Psychosocial problems are common in primary care, inpatient, and specialty medical settings (Gaynes et al., 2005; Manderscheid & Kathol, 2014; Rothenhäusler, 2006). It has also been well established that mental and physical problems are often comorbid (Buist-Bouwman, de Graaf, Vollebergh, & Ormel, 2005; Scott et al., 2007). Psychosocial difficulties can be detrimental to patients’ quality of life and place a financial burden on the healthcare system (Brenes, 2007). Research suggests that patients with medical and behavioral comorbidities have higher utilization of health care resources than patients with medical problems alone (Katon, 2003). Additionally, mental health and substance use disorders are anticipated to surpass physical disease as a cause of worldwide disability by 2020 (Crowley & Kirschner, 2015).

Primary care has been called the de facto mental health system (Kessler & Stafford, 2008). A factor partially responsible for this trend is that 50% to 90% of specialty referrals for behavioral medicine providers do not result in patients following through with making appointments (Callahan et al., 2002). As such, primary care physicians are delivering an increasing amount of behavioral medicine services, are treating a wider variety of psychosocial problems, and are prescribing a larger quantity and assortment of psychotropic medications (Olfson, 2016). While inpatient and non-psychiatric specialty physicians also have patients with psychosocial difficulties, literature on their role in treating these problems is scarce.

Despite the prevalence and severity of psychosocial problems in primary, specialty, and inpatient settings, many internal medical residencies do not require the integration of behavioral medicine education into training. For residency programs who do have training in the assessment and treatment of psychosocial problems it is often inadequate (Hemming & Loeb, 2013). In sum, internal medicine physicians are more frequently providing treatment for problems and disorders they received little training on during residency.

A solution to this issue is developing and implementing a comprehensive behavioral medicine curriculum into internal medicine residency (Hemming & Loeb, 2013). Doing so is a reasonable step toward addressing the need for more adequate assessment (Smith, 2011) and treatment of patients with a psychosocial problem (Stark, Joseph, & Pels, 2014). Many educators have come to incorporate psychosocial patient wellbeing and medical interviewing into their education protocols (Smith, 2011). However, there is still a call for a significant shift in educating residents in practical skills to manage common patient difficulties, such as anxiety, depression, substance misuse, and chronic pain (Smith, 2011). Additionally, there is a gap in the literature pertaining to evidence for integrating behavioral medicine training into internal medicine residency and how these curricula can meet the training needs of residents (Smith et al., 2014).

Due to the prevalence and seriousness of psychosocial issues and the lack of resident training aimed at addressing these problems, this article intends to cover the following aims:

1. Outline an approach to providing behavioral medicine education in internal medicine residency.

3. Describe evidence supporting the benefits of including behavioral medicine education in internal medicine residency.

3. Discuss resident qualitative feedback regarding components of a behavioral medicine curriculum.

The University of Nebraska Medical Center’s (UNMC) IRB personnel determined this to be a quality improvement project and consequently did not need IRB approval.

Setting

The UNMC internal medicine residency program consists of 70 categorical and primary care residents. The residency program is housed in a university hospital system with a traditional curriculum that includes monthly rotations and weekly continuity clinic. The residents’ clinical experiences include a 550-bed tertiary care facility with multiple active transplant programs, a VA healthcare system, and exposure to rural health care. The resident continuity clinic functions as a patient-centered medical home with a large underserved, medically complex patient panel. The residency program utilizes daily morning report and hour-long noon conferences as the primary method of educational delivery. The noon conference sessions encompass core medicine-based didactics in an 18-month recurring curriculum but also include quality improvement and patient safety case conferences and professional development sessions.

Resident Behavioral Medicine Education Program Description

Because of the aforementioned need and gap in training, our residency program implemented a behavioral medicine education curriculum. Residents participate in monthly didactic hour-long behavioral medicine noon conferences in which they learn about psychosocial aspects of patient care and best practices for enhancing the quality of patient-provider interactions. Noon conference lecture topics include the following: structuring the biopsychosocial interview, working with a team, psychotropic medication, brief psychosocial interventions, assessment and treatment of depression and anxiety, enhancing resident wellbeing, motivational interviewing, improving patient satisfaction, biopsychosocial pain management, and treating complex patients.

Residents also participate in behavioral medicine seminar sessions. Seminars consist of video reviews of patient encounters that residents deem “difficult” due to psychosocial concerns, adherence issues, or poor patient-provider relationship. Two to three residents join behavioral medicine faculty for these video review sessions that occur twice monthly. Each resident participates in two seminar sessions per academic year. Through review and discussion of recorded encounters, residents receive feedback from faculty and resident colleagues regarding current strengths, strategies for improving patient care, and enhancing patient-provider relationships.

