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Pediatric Residency Training and Behavioral HealthModels and Outcomes from a Multi-site Study
• Jeffrey D. Shahidullah, PhD, Assistant Professor, Rutgers University, New Brunswick, NJ
•Paul W. Kettlewell, PhD, Director of Pediatric Psychology, Geisinger Health System, Danville, PA
•Mohammed H. Palejwala, MA, Doctoral Student, Michigan State University, East Lansing, MI
•Kathryn A. DeHart, MD, Pediatrician, Geisinger Health System, Danville, PA
Session # F6
CFHA 19th Annual ConferenceOctober 19-21, 2017 • Houston, Texas
Faculty DisclosureThe presenters of this session have NOT had any relevant financial
relationships during the past 12 months.
Conference Resources
Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2017
Slides and handouts are also available on the mobile app.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Identify current training needs related to behavioral health in pediatric residency programs
• Describe existing models of behavioral health training and the advantages/weakness of each
• Discuss how aspects of the enhanced training curricula discussed in this presentation may be tailored/adapted for implementation in other training programs across the country
1. American Academy of Pediatrics. (2009). Policy Statement—The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care, Pediatrics, 124, 410-421.
2. Horwitz, S. M., Storfer-Isser, A., Kerker, B. D., Szilagyi, M., Garner, A., O’Connor, K. G.,…Stein, R. E. (2015). Barriers to the identification and management of psychosocial problems: Changes from 2004 to 2013. Academic Pediatrics, 15, 613-620.
3. Stancin, T., & Perrin, E. C. (2014). Psychologists and pediatricians: Opportunities for collaboration in primary care. American Psychologist, 69, 332-343.
4. McMillan, J. A., Land, M., & Leslie, L. K. (2017). Pediatric residency education and the behavioral and mental health crisis: A call to action. Pediatrics, 139, 21-41.
5. Horwitz, S. M., Caspary, G., Storfer-Isser, A., Singh, M., Fremont, W., Golzari, M., & Stein, R. E. (2010). Is developmental and behavioral pediatrics training related to perceived responsibility for treating mental health problems? Academic Pediatrics, 10, 252-259.
Bibliography / Reference
Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this
presentation.
Key Points
• 3 behavioral health training curricula
• Assessing residents’ response to curricula
• 1st year outcomes/next steps
Background
• PCPs positioned to serve increasing number of youth w/ BH concerns in PC
• 50-70% of patients seen in PC have BH referral concerns (Belar, 2008; Gatchel & Oordt, 2003)
• ≈ 1/4 of pediatric visits involve discussion of BH concerns (Cooper et al., 2006)
Background• National shortage of specialty BH providers (Kim, 2003) →
often difficult for PCPs to make external referrals
• When specialty providers are available → lack of follow through by patients to these externally referred services (Cummings & O’Donohue, 2011)
• Resultedly, PCPs often tasked w/ managing BH care “in-house”
• PCPs report difficulty in evaluating & treating BH conditions (Steele et al., 2010)
Background• Oft cited barrier to providing effective care → lack of
training for PCPs in BH (Serby et al., 2002)
• Most PC medicine residency program directors report BH training is important & should be emphasized more (Chin et al., 2000)
• Most directors of accredited PC residency training programs in internal medicine & pediatrics report suboptimal training on topic (Leigh et al., 2006)
Background• Numerous calls for improved biopsychosocial training for
physicians: o Goldberg et al., (1980). The Lancet o IOM (2001). Crossing the Quality Chasmo Healthy People 2020 (2010)
• AAMC added large behavioral & social sciences section to MCAT in 2015
• Due to lack of formal training in BH that medical providers receive → AAP (2009) highlighted key aspirational BH competencies for pediatric PCPso AAP → attainment of competencies “requires innovations in residency
training”
Background
• Several BH training initiatives developed in past 10 years → varying levels of intensity & resultso Didactic focused (talks, seminars, readings,
vignettes)
o Varying levels of results, intensity, & feasibility
Overview• Describe an innovation in residency training by delivering a BH
curriculum to pediatric residents in setting in which BH services are integrated w/ pediatric PC
• Obtain data from 1st-, 2nd-, & 3rd-year residents → Attitudes, Knowledge, & Skills in BH service delivery
• Data from 3 pediatric residency programs in Northeastern United States
• Findings may support rationale for innovation in BH service-delivery that also aims to improve BH competencies for pediatric PC
• Implementation science framework → Most effective “dosage” (training intensity) from 3 relatively feasible options?
