Interprofessional Training in Developmental and Behavioral Health Within a Pediatric Residency Program: An Organizational Systems Case Study

Abstract

A systemic issue in traditional health service delivery models to children and adolescents is the difficulty in accessing quality developmental/behavioral health (D/BH) care. Contributors to this problem include the lack of available specialty D/BH specialists (e.g., child and adolescent psychiatrists and psychologists, developmental-behavioral pediatricians), as well as issues with insurance coverage and reimbursement when these services are paneled through behavioral health “carve-outs.” Given the difficulty in accessing these services, primary care physicians such as pediatricians and pediatric residents often become the de facto D/BH providers. However, a major barrier that these providers express in managing D/BH concerns is the lack of training they receive in medical school and residency. This chapter presents an organizational systems-level case study detailing how concerned stakeholders in a healthcare delivery system and training program have responded to problems pertaining to the need for improved care and resident training in D/BH. The case study intends to inform those who design, revise, and operate service delivery and training systems on a daily basis. To facilitate a more nuanced examination of implementation experiences, a simulated question and answer discussion is included at the end of this chapter.

Authors Respond to Questions Concerning the Systems-Level Innovation: Dr. Paul Kettlewell (PK), Psychologist Involved in Training Curricula Implementation, Dr. Paul Bellino (PB), Pediatric Residency Program Director

• Question 1. You described several possible options for enhanced D/BH training (didactics, shared care for patients, case conferences, simulated patients, etc .). How did you decide which training approaches to use in the training model and which approaches to exclude?

PB: Determining the method for training for me is more of a practical thing than any data driven decision. The truth is that time for any additional educational activity in residency is limited, so activities that overlay or enhance already developed and practiced curricular elements fit better into this already cramped timeframe. Also, I am a believer that one learns best from experience rather than a presentation or some on-line activity that requires no effort other than clicking a mouse. When a resident is engaged in the entire process of managing a real patient, taking responsibility for all elements of patient care as well as the risk associated with the outcome, they will not forget the lessons they learn. I personally prefer to expose residents to these situations in their training as I believe it will offer a lasting and deep understanding of the issues at hand. Since not all possible scenarios can be covered during the process of caring for patients, additional lectures or other formats should be used to supplement the needed medical knowledge, but these should still try to draw off the experiential learning process obtained during the actual care of patients.

Having said that, there are some times where a quick passage of medical knowledge is all that is needed. In those cases, an hour lecture or self-directed activity is adequate. It seems to me that you can pack in more information with a lecture, but younger physicians seem to like doing role-playing or case-based discussions. These are common processes in medical schools now. Personally, I think they are a waste of time, but I am from a different era than these guys. So, when I can, I ask presenters to at a minimum wrap their presentations around a case that can be used as an anchor for the material that they will be presenting.

Computer-based activities are interesting. They can be fun and look cool, however, in my experience, when a resident has to do something on their own time, it rarely gets done unless you spend a lot of time policing them. As such, I have found these not worth the effort it takes to develop and implement them. Some residents are quite keen to complete them and prefer this type of learning, so I do have them as supplemental activities or for special things that only involve selected residents (global health curriculum, etc.). Outside of that, if it something I want everyone to do, I rarely choose a computer-based activity.

• Question 2. It appears that you have taken logical and progressive steps in the development of both the integrated care model and then enhanced D/BH training approach. You have and will continue to get some data and informal feedback from stakeholders (pediatric residents, pediatric attendings, business leaders, and patients) you likely will need to make some modifications to your approach. How do you conduct applied outcome research when you have an intervention that is not “fully fixed” and that likely will change gradually even if modestly over the next few years?

PB: Residency education is a fluid thing. The ACGME puts out mandates that are general and do not specifically spell out exactly how a program is to accomplish a required element. This is to permit programs to best utilize the resources that they have in a matter that best suits their purposes. We have had many unique training activities over the years that cannot be replicated in most programs because of Geisinger’s unique attributes. Identifying resources and using them in creative ways is commonplace in resident education.

Whenever you begin a new educational process, it is imperative to review the outcomes to determine if it is having the desired effect. I expect that we will be able to review several things pertaining to this activity to determine if additional changes are needed. It will probably be easiest to obtain general feedback from residents and faculty about the basic processes, looking specifically at their attitudes about the manner in which the integrated D/BH activity functions as well as how they feel it impacts their patients and the resident’s education. Subjective evidence like this is always easiest to come by and it offers a good starting point to make changes. The changes made from this information from my standpoint are done to get additional buy-in and correct dissatisfaction with the new process. This is not hard scientific data that can be used to determine if the outcome of the program is as expected. That will need to be seen over time and more time-consuming efforts will be needed to determine this. Directly testing residents on D/BH issues, looking at ABP and ISE scores in D/BH domains, and potentially identifying changes in the handling of patients with D/BH issues by residents by utilizing the EHR are all potential ways of seeing this objective data.

