“Oh, I Need One Too!” Integration of a Behavioral Medicine Specialist into Residency and Fellowship Programs

“Whenever I go to a national conference and bring up what our behavioral medicine specialist is doing in our program, everybody exclaims, ‘Oh, I need one too!' I think we need to write a paper about this.”

--Residency Program Director

Family medicine has a long history of incorporating a mental health/behavioral medicine specialist as core faculty into its residency programs [1]. However, the act of hiring an individual solely dedicated to supporting physician well-being, while also actively educating trainees about the wide-variety of topics under the behavioral medicine umbrella, is uncommon across other specialties and subspecialties in Graduate Medical Education (GME) [2].

Our Behavioral Medicine Specialist (BMS) has been working for many years with residents and faculty in internal medicine, neurology, general surgery, and numerous other GME programs at our institution. She additionally works with fellows in all the programs throughout our healthcare system. The BMSs role stretches far beyond providing lectures (Table 1); and, in fact, may challenge the individual in this role to “unlearn” much of what they were taught in graduate school to be best equipped to offer very brief and practical educational pearls to their physician learners, rather than focusing on long, theoretical discussions and deep, uncovering therapeutic techniques. Learning to be an informal, confidential “coach/mentor” for young physicians, versus a traditional therapist, is key.

“I feel like I am the only one struggling…I feel like my colleagues ‘have it together’…and this makes me feel like I am failing or don’t have the right to be here in this program.”

--PGY2 Resident

Many trainees struggle with feelings of incompetency or “imposter syndrome” and, unless they feel safe sharing those concerns with a trusted person, anxiety, depression, and absenteeism…even physician suicide can result. The BMS can serve effectively as that trusted, “safe” individual.

The following are two of the most important functions, in our opinions, of a BMS in residency and/or fellowship programs:

Via self-referral: A BMS in a GME residency and/or fellowship program is viewed as an “in-house” coach who offers informal and confidential counseling (via phone, virtual or in-person platforms) to trainees and faculty physicians alike. In their meta-analysis of randomized controlled trials and controlled trials, Mendez Miller and colleagues found there was a moderate improvement in work-related stress outcomes among physicians receiving Cognitive Behavioral Therapy (CBT) based interventions versus no interventions [3]. Hence, when coaching physician trainees, it is recommended the BMS utilize targeted cognitive behavioral techniques, such as cognitive restructuring [4], as well as other brief, evidence-based interventions, including mindfulness [5], and diaphragmatic breathing strategies [6].

While most of these coaching discussions are scheduled, the BMS should ideally be available as needed for urgent calls/meetings. Evening and weekend calls/meetings are not uncommon, given the fact that most trainees in distress may not be available during “normal” working hours secondary to being on nights or other busy rotations. The BMS also provides referrals for traditional therapy, and psychiatric care, as needed.

Via program referral: In addition, the BMS should also be available to assist programs with performance improvement issues of learners; specifically, in the core competency areas of interpersonal/communication skills and professionalism. These meetings are also confidential; however, since these trainees have been referred by programs (usually as part of a performance improvement plan), the BMS will communicate with the Program Directors to inform them that the trainee has been participating in coaching and will also request that the program provide feedback about the trainee’s progress, so the BMS will know whether their interventions have been successful in terms of helping the learner improve their performance. In this regard, it is important the BMS attend Clinical Competency Committee (CCC) meetings in each program for which they serve (while maintaining strict confidentiality of the trainees who are known to him/her).

“We get so many talks on the science of medicine, but not many on HOW to be an empathic doctor and how to care for ourselves---even in the most challenging Doctor-Patient scenarios. This is why I love when she gives us lectures!”

---First Year Fellow

Lectures which are directly, or indirectly, related to physician well-being should be presented by the BMS on a consistent basis. Some of the topics on which our BMS presents are Physician Well-Being (targeted to the specific audience), Communication Skills (Motivational Interviewing/Stages of Change), and Professionalism, Understanding Patients with Substance Use Disorders, Dealing with Difficult Patient Interactions, Loss and Breaking Bad News: Caring for Your Patient, Their Family and Yourself. Additional topics are included, depending on the needs of each specific program.

This brief paper was written to give an overview of the unique, but much-needed, role of our BMS in multiple GME training programs at our institution. For specific information about some of additional functions of our BMS, please see the following articles:

• My office is always open: Reflections from a Behavioral Medicine Specialist in Graduate Medical Education [2]: https://meridian.allenpress.com/jgme/article/12/2/227/442178/My-Office-Is-Always-Open-Reflections-From-a
• Enhancing surgeon wellness: Integrating a Multidimensional Behavioral Medicine Approach into a General Surgery residency program [7]: https://www.facs.org/for-medical-professionals/news-publications/journals/rise/articles/multidimensional/
• Seeking to enhance surgical resident wellness using “complications” small groups and shadowing [8]: https://www.facs.org/for-medical-professionals/news-publications/journals/rise/articles/shadowing/
• Assurance for endurance? Introducing a novel ergonomics curriculum to reduce pain and enhance physical well-being among gi fellows [9]: https://link.springer.com/article/10.1007/s10620-020-06406-z

Throughout the years, we have received resoundingly positive feedback from learners, as well as faculty, program directors, and institutional leaders regarding our BMSs contributions to our individual learner’s education, and to improving the overall culture and morale of our residency and fellowship programs at our institution (Table 2) and comments below:

“Our BMS is a key part of our core faculty and serves in several of the functions outlined by the ACGME, including membership in the CCC, designing curriculum, and advising and coaching residents. She helps design remediation plans for the competencies that are the most difficult to remediate – Professionalism and Interpersonal/ Communication Skills. She meets with the interns early in their training to introduce the concept of wellness. This meeting is key and indicates clearly that asking for help is a core part of residency success. As a PD, having a BMS is a great comfort. An unexpected benefit is knowing she is there to help me navigate difficult conversations with residents and most of all to help me guide residents through very difficult life situations as they arise during the normal course of residency.”

