Exploring family and social context through the electronic health record: Physicians' experiences.

INTRODUCTION: There is ample evidence that social and familial context significantly impacts health. However, family and social history templates typically used in clinical practice exclude prompts to explore important contextual information, such as family dynamics, health beliefs, housing, and neighborhood environment. METHOD: At the Residency Program in Social Medicine at Montefiore Medical Center/Albert Einstein College of Medicine in Bronx, NY, we developed and piloted an expanded family and social information (FSI) template in our electronic health record (EHR) system. After 10 physicians used the FSI template during routine clinical practice, we conducted and qualitatively analyzed transcripts of semistructured interviews to assess their experiences. RESULTS: The major themes of physician's experiences using the FSI template included: expanded thinking (promoted thinking and discussion about contextual information), relevancy to care (highlighted important life events, helpful resource for future care or for team-based care), fragmentation (patient narrative difficult to categorize into discrete sections), and abstract phrasing (prompts too abstract and/or too complex to explore well). Some minor themes (themes that were repeated often, but not consistent in all interviews) were also noted: practice demands, educational purpose, and wish list. DISCUSSION: Within our small sample, we found that an expanded family and social information template broadened physicians' clinical thinking during routine visits. We also found that the structure of the EHR and practice demands create significant barriers to exploring a patient's narrative effectively. Themes identified in this research will inform national efforts to prioritize a contextual and biopsychosocial perspective in EHR systems. (PsycINFO Database Record

Teaching family in family medicine residency programs: results of a national survey.

BACKGROUND AND OBJECTIVES: Integrating family into family medicine has been recognized as important for the discipline, yet there is little known about how family-oriented care is taught in training environments. This paper presents results of a national survey assessing the status of teaching family concepts/skills in family medicine residency programs. METHODS: We sought to survey the program director (PD), a behavioral science faculty (BSF), and a chief resident (CR) from all 454 Accreditation Council for Graduate Medical Education (ACGME) family medicine residency programs. RESULTS: Respondents (n=489) were PDs (29%), CRs (34%), and BSF (36%). Of all respondents, 47% to 66% believe that integrating family concepts/skills into family medicine training is very important (highest level of importance). However, only 19%--23% believe their own programs place this level of importance on this curricular area. Less weight is given to family topics when compared with other behavior science subjects. Behavioral scientists who reported inclusion of (1) family concepts/skills in the formulation of ACGME competencies, (2) evaluation of residents on these skills, or (3) the presence of a family champion or scholar in the program, all reported teaching significantly more family-oriented skills compared to those that did not, respectively, 1 (6.96 versus 4.48), 2 (6.55 versus 4.97), and 3 (6.62 versus 4.54). CONCLUSIONS: Teaching about the family in family medicine continues to be highly valued among educators and their trainees; however, it is not perceived to be similarly valued in residency programs. Current changes in health care offer opportunities to promote and affirm family-oriented care. New curricular strategies are needed so that family-oriented care continues to define the uniqueness of family medicine.

Learning social medicine in the Bronx: an orientation for primary care residents.

BACKGROUND: Primary care educators face the challenge of teaching the social context of health and disease to clinicians. DESCRIPTION: Since 1975, the Residency Program in Social Medicine has trained clinicians to practice in urban underserved communities. During Orientation Month, 1st-year residents are relieved of inpatient duties and participate in learning activities addressing social and cultural aspects of health. Learning objectives include understanding patients' social context, their community, and the role of physicians as professionals. Recent innovations include incorporating an overall theme, weekly case studies, "triple jump" exercises, community mapping projects, patient-led community tours, and theme-specific visits to community institutions (e.g., prisons). EVALUATION: Residents complete weekly formative evaluations, a summative evaluation, and narrative reflections. Faculty complete an evaluative questionnaire. CONCLUSIONS: Orientation is a highly rated and valued part of our curriculum. Its success derives from ongoing curricular innovation and evolution, a departmental commitment to social medicine, and positive community response to our learners' interest and energy.

The residency program in social medicine of Montefiore Medical Center: 37 years of mission-driven, interdisciplinary training in primary care, population health, and social medicine.

Founded in 1970 to train physicians to practice in community health centers and underserved areas, the Residency Program in Social Medicine (RPSM) of Montefiore Medical Center, Bronx, New York, has graduated 562 board-eligible family physicians, general internists, and pediatricians whose careers fulfill this mission. The RPSM was a model for federal funding for primary care residency programs and has received Title VII grants during most of its history. The RPSM has tailored its mission and structured its curriculum to promote a community and population orientation and to provide the requisite knowledge and skills for integrating social medicine into clinical practice. Six unique hallmarks of RPSM training are (1) mission-oriented resident recruitment/selection and self-management, (2) interdisciplinary collaborative training among primary care professionals, (3) community-health-center-based and community-oriented primary care education, (4) biopsychosocial and ecological family systems curriculum, (5) the social medicine core curriculum and projects, and (6) grant support through Title VII. These hallmark curricular, training, and funding elements, in which population health is deeply embedded, have been carefully evaluated, regularly revised, and empirically validated since the program's inception. Practice outcomes for RPSM graduates as leaders in and advocates for population health and the care of underserved communities are described and discussed in this case study.