Even when all of this is completed and it is felt that the system is running well, change will be inevitable. Alterations in facilities, patient expectations, social issues, ACGME educational requirements, etc., all will occur over time, making continued evaluation and alteration of the program necessary. It is anticipated that this process will need to be altered at some point to meet the changing needs of our learners, faculty, and their patients.

• Question 3. Pediatric residents have numerous demands on them during their residency. What challenges did you face in getting them to commit to learning about behavioral health and doing the things you required such as attending didactic lectures or collaborating with psychologists in their continuity clinics?

PB and PK: Any primary care provider is, by definition, a generalist and is expected to handle a broad range of health problems. For a resident in training this is a daunting and at times an overwhelming task. It is one of the reasons that some residents choose to specialize, so that they have more sense of mastery over the areas of healthcare they are expected to be competent in managing. Because of that challenge for broad skills that pediatric residents must master and the limited time they have, we developed our training model to be especially efficient. Most specifically, the curriculum involves lectures/discussions on D/BH topics that are only 30 min long and emphasize bottom-line knowledge and skills, with each lecture labeled, “What every pediatrician should know about ….”. Additionally, by moving our D/BH training to their continuity clinic, and providing help to them with their own patients, they could acquire skills in managing D/BH problems at the time in which they are most in need. Rather than being another training experience they have to squeeze into a busy week, our training experience often helped them get their job done more adequately and efficiently, which improved their “buy-in” with our training and curricula.

We also introduced numerous mechanisms to ensure that we received direct feedback from residents so that our training curricula could be implemented in an iterative process. Examples included focus groups, individual meetings with residents and faculty, confidential rating systems during didactic lectures for feedback, as well as other informal mechanisms such as conversations with residents in their continuity clinic. As indicated in the case study, there were numerous changes that occurred throughout the training year that were adaptations/modifications from the original curricular design. I would add that residents are motivated by the fear that they will need to know how to do something when they get out of residency. They know full well that they will need to handle D/BH issues and quite frankly are anxious that they will not have the needed skills to do so adequately. In educating residents, feeding off of this anxiety is quite useful. Residents will be more likely to cooperate with processes that offer them the practical information and practice experience that they feel will be needed for their future work as a general pediatrician.

• Question 4. Health care organizations change leadership and resulting areas of emphasis at times. How can the changes you have made in service delivery and in enhanced training be sustainable if your organization’s priorities change? How can you solidify your changes so they are more likely to “stick”?

PK: In some ways it is fortunate for any of us involved in D/BH service delivery and training that in almost all health care delivery systems, there is a shortage of adequate D/BH services and training. Therefore, if a health care organization changes leadership, when the new leadership team assesses service delivery and training needs, D/BH will be among key areas that require attention. More importantly, if the D/BH training is of value and helps pediatric residents become both more competent and comfortable handling D/BH problems, it will be valued by both resident and attending pediatricians. Additionally, by combining our D/BH training with the implementation of the integrated pediatric primary care model we attempted to help attending pediatricians’ and residents’ experience the added value that the integrated care model provided. At least some of the pediatric primary care providers have told us that they no longer are willing to practice in a primary care setting without a BHC as a central member of their team.

In our health system, we did experience a change of senior leadership (a new CEO) from the time that our initiative (to change our D/BH service delivery and training approaches) was developed and proposed until the time we actually implemented it. The changes in leadership involved a transition from an emphasis on sound business strategies to an emphasis on excellence in the patient experience. This involved some clear differences in emphasis, but frankly, both approaches required sound business approaches as well as genuine care for patients, so the changes were more complementary and a natural progression than a radical change. As a result, our initiative was not negatively impacted by system leadership changes.

Also, research shows that an element of organizational capacity that has been repeatedly found to be central to any type of systems innovation is strong leadership. We are fortunate that the key stakeholders behind this initiative—division heads and leaders from the systems health plan—were very supportive of the program and all the people who implemented it. This type of active support is critical, particularly when organizational turnover occurs—our health system’s CEO in our case—as these stakeholders in leadership positions can often engage the new decision-makers for ongoing support.