TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER DEPARTMENT
OF
FAMILY & COMMUNITY MEDICINE
Family Medicine Residency Program
Behavioral Science Curriculum Lance Evans, Ph.D. Director of Behavioral Science
BSC 3.2.2 (12/01/2010)
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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TABLE
OF
CONTENTS
Introduction to Behavioral Science in Family Medicine ...................................................... 4 Overview of Behavioral Science Curriculum .................................................................... 11 Explanation of Behavioral Science Methodologies ............................................................ 13 Tuesday Conference Behavioral Science Lectures & Workshops (TC) .......................... 13 Support Groups (SG) ................................................................................................... 14 Balint Group (BG) ....................................................................................................... 15 Behavioral Science Precepting: Family Medicine Clinic (BSP-F) .................................. 16 Behavioral Science Consulting (BSC)........................................................................... 17 Office Rotation ............................................................................................................ 18 Independent Studies in Behavioral Science (ISBS) .................................................. 18 Shadowed Encounters (SE) ..................................................................................... 19 Videotaped Encounters (VE) ................................................................................... 20 Behavioral Science Chart Review (BSCR) ............................................................... 21 Self-Study in Patient Satisfaction (SSPS) .................................................................. 22 Complex Case Conference (CCC) .......................................................................... 23 Behavioral Science Precepting: Pain Clinic (BSP-P) ................................................ 24 Personal Learning & Development Plan (PLDP) ..................................................... 25 Appendix.......................................................................................................................... 26 Developmental Assessment of Medical Interviewing Skills (DAMIS) ........................... 27 Behavioral Science Chart Review Form ....................................................................... 30 Self-Study in Patient Satisfaction Form ......................................................................... 31
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Complex Case Conference Guidelines ........................................................................ 32 Behavioral Science Family Medicine Pain Clinic Handbook ....................................... 37 Personal Learning & Development Plan Forms............................................................ 50
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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INTRODUCTION
TO
BEHAVIORAL SCIENCE
IN
FAMILY MEDICINE
The Philosophy of Family Medicine In the United States, there are currently 26 medical specialty boards.1 Of these specialties, Family Medicine is the only one based on an ideal (as opposed to a demographic population, procedure, disease, or part of the anatomy). Why is this and what is the ideal upon which Family Medicine is based? Family Medicine, which was established as a medical specialty in 1969, rests on a three-part ideal. William Stewart, one of the specialty’s founders, explains: …the first requirement for any physician is to know that part of medical science which is the foundation for the medicine he or she practices. The requirement is no less important for the Family Physician. The second requirement for a Family Physician is to understand the person of the patient, how he or she reacts to stress, how he or she copes. I believe those insights are best gained by understanding the development of a person, and that brings us back to the family. This understanding sets the stage for accepting a patient where he or she is and remaining nonjudgmental. This information and attitude serves one well in helping patients solve their psychosomatic and psychological problems. Lastly, it is the person, or self, or personhood of the Family Physician that interacts with the patient, that communicates concern and understanding, that establishes a trusting and tenured doctor-patient relationship. Without this relationship, patients are unlikely to provide a full and accurate history complete with their feelings (which are often even more important). This relationship is likewise essential if the patient is to accept the suggestions and advice of the Family Physician. I believe young physicians need to gain insight into their motivations, to learn how and when to use their personhood in behalf of their patients. To me, this is the essence of being a Family Physician rather than a mere doctor of medicine.2 More recently, the American Academy of Family Physicians states: Family medicine is a three-dimensional specialty, incorporating (1) knowledge, (2) skill, and (3) process. Although knowledge and skill may be shared with other specialties, the family medicine process is unique. At the center of this process is the patient-physician relationship with the patient viewed in the context of the family. It is the extent to which this relationship is valued, developed, nurtured and maintained that distinguishes family medicine from all other specialties.3 And finally, the scope of Family Medicine (as detailed by the American Academy of Family Physicians) highlights its uniqueness: Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family © 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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medicine encompasses all ages, both sexes, each organ system and every disease entity.4 Behavioral Science in Family Medicine Given Family Medicine’s philosophical underpinnings, scope, and focus on the doctorpatient relationship, it’s not surprising that the “behavioral sciences have been credited with a major role in shaping both the specialty of Family Medicine and Family Medicine’s identity as an academic discipline.”5 Despite this historical influence, however, many of today’s residents are unclear about the role of behavioral science in Family Medicine. To address this issue, the Society for Teachers of Family Medicine’s (STFM) Group on Behavioral Science recently proposed a set of core principles6 that were adopted by the STFM Board in November 2008. The core principles outline the role of behavioral science (and behavioral science faculty) in Family Medicine, and read as follows: The role of behavioral science faculty is to consult and teach physicians and other health care providers; treat patients and families with emotional, interpersonal, and psychosocial concerns; participate in scholarly activity; and continually upgrade knowledge and skills in behavioral science. Behavioral science faculty and practitioners operate from a core set of principles, drawing upon behavioral and social science pedagogy and research. These principles include elements of other related evidence-based fields such as behavioral medicine, behavioral health, health psychology, integrative medicine, and integrated mental and behavioral health. These core principles apply, but are not limited to, physicians, nurses, behavioral medicine specialists, social workers, psychologists, psychiatrists, and counselors working in health care or community settings. The identified core principles for behavioral medicine encourage practitioners to:
use biopsychosocial and relationship-centered approaches to care; promote patient self-efficacy and behavior change as primary factors in health promotion, disease prevention, and chronic disease management; integrate mental health and substance abuse care into primary health care services; integrate psychological and behavioral knowledge into the care of physical symptoms and diseases; promote the integration of sociocultural factors within the organization and delivery of health care services; emphasize the impact of familial, social, cultural, spiritual, and environmental contexts in patient care to improve health outcomes; practice a developmental and life cycle perspective with learners and patients; encourage and support provider self-awareness, empathy, and well-being.
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Behavioral Science in Family Medicine and the ACGME Core Competencies Although residency training in Family Medicine involves various rotations and experiences, graduate medical education as a whole is organized around six core competencies. These core competencies are mandated by the Accreditation Council for Graduate Medical Education (ACGME), and it is the task of residency educators to ensure that trainees are competent in all six areas as a prerequisite for graduation. The competencies, as articulated by the ACGME, are as follows:7 Core Competency Patient Care Medical Knowledge
Practice-based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Definition Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Residents are expected to develop skills and habits to be able to meet the following goals: identify strengths, deficiencies, and limits in one’s knowledge and expertise; set learning and improvement goals; identify and perform appropriate learning activities; systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement; incorporate formative evaluation feedback into daily practice; locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems; use information technology to optimize learning; and, participate in the education of patients, families, students, residents and other health professionals. Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to: communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds; communicate effectively with physicians, other health professionals, and health related agencies; work effectively as a member or leader of a health care team or other professional group; act in a consultative role to other physicians and health professionals; and, maintain comprehensive, timely, and legible medical records, if applicable. Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate: compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy; accountability to patients, society and the profession; and, sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Systems-based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to: work effectively in various health care delivery settings and systems relevant to their clinical specialty; coordinate patient care within the health care system relevant to their clinical specialty; incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate; advocate for quality patient care and optimal patient care systems; work in interprofessional teams to enhance patient safety and improve patient care quality; and participate in identifying system errors and implementing potential systems solutions.
To elucidate the process by which (Family Medicine) residents develop competency in the six core competencies, the ACGME has endorsed a competency development model based on the work of Stuart and Hubert Dreyfus.8 The model identifies six progressive steps to skill acquisition: novice, advanced beginner, competent, proficient, expert, and master. According to this model, early skill acquisition is dependent on adherence to rules, and progression and development to the more advanced stages occurs as practitioners become less dependent on rules and more on context. Applying the model to residency training, the ACGME asserts that interns theoretically begin residency as advanced beginners and, over the course of their residency training, advance to the competent stage as training, education, and progressive experience help them develop from methodical, rule-bound problem-solvers to intuitive responders.9 A graphic illustration of the Dreyfus model is provided below.
Interns – adherence to rules; methodical, rule-bound problemsolvers. Residency Training & Education
Residency Graduates – intuitive responders; pattern recognition, contextual understanding.
