The 25th Forum for Behavioral Science in Family Medicine
Downtown Chicago: September 30 - October 3, 2004

Seminars/Workshops/Networking Breakfast

GATHERING IN
Whether this is your first Forum or one of several you have attended, the "gathering-in" time is designed to help participants get acquainted and oriented to the meeting. Many past participants have commented on the value of this beginning session.

RESOURCE DISPLAY
Please bring extra copies of seminar, workshop, or networking breakfast materials to share at a resource table at the conference. These and other materials, such as books, monographs or articles, are greatly appreciated by attendees, especially newcomers.

SEMINAR 101
Embracing relationships: Teaching strategies of relationship-centered core
John Cavacece, DO; Vic Wagner, PhD
Students entering family medicine generally have a strong desire to practice medicine in a way that empasizes the importance of the doctor-patient relationship. Unfortunately, residents are inundated with disease oriented data in the early months of residency that subordinates the importance of relationships. As interns in the outpatient setting, they have little opportunity to develop the skills required to develop relationships with patients.
In our residency, we base our behavioral medicine curriculum on Relationship-Centered Care (RCC). RCC is a construct for practice that requires emphasis on personal awareness, understanding the patient's perspective of their illness, effective communication, and development and nurturing of relationships with patients. Our residency has ample teaching of the first three factors, but admittedly struggles to find the optimum method of teaching relationship building.
By the use of a problem list that facilitates the collection of relationship-centered data on first visits with patients, residents learn to routinely practice assessing relationships. We will demonstrate a mnemonic to use during the patient encounter that allows immediate documentation of this information. We will also demonstrate teaching methods that address the rationale for using relationship-centered care.
Goals: 1) Understanding of the concept of Relationship-Centered Care. 2) Developing strategies to teach relationship building skills.
Objectives: 1) Participants will be able to list the components of RCC. 2) Participants will understand the use of tools to teach principles of RCC. 3) Participants will be able to discuss various ways of teaching RCC skills. 4) Participants will share stories and examples of RCC.

SEMINAR 102
Giving patient centered ideas life in the exam room
Karen Kent, MD; James Olson, MD
The process of taking the concepts of patient centered interviewing from a lecture or discussion format and inspiring doctors to use them without fail in actual patient interactions is challenging. We have developed a three-year curriculum that utilizes teaching the concepts and practicing them in small groups led by FP attending physicians. The evaluation of these skills is done in "real time", in exam rooms, in the emergency department, in the delivery room and anywhere residents interact with real patients. Our feedback from graduates is that this training is useful on a daily basis out in practice. In our presentation we would like to share the curriculum and teaching materials that we use, and offer the instruments that we use for evaluation of this important competency. We would like to know how others have attemtped to bridge this all-important gap from concept to practice.

SEMINAR 103
Antidepressant medications: Rational clinical usage and side effect management
Randy Ward, MD
Depression is a complex disorder, with psychological, social, and biological components. Family physicians have taken on an expanded role in the treatment of depression, particularly in the area of psychopharmacology. In many ways depression has become a primary care disorder, with the majority of patients being managed in the primary care physician's office, as opposed to the psychiatrist's. One of the reasons for this change has been the expansion in the number of relatively safe, effective antidepressant medications. While this increase in medication availability and variety has allowed family physicians to treat many more patients, it has led to confusion as to their rational and appropriate clinical use. This workshop will help bridge the gap between the symptoms of depression, their biological basis, actions of antidepressant medication, medication side effects, and clinical treatment, in a structured, practical manner useful for behavioral scientists and family physicians.
GOAL: Participants will learn a basic framework for the rational use of antidepressant medications, and management of medication side effects.
OBJECTIVES: 1. Develop basic knowledge and understanding of the neurobiologic aspects of depression. 2. Develop basic knowledge and understanding of the differences in antidepressant medications in terms of medication mechanisms, clinical effects and side effects.3. Relate the various clinical symptoms in patients with depression to the rational choice of initial medication for particular presenting symptom profiles. 4. Understand what an appropriate treatment trial entails, and the strategies for changing medications, and augmenting medications. 5. Review the major side effects of antidepressant medications, and strategies for their management.

SEMINAR 104
Evaulation and treatment of patients with war trauma in the family practice setting
H. Russell Searight, PhD, MPH; Jennifer Gafford, PhD; Audrey Montooth, MD
As the United States continues to accept immigrants from war torn countries, family physicians are increasingly treating patients with physical and psychological symptoms of war trauma. In the past, these patients often came from Vietnam, Laos, and Cambodia. More recent immigrants include patients from Bosnia and Afghanistan, many of whom have witnessed atrocities such as mass killings and the deaths or disappearances of family and friends. As a result, many of these refugees exhibit psychiatric conditions such as Major Depressive Disorder, Somatoform Disorder and Post-Traumatic Stress Disorder, as well as ongoing medical problems. Interviews suggest that these refugees often had sub-optimal medical and mental health care before arriving in the U.S. Patients with war trauma often present an array of symptoms that may be confusing to U.S. physicians and mental health professionals. Symptoms such as chronic limb pain, near-syncope, paresthesias, chest discomfort, choking sensations and numbness of the face and hands, often lead to multiple negative medical evaluations. Language differences, cultural influences of symptom presentation, and views of health care professionals further complicate clinical assessment and treatment.
Goals: Participants will: (1) Acquire information about current war-related immigration patterns to the U.S.; (2) Acquire knowledge about the prevalence and duration of common psychiatric conditions associated with war trauma; (3) Develop skills in conducting assessment interviews with patients having experienced war trauma; (4) Develop a working knowledge of clinical management and treatment of war trauma patients.
Objectives: Participants will acquire: (1) A working clinical knowledge of how war trauma exposure affects presentation of common psychiatric conditions such as Major Depressive Disorder and Post-Traumatic Stress Disorder; (2) Information about common somatic symptoms often associated with war trauma and the process of medical differential diagnosis; (3) Guidelines for conducting clinical interviews with the aid of a translator. Issues such as secondary traumatization that may occur during an interpreted interview will be included; (4) A clinical treatment protocol for psychotherapy referrals as well as for psychotropic medication treatment.

