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The development of behavioral science in a family practice residency has first to be structured around a statement of purpose and adequate goals. These goals can only be implemented when the purely custodial function of the medical profession is rejected and the ethical responsiblity of the physician to society is allowed to direct the role innovations that must be incorporated. It is the person of the physician as a diagnostic and therapeutic tool that must be cultivated. The curriculum presented has included behavioral science conferences, a one-month behavioral science rotation, a two-month orientation program, behavioral science clinical attendings, and a personal counseling program for each resident throughout the three years of training. To be complete, such a program requires the further refinement of behavioral objectives that allow reliable evaluation and redefinition by residents and faculty.

This study replicates the design reported by Schwenk et al and addresses a key methodologic issue in their paper. The original questionnaire by Schwenk et al was administered to one half of the sample of patients, while the other half completed a reworded questionnaire asking what they "want" in the area of psychosocial help, as opposed to what they think their family physician "would" do (the original wording). The hypothesis was that expectations for physician involvement will be higher if patients are asked what they want as opposed to what they expect. Patients were asked to complete a four-page questionnaire, alternating the questions described by Schwenk et al with the reworded questionnaire, in which they were required to rank the level of involvement requested from their physician regarding 45 psychosocial problems (level 1 = no involvement, level 4 = major involvement). Results using the originally worded questionnaire closely paralleled findings of Schwenk et al, whereas asking people what they "wanted" showed statistically significant differences in 18 of the 45 items. The paper concludes with discussion of patient preferences vs patient expectations, with implications for the behavioral science curriculum.

British psychoanalyst Michael Balint made important theoretical and pragmatic contributions to family practice, through the seminars of general practitioners he led at the Tavistock Clinic. A weekly Balint seminar, modeled on the Tavistock groups, was held in a family practice residency. The group of second and third year residents, co-led by a behavioral scientist and a family practice faculty member, met for 12 weeks and then re-evaluated topics and discussion format. Issues covered included physician-patient relationships, ethical dilemmas, group therapy concerns, and coping with clinic pressures. Objective evaluation of these seminars, where the goal is attitudinal rather than behavioral change, presents some difficulty. The conclusion is that residents benefited from the seminar, and that some aspects of psychoanalytic theory and technique are applicable to the teaching of behavioral science in family practice residencies.

Fifty-six family practice residents representing programs in 23 different states were surveyed concerning their training experience in behavioral science. Questions covered three basic areas of concern: experiential content, subsequent relevance to family practice, and suggestions for curriculum improvement at the residency level. The results point out definite knowledge of medical psychology, psychiatric consultation to medical patients, and practical intervention skills. Suggestions are made concerning curriculum development in behavioral science which (1) emphasize some new areas of concern raised by the residents, (2) recommend a more practical, integrated approach beginning in the medical school training, and (3) emphasize a dual approach requiring skills in medical psychology and skills more traditionally subsumed under the "mental health" field.

Assessment and treatment of the varied psychosocial problems which affect patient health often present primary care physicians with their most difficult and frustating problems. This paper outlines criteria which can be used to select a model of psychosocial treatment compatible with an active family practice clinic. It also describes one treatment model which fits the criteria and can be used to assess and treat a wide range of psychosocial problems common to family practice.

To tailor a behavioral science curriculum to family practice needs, less importance should be given to inpatient psychiatry, and more emphasis to the common outpatient problems seen in the primary care setting. The experience of co-leading a short-term couples therapy group during residency training can assist the family physician in becoming more comfortable with marital counseling. Each couples group was co-led by a resident and a behavioral scientist, with couples who had requested marital treatment from the mental health service of a health maintenance organization. After couples were initially evaluated with a pregroup questionnaire, a number of group therapy sessions were co-led, using specific communications techniques and exercises. Benefits to the resident included development of skills in handling small groups, learning behavioral tools for assisting couples, and developing increased comfort in approaching psychosocial issues.

The Family Practice Center of Akron has developed and implemented a human relations training program as an integral part of the family practice residency curriculum. Following two years of planning and experimenting, a 12-month course of study was formalized in July 1975. Two full-time behavioral scientists are responsible for planning, coordinating, and teaching the curriculum. The curriculum includes a variety of learning experiences throughout the three years and represents approximately ten percent of educational programming and costs.

The purpose of this study was to assess the current status of behavioral science instruction in family practice residency training programs. The primary areas of interest were: (1) characteristics of those who teach behavioral science (number of persons teaching behavioral science by discipline and academic degree, number and percent of time behavioral science personnel employed, work responsibilities, academic unit responsible for instruction, description of those who provide inservice training in behavioral science ), (2) the relative importance of various behavioral science topics as perceived by faculty/staff (21 topics), and (3) preferred methods of instruction. The data revealed a wide variety of persons involved in behavioral science instruction, a strong emphasis placed on communication and counseling skills, and similar, but not innovative, teaching methods used for behavioral science instruction.

A questionnaire survey of residency trained graduates and nonresidency trained family physicians showed both groups reporting relatively infrequent practice of behavioral medicine. Referrals and counseling sessions/visits produce a combined total of 20 activities per month, or two to four percent of all patient encounters, even though the physicians in the sample reported that 33 percent of their diagnoses were behavioral/psychological. More than 85 percent of the physicians reported access to more than one mental health provider. The six most common health problems encountered in the office were depression, anxiety, obesity, marital discord, alcohol abuse, and sexual problems. Physicians responding to this survey expressed an interest in continuing education programs that emphasize individual, marital, and parenting counseling, and psychopharmacology. There is a major need to improve the mental health component of residency training, which will enable physicians to better manage psychosocial problems in practice settings.

Curriculum in family medicine and primary care includes various areas of concern for educators in the behavioral sciences. Most of this concerns the physician-patient relationship as the focus for teaching and learning. This paper outlines the work of a longitudinal, case oriented group of family physicians as it reflects the correlation between the actualities of practice and the curriculum in behavioral science for family practice residents. Also discussed is the issue of potential "typologies" as elaborated in the family physicians' reasons for case presentations. Such groups assist faculty and practitioners in their own awareness of educational and patient care issues in the physician-patient relationship as well as serve as a foundation for building a relevant behavioral science curriculum for residents and students.

Patients have infrequently been assessed about their desire for their family physician to possess a certain level of expertise in managing a wide range of behavioral science problems. This has led to inconsistencies in the type of behavioral science training offered to family physicians and thence to a marked discrepancy between the amount of training offered (relatively large) and the amount of mental health care provided (relatively small). This study reports the result of a study of patient attitudes concerning the level of involvement by their family physician for each of 45 psychosocial problems. The levels offered were (1) no help, (2) referral, (3) compassion, concern, and minor advice, and (4) expert therapeutic help. The mean responses place a majority (25 of the 45) of the problems in level 3. Certain obvious problems appeared in level 1 (religious/church problems) and level 4 (pregnancy). Child behavioral problems dominated in level 2. Certain surprises were also found, such as the presence of problems of marital discord in level 1, and the problem of long-term pain in level 4.