This blog series is done in collaboration with the Society of Teachers of Family Medicine. Come back for later posts.
Training for Family-Centered Care (in 6 minutes and 40 seconds)
What can you learn in 6 minutes and 40 seconds? Is this enough time to deeply listen to the person in front of you? Can you walk away with a new idea, a challenging proposition, motivation to learn more? We think so! Pecha Kucha (https://www.pechakucha.org/) is a structured approach to presentations that allows 20 images with 20 seconds of talk time for a presenter to use to communicate with an audience. Pecha Kucha gives us just shy of 7 minutes to engage and learn something new.
I am delighted to introduce a series of blog posts co- hosted (and co-posted!) by the Society of Teachers of Family Medicine (STFM) and the Collaborative Family Healthcare Association (CFHA). Both organizations are near and dear to my heart. STFM, founded in 1967, boasts a tagline of “Transforming health care through education” and as a professional home for family medicine faculty from multiple many disciplines, achieves that mission daily. (http://www.stfm.org/About) CFHA, founded in 1995, “promotes comprehensive and cost-effective models of healthcare delivery that integrate mind and body, individual and family, patients, providers and communities.” (https://www.cfha.net/page/MissionStatement)
This series of blogs is based on a seminar presented at the 2018 STFM conference, in which the presenters, Randall Reitz, PhD, LMFT, Amy M. Romain, LMSW, ACSW, Valerie Ross MS, LMFT, and Daniel S. Felix, PhD, LMFT used the pecha kucha format to provide an engaging, visually stimulating overview of important concepts from family systems theory.
Understanding the concept of shared family beliefs allows a physician to recognize when a certain lifestyle change might be easier or harder for the patient sitting in front of them.
Family physicians we should make a clear stand for the importance of family systems approaches. Otherwise we are glorified (or un-glorified) internists who sometimes deliver babies and see kids!
Today’s post is from Randall Reitz and focuses on creating a culture of family-centeredness. Over the next few weeks we’ll have posts on triangulation, circular causality, homeostasis or systems stability, and family shared beliefs.
Colleen Fogarty, MD, M.Sc., is Associate Professor at the University of Rochester/Highland Hospital Department of Family Medicine, where she serves as the Associate Chair and Medical Director of Highland Family Medicine.
Creating a Culture of Family-Centeredness
I’m the father of 3 children. I’m also a family therapist. You don’t want to be the child of a family therapist. The kids end up being guinea pigs for some of the parents’ worst ideas. For example, I’ve often implemented token economies with families I see in therapy. You know how it works: you get a quarter or a dollar for specific good behaviors. You lose a quarter or your cell phone for specific bad behaviors.
It started out with a simple job chart on the fridge, but eventually grew to include chores, exercise, music, and homework. The kids loved it. They could earn money for tasks they were required to do anyway. But, quickly the system started failing us. The kids were constantly bickering about if they’d done enough to earn their money, or they’d refuse to do things that weren’t on the chart, or say “No thanks, it’s just not worth a quarter.”
About this same time I saw a TED Talk from Daniel Pink that shared ideas about intrinsic motivation from his book “Drive”. I bought this book, devoured it, and then purchased it for all my faculty colleagues for Christmas. It helped me understand, not only why my chart was failing my children, but also how to build a culture of intrinsic motivation within my clinic and residency.
I’ll let you watch the youtube or read the book to get the background on the research, but the 10,000 foot summary is that people who receive extrinsic rewards for doing their jobs learn more slowly, produce more slowly, and lose their skills more quickly.
The basic premise of the book is that organizations need to focus on creating a culture of intrinsic motivation. Culture is important because it is the truth of the organization. Far more than a policy, job chart, or curriculum document, culture represents the grass roots reality.
He asserts that effective cultures create and sustain intrinsic motivation through 3 overlapping pursuits:
· Mastery, the desire to continually improve at something we value;
· Autonomy, the desire to be self-directed; and
· Purpose, the desire to contribute to something that transcends us.
These principles are the foundational values of the fellowship I run and my residency’s behavioral science curriculum. Especially in the education of family-oriented care we believe our trainees will invest more deeply and progress much further if we promote purpose, mastery, and autonomy throughout the system.
First, purpose. On a group level, the shared purpose is delineated in a mission statement. For a curriculum, it is codified in the preamble to the goals and objectives document for the rotation. Ensure that these central documents are explicit about a family focus. For example, our clinic’s mission statement refers to family-centered care, not patient-centered care.
For the individual resident, their purpose is often found in their personal statement from their application. They frequently speak to a vision of cradle to grave services for an entire family. This pre-residency idealism is gold, yet frequently it is squelched through the reductionism of medical education. Maintaining a value for family-centered care is one of the most important tasks of a behavioral science curriculum. It’s much more vital than the techniques and skills that populate our curricula.
Second, mastery. Mastery feels good. Mastery builds confidence. Mastery in a job comes from having clearly defined expectations and competencies and a process to develop the skills for achieving the expectations. In the medical tradition, this is often carried out through the apprenticeship rubric of see one, do one, teach one. It is tempting to have the behavioral faculty provide solo leadership in this effort, but seeing physician faculty prioritize the family in family medicine will do more than all of our preaching.
At a next level, it requires on-going training and support to remediate shortcomings. At the highest level, every resident should have a personal development plan that maps out their desires for growing in family-oriented care and the specific supports the residency and clinic offer them.
To assess progress toward mastery, we include family-centered care in our milestone documents, which are then used for live observation, such as walking rounds, video precepting, and joint appointments. We set aside time to go over our observations and then debrief the perspective of the residents. This often looks like solution-focused therapy.
And third, Autonomy, the area that I value most. Autonomous practice is the over-arching goal of resident education. What does this look like for family-centered care? I’d suggest the overall goal is to be able to connect family members as part of the continuity of care.
We don’t expect every resident to practice like a family therapist, but there should be EPA’s for family-centered care. These activities would include taking a family history, assessing the family environment and developmental life cycle, conducting a family conference, and engaging a family and managing conflict in the exam room.
Autonomy can be tricky. As with all medical education we need to balance resident autonomy with patient safety. At what point do I stop observing and start intervening when things are going poorly? And, just as not every resident wants to provide OB care after graduation, not every resident will value family-centered care.
If we push too hard against a resident’s expressed interest in the area, we might gain short-term compliance, but lose the bigger goal of training the next generation to love family. This is especially fraught because most residencies don’t invest in family-centered care as much as they do to inpatient care, pediatric care, and other core rotations.
For these reasons, it has always been my goal to integrate family across all rotations. I want the faculty lead for the teaching service to champion family-centeredness. I want all education on pediatrics to lead with family as the central unit of pediatric care.
It is through being repeatedly exposed to family in every aspect of medicine that we create a culture of family-centeredness. It stops being “what we do” and eventually becomes “who we are”.
I’ll wrap-up where I started—with my family. We are quite diverse—much like families and family physicians. My wife is a Brazilian Mormon and I’m an American skeptic. We try to raise our children in a pluralistic, bicultural way—much like family medicine. As such, we often lack role models of families with similar goals.
So, to reinforce our unique family culture we frequently repeat the expression “This is the Reitz way of doing things”. I recommend something similar to this expression as you develop a culture of family. Speak openly about the culture you pursue, analyze times when the culture didn’t hold up. Celebrate times when the best of your culture is on display.
Randall Reitz is the Director of Behavioral Medicine at the St Mary’s Family Medicine Residency in Grand Junction, Colorado.