SEMINAR 105
Management strategies for challenging patients: A diagnosis, treatment, and practice policy model
Mary Talen, PhD; Carole Stokes-Brewer, PhD, LISW, CCDCIII; Jonathan Sorscher, MD
Training residents to gain professional confidence and competency in coping with the challenging patients is essential. The goal of this seminar is to present didactic, clinical precepting, and practice management strategies that help residents understand and intervene with emotionally and medically taxing patients. We have developed a structured protocol to guide residents in the process of assessing and coping with challenging patient issues. First, residents are taught a model for assessing the severity of the patient issues. The protocol is used to encourage the residents to identify their own reactions and specify alternative approaches that match the intensity of the patients' issues. Second, residents and preceptors can use the model to help evaluate and effectively intervene with patients. During case presentations, a list of questions are used to help the preceptors focus the resident's knowledge, skills and attitudes with these patients. Third, the residents are exposed to practice management policies such as "no show" letters or treatment plan agreements that are consistent with the patient issues and treatment goals. These practice management policies help clarify and document the physician-provider relationship and expectations. Most importantly, this model can assist residents in avoiding the "blaming" the patient reactions and foster a guided process for addressing patient needs while maintaining clinical continuity. We will share the structured protocol, give video examples of residents and preceptors, and offer practice management examples.

SEMINAR 106
"How are you well today?" Positive psychology and family medicine
Paul Hershberger, PhD
Despite Family Medicine's emphasis on prevention and health promotion, in the mental health arena family physicians typically focus on identifying and managing mental health problems. This is not surprising given that clinical psychologists and social workers also are characteristically trained to address problems rather than promote well-being. However, the positive psychology movement is calling attention to opportunities for the development and nurturance of human strengths and virtues, emotional well-being, life satisfaction, and happiness. This seminar will review the core components and resources of positive psychology, consider opportunities for resident and faculty development, and discuss how family physicians can utilize aspects of positive psychology interventions with patients. The case will be made that the principles of positive psychology warrant inclusion in creating the future of family medicine. Objectives: Seminar participants will: 1) Enhance knowledge regarding correlates of and pathways to happiness; 2) Gain familiarity with a recently published classification of human strengths and virtues; 3) Learn several positive psychology interventions; 4) Acquire ideas of how positive psychology interventions can be used for student, resident, and faculty development; and 5) Discuss implications of positive psychology for patient care.

SEMINAR 107
Ethical issues arising when psychologists and physicians work together
Nicholas Apostoleris, PhD; Beth Kurtz Mazyck, MD; Silvia DeGirolamo, PsyD
The Fitchburg Family Medicine Residency, located within a community health center, has in the past five years evolved into a setting where medical and mental health care is provided with a high level of collaboration. Psychologists and physicians have been traind in very different environments which has led to differences in their professional cultures. These cultural differences extend to the domain of professional ethics.
This session will examine ethical issues arising when these providers join a culture of collaboration. The three presenters offer distinct perspectives on this issue, with a faculty physician/medical director who serves on a hospital ethics committee, a psychologist who has been in Family Medicine as a Behavioral Scientist for five years, and a post doctoral fellow in Primary Care Psychology. As integrated primary care in which mental health and medical personnel work collaboratively becomes more prevalent, ethical issues arising from these collaborations will likely increase and need to be addressed.
Goals and Objectives: A) Gain knowledge about a. Similarities and differences between ethics in medicine and psychology including i. boundaries and boundary violations ii. differences in form and role of Ethics Codes b. How psychologist/physician/NP collaboration works in a family medicine residency located in a community health center c. Specific ethical issues which need clarification as collaboration grows B) Engage in a conversation regarding a. Our understanding of what "ethics" means in medicine and psychology b. Integration of mental health and medical training programs c. Ethical concerns from seminar participants raised by the presenters or encountered in participants' experiences d. Future directions, opportunities, and challenges.

SEMINAR 108
The Schwartz Center Rounds
Michael Floyd, EdD; Avram Kraft, MD
The Schwartz Center Rounds are a unique and highly effective forum for improving the relationship and increasing the understanding between patients and clinical caregivers by:

• exploring the human dimension of health care;
• enhancing communication among caregivers;
• promoting teamwork among caregivers;
• providing support to caregivers; and
• giving caregivers knowledge and insight into the non-clinical aspects of patient care.

Purpose
The constant and unrelenting stresses of our modern health care system threaten the delivery of compassionate health care. Financial pressures and greater bureaucratic demands mean less face-to-face time with the patient, and a focus on the illness, its diagnosis and treatment rather than the effect of the illness on the patient's life and family. Many caregivers today are anxious, frustrated and under pressure. They have no structured outlet where they can express their feelings. In addition, with little or no training to handle the non-clinical aspects of patient care, many feel inadequate when responding to the difficult social and emotional issues that are an inevitable part of patient care.
That is why the Schwartz Center Rounds were created - to provide a multidisciplinary forum where clinical caregivers have the opportunity to discuss their experiences, thoughts and feelings. The Rounds, which differ from medical or ethics rounds, offer caregivers a safe,
open and relaxed place where they can share their concerns and their fears, both for their patients and themselves. The premise is that caregivers are better able to make a personal connection with patients when they have greater awareness of and insight into their own responses and feelings. The Rounds integrate the social, emotional and personal realms of patient care with the technical, efficiency driven and economically focused side of modern medicine.
The fact that the Rounds have thrived in diverse environments (academic medical centers, community hospitals, chronic care facilities and outpatient settings) shows that they are fulfilling a tremendous need. Participants have commented that before the Schwartz Center Rounds, there was no real opportunity in the regular workday to discuss these kinds of issues in depth. They are consistently grateful for the Rounds, which have also stimulated small and informal follow-up discussions among co-workers.