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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For Family Medicine, the behavioral sciences are an integral part of all six core competencies. For example, it is well-documented that (a) primary care is the de facto mental health provider in the United States,10 and (b) behavior (e.g., lifestyle, diet, exercise, smoking, drinking, medication adherence) has a significant impact on the onset, course, and outcome of medical conditions.11 From these examples, the need for behavioral science education is clear in both the Patient Care and Medical Knowledge competencies. However, there are other competencies (e.g., Interpersonal and Communication Skills) that require an understanding of applied behavioral science concepts. Conceptually, these two areas can be categorized as Behavioral Science Content and Applied Behavioral Science Principles. 1. Behavioral Science Content: Behavioral Science topical knowledge or content necessary to function as a competent Family Physician. Although there are myriad Behavioral Science topics that could be covered over the course of residency training, Marvel and Major12 have provided a survey-based, rank-order list of the most important Behavioral Science topics to be taught in Family Medicine residency. The 28 topics in this survey were ranked on a 4-point scale (with 1 = low importance and 4 = high importance): Depression (3.79) Anxiety (3.53) Lifestyle and behavior change, smoking cessation (3.48) Headaches (3.39) Difficult patients (3.37) Interviewing techniques (3.37) Stress-related disorders (3.37) Geriatrics (3.36) Physician well-being and self-awareness (3.27) Patient education (3.26) Chronic pain (3.24) Substance abuse (3.16) Death and dying (3.15) Child behavior problems (3.06) Adolescent care (3.05) Chronic medical illness (2.94) Somatoform disorders (2.91) ADHD (2.90) Psychiatric emergencies (2.89) Sleep problems (2.88) Family violence (2.86) Community resources (2.78) Sexual problems (2.75) Family skills (2.64) Eating disorders (2.64) © 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Psychotic disorders (2.48) Culture/diversity issues (2.42) Enuresis/encopresis (2.40)
2. Applied Behavioral Science Principles: In addition to topically-based content, Daugherty13 has suggested that Behavioral Science should be taught as applied principles. Examples include: Interpersonal process (doctor-patient relationship) Communication skills Time management Readiness to Change Collaborative Care (e.g., working with psychologists, other physician specialties, ancillary staff) Motivational Interviewing Fundamental Attribution Error Systems Theory Cultural Competence Transference and Countertransference In sum, a robust Behavioral Science education is necessary to ensure that Family Medicine residents become competent in the six ACGME core competencies. What follows in the remaining sections of this document is a description of the TTU-HSC Family Medicine Behavioral Science curriculum. References 1. American Board of Medical Specialties. Specialties and Subspecialties (http://www.abms. org/Who_We_Help/Physicians/specialties.aspx). Accessed January 16, 2009. 2. Stephens GG et al. The intellectual basis of Family Medicine revisited. Family Medicine. 1985;17(5):219-230. 3. American Academy of Family Physicians. Scope and Philosophical Statement of Family Medicine. (http://www.aafp.org/online/en/home/policy/policies/f/scopephil.html) 4. American Academy of Family Physicians. Definition of Family Medicine. (http://www.aafp.org/online/en/home/policy/policies/f/fammeddef.html) 5. Fischetti LR, McCutchan FC. A contextual history of the behavioral sciences in family medicine revisited. Families, Systems, & Health. 2002;20(2):113-129. 6. Society for Teachers of Family Medicine Group on Behavioral Science. Core principles of behavioral science in family medicine (http://www.stfm.org/group/behavioral.cfm). 7. Accreditation Council for Graduate Medical Education. The ACGME Outcome Project (http://www.acgme.org/Outcome). 8. Dreyfus HL, Dreyfus SE. Mind over machine: The power of human intuition and expertise in the era of the computer. New York, NY: Free Press; 1986. 9. Batalden P, Leach D, Swing S, Dreyfus H, Dreyfus S. General competencies and accreditation in graduate medical education. Health Affairs. 2002;21(5):103-11. © 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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10. deGruy F. Mental health care in the primary care setting. In: Institute of Medicine, Division of Health Services, Committee on the Future of Primary Care. Primary care: America’s health in a new era. Washington, DC: National Academy Press, 1996: 285311. 11. Cuff PA, Vanselow N, eds. Introduction. In: Improving medical education: Enhancing the behavioral and social science content of medical school curricula. Washington, DC: The National Academies Press, 2004. 12. Marvel K, Major G. What should we be teaching residents about behavioral science? Opinions of practicing family physicians. Family Medicine. 1999;31(4):248-251. 13. Daugherty SR. Principles, not topics: An alternative approach to thinking about the behavioral sciences in medical education. Annals of Behavioral Science and Medical Education. 2005;11(1):40-43.
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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OVERVIEW
OF
BEHAVIORAL SCIENCE CURRICULUM
Using the ACGME core competency categories as a guide, the following table outlines the goals and objectives of the Behavioral Science curriculum. PATIENT CARE Goal: Provide compassionate, appropriate, and effective patient care based on an integrative understanding of the patient. Objectives Methodology Demonstrate ability to gather essential and accurate biological, Primary psychological, and social information from patients. BSP-F, BSP-P, BSC, BSCR, Demonstrate ability to formulate an integrative (bio-psycho-social) SSPS, CCC assessment of patient. Demonstrate ability to treat patients’ health problems and psychosocial Secondary TC, BG, SE, or mental health conditions compassionately, appropriately, and VE, ISBS effectively, based on an integrative understanding of patient.
MEDICAL KNOWLEDGE Goal: Residents must demonstrate knowledge of the social-behavioral sciences (established and evolving), as well as the application of this knowledge to patient care. Objectives Methodology Primary TC, BSP-F, Demonstrate knowledge of the social-behavioral sciences relevant to BSP-P, BSC, Family Medicine. BSCR, ISBS, Apply knowledge of the social-behavioral sciences relevant to Family CCC Medicine. Secondary SE, VE
INTERPERSONAL & COMMUNICATION SKILLS Goal: Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Objectives Methodology Primary BG, BSP-F, Communicate effectively with patients and their families, as BSP-P, BSC, appropriate, across a broad range of socioeconomic and cultural SE, VE, CCC backgrounds. Secondary Communicate effectively with Behavioral Science faculty and staff. TC, SG, SSPS, ISBS © 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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PRACTICE-BASED LEARNING & IMPROVEMENT Goal: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Objectives Methodology Identify strengths, deficiencies, and limits of one’s own knowledge. Systematically analyze practice using quality improvement methods, Primary and implement changes with the goal of practice improvement. BG, SE, VE, Set learning and improvement goals. BSCR, SSPS, CCC, PLDP Identify and perform appropriate learning activities. Secondary Incorporate formative evaluation feedback into daily practice. SG, BSP-F, Locate, appraise, and assimilate evidence from scientific studies BSP-P, BSC related to patients’ health problems. Participate in the education of patients, families, students, residents and other health professionals. PROFESSIONALISM Goal: Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Objectives Methodology Primary Demonstrate compassion, integrity, and respect for patients. SG, BG, SE, Demonstrate responsiveness to patient needs that supersedes selfVE, SSPS, interest. CCC Demonstrate respect for patient privacy and autonomy. Secondary Demonstrate sensitivity and responsiveness to a diverse patient TC, BSP-F, population (e.g., gender, age, culture, race, religion, disabilities, and BSP-P, BSC, sexual orientation). PLDP SYSTEMS-BASED PRACTICE Goal: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Objectives Methodology Primary BSP-F, BSP-P, Coordinate patient care within the health care system relevant to BSC, CCC Family Medicine. Secondary Work in inter-professional healthcare teams to improve patient care TC, SG, BG, quality. BSCR, ISBS, PLDP
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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EXPLANATION Activity:
Explanation:
Targeted Core Competencies: Year Completed: Goals: Objectives: Evaluation:
OF
BEHAVIORAL SCIENCE METHODOLOGIES
Tuesday Conference Behavioral Science Lectures & Workshops (TC) For approximately 10 of the 12 months of each academic year, a behavioral science lecture or workshop activity will be scheduled on the first Tuesday of the month from 2:00-3:00. These lectures and workshops will be facilitated by Dr. Evans. When possible, the content of the Behavioral Science lecture or didactic activities will be organized around one of the 18 monthly themes of the residency curriculum. The lectures/workshops will come from one of the following topics: Common Psychiatric Disorders in Primary Care (given annually) Physician Well-Being & Self-Awareness (given annually) Stress Related Disorders in Primary Care Suicide Assessment in Primary Care Somatic Fixation in Primary Care Health Behavior Change, Smoking Cessation Headaches & Insomnia in Primary Care Finishing Well: 7 Strategies for Organizing a Medical Visit BATHE Technique Domestic Violence in Primary Care Childhood Behavioral Problems in Primary Care Death, Dying, & End-of-Life Issues Patient Education & Health Literacy Personality Disorders in Primary Care Quadrants of Care Model Collaborative Care Emotional IQ & Leadership Patient Satisfaction Substance Abuse in Primary Care Trust in the Physician-Patient Relationship Cultural Competency in Primary Care Medical Knowledge PGY-I, PGY-II, PGY-III This activity will enable residents to obtain knowledge of the socialbehavioral sciences (established and evolving) relevant to Family Medicine. Residents will demonstrate a developmentally-appropriate level of knowledge of the social-behavioral sciences (established and evolving) relevant to Family Medicine. Attendance and participation
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Activity:
Explanation:
Targeted Core Competencies: Year Completed:
Goals:
Objectives: Evaluation:
Support Group (SG) From July through August of each year, each resident will participate in a support group led by Dr. Evans. There are two different support groups: Intern Support Group and Upper-Level Support Group. Intern Support Group meets every Thursday from 12:00-1:00 PM. UpperLevel Support Group meets every third Wednesday of the month from 12:00-1:00 PM. Attendance at both of these activities is required, and residents are expected to be present unless they are on Family Medicine Service. Residents on rotation in other departments should let their respective attendings know in advance that they have a required departmental activity on the appropriate day. Residents are free to bring lunch to eat during these meeting. The purpose of both of these support groups is to provide a semi-structured opportunity to discuss/process residency-related issues in a supportive atmosphere. Topics for discussion may include: Adjustment to residency training Residency stressors Difficult attendings Residency logistical matters Adjustment to American/Western medicine or culture Interpersonal conflict Difficult rotations Difficult patient issues Professionalism PGY-I, PGY-II, PGY-III The AMA’s Code of Ethics states that “a physician shall be dedicated to providing competent medical care.” Part of being a competent physician involves self-awareness and self-care, so as to ensure that stress, personal matters, interpersonal difficulties, etc. do not adversely affect patient care. This activity will enable residents to develop a commitment to carrying out professional responsibilities in accordance with this ethical principle. Residents will demonstrate a developmentally-appropriate ability to respond to patient needs in a manner that supersedes self-interest. Attendance and participation