Procedure

To evaluate the impact of the behavioral medicine education curriculum, we developed a survey feedback method for assessing curriculum utility and for determining which psychosocial skills residents perceived as most beneficial and which skills residents would still like to learn. Extant literature supports this method for the purpose of  determining if relevant learning has occurred (Cleary, Happell, Lau, & Mackey, 2013) and for curriculum modification (Goldfarb & Morrison, 2014). Receiving the input of the primary stakeholders themselves, the residents, has been an important step in assuring psychosocial training needs are met.

Following each component of the behavioral medicine curriculum, both noon conferences and seminars, for a 24-month period, 1^st, 2^nd, and 3^rd-year internal medicine residents completed a brief survey.

Survey

A four-question survey (See Table 1) was designed to provide a basis for understanding the strengths of the noon conferences and seminars and for identifying areas that need improvement to best meet resident needs. Results of the survey for behavioral medicine seminars and noon conferences are reported separately as a means to display the feedback for each component of the behavioral medicine education program. To promote anonymity, identifying information was not requested.

Table 1. Behavioral medicine survey questions

Analysis

Researchers utilized thematic analysis, a qualitative method used to identify and report patterns within data, to analyze responses from open-ended survey questions (Braun & Clarke, 2006). Researchers coded data and subsequently developed themes and sub-themes based on those codes. Descriptive statistics were used to identify the frequency of responses, which were coded under each theme.

Behavioral Medicine Noon Conference Survey Findings

Residents completed 52 surveys that contained at least one response. Feedback was positive overall. The majority of residents reported learning multiple behavioral medicine skills they plan to implement in their practice. Residents reported noon conferences were highly useful (mean=8.1, SD=1.3). Using thematic analysis, the following themes emerged.

Response themes: skills residents learned

Goal Setting. 18 out of the 64 responses to this survey question pertained to goal setting, making it the most frequently mentioned theme. Residents reported that learning to collaborativaely set goals with patients will be beneficial for their clinical practice. They also noted the perceived benefit of assisting patients with developing both short and long-term goals, and “asking patients to set his/her own goals instead of doing it for them.” Residents also noted learning the benefits of assessing patient barriers to meeting goals and recurrently checking in on patient progress toward goals.

Structuring patient encounters. With 17 responses, learning skills for structuring patient encounters was the second most commonly reported benefit of behavioral medicine noon conference. Setting the agenda as a means of guiding a patient visit was the most frequently cited structuring skill residents noted. Residents indicated that setting an agenda could help them to save time, feel less rushed, maintain a better conversation, and prevent “derailed” encounters.

Self-care. There were a total of eight comments regarding the importance of learning about self-care. Residents noted that learning ways to decrease guilt surrounding their work and home life, using gratitude in daily practice, and attempting to develop a more helpful perspective were especially applicable skills. Making time for family and exercise were also mentioned as activities residents planned to implement in their lives.

Chronic pain. Five residents reported that learning about non-pharmacological strategies to manage chronic pain would be useful in their clinical practice. They also indicated that learning strategies for discussing pain management goals with patients was constructive and thought that helping patients “manage the pain rather than cure the pain” could be a useful strategy.

Patient-provider relationship. Residents reported learning ways to improve the patient-provider relationship. These skills included showing empathy and meeting patients where they are.

Whole-patient care. Comments in this theme pertained to taking into greater consideration how a disease impacts all aspects of patients’ lives and how the patient's illness impacts their family.

Teach back. Residents commented on the benefits of learning about specific “teach back” techniques. This skill allows them to tailor patient education to specific patient needs, after first gaining an understanding of what the patient knows about managing their disease. 

Table 2.  Themes of skills residents reported learning

Response themes: additional skills residents would like to learn

Strategies for patient conversations. Residents most frequently commented on wanting to learn more about strategies for facilitating useful patient conversations, particularly with patients who are resistant to trying any treatment other than medications for psychosocial problems, redirecting patients, asking “difficult” questions about drugs and sexual history, and training for additional methods for making encounters more structured.

Pain management. Residents wanted to review more about specific elements of non-pharmacologic interventions for pain as well as “chronic pain counseling [and] discussion tips.”

Practice and examples. Residents mentioned a desire for additional practice using behavioral medicine skills they learned in noon conferences. Responses indicated that use of videos or examples would be beneficial in enhancing skills.

Relaxation strategies. Residents reported wanting more preparation on non-pharmacologic methods for helping patients relax.

Resident wellness. Learning more about resident wellness and strategies for developing specific techniques for promoting personal resilience during residency was requested.  

Medication adherence. Residents stated they wanted to gain additional skills related to interviewing patients about their medication-related beliefs and how to address treatment compliance issues with patients.