SEMINAR 109
Identifying and resolving conflict - helping residents learn the basics
Deborah Taylor, PhD
Residencies are a natural breeding ground for conflict and that is a gift to residency educators. Using real life examples of common residency situations will help you: define different types of conflict, examine your own conflict management family history, discover the wisdom for knowing that there are different kinds, and outline 6 steps to help you approach (versus avoid) conflict. Canned noontime lecture for quick transport back to your residency (built in group exercise) will be available.

SEMINAR 110
Who's on first? What's on second? A diagnostic dilemma of suspected domestic abuse
Anne VanDyke, PhD; Jodie Eckleberry-Hunt, PhD; Marisa Abbo, DO
This presentation addresses the diagnostic dilemma that health care providers can be confronted with when patients well known to us throw us a curve ball. With the goal of not striking out, this presentation will equip participants with the knowledge and skills needed to solve a puzzling and incongruent patient presentation. Presentation objectives include reinforcing the benefits and necessity of a collaborative and systems based approach to patient care; highlighting the role that cognitive and memory assessment can play in detecting and managing clinical issues, and emphasizing the critical importance of maintaining trust and partnership in the doctor/patient relationship.
The instructional format will involve an unfolding case presentation by both behavioral medicine and physician faculty. Participants will be encouraged to share their ideas and thoughts in determining the differential diagnosis as the case unfolds.

WORKSHOP 111
Prepare for the future: Implement depression screening now
Elizabeth Klein, MD; Ralph Bramucci, PhD; Charlotte Navarre, RN
Depression is common, easily missed, and treatable with a huge impact on patient wellness. We are told that we should be screening for depression, but how to do this remains elusive to many. Participants in this workshop will learn a physician and patient friendly method to implement depression screening. We will share valuable handouts on depression, stress reduction and depression self care in Spanish, Russian and English. Using our experience, participants will learn methods for implementation, how to overcome the obstacles and see the benefits of depression screening in a busy family practice residency clinic.
Goals and Objectives: At the conclusion of this workshop, participants will be able to
1) Discuss the importance of Depression and Depression Screening in Family Practice
2) Use and implement a patient and physician friendly depression screening tool which has validity and reproducibility; the Patient Health Questionnaire
3) Discuss practical methods to assist with implementation of depression screening in a busy family practice residency clinic.
4) Use excellent patient education on depression, stress reduction and depression self -care.
5) Discuss the potential for a Depression Registry (patient tracking) to improve compliance and outcomes utilizing the electronic medical record.

WORKSHOP 112
Embracing the core of personal expression through narrative
Richard Holloway, PhD; Chris McLaughlin
There is an emerging literature that suggets that there is substantial benefit to writing for personal expression for both patients and providers. Anecdotally, these effects have been evident for some time. The purpose of this workshop will be to continue and advance a process of writing personal narratives for health benefit, publication and storytelling. The goals of this workshop will be to: determine anumber of outlets for personal writing; creating a context for personal writing; describe the purposes for personal writing; engage in several exercises regarding personal writing; produce at least one personal essay.

SEMINAR 113
The Balint Group experience
Steve Crossman, MD; Maria Devens, PhD; Michael Floyd, EdD; Albert Lichenstein, PhD; Laurel Milberg, PhD
Baliant groups can be a powerful method to assist the synthesis of cognitive and affective processing leading to a more precise, empathic, and practical understanding of doctor-patient interactions.
Method: Three 90' sessions (one each day) provide participants an experience for learning abuot Balint methods. Participant backgrounds may range from those who have never experienced a Balint group to those with established leadership skills. We ask that participants have clinical contact with patients, be willing to present a case, and commit to attend all three sessions.
Objectives: 1) Define the purpose, essential elements, and outcomes of Balint groups. 2) Distinguish Balint from support or other types of groups. 3) Expand leadership skills; 4) Describe ways to start and maintain a group in medical school and residency settings.
Timeline: Day 1 Introductions, purpose, elements, anticipated outcomes of Balint groups (15'). Actual Balint groups (8-10) with 2 faculty per group. Participants with experience offered leadership opportunity. Discussion of group process and leadership issues (75').
Days 2 & 3. Address questions, resume Balint group sessions. Each day, participants encouraged to lead groups (two, 45' sessions). Debrief and feedback to volunteer leaders. Final session topics: "Starting and Maintaining groups" and "Avoiding Common pitfalls" (30').