Dependent Variables
• Attitudes/Comfort
• Knowledge/Skills…in behavioral health
Independent Variables
• Innovation in residency training → formal behavioral health curricula
• 3 different “dosages” (intensity levels)1) Integrated Service-Delivery + Didactic focus
2) Didactic focus only
3) Control (training as usual)
16
Site 1
Service-Delivery + Didactic ExposureService-Delivery Components
Requiring an embedded BH provider
Didactic Components
Not requiring an embedded BH provider
Warm hand-offs• On-site BH provider (psychologists)
• Direct patient care in well and sick-child visit
Lectures on BH topics• 18 lectures throughout
• AAP/AACAP practice parameters
Behind-the-scenes consults• On-site behavioral health providers (psychologists)
• Indirect patient care in conjunction w/ a well-/sick-child
visit
Readings and quizzes• AAP/AACAP practice parameters
• Evidence-based evaluation of ADHD, anxiety,
depression, suicide/crisis intervention;
• Quizzes over readings with feedback
Observation/Performance Feedback• Feedback provided for ADHD, anxiety, depression, and/or
suicide risk assessments
• Direct observations by embedded psychologists
• Feedback provided
Vignettes• Vignettes describing behavioral health concerns
• Identify course of treatment based practice parameters
• Feedback provided
Joint Precepting• Psychologist precepts residents and psychology fellows in
shared space
• Psychologist also precepts the resident in conjunction with
medical preceptor
Performance Feedback
ADHD Components• Inquire about inattention, hyperactivity, impulsivity,
academic/behavior problems
•More than one setting
•Data regarding:
• Duration of symptoms
• Severity of symptoms
• Degree of impairment
•Physical exam
•Screen for sensory impairments (vision/hearing)
•Administer parent/teacher rating scales
•Determine diagnosis
• Symptom criteria met in IA and/or HI domains
• Age of onset
• Impairment in multiple settings
Components Completed?
1 Allowed for performance feedback to occur in a setting preferred by
the resident
Yes No
2 Clearly stated that the performance feedback conversation would
remain confidential and it would not be used for formal performance
evaluation within residency program
Yes No
3 Asked/allowed time for resident to self-assess their performance
before completing checklist and receiving feedback from observer
Yes No
4 Completed checklist of practice parameter steps completed by resident
Yes No
5 Provided positive feedback for checklist items completed and
observed strengths
Yes No
6 Provided feedback on interpersonal and communication skills
Yes No
7 Provided suggestions for improvement that were accompanied by
rationales for why changes are important and how changes will
improve outcomes
Yes No
8 Allowed residents time to reflect on/ask questions about suggestions,
if they so chose
Yes No
9 Summarized performance feedback session in the form of major
“take-aways” and/or upcoming action steps
Yes No
10 Performance feedback session lasted between 5 and 15 minutes
Yes No
Process Components
18
Site 2
Didactic Exposure-Only
Service-Delivery Components
Requiring an embedded BH provider
Didactic Components
Not requiring an embedded BH provider
Not provided
Lectures on BH topics• 18 lectures throughout the year
• AAP/AACAP practice parameters
Readings and quizzes• AAP/AACAP practice parameters
• Evidence-based evaluation of ADHD, anxiety, depression,
suicide/crisis intervention
• Quizzes over readings with feedback
Vignettes• Vignettes describing behavioral health concerns
• Identify course of treatment based practice parameters
• Feedback provided
19
Behavioral Health Seminar for Pediatric Residents
Date Topic
10/16 The Behavioral Health Referral
10/23 Pediatric Behavior Management: The Basics
11/6 Pediatric Behavior Management: The Skills
11/20 ADHD: Evaluation (AAP)
12/4 ADHD: Treatment (AAP)
12/18 Anxiety: Evaluation (AACAP)
1/8 Anxiety: Treatment (AACAP)
1/22 Motivational Interviewing in Primary Care (1)
2/5 Motivational Interviewing in Primary Care (2)
2/19 Depression: Evaluation (AACAP)
3/4 Depression: Treatment (AACAP)
3/18 Suicide/Crisis Response (AACAP) (1)
3/25 Suicide/Crisis Response (AACAP) (2)
4/1 Sleep
4/22 Feeding
5/6 Toileting
5/20 Child Abuse
6/3 Schools (SPED system & bullying)
6/17 Medically unexplained physical symptoms
Examples of Readings•AACAP & AAP Practice Parameters• American Academy of Child and Adolescent Psychiatry. (2007). Depression Practice Parameters.