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Activity:
Explanation:
Targeted Core Competencies: Year Completed:
Goals:
Objectives:
Evaluation:
Balint Group (BG) From August through May of each year, upper-level residents will participate in a Balint Group led by Dr. Evans and a physician faculty member. Balint Group meets on the third Wednesday of the month from 12:00-1:00 PM. Attendance at Balint Group is required, and residents are expected to be present unless they are on Family Medicine Service. Residents on rotation in other departments should let their respective attendings know in advance that they have a required departmental activity on the appropriate day. Residents are free to bring lunch to eat during this meeting. The purpose of the Balint Group is to provide a learning experience whereby residents can develop an enriched understanding of the doctor-patient relationship and the therapeutic possibilities of communicating more skillfully with patients. Interpersonal & Communication Skills, Practice-Based Learning & Improvement, Professionalism PGY-I, PGY-II, PGY-III This activity will enable residents to develop: Interpersonal and communication skills that result in the effective exchange of information and collaboration with patients and their families; The skills needed to investigate, evaluate, and improve their care of patients; and A commitment to carrying out professional responsibilities in accordance with ethical principles. Residents will demonstrate a developmentally-appropriate ability to: Communicate effectively with patients and their families, across a broad range of socioeconomic and cultural backgrounds; Convey compassion and respect for patients; Respond to patient needs in a manner that supersedes self-interest; and Use feedback, discussion, and self-acquired insight to identify strengths, deficiencies, and limitations with respect to interpersonal and communication skills and professionalism. Attendance and participation
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Activity:
Explanation:
Targeted Core Competencies: Year Completed:
Goals:
Objectives:
Evaluation:
Behavioral Science Precepting: Family Medicine Clinic (BSP-F) Dr. Evans will provide behavioral science precepting (i.e., supervision, guidance, and teaching) for residents at select times in the Family Medicine Clinic. Behavioral science precepting in the Family Medicine Clinic will focus on a broad range of issues including: assessment-diagnostic issues, mental health and psychosocial conditions, doctor-patient relationship issues, behavior change, adherence, treatment and referral issues, difficult patient encounters, cross-cultural issues, end-of-life issues, individual and family responses to illness and disease, somatic fixation, or any other psychosocial issue that affects the process and outcome of healthcare. Patient Care, Medical Knowledge, Interpersonal & Communication Skills, Systems-Based Practice PGY-I, PGY-II, PGY-III This activity will enable residents to: Provide compassionate, appropriate, and effective patient care based on an integrative understanding of the patient; Obtain knowledge of the social-behavioral sciences (established and evolving), as well as the application of this knowledge to patient care; and Develop interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals; and Develop an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents will demonstrate a developmentally-appropriate ability to: Gather essential and accurate biological, psychological, and social information from patients. Formulate an integrative (bio-psycho-social) assessment of patient. Treat patients’ health problems and psychosocial or mental health conditions compassionately, appropriately, and effectively, based on an integrative understanding of patient. Obtain and apply knowledge of the social-behavioral sciences (established and evolving) to patient care. Communicate effectively with patients and their families, across a broad range of socioeconomic and cultural backgrounds; Communicate effectively with Behavioral Science faculty and staff; Coordinate patient care within the health care system; and Work in inter-professional healthcare teams to improve patient care quality. BSP-F Evaluation Form
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Activity:
Explanation:
Targeted Core Competencies: Year Completed:
Goals:
Objectives:
Evaluation:
Behavioral Science Consulting (BSC) Dr. Evans will provide behavioral science consultation for residents on a PRN basis. Behavioral science consultation includes “curbside” consultations, as well as more extensive workups or assessing/treating patients conjointly. The purpose of behavioral science consultation is to provide residents with an opportunity to learn the skills necessary to work in a collaborative and consultative manner with a behavioral science professional in patient matters such as mental health or psychosocial assessment/treatment, physician-patient relationship issues, referral issues, etc. Patient Care, Medical Knowledge, Interpersonal & Communication Skills, Systems-Based Practice PGY-I, PGY-II, PGY-III This activity will enable residents to: Provide compassionate, appropriate, and effective patient care based on an integrative understanding of the patient; Obtain knowledge of the social-behavioral sciences (established and evolving), as well as the application of this knowledge to patient care; and Develop interpersonal and communication skills that result in the effective exchange of information and collaboration with other health professionals; and Develop an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents will demonstrate a developmentally-appropriate ability to: Treat patients’ health problems and psychosocial or mental health conditions compassionately, appropriately, and effectively, based on an integrative understanding of patient. Obtain and apply knowledge of the social-behavioral sciences (established and evolving) to patient care. Communicate effectively with Behavioral Science faculty and staff; Coordinate patient care within the health care system; and Work in inter-professional healthcare teams to improve patient care quality. BSP-P Evaluation Form
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Office Rotation Office Rotation is a month-long block rotation taken once a year for all three years of residency. Each year, residents spend a portion of their time on Office Rotation engaged in behavioral science activities which are supervised under the direction of Dr. Evans. Descriptions of these behavioral science activities by year, as well as explanations of the activities themselves, are provided below. Behavioral Science Activity Independent Studies in Behavioral Science (ISBS) Shadowed Encounters (SE) Videotaped Encounters (VE) Behavioral Science Chart Review (BSCR) Self-Study in Patient Satisfaction (SSPS) Complex Case Conference (CCC) Behavioral Science Precepting: Pain Clinic (BSP-P) Personal Learning & Development Plan (PLDP) Activity:
Explanation:
Targeted Core Competencies: Year Completed: Goals: Objectives: Evaluation:
PGY-I
PGY-II
PGY-III
Independent Studies in Behavioral Science (ISBS) Each year, residents will complete an independent study in behavioral science. These independent studies are organized into modules, one for each year (i.e., PGY-I Module, PGY-II Module, PGYIII Module). Each module contains readings that the resident must complete. Once the resident has completed the readings contained in a module, they will take a post-test. The post-tests are “open-book;” however, the resident must correctly answer 80% of the questions to successfully complete the module. Post-test scores, as well as any questions the resident may have about the content of each module, will be reviewed and discussed with Dr. Evans. In addition, the resident will develop a plan (which will be recorded in his or her Personal Learning & Development Plan) for applying what they have learned in the module to patient care. Medical Knowledge PGY-I, PGY-II, PGY-III This activity will enable residents to obtain knowledge of the socialbehavioral sciences (established and evolving) relevant to Family Medicine. Residents will demonstrate a developmentally-appropriate level of knowledge of the social-behavioral sciences (established and evolving) relevant to Family Medicine. Post-tests
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 18
Activity:
Explanation:
Targeted Core Competencies: Year Completed:
Goals:
Objectives:
Evaluation:
Shadowed Encounters (SE) Residents will be accompanied by Dr. Evans in 1-2 clinical encounters with patients. Dr. Evans will make observations and collect information that will be collaboratively reviewed, discussed, and evaluated by Dr. Evans and the resident. The resident will incorporate information from the review-discuss-evaluate process into his or her Personal Learning & Development Plan. Interpersonal & Communication Skills, Practice-Based Learning & Improvement, Professionalism PGY-I This activity will enable residents to develop: Interpersonal and communication skills that result in the effective exchange of information and collaboration with patients and their families; The skills needed to investigate, evaluate, and improve their care of patients; and A commitment to carrying out professional responsibilities in accordance with ethical principles. Residents will demonstrate a developmentally-appropriate ability to: Communicate effectively with patients and their families, across a broad range of socioeconomic and cultural backgrounds; Convey compassion and respect for patients; Respond to patient needs in a manner that supersedes self-interest; Use formative evaluation feedback to identify strengths, deficiencies, and limitations with respect to interpersonal and communication skills and professionalism; Set learning and improvement goals with respect to interpersonal and communication skills and professionalism; and Identify appropriate learning activities to reach these goals. Developmental Assessment of Medical Interviewing Skills (DAMIS)
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 19
Activity: Explanation: Targeted Core Competencies: Year Completed:
Goals:
Objectives:
Evaluation:
Videotaped Encounters (VE) Residents will be videotaped during a clinical encounter with a patient. This videotaped encounter will be collaboratively reviewed, discussed, and evaluated by Dr. Evans and the resident. The resident will incorporate information from the review-discuss-evaluate process into his or her Personal Learning & Development Plan. Interpersonal & Communication Skills, Practice-Based Learning & Improvement, Professionalism PGY-II This activity will enable residents to develop: Interpersonal and communication skills that result in the effective exchange of information and collaboration with patients and their families; The skills needed to investigate, evaluate, and improve their care of patients; and A commitment to carrying out professional responsibilities in accordance with ethical principles. Residents will demonstrate a developmentally-appropriate ability to: Communicate effectively with patients and their families, across a broad range of socioeconomic and cultural backgrounds; Convey compassion and respect for patients; Respond to patient needs in a manner that supersedes self-interest; Use formative evaluation feedback to identify strengths, deficiencies, and limitations with respect to interpersonal and communication skills and professionalism; Set learning and improvement goals with respect to interpersonal and communication skills and professionalism; and Identify appropriate learning activities to reach these goals. Developmental Assessment of Medical Interviewing Skills (DAMIS)
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 20
Activity:
Explanation:
Targeted Core Competencies: Year Completed:
Goals:
Objectives:
Evaluation:
Behavioral Science Chart Review (BSCR) Residents will select a mental health or psychosocial condition common to their practice (e.g., depression, behavior change). The resident will then obtain at least five (5) peer-reviewed, scholarly articles pertinent to their chosen condition. The resident will review these articles to determine best practices with respect to the assessment and treatment of his or her chosen condition. The resident will also select at least one (but preferably more) patient(s) from their practice for whom this condition is relevant. Using these best practices as a guide, resident will evaluate their assessment and treatment of their selected patient(s), and use this information to make any needed adjustments to patient care. The resident will document completion of this activity by filling out the Chart Review form which he or she will turn in—along with copies of the first page of the five (5) peer-reviewed, scholarly articles—to Dr. Evans. In addition, the resident will incorporate thoughts and observations about their own personal learning process into his or her Personal Learning & Development Plan. Patient Care, Medical Knowledge, Practice-Based Learning & Improvement PGY-III This activity will enable residents to: Provide appropriate and effective patient care based on an integrative understanding of the patient; Obtain knowledge of the social-behavioral sciences (established and evolving), as well as the application of this knowledge to patient care; and Obtain the skills needed to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to improve patient care. Residents will demonstrate a developmentally-appropriate ability to: Appropriately and effectively assess and treat mental health or psychosocial conditions based on an integrative understanding of the patient; Use a systematic process to identify strengths, deficiencies, and limitations with respect to social-behavioral science knowledge and its application to patient care; Set learning and improvement goals with respect to socialbehavioral science knowledge and its application to patient care; and Identify appropriate learning activities to reach these goals. Turn in a copy of BSCR Form
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 21
Activity:
Explanation:
Targeted Core Competencies: Year Completed:
Goals:
Objectives:
Evaluation:
Self-Study in Patient Satisfaction (SSPS) Using a form provided by Dr. Evans, residents will collect patient satisfaction data from their clinic patients. These data will be compiled, and collaboratively reviewed, discussed, and evaluated by Dr. Evans and the resident. The resident will incorporate information from the review-discuss-evaluate process into his or her Personal Learning & Development Plan. Patient Care, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, Professionalism PGY-II This activity will enable residents to develop: The skills needed to provide compassionate and effective patient care; Interpersonal and communication skills that result in the effective exchange of information and collaboration with patients and their families; The skills needed to investigate, evaluate, and improve their care of patients; and A commitment to carrying out professional responsibilities in accordance with ethical principles. Residents will demonstrate a developmentally-appropriate ability to: Treat patients’ health problems and psychosocial or mental health conditions effectively; Communicate effectively with patients and their families, across a broad range of socioeconomic and cultural backgrounds; Convey compassion and respect for patients, including respect for privacy and autonomy, and sensitivity and responsiveness to individual or cultural needs; Respond to patient needs in a manner that supersedes self-interest; Use a systematic process to identify strengths, deficiencies, and limitations with respect to patient care and satisfaction; Set learning and improvement goals with respect to patient care and satisfaction; and Identify appropriate learning activities to reach these goals. Turn in copies of patient satisfaction forms
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 22
Activity:
Explanation:
Targeted Core Competencies: Year Completed:
Goals:
Objectives:
Complex Case Conference (CCC) Residents will participate in Complex Case Conference, a consultative forum to discuss the care of complex patients. For the purposes of this activity, complex patients are defined as challenging patients whose healthcare is difficult to manage due to a variety of factors such as complicated medical presentation and/or medication management, communication and interpersonal difficulties, physician-patient relationship difficulties, psychological and behavioral issues, social or cultural issues, religious or spiritual factors, familial and relational factors, mental illness, nutritional issues, adherence issues, financial issues, lifestyle issues, or language barriers. The resident will select an on-going and current complex case for presentation. After a brief introductory presentation by the resident, the case will be collaboratively reviewed by an interdisciplinary healthcare team comprised of an attending physician, a psychologist, a marriage & family therapist, a nursing professional, and a nutritionist. The resident will develop a plan (which will be recorded in his or her Personal Learning & Development Plan) for applying what they have learned to patient care. Patient Care, Medical Knowledge, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, Professionalism, Systems-Based Practice PGY-II This activity will enable residents to: Develop the skills needed to provide compassionate, appropriate, and effective patient care based on an integrative understanding of the patient; Obtain knowledge of the social-behavioral sciences (established and evolving), as well as the application of this knowledge to patient care; Develop interpersonal and communication skills that result in the effective exchange of information and collaboration with patients and their families; Develop the skills needed to investigate, evaluate, and improve their care of patients; Develop a commitment to carrying out professional responsibilities in accordance with ethical principles; and Develop an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents will demonstrate a developmentally-appropriate ability to: Assess and treat patients’ health problems and psychosocial or mental health conditions compassionately, appropriately, and effectively, based on an integrative understanding of patient;
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Evaluation: Activity:
Explanation:
Targeted Core Competencies: Year Completed:
Goals:
Apply social-behavioral science knowledge to patient care; Communicate effectively with patients and their families, across a broad range of socioeconomic and cultural backgrounds; Communicate and consult effectively with members of an interprofessional healthcare team; Coordinate patient care within the health care system relevant to Family Medicine; Use a systematic process to identify strengths, deficiencies, and limitations with respect to patient care, medical knowledge, interpersonal & communication skills, professionalism, and systems-based practice; Convey compassion and respect for patients, including respect for privacy and autonomy, and sensitivity and responsiveness to individual or cultural needs; Respond to patient needs in a manner that supersedes self-interest; Set learning and improvement goals with respect to patient care, medical knowledge, interpersonal & communication skills, professionalism, and systems-based practice; and Identify appropriate learning activities to reach these goals. Included in PLDP Behavioral Science Precepting: Pain Clinic (BSP-P) Dr. Evans will provide behavioral science precepting (i.e., supervision, guidance, and teaching) for residents in the Pain Clinic. Behavioral science precepting in the Pain Clinic will primarily focus on assessment and diagnostic issues, mental health and psychosocial conditions, treatment and referral issues, doctor-patient relationship issues, adherence, behavior change, somatic fixation, and difficult patient encounters. Patient Care, Medical Knowledge, Interpersonal & Communication Skills, Systems-Based Practice PGY-I, PGY-II, PGY-III This activity will enable residents to: Provide compassionate, appropriate, and effective patient care based on an integrative understanding of the patient; Obtain knowledge of the social-behavioral sciences (established and evolving), as well as the application of this knowledge to patient care; Develop interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals; Develop an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 24
Objectives:
Evaluation: Activity:
Explanation:
Targeted Core Competencies: Year Completed:
Goals:
Objectives:
Evaluation:
Residents will demonstrate a developmentally-appropriate ability to: Gather essential and accurate biological, psychological, and social information from patients; Formulate an integrative (bio-psycho-social) assessment of patient; Treat patients’ health problems and psychosocial or mental health conditions compassionately, appropriately, and effectively, based on an integrative understanding of patient; Obtain and apply knowledge of the social-behavioral sciences (established and evolving) to patient care; Communicate effectively with patients and their families, across a broad range of socioeconomic and cultural backgrounds; Communicate effectively with Behavioral Science faculty and staff; and Work in inter-professional healthcare teams to improve patient care quality. Included in PLDP Personal Learning & Development Plan (PLDP) Each year, near the end of the rotation, residents will complete a Personal Learning & Development Plan (PLDP). The form for completing the PLDP will be provided by Dr. Evans. The PDLP will contain the resident’s thoughts, observations, and points of learning from the rotation experiences, as well as goals, plans for future learning, and application points. The PLDP will be collaboratively reviewed and discussed by Dr. Evans and the resident. In addition, the resident will share the PLDP with his or her advisor. Practice-Based Learning & Improvement PGY-I, PGY-II, PGY-III This activity will enable residents to: Develop the skills needed to investigate, evaluate, and improve their care of patients; Conduct a self-evaluation relevant to patient care; and Develop an attitude of life-long learning. Residents will demonstrate a developmentally-appropriate ability to: Use a systematic process to identify strengths, deficiencies, and limitations with respect to patient care, medical knowledge, interpersonal & communication skills, professionalism, and systems-based practice; Set learning and improvement goals with respect to patient care, medical knowledge, interpersonal & communication skills, professionalism, and systems-based practice; and Identify appropriate learning activities to reach these goals. Turn in copy of PLDP Form
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 25
APPENDIXES
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 26
Developmental Assessment of Medical Interviewing Skills—Primary Care (DAMIS—PC 1.3.3) Name: Gender:
Male Female
Age:
years old
Check One: MS‐III MS‐IV PGY‐I PGY‐II PGY‐III Fellow Practicing Physician years in practice
Check One: Family Medicine Internal Medicine Pediatrics OB‐GYN
Race/Ethnicity: White Asian Hispanic or Latino Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Evaluator: Lance Evans, PhD
Date:
Check One: New Patient Follow Up Urgent Care
Knocks on door Introduces self (if new or unfamiliar) Warm greeting SECTION 1 Makes eye‐contact Establishing Relationship & Building Rapport Acknowledges patient and other attendees by name Note behaviors as they occur to the right. Sum behaviors Sits down and assign score accordingly in the far right box. Smiles Connects with patient using friendly, non‐medical language Uses humor (appropriately) Notes:
Score
Explicitly acknowledges pre‐visit information to patient Asks about or acknowledges reason for visit (e.g., “what brings you in today?”) Allows patient to complete opening statement without interrupting or pressuring to finish SECTION 2 Elicits further concerns from patient after opening statement (e.g., “anything else?”) Establishing the Focus: Opening the Discussion, Uses 2 or more open‐ended questions Gathering Information, & Setting the Agenda Use closed‐ended questions appropriately Note behaviors as they occur to the right. Sum behaviors Use 2 or more paraphrasing or summary statements and assign score accordingly in the far right box. Confirms what is most important to patient Communicates physician agenda items to patient Explicitly negotiates today’s agenda with patient Notes:
Score
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 27
SECTION 3 Managing the Encounter I: Enhancing the Relationship & Maintaining Rapport Note behaviors as they occur to the right. Sum behaviors and assign score accordingly in the far right box.