SEMINAR 114
Borderline personality disorder: Biological, developmental and psychodynamic issues, primary care diagnosis and management
Randy Ward, MD
The management of patients with borderline personality in the primary care setting can be very challenging. These patients can cause much stress, frustration, and other feelings on the part of the physician and staff. They tend to use high levels of medical resources, and have poor health outcomes. Patients with this disorder often require specific behavioral management strategies, and at times formal management contracts. Family physicians can feel quite overwhelmed trying to care for these patients. A basic knowledge of some of the etiologic factors, interpersonal dynamics, and biological abnormalities inherent in patients with this disorder, coupled with screening, diagnostic, and management strategies, can help the physician develop better working relationships with these patients, less chaotic clinical encounters, and better health outcomes for the patient
GOAL: Improve knowledge and skills in the assessment and management of patients with borderline personality disorder in the primary care setting.
OBJECTIVES: a. Develop a basic understanding of biological, developmental and psychodynamic issues relevant to borderline personality disorder.
b. Review current perspectives on the relation of early trauma and borderline personality disorder. c. Review current knowledge of the neurobiology and pharmacologic approaches to borderline personality disorder. d. Improve diagnostic skills and management of interpersonal dynamics with respect to patients with borderline personality disorder in the primary care setting. e. Develop management strategies for patients with borderline personality in the primary care setting focusing on boundaries, limit setting, treatment plans and contracts, pharmacotherapy, and co-management issues.

SEMINAR 115
Creating the perfect physician: Applications of a flawed ideology
Jodie Eckleberry-Hunt, PhD; Barbara Joyce, PhD; T. Michael Calcut, Jr, MD
The quest for perfection in medicine presents physicians with a harsh paradox. To be perfect menas never to err, and never to err, means to be inhuman. This dilemma is especially painful for physicians in training who are now mandated to be humanistic and error-free.
Seminar Goals: 1) Th perils of perfectionistic thinking will be reviewed. 2) The ways in which perfectionism is taught and reinforced in academic medicine will be presented with audiotaped interviews from actual residents and faculty. 3) Methods to balance the need for perfectionism with phychological wellness in medicine will be introduced.
Seminar Objectives: 1) Attendees will understand the function and dysfunction associated with perfectionism, especially applied to medicine. 2) Attendees will increae their awareness how perfectionism is taught in academic medicine and how this interferes with learning. 3) Attendees will learn strategies to teach residents through the use of errors and recognition of humanity.

SEMINAR 116
Creating an effective collaborative behavioral science curriculum
Therese Namenek, DPP; Patricia Pletke, MD
The ACGME requirements for a Residency Education in family medicine provide a list of content areas and skills which should be taught through a combination of longitudinal experiences and didactic sessions. It also recommends that the human behavior and mental health curriculum be integrated with all disciplines and invovle the participation of physicians as well as behavioral scientists.
The goal of this seminar is to demonstrate that collaboration is not only possible but desirable. The physician/psychologist co-presenters will describe a series of methods that have evolved over a period of almost three decades and were found to be effective. At the conclusion of the seminar participants will be able to identify a variety of collaborative teaching strategies, assess their strengths and limitations and discuss ways to implement them in one's own program.
Following a structured presentation this workshop is intended to be interactive with participants sharing their own experiences, their successes and challenges. Hopefully it will serve as a mentoring opportunity where "old timers" can inspire teachers who are new in their position.

SEMINAR 117
Using personal health experiences in graduate medical education
Alan Wolkenstein, MSW; Dennis Butler, PhD
As Behavioral Science continues to critically look at teaching and patient care, the physician/patient relationship, and professionalism, we need to evaluate the use of educators' personal health histories. What are our core beliefs about utilization of personal health histories in our peer relationships and teaching.Personal health histories or "critical incidents" are those experiences that have a significant strategic impact on our being: from health care crisis to psychosocial challenges. For the purpose of the seminar we would like to focus on health care issues only. The presenters will run a small group experiential learning seminar in which participants will generate discussion of the ethics, practicality, and outcomes of revealing significant parts of ourselves to others. The discussion will focus on the role of self-disclosure with peers and colleagues, residents and students, patients and families… and the impact of these on our psyche, professionalism, and spirit.This is the time to take a more critical look at some of our behaviors as core attitudes, beliefs, and values of our profession. Our colleagues expect this, our patients are entitled to this, and our residents and students deserve this. Come join us for an interesting problem-solving seminar.

SEMINAR 118
Motivating residents to motivate others: Lifestyle change in high-risk patients
William Gaertner, MD; Jeffrey Morzinski, PhD, MSW
Family physicians need to acquire practical skills for comunicating with patients about lifestyle change. Motivational interviewing (MI) is a set of powerful concepts and tools for counseling patients. A growing body of evidence supports the use of MI, and it was the topic of a recent Forum keynote presentation.
While the importance of motivational interviewing (MI) has been established, a recent survey we conducted with practicing primary care physicians in Wisconsin showed that significant barriers prevent them from implementing MI practices. The largest barriers to their using MI tools were gaps in systems-based resources and communication skills. Therefore, this seminar presents a MI curriculum for family medicine residents that focuses on the ACGME competencies of communication and systems-based practice.
Objectives: Learners will describe and apply appropriate MI concepts to three outpatient cases marked by obesity and cardiovascular risk factors. Cases illustrate different "change readiness" stages and invite learners to try out MI approaches.
This seminar is divided into three parts: 1) An introduction and refreseher on MI principles and techniques, 2) facilitated case discussion groups, including worksheet completion on MI-focused diagnosis and care plan, 3) case reports and debriefing, especially on MI curriculum evaluation. Curriculum material will be distributed.

