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

2. 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

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

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

5. 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

6. 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

7. 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

8. The BATHE Technique

9. 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.

10. 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”

11. 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).

12. 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

13. Asking about Feelings …..

14. 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

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

16. Questions or Comments so far?

17. 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

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

19. “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

20. 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

21. 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

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

23. 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
Small group learning: Includes behavioral skills training
Traditionally longitudinal program. Student ownership of patients, required to have continuity.

24. 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 )
Action Plan (New for )
Ethical Dilemmas

25. 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

26. rned

27. 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

29. 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

30. 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

31. 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

32. Smoking Cards : #333

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

34. BATHE Card

35. 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

37. 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

39. 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

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

42. 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

43. References
AAMC: Behavioral and Social Science Foundations for Future Physicians
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),
Searight, R. H. (2009). Realistic approaches to counseling in the office setting. Am Fam Physician. Feb 15;79(4):
STFM: The family medicine clerkship curriculum. STFM website
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
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.

44. STFM Student Conference 2012