Expresses empathy or concern (verbally or non‐verbally) Uses reflection (of feeling) statements Uses verbal tracking statements Offers reassurance or encouragement Uses humor (appropriately) Smiles Maintains connection with patient using friendly, non‐judgmental behavior
Score
Notes:
SECTION 4 Managing the Encounter II: Using the Electronic Medical Record (EMR) Appropriately Note behaviors as they occur to the right. Sum behaviors and assign score accordingly in the far right box. Notes:
SECTION 5 Managing the Encounter III: Physical Exam Note behaviors as they occur to the right. Sum behaviors and assign score accordingly in the far right box. Notes:
Clearly orients the EMR monitor so that it can be seen by patient Clearly explains use or purpose of EMR to patient Uses verbal statements to narrate use of EMR (e.g., “let’s take a look at your lab values”) Uses non‐verbal behavior to involve patient in use of EMR (e.g., pointing to monitor) Maintains or reestablishes presence with patient while using EMR (e.g., reestablishing eye contact)
Score
Prepares patient before physical exam actions and behaviors Uses verbal statements to narrate physical exam Conducts physical exam respectfully and with care Describes physical exam findings to patient
Score
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 28
SECTION 6 Managing the Encounter IV: Psychosocial Content (if Acknowledges patient’s verbal and non‐verbal cues regarding psychosocial content Applicable) Note behaviors as they occur to the right. Sum behaviors Uses BATHE or similar technique to manage and/or organize psychosocial content and assign score accordingly in the far right box.
Score
Section Applicable (circle one)? Yes No
Notes:
SECTION 7 Facilitating Behavior Change (if Applicable) Explores patient’s knowledge regarding behaviors that adversely affect health Note behaviors as they occur to the right. Sum behaviors Assesses patient’s readiness to change behaviors that adversely affect health and assign score accordingly in the far right box. Provides a stage‐appropriate intervention for health behavior change
Score
Section Applicable (circle one)? Yes No
Notes:
Acknowledges and investigates patient’s verbal/non‐verbal cues regarding health, illness, or treatment SECTION 8 Explores at least one (1) contextual factor (e.g., family, culture, gender, age, SES, spirituality) as it relates Understanding the Patient’s Perspective to patient’s health, illness, or treatment Note behaviors as they occur to the right. Sum behaviors Explores beliefs, concerns, or expectations regarding patient’s health, illness, or treatment and assign score accordingly in the far right box. Responds to patient’s ideas, thoughts, or feelings regarding health, illness, or treatment Notes:
Score
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 29
Explains problems, diagnoses, etc. using language (e.g., avoids jargon) that patient can understand. Checks to ensure that patient comprehends and understands problems, diagnoses, etc. SECTION 9 Respectfully introduces plan to patient Sharing Information with the Patient, Reaching Investigates patient’s willingness and/or ability to follow the plan Agreement on a Plan, & Closure Investigates patient’s available resources to follow the plan Note behaviors as they occur to the right. Sum behaviors Solicits questions regarding today’s encounter, problems, diagnoses, etc. and assign score accordingly in the far right box. Summarizes or restates the plan (including any modifications) and checks/affirms patient agreement Discusses follow‐up (e.g., next appointment, plan for unexpected outcomes) Notes:
Score
General Notes:
© 2011 Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 30
PGY‐III Office Rotation Behavioral Science Chart Review Form Resident Name:
Month:
Year:
Behavioral Science Chart Review What mental health or psychosocial condition are you investigating? What, specifically, is your question regarding this mental health or psychosocial condition? Please list the citations for your five (5) peer‐ reviewed, scholarly articles (also attach a copy of the first page of each article to this form) Using your articles, briefly summarize the best practices for the mental health or psychosocial condition you are investigating
Compared to the above best practices, please describe how your assessment and treatment of 1‐5 actual patients is or is not appropriate?
In light of this exercise, please describe any adjustments you need to make to your clinical practice.
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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PLEASE COMPLETE THIS FORM AND RETURN IT TO THE CHECK‐OUT PERSONNEL. THANK YOU.
How did we do today?
Provider’s Name:
Date:
Please help us improve our patient care by answering some questions about the services you received today. We are interested in your honest opinions, whether they are positive or negative. Please answer all of the questions by circling the number that corresponds to your opinion. Also, please provide any comments or feedback that you feel would be helpful for us to know.
1 Not at all
2
3
4 Completely
How satisfied were you with the discussion of your problem?
1 Not satisfied
2
3
4 Very satisfied
To what extent did your doctor listen to what you had to say?
1 Not at all
2
3
4 Completely
To what extent did your doctor explain your problem(s) to you?
1 Not at all
2
3
4 Completely
1 Not discussed
2
3
4 Completely
To what extent did your doctor explain treatment?
1 Not at all
2
3
4 Very well
To what extent did your doctor explore how manageable this (treatment) would be for you? He/she explored this:
1 Not at all
2
3
4 Completely
8.
How well do you think your doctor understood you today?
1 Not at all
2
3
4 Very well
9.
To what extent did your doctor discuss personal or family issues that might affect your health?
1 Not at all
2
3
4 Completely
10. To what extent are you satisfied with the healthcare you received from your doctor today?
1 Not satisfied at all
2
3
11. To what extent are you satisfied with the amount of time your doctor spent with you today?
1 Not satisfied at all
2
3
12. To what extent do you have doubts about your doctor’s ability?
1 Significant doubts
2
3
1.
To what extent was your main problem(s) discussed today?
2.
3.
4.
5.
To what extent did you and your doctor discuss your respective roles? (Who is responsible for making decisions and who is responsible for what aspects of your care?)
6.
7.
4 Very satisfied 4 Very satisfied 4 No doubts at all
What other feedback do you have?
CHECK‐OUT PERSONNEL: Please place this feedback form in the file folder marked “Dr. Evans—Feedback Forms” © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 32
DEPARTMENT
OF
FAMILY & COMMUNITY MEDICINE
MEMORANDUM COMPLEX CASE CONFERENCE From: RE:
Lance Evans, PhD Complex Case Conference
As part of your Office Rotation experience this month, you are scheduled to participate in Complex Case Conference (CCC). CCC is a didactic consultative forum for you to discuss the care of complex and challenging patients. Please use the following guidelines to prepare for this activity. Purpose of the Conference The overall purpose of the CCC is to assist residents in developing integration and collaboration skills pertinent to the increasingly complex practice of primary care. More specifically, the CCC will: Provide residents, faculty, and other healthcare providers with alternatives, resources, and direction for caring for patients who are particularly challenging. Encourage interdisciplinary collaboration among and between healthcare providers in the provision of primary care. Encourage holistic integration of the multiple factors that affect the course and outcome of health problems and healthcare. Encourage systems-based, biopsychosocial case conceptualization and treatment. Selecting a Patient for Conference For the purposes of this activity, complex patients are defined as challenging patients whose healthcare you find difficult to manage due to any of the following factors:
Complicated medical presentation and/or medication management Communication and interpersonal difficulties Physician-patient relationship Psychological and behavioral issues Social, cultural, and spiritual factors Familial and relational factors Mental illness Nutritional issues Compliance issues Financial issues Lifestyle issues Language barriers
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 33
The case that you select must be an on-going and current case; deceased patients, patients that you have not seen in while, patients that have been fired, or patients that you have only seen intermittently would not be appropriate. The only exception to this requirement will be with interns, who may not have had enough clinical time to build up a case load from which to choose a patient. In this case, interns are instructed to choose a patient who most closely meets the requirements. See Dr. Evans if you have questions regarding the selection of a complex case. Presenting Your Case at Conference Each resident will be given approximately 45 minutes to focus on their case. The first 5-10 minutes will consist of a brief introductory presentation by the resident; the remainder of the time will be used to collaboratively review the case with an interdisciplinary healthcare team of physicians, psychologists, marriage & family therapists, case managers and social workers, nursing professionals, pharmacotherapy clinicians, and a nutritionist. To help the interdisciplinary healthcare team assist you with the case, your 5-10 minute introductory presentation should be accompanied by a patient summary form (please see the patient summary form at the end of this memo). Please bring 6-7 copies of the patient summary form to conference. Remember, CCC is a unique type of case conference in that you are required to present a patient with whom you are struggling. It is unlike other case conferences where you are expected to have all of the answers to the most complex and challenging aspects of the case. As such, it would be inappropriate to present a difficult and challenging patient whose care you have under control. Instead, pick a case that frustrates you or one that you are having difficulty managing. If you are unsure about your case, or if you need help making your case selection, please do not hesitate to contact me for assistance prior to your conference. Should you have any questions, please do not hesitate to contact me at 3-1100, extension 262.
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 34
COMPLEX CASE CONFERENCE PATIENT SUMMARY FORM Resident name: Date of Complex Case Conference:
Patient’s initials: Patient’s age: Patient’s gender: Patient’s ethnicity: Previous resident provider: Are you currently treating this patient?
□
Yes
□
No (If “No,” the patient is not appropriate for presentation)
When was the last time you saw this patient?