SEMINAR 119
The international medical graduate and residency education: Adapting behavioral and biomedical curricula
H. Russell Searight, PhD, MPH; Jennifer Gafford, PhD; Audrey Montooth, MD
Recent Match results indicate that International Medical Graduates (IMGs) are filling approximately 40% of U.S. family medicine residency positions. Of these IMGs, many are recent immigrants to the U.S. These residents often come from countries with approaches to medical education, doctor-patient relationships, and the context of medicine, itself, that differs from the U.S. model. Through a qualitative interview study, IMG family practice residents described distinct process differences such as a collaborative style of doctor-patient and teacher-learner interactions in the U.S. Content differences were described as well, including a greater emphasis on preventive care, psychiatric conditions, documentation, and psychosocial issues in the U.S. as compared with many other countries. These culturally based differences often contribute to incorrect faculty assumptions about IMG's training, skills and knowledge base. At the same time, understanding these culturally-based differences may assist faculty in focusing educational activity to IMGs as they are learning about and adapting to U.S. standards. This presentation will highlight these issues with case vignettes and results of a qualitative investigation. Educational strategies to address these culturally based differences will be presented as well.
Goals: Participants will acquire knowledge about (1) Recent family medicine match results and the growing number of IMGs in family medicine residencies; (2) Common differences between medical education in the U.S. compared to many international institutions; (3) Differences between the U.S. and IMG's home countries in the doctor-patient relationship and role of psychosocial issues in medicine; (4) Strategies for addressing these differences during residency education.
Objectives: Seminar participants will: (1) Develop knowledge and skills for teaching residents about cultural differences in doctor-patient relationships along a continuum of paternalistic to collaborative models of care; (2) Develop an appreciation for the distinctive consumer orientation toward patient care in the U.S. as compared with less-developed countries; (3) Understand common differences between the U.S. and other societies in the content of family practice encounters such as the relative value of providing anticipatory counseling, psychiatric care, and treatment of acute versus chronic medical conditions; (4) Acquire educational strategies to address these issues including lectures, role plays, videotapes, and clinical protocols.

WORKSHOP 120
Learning from emotions in primary care: Drama, poetry, and visual arts
Mark Marnocha, PhD; Deborah Schultz, MD; Robin Price, MD
The deaths of patients who are young, who have refused interventions late in terminal illness, who are beyond treatment, who have been close to the primary provider, or who are colleagues or family, all call forth emotions beyond those readily contained within daily routine. Residents' objective scientific training, combined with intense time and performance demands, leaves them uncomfortable and unfamiliar with such emotions. Balint groups, self-awareness programs, and personal explorations of family all contribute to skills for processing such emotional events. Humanities activities augment these approaches via access to techniques and traditions outside the medical realm.
This program presents medical humanities activities to strengthen residents' emotional skills in primary care, with emphasis on poetry, drama, and visual arts techniques that encourage both appreciation and creation. The program reviews critical residency events, summarizes components of emotional processing, illustrates practical humanities techniques, allows participants to practice techniques, and encourages sharing of participants' own emotional events and learnings.
Goals and Objectives: Participants will: [20'] A. Review emotional education needs in residency via Examining critical events in resident development; Reviewing gaps in physicians' emotional education; Considering recommendations from ACGME and other sources concerning professionals' emotional skills. 20'] B. Become familiar with components of interpersonal and emotional skills via Appreciating research on primary care process, counselor effectiveness, trauma recovery, and predictors of MD success; Reviewing useful program components for emotional education; Examining the rationales and precedents for use of Humanities in residency. [80'] C. Gain comfort and familiarity with Humanities techniques via Sharing of critical emotional events and lessons learned; Participating hands-on in visual humanities appreciation and drawing, poetry exercises and responses, and drama expression techniques; Sharing and integrating important personal experiences.

WORKSHOP 121
Using a commerical videotape to teach professionalism expectations in residency
Joane Baumer, MD; Anita Webb, PhD
Problem/Gap: 1) Public demands for physician professionalism 2) Pressure on state boards fo physicians examiners to agressively discipline unprofessional physicians 3) Physician dissatisfaction with an increasingly hostile practice environment.
Goal: Teach residents about professionalism expectations
Objectives: 1) Introduce a videotape designed by a state board of physician examiners for teachign physiicans-in-training about professionalism expectations 2) Discuss the advantages and disadvantages of using this videotape strategy 3) Describe our research on the videotape and present our results 4) Follow-up on our presentation on professionalism expectations at last year's Forum.

WORKSHOP 122
Enhancing residents' skills for promoting health behavior change
Julie Rickert, PsyD; Kimberly Krohn, MD, MPH
The patient’s behavior has a tremendous impact on the outcome of their healthcare, yet is one of the most difficult factors to impact in the consultation. Research suggests that simply bringing up the need for behavior change is ineffective in changing patient behavior. However, with accurate assessment of patient characteristics, the use of patient centered communication techniques, skillful use of techniques to initiate, promote, and reinforce behavior change, and skills to cope with resistance, slips, and relapse the physician can have a powerful impact on patient behavior. Goals: Workshop participants will: 1. Gain familiarity with major theories of health behavior change; 2. Explore specific skills which can be used to impact patient behavior; 3. Explore opportunities and practice methods to teach these skills to family practice residents. Objectives: Workshop participants will: 1. Be able to describe the major theories of health behavior change; 2. Be able to identify key skills in assessing readiness to change, encouraging patient commitment to change, and educating patients in the skills necessary to be successful in changing; 3. Be able to identify specific skills to cope with resistance, slips, and relapse; 4. Identify methods to teach these skills to family practice residents.

