George W' Saba, Ph'D'

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Training Family Physicians to Create Effective
Healing Relationships Lessons from an Urban
Public Health Center
George W. Saba, Ph.D. Teresa J. Villela,
M.D. Department of Family and Community
Medicine University of California, San Francisco
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Patient Population
Native American 1
White 15
African-American 10
Latino 54
Asian/Pacific Islander 20
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Key Capacities

• Think Relationally
• Act Relationally
• Search for Strengths
• Foster Healing
• Use Power Appropriately

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Key Capacities

• Face the Truth
• Manage Uncertainty
• Reflect
• Articulate Ones Model of Healing
• Maintain Balance

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Principles of Learning

• Practice-Based
• Experiential
• Longitudinal
• Reflective
• Integrative
• Collaborative
• Formational

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Live Supervision of Clinical Practice

• Within the context of ones clinical practice, to
  learn
• Systems-oriented model of primary care
• Reflection-on-action and in-action

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Live Supervision of Clinical Practice
Context of Live Supervision
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Live Supervision of Clinical Practice

• Two-on-Two Curriculum
• PGY1 residents
• Two faculty co-teachers
• Meet weekly for one year
• Occurs during outpatient clinic sessions
• Regularly scheduled medical visits
• Live supervision and videotape review

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Live Supervision of Clinical Practice

• Linkage Curriculum
• PGY 2 and PGY3 residents
• Faculty continuity over three years
• Occurs during outpatient clinic sessions
• 60 of clinic sessions supervised

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Relationships and Health

• To learn how to develop mutually healing
  relationships
• Systems therapy
• Physicians model of healing
• Physician formation

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Relationships and Health

• Structure
• PGY2 and PGY3 residents
• Small group meets for 4 hours weekly for 3 months
  each year
• Residents select patients and families
• Live supervision and video review

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Relationships and Health

• Systems Therapy
• Elicit patients/familys models of healing
• Identify strengths
• Evaluate context (e.g., biologic, intra-personal,
  familial, cultural, spiritual)
• Reframe within a contextual perspective

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Relationships and Health

• Systems Therapy
• Identify issues of power
• Communicate cross-culturally
• Foster empowerment
• Intervene in relational patterns

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Relationships and Health

• Physicians Personal Model of Healing
• Reflect on beliefs, values and assumptions
• Articulate these among colleagues
• Discover how model operates in clinical
  decision-making (via live supervision and
  videotape review)

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Relationships and Health

• Physicians Formation
• Examine ones development as a physician
• Share methods for enhancing well-being
• Explore disciplined practices (e.g., prayer,
  mindfulness meditation, structured reflection)

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Practice-Based Learning

• Through a longitudinal, practice-based
  collaborative format
• Integrate the vast domains of practice
• Learn how to learn

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Practice-Based Learning

• Structure
• 2-year curriculum
• Three PGY2 and three PGY3 residents
• Two faculty members
• Meet for 4 hours weekly over 6 months each year
• Same group composition in the year

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Practice-Based Learning
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Practice-Based Learning

• Domains of Inquiry
• Evidence-based medicine
• Patient-physician relationship
• Family systems theory
• Cross-cultural care
• Collaborative team care
• Population-based health

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Evaluation of Live Supervision

• Residents asked to rank methods in
• order of effectiveness for learning the
• skills of Family Practice
• Case Discussion
• Lectures
• Live Supervision
• One-to-One Consultation
• Readings
• Role Playing
• Videotape Review

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Evaluation of Live Supervision

• Past six years, 90 of graduating residents
• rank live supervision as most effective
• Immediate relevant feedback and support
• Intimate faculty involvement
• Evidence-based evaluation

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Evaluation of Practice-Based Learning

• Residents reported that the curriculum provided
• A context for in-depth reflection on the dilemmas
  and challenges in ones relationships with
  patients
• An opportunity to collaborate with peers in
  sharing and learning through practice experiences

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Evaluation of Practice-Based Learning

• An affirmation of the depth of the groups
  expertise
• A complement to learning through lectures
  yielding knowledge relevant to actual patients
  for whom they are responsible
• An increased control over the learning process