Forest and the Trees: The Roots of Culture Shift in Academic Family Medicine

Jonathan Mitchell, PhD & the Integrated Primary Care SIG

Primary care in the United States continues to benefit from major healthcare quality organizations calling for more investment in integration (Bierman et al., 2021, Tong et al., 2023). Beginning in 2020, the Accreditation Council for Graduate Medical Education (ACGME) enacted new policies requiring integrated behavioral health care within family medicine residencies and expanded the description of the specialty to highlight the imperative of managing behavioral and psychosocial issues (ACGME, 2023). These kinds of developments not only open doors for emerging professionals, but also underscore the opportunities for integrated providers to leverage their full professional skillset.

Fostering culture shift represents one such opportunity. A system’s culture involves shared values, norms, and behavioral expectations (King et al., 2018). Culture may be reflected in something as concrete as organization of physical space or as abstract as attitudes and beliefs individuals hold toward their work. Any change to a complex system can initiate culture shift - a realignment of those values, norms, or expectations. Especially in newly integrated clinics, the diversity of views toward behavioral healthcare heralds the potential to make culture shift an active process (Fong et al., 2019).

Teaching about broad behavioral health issues can hasten culture shift. Those of us working in formal training environments or residencies know that consultation and didactics subtly infiltrate our resident’s conceptualization of their patients and influence how they weigh medical decisions, and consistent findings from interprofessional education (IPE) researchers support this (Reeves, 2013). The needs are broad, but discernable; our learners consistently seek support around psychopharmacology, motivational interviewing, and complex mood syndromes, including trauma responses. Importantly, they also note challenges with time management, having difficult conversations, and addressing their own strong emotional responses. All of these can be woven into a focused training plan, which we build collaboratively. Importantly, we can translate this process to the whole team.  

Fostering culture shift unfolds through elevating biopsychosocial principles that yield high impact care. Patients bring between 3 and 5 health concerns to a typical primary care visit (Flocke et al., 2001), with 30% to 80% of all visits addressing psychosocial issues (Wodarski, 2014). For patients with multiple chronic conditions as well as trends toward fewer visits per year overall, efficient care has become a bedrock need (Bierman et al., 2021). Highlighting concepts like multiple health behavior change (MHBC) may be one way the team’s approach to patient care evolves. Using MHBC as a common language for planning treatment draws the team’s attention to the centrality of patient choice as well as their potential to improve their own health.

Forests may be instructive parallels to this kind of culture shift. There is evidence that dense tree root networks have the capacity to share biodynamic information about their specific regions and even individual trees (Figueiredo et al., 2021). Chemical and structural mechanisms enlist symbiotic organisms like fungi to shift the collective assets of the system, thereby altering soil conditions to increase fitness of a given region. This culture of interdependence allows a forest to function as an organism; the health of the ecosystem and its ability to sustain the life that thrives alongside it is all downstream from some basic principles that are rooted in community health. 

Permanent primary care transformation faces challenges (Strange, 2023), and we have a strong asset in culture shift. To actively support integrated culture shift means both delivering important behavioral interventions and encouraging behavioral principles to permeate the workings of our system, our communication, and our professional relationships. Done successfully, this effort makes culture more relevant to those who may not have time to consider it as such and sets the stage for greater adaptability and responsiveness to the complex needs of the people we serve.

References

Accreditation Council for Graduate Medical Education: ACGME program requirements for graduate medical education in family medicine. Revised September 17, 2022. https://www.acgme.org/globalassets/pfassets/programrequirements/120_familymedicine_2023.pdf

Bierman, A.S., Wang, J., O'Malley, P.G., Moss, D.K. (2021). Transforming care for people with multiple chronic conditions: Agency for Healthcare Research and Quality's research agenda. Health Services Research, 56(S1), 973- 979. doi:10.1111/1475-6773.13863

Figueiredo, A.F., Boy, J. & Guggenberger, G. (2021). Common mycorrhizae network: A review of the theories and mechanisms behind underground interactions. Frontiers Fungal Biology, 2, 735299. doi: 10.3389/ffunb.2021.735299

Flocke, S. A. , Frank, S. H. & Wenger, D. A. (2001). Addressing Multiple Problems in the Family Practice Office Visit. The Journal of Family Practice, 50 (3), 211-216.

Fong H, Tamene M, Morley DS, et al. Perceptions of the Implementation of Pediatric Behavioral Health Integration in 3 Community Health Centers. Clinical Pediatrics. 2019;58(11-12):1201-1211. doi:10.1177/0009922819867454

King, M. A., Wissow, L.S., Baum, R.A. (2018). The role of organizational context in the implementation of a statewide initiative to integrate mental health services into pediatric primary care. Health Care Management Review 43(3), 206-217. doi: 10.1097/HMR.0000000000000169

Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. (2013). Interprofessional education: effects on professional practice and healthcare outcomes (update). Cochrane Database of Systematic reviews 28;2013(3), CD002213 doi: 10.1002/14651858.CD002213.pub3. PMID: 23543515; PMCID: PMC6513239.

Stange, K.C. (2023). It is time for family medicine to stop enabling a dysfunctional health care system. The Annals of Family Medicine, 21(3) 202-204; doi: https://doi.org/10.1370/afm.2981

Tong, S.T., Morgan, Z.J., Stephens, K.A., Bazemore, A., & Peterson, L.E. (2023). Characteristics of Family Physicians Practicing Collaboratively With Behavioral Health Professionals. Annals of Family Medicine, 21(2), 157-160. https://doi.org/10.1370/afm.2947

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