions Instrument developed by us Recruited IM and FM residencies from SGIM, AAFP networks Interviewed faculty to determine eligibility Subjects recruited via e-mail and in-person

Methods Independent Variables Total number of co-managed patients Type of co-management interactions Medical specialty Dependent Variables Confidence in managing BH conditions Attitudes toward BH co-management Receipt of feedback on co-management Qualitative themes of learning

Respondents 5 residencies (2 IM, 3 FM- 7 clinic sites) Maryland, Colorado, Massachusetts 2 Academic and 3 Community 2 Rural and 3 Urban 71.3 % Response Rate (117/163) 66 % Women 58 % White, 5 % Black, 35 % Asian

Research questions Is BH Co-management associated with residents’ confidence in managing BH? How do residents co-manage patients and perceive impact on their learning? What differences do FM and IM residents have in their perceptions of BHI? What learning topics are residents getting from co-management?

Co-management of MDD

Co-management by BH Condition

Research questions Is BH Co-management associated with residents’ confidence in managing BH? How do residents co-manage patients and perceive impact on their learning? What differences do FM and IM residents have in their perceptions of BHI? What learning topics are residents getting from co-management?

Learning Modes

Receipt of Feedback Percent receiving feedback   Percent receiving feedback Adjusted Odds Ratio (95 % CI) No shared appointment or face-to-face meeting 9 % (2/21) n/a Met face-to-face, no shared appointment 50 % (15/30) 7.9 (1.9 - 46.3) Shared appointment, no outside face-to-face meeting 62 % (13/21) 12.0 (1.9 – 75.8) Shared appointment and face-to-face meeting 73 % (30/41) 21.2 (3.4 – 131.7)

Research questions Is BH Co-management associated with residents’ confidence in managing BH? How do residents co-manage patients and perceive impact on their learning? What differences do FM and IM residents have in their perceptions of BHI? What learning topics are residents getting from co-management?

Differences in Residency Training Family Medicine Internal Medicine 3 years Priority: outpatient training Some paths to subspecialty Program size often <40 ACGME requirements for BH 3 years Priority: inpatient training Primary pathway to > 12 subspecialties Program size 60-150 No ACGME requirements for BH

Comparing IM residents to FM residents   Internal Medicine Family Medicine p value Involvement of IBHC diminishes PCP role 40 % 15 % <.01 Considered presence of BHI in choice of residency 22 % 64 % BHI has strong positive impact on patient care 42 % 67 %

Research questions Is BH Co-management associated with residents’ confidence in managing BH? How do residents co-manage patients and perceive impact on their learning? What differences do FM and IM residents have in their perceptions of BHI? What learning topics are residents getting from co-management?

Types of Learning: Categories and Themes

What did you learn? Co-management and Skills Specific Conditions Opioid dependence Chronic pain Depression Anxiety Management Strategies Weight loss strategies Quick interventions in a single visit 12/5/2018

Types of Learning: Categories and Themes

What did you learn? Interpersonal skills “I learned to ask what other concerns the patient has-- if there is a part that is missing from what the patient is telling me-- that can help the therapeutic relationship.” “I learned to allow the patient to vocalize what form of treatment would be the best for her.”

Types of Learning: Categories and Themes

What did you learn? New Attitudes “With BHI, patients have additional support and tend to be more compliant” “BHI makes it less stressful to take care of complex patients.”

Synthesis Co-management fosters confidence Co-management seen as valuable Attitudes and barriers must be addressed Leverage existing educational imperatives

What next? Build multi-specialty approaches BH educational competencies Create and share BH teaching methods Evaluate and share findings

Questions and Discussion

What did you learn? Interpersonal skills   No Yes p value Feedback Received 7% (4) 28% (18) .015 Shared appointment 12 % (6) 24 % (15) .09

What did you learn? IM vs. FM  Theme Internal Medicine Family Medicine p value Interpersonal Skills 7% (4) 28% (18) <.01 BH Co-management 9 % (5) 30 % (19) Attitudes 12 % (8) 12 % (7) 0.942