Teaching adaptive leadership to family medicine residents: what? why? how?

Health care reform calls for patient-centered medical homes built around whole person care and healing relationships. Efforts to transform primary care practices and deliver these qualities have been challenging. This study describes one Family Medicine residency's efforts to develop an adaptive leadership curriculum and use coaching as a teaching method to address this challenge. We review literature that describes a parallel between the skills underlying such care and those required for adaptive leadership. We address two questions: What is leadership? Why focus on adaptive leadership? We then present a synthesis of leadership theories as a set of process skills that lead to organization learning through effective work relationships and adaptive leadership. Four models of the learning process needed to acquire such skills are explored. Coaching is proposed as a teaching method useful for going beyond information transfer to create the experiential learning necessary to acquire the process skills. Evaluations of our efforts to date are summarized. We discuss key challenges to implementing such a curriculum and propose that teaching adaptive leadership is feasible but difficult in the current medical education and practice contexts.

Teaching team membership to family medicine residents: what does it take?

Primary care reform proponents advocate for patient-centered medical homes built on interdisciplinary teamwork. Recent efforts document the difficulty achieving reform, which requires personal transformation by doctors. Currently no widely accepted curriculum to teach team membership in Family Medicine residencies exists. Organizational Development (OD) has 40 years of experience assessing and teaching the skills underlying teamwork. We present a curriculum that adapts OD insights to articulate a framework describing effective teamwork; define and teach specific team membership skills; reframe residents' perception of medicine to make relationships relevant; and transform training experiences to provide practice in interdisciplinary teamwork. Curriculum details include a rotation to introduce the new framework, six workshops, experiential learning in the practice, and coaching as a teaching method. We review program evaluations. We discuss challenges, including institutional resources and support, incorporation of a new language and culture into residency training, recruitment "for fit," and faculty/staff development. We conclude that teaching the relationship skills of effective team membership is feasible, but hard. Succeeding has transformative implications for patient relationships, residency training and the practice of family medicine.

Opportunistic approaches for delivering preventive care in illness visits.

OBJECTIVE: To describe how clinicians create opportunities to deliver preventive care in illness visits and assess the impact this has on preventive service delivery. METHOD: Detailed and descriptive fieldnotes were collected from 18 purposefully selected family practices, including direct observations of 53 primary care clinicians and 1620 patient encounters. Conversation analysis was used to examine the conversational techniques employed to deliver four preventive services (smoking counseling, immunization delivery, mammography, and cervical cancer screening) in illness visits. Qualitative data was coded and analyzed to assess impact on preventive service delivery rates. RESULTS: Two methods for opportunistic preventive service delivery were observed. In the first, clinicians used the close of the medical encounter to make arrangement for follow-up preventive care. In the second approach, clinicians use a stepwise conversational device to exit talk about the patient's presenting problem and enter into relevant health habit advice. Quantitative analyses show that opportunistic methods are rarely used to deliver preventive services in illness visits. The stepwise technique was the most frequently used method. Patients treated by clinicians who used opportunistic techniques to deliver preventive care in illness visits were more likely to be up-to-date on smoking counseling and cervical cancer screening than those patients who were treated by clinicians who did not use opportunistic approaches. CONCLUSIONS: Opportunistic preventive service delivery in illness visits can be an efficient and effective way to deliver preventive care. Although infrequently used, quantitative data suggest that the use of opportunistic approaches to deliver preventive services during illness visits can enhance preventive care rates. Interventions aimed at helping clinicians develop effective strategies for offering preventive care during illness visits may be an important complement to existing mechanical interventions that might, by themselves, be insufficient to improve preventive care.

Assessing diversity and quality in primary care through the multimethod assessment process (MAP).

The U.S. health care system serves a diverse population, often resulting in significant disparities in delivery and quality of care. Nevertheless, most quality improvement efforts fail to systematically assess diversity and associated disparities. This article describes application of the multimethod assessment process (MAP) for understanding disparities in relation to diversity, cultural competence, and quality improvement in clinical practice. MAP is an innovative quality improvement methodology that integrates quantitative and qualitative techniques and produces a system level understanding of organizations to guide quality improvement interventions. A demonstration project in a primary care practice illustrates the utility of MAP for assessing diversity.