SEMINAR 123
From statistical to personal significance: Teaching EBM in residency
Mark Marnocha, PhD; Deborah Schultz, MD; Robin Price, MD
Residency education must include evidence-based medicine (EBM) content. Medical and behavioral faculty have general education in statistics and epidemiology, yet many feel uncomfortable with technical aspects of studies, and even more so with teaching or critiquing those aspects. However, the best teachers and role models for EBM are practicing clinicians/educators, not biostatisticians. This presentation will examine experiences and resources for the nonstatistician teaching EBM, considering Journal Club format as a primary setting.
This presentation considers ACGME expectations for EBM skills, and reviews EBM education techniques such as encouraging evidence questions, providing key resources, just-in-time teaching about EBM, faculty role-modeling, user-friendly presentation of statistics, convening journal club teams by interest areas, and using EBM to make clinic-wide decisions about new medical techniques. Included in the presentation will be practical approaches to such topics as diagnostic utility, ROC curves, confidence intervals, research designs, strength of evidence, and kinds of statistics. This presentation will be most useful for faculty who are early in the stages of teaching EBM, or who have more experience but would value further strategies for this challenging area. Participants will share backgrounds, critique articles, and summarize effective approaches within their programs.
Goals and Objectives:
Participants will: Gain familiarity with key components of evidence-based medical practice via
Examining ACGME competency expectations; Reviewing the history of the EBM movement; Considering roles of faculty, medical and psychosocial, in the EBM process. Explore techniques of EBM education via Discussing components of attendees' programs;
Examining rationales and techniques for convening a personally relevant Journal Club;Analyzing critical roles of all faculty in EBM practice. Improve comfort with key EBM content via Participating in small group exercises in calculations and critiques; Understanding summaries of basic design and statistics concepts and resources; Identifying areas of personal interest and investment in the EBM teaching process.

SEMINAR 124
Melting-pot medicine: Teaching to the challenges of medicine by translation
Lee Petersen, PhD; Molly McNees, PhD; Steve Athanail, MD
In a perfect medical world, the assigned doctor could always speak each patient's language well enough to deliver truly comprehensive and compassionate care. In the real medical world more and more of us are encountering, physicians often struggle with untrained translators - perhaps even family members and companions - or distant telephone translators who may have difficulty even conveying symptoms and treatment directions with appropriate accuracy. And, dare we even think about patient expectations?...cultural explanations? …tradition-based remedies and interactions? …or family issues? …when translation patients present to our western medical system with what seems a very "foreign" mindset?
Using training films, videotapes of resident-patient translator sessions, and the accumulated experience of faculty with many years of interfacing with countless cultures amidst our patients, our residents and our faculty, presenters will offer both theoretical guidelines and practical suggestions for helping residents maintain standards of quality Family Practice medical care.
Objectives focus on addressing resident expectations and management of the translation encounter -- e.g., importance of the physical arrangement of participants, need for ongoing 'supervision' of translation process, special importance of non-verbal behavior and messages, managing low expectation about comprehensiveness of care in medicine by translation, etc. Discussion of others' experiences, quandaries, and solutions welcome.

WORKSHOP 125
Journey to the core: Drama-based learning to explore values and enhance communication Andrew Stewart, PhD; Jay Won Lee, MD
Self-reflection and effective communication are central to our work as healthcare professionals. Furthermore, the capacity to teach or inspire self-reflection and effective communication is part and parcel of our role as behavioral scientists. Among the numerous methods for facilitating these capacities is creative drama, which, through its spontaneity and emotional intensity, can focus attention, heighten awareness, and dynamically convey ideas beyond more rigid, traditional teaching tools. In a structured drama-based learning activity developed by the authors and now used effectively in agencies across the country, attendees will create dramatic vignettes that explore core values, attitudes and concerns at the heart of behavioral science in family medicine that shape teaching and patient care, the doctor-patient relationship, and how we behave as professionals in general. The goal of participation is to develop attendees' awareness of their own core values, as well as to develop a replicable set of structured skills they can use to facilitate self-reflection, empathy, and effective communication in others. Participants will receive a detailed manual for use at their own agency.
Goals: Workshop participants will: 1) Enhance their understanding of the role of play, creativity, and emotional attunement in relationships with patients and colleagues; 2) Become more aware of attitudes and feeling states in themselves, patients, and colleagues that influence teaching, healer-patient relations, and professional behavior in general; and, 3) Acquire a replicable set of structured skills, namely, improvisation, character and script development, and emotive techniques, that may be used to facilitate clinical and organizational problem-solving.
Objectives: Workshop participants will: 1) Be able to actively demonstrate effective multi-sensory (i.e., verbal and non-verbal) communication skills; 2) Be able to identify core values, attitudes, and concerns that impact their professional and personal lives; and 3) Be able to adapt the skills acquired in this workshop to addressing other conditions and situations in healthcare, for example, organizational conflict resolution.

WORKSHOP 126
Journey to acceptance: A personalized diversity curriculum
Kim Marvel, PhD; Cherie Glazner, MD, MSPH; Michael Towbin, MD; Jennifer Juarez, MEd
No longer can physicians care for people with medical facts and technology alone. To skillfully recognize and address diverse cultural needs of patients, physicians must first recognize their own backgrounds, belief systems and attitudes. Ideally, these skills should be built into every activity of a physician-in-training, but the current medical training system fragments culture from technology. Thus, the need to address diversity issues in a defined curriculum.
This workshop presents a unique diversity curriculum, which customizes learning and allows personal growth while broadening acceptance of patients who present the largest challenge. A series of experiential learning situations are presnted to the residents. These include: non medical home visits, simulated patients, collage creation, and focused music and writing exercises. Outcome data demonstrate the effectiveness of the curriculum by documenting improvements in resident interviewing skills and attitudes, as measured by the Q-sort, standardized patient feedback, and videotapes of physician-patient interviews.
Objectives: 1) Describe the broad definition of diversity and the concept of cultural humility 2) Implement select experiential teaching methods utilized in this curriculum 3) Summarize the impact of the curriculum on resident attitudes and behavior (based on data presented).