Table 3. Requested noon conference education topic themes

Notable “Additional Comments” regarding the noon conferences include: “I took a lot from this and will definitely affect my patient discussions,” “Very useful. I enjoyed & learned a lot in these sessions,” and “More specific examples with case scenarios would be helpful.”

Behavioral Medicine Seminar Survey Findings

Residents returned 24 surveys that had a minimum of one survey question answered. Again, the response was generally positive. The majority of residents indicated having learned multiple behavioral medicine skills and principles they plan to use in their professional practice. Residents reported the behavioral medicine seminar was highly useful (mean=8.3, SD=1.4). Using thematic analysis, the following themes emerged.

Response themes: skills residents learned

Strategies for patient communication. The most frequently cited theme was enhancing patient communication strategies. Residents reported that the following communication strategies will likely be useful in their clinical practice: agenda setting, discussing patients’ goals for care, collaboratively creating a treatment plan with the patient, and effectively using teach back strategies. One resident commented that they plan to “do better at allowing patients to talk more/expand without interrupting or interjecting.”

Patient-centered approaches. Nine residents reported that learning how to deliver patient-centered care was beneficial. Specific skills for a patient-centered approach to care included learning to recognize and comment on positive health behaviors patients already engage in to meet their health goals, encouraging patients to actively participate in their own healthcare, and assisting patients with identifying perceived barriers to meeting health-related goals.

Facilitating difficult interactions. Residents gained useful knowledge and skills regarding how to facilitate difficult interactions. Residents commented on learning strategies for asking “difficult” questions (e.g., sexual history, drug use), talking about depression, and discussing the potential benefits of scheduling an appointment with a behavioral medicine provider. They also reported having learned skills for facilitating conversations with patients who have chronic pain and are convinced medication is the only legitimate option for control.

Motivational Interviewing. Three residents noted that it was beneficial to learn Motivational Interviewing techniques, such as pointing out discrepancies in patient desires and behaviors and using scaling questions. They also noted learning conversation starters to assist patients with enhancing their motivation for health behavior change.

Table 4. Themes of skills residents reported learning

Response themes: additional skills residents would like to learn

Motivation enhancement. 16 of the 29 surveys indicated the residents were interested in learning more about motivation enhancement. Specific responses related to residents wanting to discern how to address patient noncompliance with treatment and specific strategies for facilitating conversations about health behavior change.

Patient social support. Six respondents reported they wished to learn additional skills for engaging social support in patient care by including family members in patient care, managing interactions with upset family members, and exploring types of social support available to patients during encounters.

Mental health. Five responses indicated that they wanted additional skills to assess for mental health difficulties appropriately and wished to develop skills such as biofeedback or relaxation techniques to employ with patients who do not want to see a behavioral medicine provider.

Pain management. Residents also wished to learn more about how to discuss coping skills for managing chronic pain with patients. They additionally wanted to develop skills for having productive conversations with patients who appear to be seeking narcotics.

Table 5. Requested behavioral medicine seminar education topic themes

Notable “Additional Comments” regarding behavioral medicine seminar include: “Continue doing video review- helpful,” “I took a lot from this and will definitely affect my patient discussions. Thanks!,” “Seeing yourself interview a patient and getting input from co-residents is a great self-improvement strategy,” “Very resident education focused, great feedback, valuable experience,” and “Always helpful to watch yourself [and] bounce ideas off each other.”

Skills Residents Learned

Residents indicated that they valued the knowledge and skills gained through the behavioral medicine program, in both the noon conferences and behavioral medicine seminars. Topics that were reported to be particularly beneficial include strategies for patient communication, goal setting, and structuring patient encounters. These topics are reflected in the previous research, which purports effective patient-provider communication is not only crucial in optimizing patient care, it is also a skill that can improve with training (Ravitz et al., 2013). Researchers have noted that patient-centered communication improves patient satisfaction and enhances physician self-efficacy, empathy, and reduces physician burnout (Boissy et al., 2016).

Residents also reported that they learned self-care strategies and ways to manage difficult patient interactions. Research has shown a positive association between the frequency of difficult patient interactions and burnout (An et al., 2009). Thus, using both self-care strategies and applying effective management of difficult patient interactions could enhance both patient and resident experience and satisfaction. Considering physicians frequently encounter challenging patients (An et al., 2009), it was unsurprising that self-care was a frequently stated theme residents reported both learning and wishing to learn more about it. Preparing residents for these encounters may be beneficial, given their challenging nature and relationship to burnout.