Medical conditions for which you see the patient: Include: Diagnoses, chronology, any aggravating or alleviating factors, treatments, patient’s understanding of the condition, patient’s adherence to treatment, diagnostic test results, referrals to other providers, other providers involved in patient’s care, medications, prognosis, how you monitor condition © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 35
Brief description of hospital admissions:
Brief description of any psychiatric conditions:
Psychosocial situation:
Include: Family situation (significant other, children, etc.), social support system, lifestyle or behavioral issues, stressors, language barriers, financial issues, social situation, cultural background, spirituality
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 36
Brief description of the quality of your relationship with the patient and his/her family:
Brief description of how typical appointments with this patient are experienced by you:
Brief description of any healthcare system barriers that make your work with this patient challenging:
Finish this sentence: This patient is challenging to me because:
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 37
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER DEPARTMENT OF FAMILY & COMMUNITY MEDICINE
Behavioral Science Handbook for Family Medicine Pain Clinic Lance Evans, Ph.D. David R.M. Trotter, M.A. © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
Page 38
TABLE OF CONTENTS Introduction to Behavioral Science in Family Medicine Pain Clinic ............................................................ 39 Pain Clinic Behavioral Science Assessment ................................................................................................. 40
Basic Demographics, Lifestyle Issues, Stress & Coping ........................................................................ 40
Pain Assessment ................................................................................................................................... 40
Disability & Functioning ........................................................................................................................ 40
Opioid Abuse ........................................................................................................................................ 40
Illness Behavior ..................................................................................................................................... 41
Depression, Anxiety, & Somatization ................................................................................................... 41
Quality of Life ....................................................................................................................................... 41
Readiness to Adopt a Self‐Management Approach to Chronic Pain .................................................... 41
References .................................................................................................................................................. 47 Pain Patient Personal Profile Example ........................................................................................................ 48 © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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INTRODUCTION TO BEHAVIORAL SCIENCE IN FAMILY MEDICINE PAIN CLINIC As part of Office Month rotation, residents will participate (1‐3 times) in the Family Medicine Pain Clinic. Residents’ participation in this experience will be supervised by Drs. Whitham and Evans. Dr. Evans’ portion of this experience will primarily focus on psychosocial assessment and diagnostic issues, the doctor‐patient relationship, adherence, behavior change, somatic fixation, and difficult patient encounters. To facilitate this experience, Dr. Evans will conduct an assessment of the patient which will be collaboratively reviewed with Dr. Whitham and the resident. What follows is an explanation of the different types of psychosocial assessment Dr. Evans will provide, as well as their relevance to the treatment and management of chronic pain patients. Targeted Competencies: Patient Care, Medical Knowledge, Interpersonal & Communication Skills, Systems‐Based Practice Goals: This activity will enable residents to provide compassionate, appropriate, and effective patient care based on an integrative understanding of the patient; obtain knowledge of the social‐behavioral sciences (established and evolving), as well as the application of this knowledge to patient care; develop interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals; and develop an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Objectives: Residents will demonstrate a developmentally‐appropriate ability to gather essential and accurate biological, psychological, and social information from patients; formulate an integrative (bio‐ psycho‐social) assessment of patient; treat patients’ health problems and psychosocial or mental health conditions compassionately, appropriately, and effectively, based on an integrative understanding of patient; obtain and apply knowledge of the social‐behavioral sciences (established and evolving) to patient care; communicate effectively with patients and their families, across a broad range of socioeconomic and cultural backgrounds; communicate effectively with Behavioral Science faculty and staff; and work in inter‐professional healthcare teams to improve patient care quality. © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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FAMILY MEDICINE PAIN CLINIC BEHAVIORAL SCIENCE ASSESSMENT Basic Demographics, Lifestyle Issues, Stress & Coping Rationale for assessment: Obtaining demographic, lifestyle, and stress and coping information will put the patient’s experience of pain in context. Demographic, lifestyle, and stress and coping information will be assessed by simple checklist and/or questionnaire. Information will include gender, age, ethnicity, disability status (including any legal action associated with obtaining disability status), pain medications, psychoactive medications, illicit drug use, addictions (e.g., smoking), psychosocial stressors, and coping behaviors. Pain Assessment Rationale for assessment: Subjective and objective measures of pain are necessary to determine the intensity of the patient’s experience of pain. Pain will be assessed subjectively using a visual analog pain rating scale (VAPRS).1 A VAPRS provides a measure of pain intensity along a numerical scale. Ratings are obtained for worst last week, least last week, on average, and right now. Scores are interpreted as mild, moderate, or severe. Pain will also be assessed objectively using a revised and shortened form of the McGill Pain Questionnaire (MPQ).2 The MPQ provides a measure of pain intensity along five (5) dimensions: continuous (e.g., throbbing, cramping), intermittent (e.g., shooting, stabbing), neuropathic (e.g., hot‐ burning, cold‐freezing), affective descriptors (e.g., tiring, sickening), and overall. Scores are either below average, average, or above average, when compared to other pain patients. Disability & Functioning Rationale for assessment: Assessing what impact the patient’s pain has on psychosocial and physical functioning is a key outcome measure. Disability and functioning will be assessed using the Pain Disability Questionnaire (PDQ).3 The PDQ measures disability and functioning for the full array of chronic disabling musculoskeletal disorders. Patients receive three (3) scores: general functioning, psychosocial functioning, and overall functioning. Scores on general functioning provide a measure of the patient’s physical functioning with respect to their chronic pain, while scores on psychosocial functioning provide a measure of the patient’s psychological and social functioning with respect to their chronic pain. Scores on overall functioning provide a measure of the patient’s combined physical and psychosocial functioning. Scores range from mild‐moderate‐severe‐extreme. Opioid Abuse Rationale for assessment: Because the medications used in the treatment of chronic pain can often be addictive, it is important to determine if the patient is at high risk for substance abuse. The potential for opioid abuse will be assessed using a short form version of the Screener and Opioid Assessment for Patients with Pain (SOAPP).4 Patient scores are categorized as either low risk or high risk. High risk scores suggest that a patient may have a substance abuse problem, and thus will need careful monitoring if opioids are used to treat their chronic pain. © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Illness Behavior Rationale for assessment: How a patient perceives, evaluates, and acts in relation to their pain is an important factor that influences the process and outcome of treatment. Illness behavior will be assessed using the Screener‐Illness Behavior Questionnaire (SIBQ).5 The SIBQ assesses for several behaviors that are likely to affect the treatment of chronic pain, as well as the relationship between doctor and patient. These behaviors include somatization, preoccupation with symptoms, and help‐rejecting behavior. Patient scores are categorized as either low, moderate, or high risk. Moderate‐High risk scores suggest that a patient may display some or all of the above behaviors. Depression, Anxiety, & Somatization Rationale for assessment: Because affect and psychological functioning can have a significant influence on the experience of pain, it is necessary to evaluate pain patients for depression, anxiety, and somatization. Depression, anxiety, and somatization will be assessed using the Pain Patient Profile (P3).6 The P3 provides a validity index, as well as scores on depression (e.g. sleep disturbance, psychomotor activity, hopelessness), anxiety (e.g., worry, nervousness, restlessness, and emotional instability), and somatization (concerns about pain, physical health, bodily processes, muscle tension, and physical abnormalities). Quality of Life Rationale for assessment: Assessing quality of life is a key outcome measure. Quality of life will be assessed using the Quality of Life Inventory (QOLI).7 The QOLI provides a measure of life satisfaction across 16 domains: health, self‐esteem, goals‐and‐values, money, work, play, learning, creativity, helping, love, friends, children, relatives, home, neighborhood, and community. Quality of life is categorized as Low, Very Low, Average, or High. Readiness to Adopt a Self‐Management Approach to Chronic Pain Rationale for assessment: Self‐management approaches to chronic pain (e.g., relaxation, breathing exercises, etc.) have demonstrated efficacy. However, many chronic pain patients are unaware of or not interested in these types of approaches, and/or would prefer a pharmacological approach only. This assessment will provide important clues as to the patient’s readiness to adopt a self‐management approach to chronic pain. Readiness to adopt a self‐management approach to chronic pain will be assessed using the Pain Stages of Change Questionnaire (PSOCQ).8 The PSOCQ scores patients as Pre‐Contemplation, Contemplation, or Preparation‐Action. By definition, adopting a self‐management approach to chronic pain involves exploration of the psychosocial aspects of pain. As such, readiness to adopt a self‐management approach to chronic pain is synonymous with the patient’s readiness to explore the psychosocial aspects of their pain. The stages, as well as interventions for each, are described below:9,10 © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Pre‐Contemplation Stage of Change Patients in the Pre‐Contemplation stage fall into four sub‐types (although there may be some overlap): Reluctant, Resigned, Rebellious, and Rationalizing. Reluctant or Resigned Pre‐Contemplation What to Expect: Little insight into the psychosocial aspects of their pain, hopeless about the prospect of change, passively resistant to change, slow to change. Action Script‐What to do Rationale “We have talked a lot about the physical aspects of your pain, I Providing patients with choice was wondering if we could also talk about other aspects of your Ask patient for facilitates openness and physical pain, like emotions and thoughts.” permission to commitment. discuss “If it is alright with you I would like to change gears slightly. I psychosocial Patients who choose a would like to discuss how thoughts and emotions affect the aspects of pain treatment are more likely to be experience of pain. Would you be interested in discussing that compliant. with me; I think you may find it helpful?” Distribute information on pain self‐management These patients need time to Gently “Plant a “connect the dots;” providing seed” Point out situations in their story where behavior and emotions info is a good way to help them affected their experience of pain, explore this with them. do that. Self‐efficacy is directly related Instill hope, and Highlight situations in the patent’s history when they successfully to change behavior. build on coped with pain. Use this as an example to build confidence. previous A little reassurance can go a successes Validate their adaptive efforts to control pain long way Express Use empathetic statements liberally: “It sounds like you have Good rapport increases empathy and really struggled with your pain”, and/or “I can see how that could compliance build rapport be very frustrating.” Empathy encourages openness Validation increases openness Validate their experiences when appropriate. Listen and and confidence provide caring Gently point out discrepancies feedback These patients are not likely to Listen to their concerns and respond respond well to confrontation
Rebellious Pre‐Contemplation What to Expect: Heavily invested in the treatments they are currently receiving (or would like to receive) and/or in their role as a pain patient. These patients will likely respond with anger and hostility, and will blame others (e.g. healthcare providers) for their ongoing experience of pain. Action Script‐What to do Rationale “We have talked a lot about the physical aspects of your pain, I Providing patients with choice was wondering if we could also talk about other aspects of your Ask patient for facilitates openness and physical pain, like emotions and thoughts.” permission to commitment. discuss “If it is alright with you I would like to change gears slightly. I psychosocial Patients who choose a would like to discuss how thoughts and emotions affect the aspects of pain treatment are more likely to be experience of pain. Would you be interested in discussing that we compliant. me, I think you may find it helpful?” Provide Provide an menu of options (e.g. several non‐opiate pain meds, These patients are heavily multiple physical therapy, behavioral management) invested in making their own options and let decisions. patient choose Encourage the pt to choose elements of their treatment © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Good rapport increases Use empathetic statements liberally: “It sounds like you have compliance and openness really struggled with your pain”, and/or “I can see how that could be very frustrating.” Express Empathy may decrease anger empathy and and blame. Let patient tell their story with minimal interruption build rapport Agree with the patient when appropriate: “You are right; it Agreeing with the patient can sounds like that situation was not handled as well as it could take the angry wind out of have been.” their sails. Arguments and confrontation What to avoid Do not argue or confront. will validate their anger and blame.