SEMINAR 127
The Balint Group experience
Steve Crossman, MD; Maria Devens, PhD; Michael Floyd, EdD; Albert Lichenstein, PhD; Laurel Milberg, PhD
Baliant groups can be a powerful method to assist the synthesis of cognitive and affective processing leading to a more precise, empathic, and practical understanding of doctor-patient interactions.
Method: Three 90' sessions (one each day) provide participants an experience for learning abuot Balint methods. Participant backgrounds may range from those who have never experienced a Balint group to those with established leadership skills. We ask that participants have clinical contact with patients, be willing to present a case, and commit to attend all three sessions.
Objectives: 1) Define the purpose, essential elements, and outcomes of Balint groups. 2) Distinguish Balint from support or other types of groups. 3) Expand leadership skills; 4) Describe ways to start and maintain a group in medical school and residency settings.
Timeline: Day 1 Introductions, purpose, elements, anticipated outcomes of Balint groups (15'). Actual Balint groups (8-10) with 2 faculty per group. Participants with experience offered leadership opportunity. Discussion of group process and leadership issues (75').
Days 2 & 3. Address questions, resume Balint group sessions. Each day, participants encouraged to lead groups (two, 45' sessions). Debrief and feedback to volunteer leaders. Final session topics: "Starting and Maintaining groups" and "Avoiding Common pitfalls" (30').

SEMINAR 128*Please note-new topic
Training the assertive practitioner of Behavioral Medicine in Family Practice: The development of a specialized Behavioral Medicine Track
Dennis Butler, PhD; Richard Holloway, PhD; Rhena Ruiz, MD; (Randy Ward, MD)
In 2001, the family medicine, behavioral science faculty of the Medical College of Wisconsin defined core attributes associated with the assertive practitioner of behavioral medicine in family practice. The assertive practitioner is one who actively incorporates psychosocial information into practice, proactively manages psychosocial and psychiatric problems and develops skills, knowledge and expertise in the behavioral medicine aspects of primary care. Using this formulation, a specific behavioral medicine track was developed at one residency. Residents who select this track tailor their three years of training to become physicians attentive to and skilled in various aspects of psychosocial practice, psychiatric treatment, family systems and behavioral medicine. In doing so, they design 4-6 elective rotations to a behavioral medicine/psychiatry focus. The track training also includes a specific didactic curriculum, training in psychopharmacology, collaborative care of patients and direct supervision. Multiple preceptors are utilized for their particular expertise at various stages of the track. As part of this presentation, a current resident in this track will describe her experience in the track and the type of practice she anticipates following her graduation.

SEMINAR 129
Prevention and the family life cycle: A collaborative approach
Catherine Bratton Vourkas, ACSW; Nancy Bermon, MD
As family medicine educators, we seek to train residents and students in the family practice model of health care - providing family health care that utilizes the biopsychosocial approach with emphasis on prevention and health education as well as treatment. In these times of reduced resources and increased patient volume, how best to present this model of care confronts us all.
We will present a model for teaching an integrated health education/prevention curriculum that was developed by a member of our family medicine faculty and our behavioral scientist. This collaborative model is designed to expose both residents and faculty to biopsychosocial health education and preventive strategies based on a family life cycle approach. The curriculum is two-tiered: consisting of integrated case seminars for residents and precepting strategies to be used by faculty.
We will share our rationale for using a family life cycle approach, describe our curriculum, techniques and strategies used and discuss our experience in introducing this model to residents and faculty. Using a case presentation, participants will be guided through a role play and group discussion that demonstrates how this model can be used in an office setting.
The overall goal of this presentation is to share our experience in introducing a fully integrated model of prevention and health education based on the family life cycle approach. Specific objectives include:
(a) Participants will learn the essential elements of the family life cycle approach and how to use this approach in teaching about prevention and health education
(b) Participants will be provided with specific examples of prevention and health education issues at each stage in the family life cycle
(c) Participants will learn educational strategies utilizing case seminars and precepting techniques that are effective in teaching this curriculum.
Time utilization: We will begin with an introduction and discuss our rationale for using the family life cycle approach (10 minutes). We will next describe our curriculum and the challenges faced in introducing it into our program (20 minutes). This will be followed by a case presentation, role play and experiential exercise (45 minutes). We will close with guided discussion and feedback (15 minutes).

SEMINAR 130
Teaching integrative family medicine: From facts to stories, and back again
David Rakel, MD; Deborah Schultz, MD; Mark Marnocha, PhD
Integrative Family Medicine practice requires multidisciplinary skills and a holistic view of patients' well-being, both cornerstones in Family Medicine's history and future. However, incorporating the Integrative approach is difficult within the busy span of residency, and more didactics are rarely met with initial favor. The problem-based approach to intervention, and the case-based approach to assessment, can serve to ground Integrative Medicine in daily primary care.
Faculty need to gain comfort with its evidence, techniques, and efficiency if Integrative primary care will be valued by resident learners. The presenters examine case examples of Integrative approaches to inflammatory illness treatment and end-of-life care. Factors and findings are considered in detail, including physiologic, dietary, and psychosocial aspects of the inflammatory cascade; connections of meaning and pathophysiology at end-of-life; and mind-body implications of key psychological history findings. Resources for Integrative Family Medicine practice will be demonstrated in a problem-based learning format, and strategies for incorporating such practice in the residency setting will be reviewed. Specific case examples will be considered in detail, and participants will be encouraged to share experiences and inquiries.
Goals and Objectives: Participants will: Gain familiarity with Integrative Family Medicine practice via Reviewing the components and history of this approach; Considering specific areas of evidence and practice; Appreciating patient preferences and values. Appreciate the value of teaching Integrative Family Medicine via Observing its connections with new biomedical findings; Discussing the future of Family Medicine's relationship with the Integrative area; Practicing the traditional case presentation augmented with problem- and case-based
Integrative Family Medicine teaching. Experience the specific clinical applications of such an approach via Following problem and case details of Integrative Family Medicine applied to
inflammatory illness; Considering Integrative approaches to end-of-life care and psychological history- taking; Discussing participant experiences applying an Integrative approach to care and teaching.