• American Academy of Child and Adolescent Psychiatry. (2007). Anxiety Practice Parameters.
• American Academy of Child and Adolescent Psychiatry. (2001). Suicidal Behavior Practice Parameters.
• American Academy of Pediatrics. (2011). ADHD Practice Parameters.
•Pediatrics in Review articles
•Resources from AAP’s Mental Health Toolkit
21
Quizzes
Vignettes
What are your treatment recommendations?
V-1: Mom reports severe ADHD symptoms; teachers say pt is an “angel”; clearly does not meet DSM criteria for diagnosis
V-2: Mom reports severe and persistent ADHD symptoms; teachers report severe and persistent ADHD symptoms; clear impairment
V-3: Mom and teachers report borderline severity ADHD and borderline impairment
24
Site 3
Control Group; Treatment as Usual
Service-Delivery Components
Requiring an embedded BH provider
Didactic Components
Not requiring an embedded BH provider
Not provided Not provided
What to Measure?AAP (2009) - Policy Statement
Call for innovations in BH training of pediatricians –
Need to address attitudes, knowledge and skills in BH service delivery
How to Measure?What did we consider? – What had previously been used?
What to do when there is no “gold standard”?
Guiding Principles• Goal not primarily to develop a measure(s)
• Address attitudes, knowledge and skills with
• Frequently occurring BH problems that pediatricians deal with
• Those for which there are some published (well accepted) standards of care
• Which categories did we select?
Our ResponseQualitative and Quantitative Approach
Quantitative
1. Self-reported Knowledge – Their views about how skilled or competent they considered themselves to be
2. Measured Skills in Behavioral Health – key categories: ADHD, anxiety, depression, suicide risk assessment
1st Year Outcomes• Must use caution to not overstate results
◦ Pilot study
◦ Small sample size
◦ Difficult to detect significant differences
• Feasibility of implementation of curricula
• Utility of assessment tool for tracking response to curricula
Background: Participants/SitesVariable
Training as Usual(TAU)
(n = 12)
Didactic Only
(DO)
(n = 20)
Didactic + Integrated
Primary Care (DIPC)
(n = 24)
Mean age, y (SD) 30.17 (2.29) 30.15 (2.41) 31.35 (2.29) F=1.74, p=0.19
Males, n (%) 1 (8.33%) 2 (10%) 6 (25%) χ2=2.50, p=0.33
Hard science major, n (%) 10 (83.33%) 12 (60%) 21 (87.5%) χ2=5, p=0.11
MD degree (vs DO), n (%)
1 (8.33%) 12 (63.16%) 12 (50%)
χ2=9.27, p=0.01
DIPC > TAU
DO > TAU
Weeks in medical school on mental health rotation, w (SD) 4.83 (2.33) 5.75 (1.74) 5.08 (1.95) F=1, p=0.38
Completed mental health training (outside of medical school/
residency, n (%) 12 (100%) 19 (95%) 20 (83.33%) F=3.32, p=0.21
Clinical rotations in primary care in medical school, n (%) 6 (100%) 20 (100%) 16 (100%)