Rationalizing Pre‐Contemplation What to Expect: Will seem as though they “have it all figured out”, or that they “have all the answers” regarding their problems. They will likely want to engage in a debate over behavior change. Unlike Rebellious individuals, rationalizing individuals will not be overly emotional. Action Script‐What to do Rationale “We have talked a lot about the physical aspects of your pain, I Providing patients with choice was wondering if we could also talk about other aspects of your Ask patient for facilitates openness and physical pain, like emotions and thoughts.” permission to commitment. discuss “If it is alright with you I would like to change gears slightly. I psychosocial Patients who choose a would like to discuss how thoughts and emotions affect the aspects of pain treatment are more likely to be experience of pain. Would you be interested in discussing that we compliant. me, I think you may find it helpful?” As the patient to list the pros and cons of continuing their Patients spend more time current coping strategies for pain management (e.g. seeking defending cons than examining meds, avoiding activities). Perform a pros. Examining pros with decisional patient tells them that you are Begin with pros first balance 1) listening, 2) interested in exercise their problems, and 3) that you Reflect on pros and cons with the patient are non‐judgmental. These things increase openness. Focus more time on pros than cons Good rapport increases Express Use empathetic statements liberally: “It sounds like you have compliance empathy and really struggled with your pain”, and/or “I can see how that could build rapport be very frustrating.” Empathy encourages openness Rational debates are likely to Avoid rational debates with these patients. However, this can be validate the patient’s beliefs, What to avoid difficult as these patients will want to engage you in this type of regardless of how sound your exchange. arguments are.
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Contemplation Stage of Change Contemplation What to Expect: Contemplators recognize that there may be some utility in self‐management of pain, but are ambivalent about adopting this style of pain management. They may, or may not be well informed about their options. They are likely open to considering change, but may be far from making a commitment. Action Script‐What to do Rationale “We have talked a lot about the physical aspects of your pain, I Providing patients with choice was wondering if we could also talk about other aspects of your Ask patient for facilitates openness and physical pain, like emotions and thoughts.” permission to commitment. discuss “If it is alright with you I would like to change gears slightly. I psychosocial Patients who choose a would like to discuss how thoughts and emotions affect the aspects of pain treatment are more likely to be experience of pain. Would you be interested in discussing that we compliant. me, I think you may find it helpful?” Encourage the patient to write down (or discuss) the pros and cons of engaging in their current pain‐management strategies. Patients in this stage tend to have roughly equal pros and Perform a It is helpful to begin with pros first cons. Helping them evaluate decisional them both sides equally can balance Spend time considering both sides create a platform from which exercise you can begin to shift the Encourage the patient to elaborate on elements of these lists balance. (e.g. Tell me more about this pro/con on our list) The goal here is to “tip” the balance towards change Encourage a Encourage patient to experiment with a brief behavioral pain trial management intervention (e.g. PMR, Imagery, Breathing A successful behavioral pain Exercises) management trial can move the patient toward change. Given patient’s history, select an intervention with a high probability of success. Good rapport increases Express Use empathetic statements liberally: “It sounds like you have compliance empathy and really struggled with your pain”, and/or “I can see how that could build rapport be very frustrating.” Empathy encourages openness
Preparation‐Action Stage of Change Contemplation What to Expect: Patients in the Preparation‐Action stage of change may still have some reservations in relation to change, but they are sufficiently motivated to attempt change. It is important that you capitalize on this motivation. Action Script‐What to do Rationale Briefly Describe the Pain‐Gate Theory of pain: “Pain is experience when Linking physical and emotional introduce the nerves in the body send pain signals to the brain. As these processes at a biological level provides a platform for you to rationale signals travel towards to the brain they enter the spine where introduce behavioral behind they meet other signals from the brain. These other signals, behavioral pain which are result of our thoughts and emotions, change the pain interventions without management signal, potentially intensifying or decreasing it. Therefore, having conveying the message that positive thoughts and emotions actually changes the experience the pain is “all in your head.” of pain at the cellular level. The exercises I am going to teach you © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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will help you create the mindset that will hopefully make your pain more tolerable. Remember, I will be teaching you skills that take some time to learn. While you may experience some pain relief as you begin to learn these skills, continued practice is necessary to the maximize benefits.” Teach 1 Self‐ regulatory and See below 1 Self‐ management skill Express empathy and build rapport
Having a better understanding behind interventions can increase compliance and openness.
See below
Good rapport increases Use empathetic statements liberally: “It sounds like you have compliance really struggled with your pain”, and/or “I can see how that could be very frustrating.” Empathy encourages openness
Self‐Regulatory Skills Action Script‐What to do Progressive Muscle Provide patient with CD, and instruct use: “Progressive muscle relaxation, or PMR, is an Relaxation (PRM) exercise in which one’s attention is focused on reducing muscle tension. Reducing muscle tension can help some people reduce pain, and can help distract you from the pain when it becomes intense. PMR has been shown to be an effective pain management tool for people with many types of chronic pain. Please listen to the PMR track on this CD and follow the directions.” Negotiate frequency of use with patient; daily use is optimal but not always possible. Deep breathing Provide patient with CD, and instruct use: “Deep breathing is an exercise in which ones attention is focused on breathing. This type of exercise can help distract you from the pain when it becomes intents. Deep breathing has been shown to be an effective pain management tool for people with many types of chronic pain. Please listen to the deep breathing track on this CD and follow the directions.” Negotiate frequency of use with patient; daily use is optimal but not always possible. Imagery Provide patient with CD, and instruct use: “Imagery is an exercise in which ones attention is focused on an external image, preferably one that is relaxing. Imagery can help some people reduce pain, and can help distract you from the pain when it becomes intents. Imagery has been shown to be an effective pain management tool for people with many types of chronic pain. Please listen to the Imagery track on this CD and follow the directions.” Negotiate frequency of use with patient; daily use is optimal but not always possible.
Action Pacing
Planning/Time management
Self‐Management Skills Script‐What to do Slowly reintroduce physical activity and exercise to increase adaptive beliefs and self‐efficacy. Set goals for activity level which are reasonable, and unlikely to exacerbate pain experience. Instruct patients to engage in activities (e.g. mowing the lawn, doing laundry) they have been avoiding. However, instruct them to stop the activity well before it causes pain. For example, if a patient can mow the lawn for 30 minutes before it causes back pain, have them mow the lawn for 15 minutes. Inform patient that it is imperative that they discontinue these activities before they become “unbearably painful” and feel “overwhelmed.” Teach Goal Setting: Create a list of achievable goals, and steps to accomplish those goals. (e.g. Goal: Fix up yard, Step 1‐ Mow grass, 2‐ Edge grass, 3‐ Weed front flower bed, 4‐ Weed back flower bed, 5‐ Trim bushes, 6‐ etc . . . ) Teach patients (and model) how to create a prioritized To‐Do list. Start with the most
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Problem Solving
important items scheduled during times of day where the patient’s energy is highest and their pain is the lowest. Three‐step problem solving. Use the following questions as a guide: 1) “What are you feeling?” (Help the patient label their reaction to the situation), 2) “What do you want?” (Helps them specify a goal), and 3) “What can you do about it?” (Focus on what can be done, and help the patient accept the things they cannot control). Practice this with the patient.