SEMINAR 131
The Balint Group experience
Steve Crossman, MD; Maria Devens, PhD; Michael Floyd, EdD; Albert Lichenstein, PhD; Laurel Milberg, PhD
Baliant groups can be a powerful method to assist the synthesis of cognitive and affective processing leading to a more precise, empathic, and practical understanding of doctor-patient interactions.
Method: Three 90' sessions (one each day) provide participants an experience for learning abuot Balint methods. Participant backgrounds may range from those who have never experienced a Balint group to those with established leadership skills. We ask that participants have clinical contact with patients, be willing to present a case, and commit to attend all three sessions.
Objectives: 1) Define the purpose, essential elements, and outcomes of Balint groups. 2) Distinguish Balint from support or other types of groups. 3) Expand leadership skills; 4) Describe ways to start and maintain a group in medical school and residency settings.
Timeline: Day 1 Introductions, purpose, elements, anticipated outcomes of Balint groups (15'). Actual Balint groups (8-10) with 2 faculty per group. Participants with experience offered leadership opportunity. Discussion of group process and leadership issues (75').
Days 2 & 3. Address questions, resume Balint group sessions. Each day, participants encouraged to lead groups (two, 45' sessions). Debrief and feedback to volunteer leaders. Final session topics: "Starting and Maintaining groups" and "Avoiding Common pitfalls" (30').

Networking Breakfasts
Using Case Presentations to Teach and Evaluate Core Competencies in Family Medicine
Theresa Drewniak, PhD; Robin Helm, MD
Our family medicine residency program has successfully used resident case presentations (RCP) as a method for teaching integrative principles of behavioral science and medicine. We are now exploring the feasibility of RCP for both teaching and evaluating several of the core ACGME competencies: communication, systems-base practice and professionalism. At this discussion we will present our RCP model and a pilot evaluation instrument that is consistent with ACGME recommendations that emphasize the outcomes of teaching on performance. Participants will learn how our program is using case presentations to teach and evaluate ACGME competencies. Participants will also gain ideas from peers on innovative techniques for teaching and evaluating competencies through case presentations. Finally, participants will evaluate and discuss the utility of using this method at their teaching site. This breakfast session is organized in three parts: Introduction (presenters describe model and instrument), discussion (participants describe prior work and ideas), and wrap-up (debrief and summarize).

How did it get so complicated? History of our system of health care funding, with implications for the future
Edwin Rogers, PhD, ABPP
Providing health care has always involved knowledge of, and negotiation within, the larger economic and social system of our society. The ACGME has explicitly acknowledged this with their requirement that residents be proficient in "systems-based practice". This includes competence in "resource allocation" in the attempt to "provide care that is of optimal value". To do this, physicians need to know about the economic and societal forces that have influenced the development of our current sytem of financing health care services. The present day predominance of systems of "managed care" developed over time in response to social and economic forces. What are the origins of our current sytems of health care financing? What aspects of physician behavior are shaped by the economics of medical practice and reimbursement, and how have these financial arrangements (and physician behavior and attitude) changed over time? What implications does the present system of managed care have for training and practice? How might efforts to rationalize delivery and financial systems ("health care reform") impact training and practice in the future?
Goals & Objectives: Seminar participants will 1)Review the development of various systems of health care financing in the 20th century. 2) Recognize the economic and social forces influencing the current sytem of health care finances and delivery. 3) Discuss the synergistic impact of financial incentives, evidence based medicine concepts, and "specialization" by function (e.g., hospitalists) on future practice patterns.

Teaching professionalism in residency
Joane Baumer, MD; Anita Webb, PhD
Problem/Gap: Public demands for physician professionalism. Pressure on state boards fo physician examiners to agrressively discipline unprofessional physicians. Physician dissatisfaction with an increasingly hostile practice environment.
Goal: Teach residents about professionalism expectations. Objectives: 1) Introduce a videotape designed by a state board of physicians examiners for teaching physicians-in-training about professionalism expectations. 2) Discuss the advantages and disadvantages of using this videotape strategy. 3) Describe our research on the videotape and present our results 4) Follow-up on our presentation on professionalism expectations at last year's Forum.

"To comfort always": Exploring and teaching the rhetoric of healing
Janet Hortin, MD; Carlann Scholl, PhD; Padmadriya Chariar, MD
The biomedical model is insufficient for responding to our patient's subjective suffering, espcially those with chronic or terminal illnesses. Medical students, residents, and physicians need to be aware of the use of language as a tool for healing. We also need to improve awareness about how language can, unfortunately, be an instrument of increased suffering. We have all heard some of these "words of hurt" that echo in our pateints' narratives and bodies years after a careless physician or nurse delivered them. We will address the topic of healing rhetoric as a tool for enhancement of the doctor/patient relationship. How can this be taught?
Goals and Objectives: 1) Explore some principles of rhetoric and how we can create healing and hope through language-even when physical cure is not possible. 2) Show how a palliative care/respite model of student/resident/patient interaction facilitates learning the rhetoric of healing. 3) Explore participants' experiences with the rhetoric of healing. 4) Discuss teaching the rhetoric of healing in medical school or residency training programs.