There were additional, notable benefits of the behavioral medicine curriculum. First, through small group and individual video review sessions we were able to observe residents’ ability to self-reflect, give and receive feedback, and understand and respond to unique patient characteristics. Second, through guided reflection during video reviews, residents were able to meaningfully witness and consider their professional identity. Professional identity has been described as a core element of being a physician and necessary for the physician’s wellbeing (Wald, 2015). Consistent with extant literature, we found that fostering a space for learning and reflecting on communication skills, difficult interactions, and the structure of patient encounters through deliberate practice can assist learners with identity formation (Cruess, Cruess, Boudreau, Snell, & Steinert, 2015).

Overall, our findings indicate residents perceived the behavioral medicine program and the topics they learned to be useful in practice. This supports the call for behavioral medicine education to be included in internal medicine residency programs (Smith, 2011). It also reflects ACGME’s requirement for competencies pertaining to a residents’ ability to demonstrate knowledge and application of social-behavioral sciences (ACGME, 2017).

Additional Skills Residents Would like to Learn

Residents indicated that they may benefit from the inclusion of additional subjects into the behavioral medicine program. These topics included education on patient motivation enhancement, engaging patient social supports, patient/physician communication tools, and mental health assessment and treatment. The following is a discussion of residents’ desire for additional education, ways in which these topics are reflected in the extant literature, and how this curriculum can be altered to better meet resident needs.  

It is not surprising that residents expressed a desire to learn more about enhancing patient motivation. Physicians frequently encounter patients who are overweight or engage in poor health behaviors such as smoking, substance use, or are physically inactive (Khaw et al., 2008). Additionally, research has estimated a significant percentage patients do not take their medications as prescribed (DiMatteo, 2004). These are conditions and behaviors which are often perceived as being well within the patient’s ability to change. The behavioral medicine program has already incorporated Motivational Interviewing (MI) into the curriculum to address problems such as these. Although MI has an extensive evidence base for addressing health behaviors(Martins & McNeil, 2009), it may be that residents desire additional tools for motivation enhancement or that residents do not feel competent in effectively and consistently practicing MI.

Residents indicated that they wanted additional education that could assist them with conducting encounters with patients’ friends or family members present. They observed that, at times, these encounters are difficult to facilitate. While the published literature on this topic is scarce, some authors have echoed for the importance of developing competence for family-oriented encounters (McDaniel, Campbell, Hepworth, & Lorenz, 2005). It may be that most residents learn skills to conduct encounters with friends or family members present through clinical experience rather than formal education. Supplementing clinical experience with additional formal education on this topic would be beneficial and, because patients often bring family members of friends to medical appointments, would serve to reflect real-world clinical experience (Fraenkel & McGraw, 2007).

Results showed residents wanted to become familiar with additional strategies for patient communication. This is encouraging given that patients also value positive patient-physician interactions (Berman & Chutka, 2016). While not all physicians are good communicators, research suggests that positive communication skills can be learned (Berman & Chutka, 2016). It is possible that residents specified that they desired to learn additional strategies for patient communication because these skills take time and practice to master and effectively use.

Finally, residents reported a perceived need for additional education on mental health assessment and treatment in the behavioral medicine curriculum. This reported need makes a great deal of sense, since there is a high number of patients seen in medical settings with co-morbid mental health difficulties (Ansseau et al., 2004). Addressing this need could include additional training on assessments that can be used to make an appropriate diagnosis, and using brief interventions such as relaxation exercises which give patients tools to better manage mental health and psychosocial symptoms.

Limitations

This article has two major limitations. First, not all residents in the program completed the surveys used for this study. Due to the anonymous nature of the surveys, we were unable to track the percentage of residents who completed the questionnaire. Consequently, there may be differences between the residents who completed the survey and those who did not. Second, study participants were residents from one internal medicine residency program and, thus, the extent our findings are generalizable is uncertain. It should be noted that successful behavioral medicine education implementation in other internal medicine residencies may take a different form, depending on the characteristics of each residency program.

Due to the importance of resident behavioral medicine education, future research should incorporate detailed outlines of behavioral medicine curricula and provide both methods for and results from evaluating this training. The number of published articles on evidence-based behavioral medicine curriculum in internal medicine residencies is limited (Smith et al., 2014). Therefore, it would be beneficial to evaluate the effectivness of curricula on key resident training needs, such as clinical competencies and patient outcomes. Doing so would allow residencies to identify a useful format for behavioral medicine training.

Behavioral medicine education provides essential skills for internal medicine residents. Training on psychosocial topics and skills allows for residents to effectively assess for and treat psychosocial difficulties that commonly accompany patient biomedical concerns. Based on results from the current study, residents may benefit from a curriculum that specifically focuses on the development of skills such as engaging patients’ social support in treatment, developing effective patient-physician communication, and enhancing motivation. Residency programs interested in developing a behavioral medicine program may benefit from including didactic and video review components, and integrating a program evaluation protocol that allows for continued assessment and modification to best meet resident education needs.