Did those primary care practice(s) have an embedded behavioral
health provider on site 5 (83.33%) 10 (50%) 2 (12.5%)
χ2=10.53, p=0.004
TAU > DIPC
DO > DIPC
What type were they? Psychologists 2 (40%) 7 (70%) 2 (100%) χ2=2.55, p=0.48
What type were they? Social Workers 4 (80%) 9 (90%) 1 (50%) χ2=1.86, p=0.66
How likely are you to go into primary care? (1-10) 3.67 (3.78) 6.90 (3.38) 5.06 (3.71) F=1.61, p=0.22
Would you be more likely to go into primary care pediatrics if it was
an integrated practice with embedded behavioral health providers? 1 (16.67%) 16 (80%) 9 (56.25%)χ2=8.2, p=0.01
DO > TAU
Current residency year, n (%)
PGY-1
PGY-2
PGY-3
5 (41.67%)
2 (16.67%)
5 (41.67%)
9 (45%)
4 (20%)
7 (35%)
13 (54.17%)
5 (20.83%)
6 (25%)
χ2=1.17, p=0.89
Completed DBP rotation, n (%) 2 (33.33%) 4 (36.36%) 4 (25%) χ2=0.43, p=0.88
Self-reported Knowledge in Behavioral Health
Evidence-based
Practice Parameter
Training as Usual
(TAU)
Didactic Only
(DO)
Didactic +
Integrated Primary
Care (DIPC)Significance
Pre
(n = 12)
Post
(n = 9)
Pre
(n = 20)
Post
(n = 17)
Pre
(n = 24)
Post
(n = 27)
ADHD
Evaluation
Treatment
7.27
6.36
8.2
7.2
6.42
5.21
6.91
5.91
6.09
5.52
7.47
6.36
Anxiety
Evaluation
Treatment
7.27
6.18
8.4
8
6.16
4.84
6.18
4.73
6.26
5.39
7
5.86
Depression
Evaluation
Treatment
7.73
6.27
9.4
8.4
7.16
5.21
6.45
4.73
7.17
5.91
7.33
6.21
Time*DO (p=0.02)
Knowledge scores range from 1 (least confident in knowledge of evidence-based practices) to 10 (most confident in
knowledge of evidence-based practice)
Measured Skills in Behavioral HealthEvidence-based Practice
Parameter
Training as Usual
(TAU)
Didactic Only
(DO)
Didactic +
Integrated
Primary Care
(DIPC)
Significance
Pre
(n = 12)
Post
(n = 9)
Pre
(n = 20)
Post
(n = 17)
Pre
(n = 24)
Post
(n = 27)
ADHD
Evaluation
Treatment
3.08
2.67
2.83
2.67
3.15
2.65
3.73
2.55
3.87
2.26
4.07
3.2
Anxiety
Evaluation
Treatment
2.55
2.42
2.67
2.33
2.55
2.05
2.82
2.18
2.83
2.09
3.8
2.47
Depression
Evaluation
Treatment
2.92
2.25
2.17
2.67
2.85
2.15
3.64
2.91
3.65
2.04
3.53
3.07
Time*DO
(p=0.04)
Possible scores ranged: ADHD evaluation, 0-16; ADHD treatment, 0-9; anxiety evaluation, 0-11; anxiety treatment 0-3; depression evaluation,
0-15; depression treatment, 0-8
Conclusions/Next StepsIBH is promising approach to training/learning enhancement of pediatric residents
Knowledge vs. Skills◦ Dunning Kruger Effect?
Continue to track outcomes over 3 years of residency
More research/advocacy needed for yet another benefit that IBH may provide (in addition to access, costs, clinical care improvement)
Session Evaluation
Use the CFHA mobile app to complete the
evaluation for this session.
Thank you!
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