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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REFERENCES 1. McDowell I. Measuring Health: A Guide to Rating Scales and Questionnaires, 3rd ed. New York: Oxford University Press, 2006. 2. Dworkin RH, Turk DC, Revicki DA, et al. Development and initial validation of an expanded and revised version of the Short‐form McGill Pain Questionnaire (SF‐MPQ‐2). Pain. 2009;144(1‐2):35‐42. 3. Anagnostis C, Gatchel RJ, Mayer TG. The Pain Disability Questionnaire: A new psychometrically sound measure for chronic musculoskeletal disorders. Spine. 2004;29(20):2290‐2302. 4. Akbik H, Butler SF, Budman SH, Fernandez K, Katz NP, Jamison RN. Validation and clinical application of the Screener and Opioid Assessment for Pain Patients (SOAPP). Journal of Pain and Symptom Management. 2006;32(3):287‐293. 5. Chaturvedi SK, Bhandari S, Beena MB, Rao S. Screening for abnormal illness behavior. Psychopathology. 1996;29:325‐330. 6. Tollison CD, Langley JC. P3 Pain Patient Profile Manual. Minneapolis, MN: Pearson, 1995. 7. Frisch MB. Manual and Treatment Guide for the Quality of Life Inventory. Minneapolis, MN: Pearson, 1994. 8. Kerns RD, Rosenberg R, Jamison RN, Caudill MA, Haythornthwaite J. Readiness to adopt a self‐ management approach to chronic pain: The Pain Stages of Change Questionnaire (PSOCQ). Pain. 1997;72:227‐234. 9. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change, 2nd ed. New York: Guilford, 2002. 10. Gatchel RJ, Robinson RC. Pain management. In: O’Donohue W, Fisher JE, Hayes SC, eds. Cognitive Behavioral Therapy: Applying Empirically Supported Techniques in Your Practice. Hoboken, NJ: Wiley & Sons, 2003. © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Pain Clinic Personal Profile Date: Name: Gender: Age: Ethnicity: Disabled: Applying for Disability: Attorney, Legal Action: Pain Meds: Psy Meds: Illicit Drug Use: Other Addictions: Coping Behaviors: Stressors:
June 17, 2009 DT Female 60 African American Yes No No Tramadol, Neurontin Wellbutrin, in the past Denied Tobacco Resting, sleeping, isolation, religion, meds $, family, health‐pain, disability
Subjective Report of Pain Intensity Pain (worst last week): Pain (least last week): Pain (average): Pain (right now):
7 7 7 7
out of 10 out of 10 out of 10 out of 10
Severe Pain Severe Pain Severe Pain Severe Pain
McGill Pain Questionnaire Continuous Pain: Intermittent Pain: Neuropathic Pain: Affective Descriptors: Overall Pain:
X 8.3 out of 10 0.7 out of 10 5.0 out of 10 8.5 out of 10 5.4 out of 10
T 61 34 53 61 52
Compared to Other Chronic Pain Patients Above Average Below Average Average Above Average Average
Pain Disability Questionnaire (General Functioning & Psychosocial Functioning) General Functioning: Psychosocial Functioning: Overall:
82 out of 90 48 out of 60 130 out of 150
Extreme Disability Extreme Disability Extreme Disability
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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SOAPP‐V1.0‐sf Abuse Risk Assessment:
5
out of 16
High Risk
SIBQ (Help‐Rejecting, Somatizing, Symptom‐Preoccupation) Risk Assessment:
4
out of 11
Low Risk
Readiness to Adopt a Self‐Management Approach to Chronic Pain Stage of Change:
Contemplation
P3: Pain Patient Profile Validity Index: Depression: Anxiety: Somatization:
9 57 48 62
out of 15 T‐Score T‐Score T‐Score
Valid Profile Severe Depression Mild‐Moderate Anxiety Severe Somatization
Quality of Life Inventory Overall Quality of Life Areas of Concern: Health Self‐Esteem Goals/Values Money Work Play Learning Creativity Helping Love Friends Children Relatives Home Neighborhood Community
32 ‐6 ‐2 ‐4 1 ‐1 1 ‐1 ‐4 ‐3 0 1 3 6 4 4 4
T‐Score Raw Score Raw Score Raw Score Raw Score Raw Score Raw Score Raw Score Raw Score Raw Score Raw Score Raw Score Raw Score Raw Score Raw Score Raw Score Raw Score
Very Low Area of Concern Area of Concern Area of Concern OK Area of Concern OK Area of Concern Area of Concern Area of Concern OK OK OK OK OK OK OK
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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PGY‐I Office Rotation Personal Learning & Development Plan Resident Name:
Month:
Year:
Research has demonstrated that goal‐setting is an extremely consistent method of motivating people. As such, the Personal Learning & Development Plan (PLDP) is designed to help you formulate goals based on your learning experiences this month. Spend some time reflecting on your answers to the below questions, and when you are done, share this PLDP with your advisor. Independent Studies in Behavioral Science: This month, you were assigned the following readings: Agerter et al (2007), Ahmed & Lemkau (2007), Katon & Geyman (2007), Kay & Tasman (2006), Lutton (2004), Mauksch et al (2008), and Miller (1992). What were the main learning points for you in these readings? What changes (e.g., to your clinical practices or behavior) do you want to make in light of these learning points? How will you quantify these changes and measure your progress (i.e., what are your goals)? What resources or personal strengths do you possess that will help you reach these goals? What personal or system barriers do you anticipate will impede or slow down your progress toward these goals?
How will you overcome these barriers?
How can your advisor help you achieve these goals?
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Shadowed Encounter: This month, Dr. Evans shadowed you in clinic (1‐2 times). Afterword, you and Dr. Evans debriefed this activity. What were the main learning points for you in this exercise? What changes (e.g., to your clinical practices or behavior) do you want to make in light of this exercise? How will you quantify these changes and measure your progress (i.e., what are your goals)? What resources or personal strengths do you possess that will help you reach these goals? What personal or system barriers do you anticipate will impede or slow down your progress toward these goals?
How will you overcome these barriers? How can your advisor help you achieve these goals? © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Behavioral Science Precepting: Pain Clinic: This month, Dr. Evans precepted you in the Family Medicine Pain Clinic. What were the main learning points for you in this exercise? What changes (e.g., to your clinical practices or behavior) do you want to make in light of this exercise? How will you quantify these changes and measure your progress (i.e., what are your goals)? What resources or personal strengths do you possess that will help you reach these goals? What personal or system barriers do you anticipate will impede or slow down your progress toward these goals?
How will you overcome these barriers? How can your advisor help you achieve these goals?
Resident Signature Advisor Signature
Date Date
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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PGY‐II Office Rotation Personal Learning & Development Plan Resident Name: Month: Year: Research has demonstrated that goal‐setting is an extremely consistent method of motivating people. As such, the Personal Learning & Development Plan (PLDP) is designed to help you formulate goals based on your learning experiences this month. Spend some time reflecting on your answers to the below questions, and when you are done, share this PLDP with your advisor. Independent Studies in Behavioral Science: This month, you were assigned the following readings: Brown et al (2003), Epstein et al (1999), Feinstein & Connelly (2007), Levinson et al (2001), Searight (2004), and Thiedke (2007). What were the main learning points for you in these readings? What changes (e.g., to your clinical practices or behavior) do you want to make in light of these learning points? How will you quantify these changes and measure your progress (i.e., what are your goals)? What resources or personal strengths do you possess that will help you reach these goals? What personal or system barriers do you anticipate will impede or slow down your progress toward these goals?
How will you overcome these barriers? How can your advisor help you achieve these goals?
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Videotaped Encounter: This month, you were videotaped in clinic. Afterword, you and Dr. Evans debriefed this activity. What were the main learning points for you in this exercise? What changes (e.g., to your clinical practices or behavior) do you want to make in light of this exercise? How will you quantify these changes and measure your progress (i.e., what are your goals)? What resources or personal strengths do you possess that will help you reach these goals? What personal or system barriers do you anticipate will impede or slow down your progress toward these goals?
How will you overcome these barriers? How can your advisor help you achieve these goals? © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Self‐Study in Patient Satisfaction: This month, you conducted a self‐study in patient satisfaction. What were the main learning points for you in this exercise? What changes (e.g., to your clinical practices or behavior) do you want to make in light of this exercise? How will you quantify these changes and measure your progress (i.e., what are your goals)? What resources or personal strengths do you possess that will help you reach these goals? What personal or system barriers do you anticipate will impede or slow down your progress toward these goals?
How will you overcome these barriers? How can your advisor help you achieve these goals? © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Complex Case Conference: This month, you participated in Complex Case Conference. What were the main learning points for you in this exercise? What changes (e.g., to your clinical practices or behavior) do you want to make in light of this exercise? How will you quantify these changes and measure your progress (i.e., what are your goals)? What resources or personal strengths do you possess that will help you reach these goals? What personal or system barriers do you anticipate will impede or slow down your progress toward these goals?
How will you overcome these barriers? How can your advisor help you achieve these goals? © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Behavioral Science Precepting: Pain Clinic: This month, Dr. Evans precepted you in the Family Medicine Pain Clinic. What were the main learning points for you in this exercise? What changes (e.g., to your clinical practices or behavior) do you want to make in light of this exercise? How will you quantify these changes and measure your progress (i.e., what are your goals)? What resources or personal strengths do you possess that will help you reach these goals? What personal or system barriers do you anticipate will impede or slow down your progress toward these goals?
How will you overcome these barriers? How can your advisor help you achieve these goals?
Resident Signature Advisor Signature
Date Date
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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PGY‐III Office Rotation Personal Learning & Development Plan Resident Name: Month: Year: Research has demonstrated that goal‐setting is an extremely consistent method of motivating people. As such, the Personal Learning & Development Plan (PLDP) is designed to help you formulate goals based on your learning experiences this month. Spend some time reflecting on your answers to the below questions, and when you are done, share this PLDP with your advisor. Independent Studies in Behavioral Science: This month, you were assigned the following readings: Epstein (1999), Novack et al (1997), Serio & Epperly (2006), Sotile & Sotile (1999a), Sotile & Sotile (1999b), and Sotile & Sotile (2002). What were the main learning points for you in these readings? What changes (e.g., to your clinical practices or behavior) do you want to make in light of these learning points? How will you quantify these changes and measure your progress (i.e., what are your goals)? What resources or personal strengths do you possess that will help you reach these goals? What personal or system barriers do you anticipate will impede or slow down your progress toward these goals?
How will you overcome these barriers? How can your advisor help you achieve these goals?
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Behavioral Science Chart Review: This month, you completed a behavioral science chart review. What were the main learning points for you in this exercise? What changes (e.g., to your clinical practices or behavior) do you want to make in light of this exercise? How will you quantify these changes and measure your progress (i.e., what are your goals)? What resources or personal strengths do you possess that will help you reach these goals? What personal or system barriers do you anticipate will impede or slow down your progress toward these goals?
How will you overcome these barriers? How can your advisor help you achieve these goals? © Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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Behavioral Science Precepting: Pain Clinic: This month, Dr. Evans precepted you in the Family Medicine Pain Clinic. What were the main learning points for you in this exercise? What changes (e.g., to your clinical practices or behavior) do you want to make in light of this exercise? How will you quantify these changes and measure your progress (i.e., what are your goals)? What resources or personal strengths do you possess that will help you reach these goals? What personal or system barriers do you anticipate will impede or slow down your progress toward these goals?
How will you overcome these barriers? How can your advisor help you achieve these goals? Resident Signature Advisor Signature
Date Date
© Lance Evans, Ph.D. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, redistributed, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 US Copyright Act, without prior written permission of the author.
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