--Residency Program Director

“Having a BMS available for me as DIO of a large institution is invaluable. She teaches the residents and faculty about techniques to improve wellness and is an active member of GME Wellness initiatives. Where I’ve valued her most has been in helping to support trainees struggling with communication skills and professionalism – she goes above and beyond to identify the root causes leading to their behaviors and helps them work through strategies that ultimately makes them better physicians.

--Designated Institutional Official/Associate Dean for Graduate Medical Education

“Having a BMS introduce caring for oneself and normalize help seeking behaviors at orientation, and reinforcing this throughout residency, was a gamechanger for our institution. Wellness is now openly discussed, as is recognizing distress and seeking help.”

--Senior Associate Dean for Graduate Medical Education and Faculty Affairs

Future research in this area will include conducting more evidence-based studies of the role of the BMS in our institution, such as investigating the effects of current coaching interventions on physician trainee well-being. In addition, we plan to explore how our positive experience utilizing a BMS might be generalized to other GME programs throughout the country.

Physician burnout/moral injury continues to escalate and has become even more problematic secondary to the increased distress our profession sustained as the result of the pandemic [10]. Our learners and faculty appear to greatly benefit from having a trusted mental health professional “in house” who is there solely to focus on caring for them by supporting their well-being and to teach them aspects related not only to the science, but also to the art, of medicine. So, while Family Medicine has had it right from the beginning by incorporating a BMS into their residencies, it is time to help the rest of GME specialties and subspecialties realize they “need one too!”

1. deGruy FV, McDaniel SH. Proposed Requirements for Behavioral Health in Family Medicine Residencies. Fam Med. 2021 Jul;53(7):516-520. doi: 10.22454/FamMed.2021.380617. Epub 2021 Jun 11. PMID: 34289496.
2. Allespach H. My Office Is Always Open: Reflections From a Behavioral Medicine Specialist in Graduate Medical Education. J Grad Med Educ. 2020 Apr;12(2):227-228. doi: 10.4300/JGME-D-19-00735.1. PMID: 32322361; PMCID: PMC7161338.
3. Mendez Miller M, Naccarato J, Radico J, Riley T. Do CBT-based interventions reduce occupational stress and burnout among physicians in developed countries? Evidence-Based Practice. 2022;25(1):13-14
4. Allespach H, Diaz Y, Burg MA, St Onge JE. Daily self-care and cognitive restructuring: A potentially potent prescription for physician wellness. Cogent Medicine Evidence-Based Medicine & Medical Informatics. 2019;6:1704151. doi: 10.1080/2331205X.2019.1704151.
5. Dunne PJ, Lynch J, Prihodova L, O'Leary C, Ghoreyshi A, Basdeo SA, Cox DJ, Breen R, Sheikhi A, Carroll Á, Walsh C, McMahon G, White B. Burnout in the emergency department: Randomized controlled trial of an attention-based training program. J Integr Med. 2019 May;17(3):173-180. doi: 10.1016/j.joim.2019.03.009. Epub 2019 Mar 29. PMID: 30956141.
6. Hopper SI, Murray SL, Ferrara LR, Singleton JK. Effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults: a quantitative systematic review. JBI Database System Rev Implement Rep. 2019 Sep;17(9):1855-1876. doi: 10.11124/JBISRIR-2017-003848. PMID: 31436595.
7. Allespach, Sleeman D, Pust GD, Schulman CI. Enhancing surgeon wellness: Integrating a multidimensional behavioral medicine approach into a general surgery residency program. American College of Surgeons Resources in Surgical Education. 2018. 
8. Allespach H, Schulman CI, Attiyat M, Pust, GD, Sleeman D. Seeking to enhance surgical resident wellness using “complications” small groups and shadowing. RISE: Resources in Surgical Education. American College of Surgeons Division of Education. 2019.
9. Sussman M, Sendzischew-Shane MA, Bolanos J, Deshpande AR, Kerman D, Allespach H. Assurance for Endurance? Introducing a Novel Ergonomics Curriculum to Reduce Pain and Enhance Physical Well-Being Among GI Fellows. Dig Dis Sci. 2020 Oct;65(10):2756-2758. doi: 10.1007/s10620-020-06406-z. PMID: 32548812.
10. Shanafelt TD, West CP, Dyrbye LN, Trockel M, Tutty M, Wang H, Carlasare LE, Sinsky C. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic. Mayo Clin Proc. 2022 Dec;97(12):2248-2258. doi: 10.1016/j.mayocp.2022.09.002. Epub 2022 Sep 14. PMID: 36229269; PMCID: PMC9472795.