IMPROVING MEDICAL EDUCATION

Enhancing the Behavioral and Social Science Content of Medical School Curricula

Committee on Behavioral and Social Sciences in Medical School Curricula

Board on Neuroscience and Behavioral Health

Patricia A. Cuff and Neal A. Vanselow, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula IMPROVING MEDICAL EDUCATION Enhancing the Behavioral and Social Science Content of Medical School Curricula Committee on Behavioral and Social Sciences in Medical School Curricula Board on Neuroscience and Behavioral Health Patricia A. Cuff and Neal A. Vanselow, Editors INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Award No. N01-OD-4-2139, Task Order No. 112, and Grant No. 046078 between the National Academy of Sciences and the National Institutes of Health, Office of Behavioral and Social Science Research and The Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number 0-309-09142-X (Book) International Standard Book Number 0-309-53001-6 (PDF) Library of Congress Control Number: 2004105404 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2004 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Adviser to the Nation to Improve Health

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula COMMITTEE ON BEHAVIORAL AND SOCIAL SCIENCES IN MEDICAL SCHOOL CURRICULA NEAL A. VANSELOW (Chair), Tulane University Health Sciences Center ROBERT DAUGHERTY, JR., University of South Florida College of Medicine PEGGYE DILWORTH-ANDERSON, School of Public Health, Health Policy and Administration, and Center for Aging and Diversity/Institute on Aging, University of North Carolina at Chapel Hill KAREN EMMONS, Harvard School of Public Health; Dana-Farber Cancer Institute EUGENE K. EMORY, Department of Psychology and Department of Psychiatry and Behavioral Sciences, Emory University DANA P. GOLDMAN, RAND Corporation; University of California Los Angeles School of Medicine and School of Public Health TANA A. GRADY-WELIKY, University of Rochester School of Medicine and Dentistry THOMAS S. INUI, Regenstrief Institute for Health Care; Indiana University School of Medicine DAVID M. IRBY, University of California San Francisco School of Medicine DENNIS H. NOVACK, Drexel University College of Medicine NEIL SCHNEIDERMAN, University of Miami Behavioral Medicine Research Center HOWARD F. STEIN, Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center Board on Neuroscience and Behavioral Health Liaisons BRUCE MCEWEN, Alfred E. Mirsky Professor, Harold and Margaret Milliken Hatch Laboratory of Neuroendocrinology, The Rockefeller University, New York RHONDA ROBINSON-BEALE, Blue Cross and Blue Shield of Michigan IOM Project Staff (starting in 2003) PATRICIA A. CUFF, Study Director BENJAMIN HAMLIN, Research Assistant JUDITH ESTEP, Senior Program Assistant IOM Project Staff (ending in 2003) LAUREN HONESS-MORREALE, Study Director OLUFUNMILOLA O. ODEGBILE, Research Assistant ALLISON BERGER, Program Assistant

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula IOM Board on Neuroscience and Behavioral Health Staff ANDREW M. POPE, Director ROSA POMMIER, Finance Officer TROY PRINCE, Administrative Assistant (starting in 2003) CATHERINE A. PAIGE, Administrative Assistant (ending in 2003)

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Independent Report Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: David B. Abrams, Brown University Nancy E. Adler, University of California, San Francisco William Branch, Emory University F. Daniel Duffy, American Board of Internal Medicine Neil J. Elgee, The Ernest Becker Foundation of the University of Washington Marti Grayson, New York Medical College William M. McDonald, Wesley Woods Health Center of Emory Healthcare Joseph P. Newhouse, Harvard University Susan Scrimshaw, University of Illinois at Chicago Lu Ann Wilkerson, University of California, Los Angeles Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the report’s conclusions or recommendations nor did they see the final draft of the report before its release.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula The review of this report was overseen by Charles E. Phelps, Provost, University of Rochester, New York, appointed by the National Research Council and the Institute of Medicine, who was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Preface There are a number of compelling reasons for all physicians to possess knowledge and skill in the behavioral and social sciences. Perhaps most important is that roughly half of the causes of mortality in the United States are linked to social and behavioral factors. In addition, our nation’s population is aging and becoming more culturally diverse. Both of these trends highlight the need for enhanced physician capabilities in the behavioral and social sciences. Knowledge from these disciplines helps physicians understand the role of stress in both their patients’ and their own lives and provides them with coping strategies. Moreover, many believe that competence in these areas is an important element in promoting humane medical practice. Cognizant of important new research findings in the behavioral and social sciences and believing that all medical students should receive up-to-date instruction in these disciplines, the Office of Behavioral and Social Science Research of the National Institutes of Health and The Robert Wood Johnson Foundation asked the Institute of Medicine to conduct a study to accomplish three purposes: Review the current approaches used by medical schools to incorporate the behavioral and social sciences into their curricula. Develop a list of prioritized topics from the behavioral and social sciences for possible future inclusion in those curricula. Consider the barriers to incorporation of behavioral and social science content into medical school curricula, and suggest strategies for overcoming these barriers.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula The committee’s ability to respond to the first part of its charge was made difficult by the lack of a comprehensive database on current behavioral and social science content and teaching techniques in medical school curricula and by a relatively sparse literature on behavioral and social science instruction in the medical school setting. As a result, the committee was forced to draw some of its conclusions from existing databases that were incomplete and from information obtained in its own survey of selected medical schools. The committee regarded the development of a prioritized list of behavioral and social science topics for inclusion in medical school curricula as the most important part of its work. Reducing the list to a realistic size was a difficult process that required extensive discussion and debate. The committee believes, however, that its ultimate recommended list not only contains highly important topics but also is compact enough for inclusion in the tightly packed 4 years of the medical school curriculum. It should also be emphasized that the committee does not recommend a specific behavioral and social science curriculum. Instead, it has chosen to outline those topics to which it believes all medical students should be exposed and to make a few suggestions regarding teaching techniques that might be employed. The way in which this material is woven into a given curriculum should be decided by the medical school’s curriculum committee and will almost certainly vary from school to school. The committee also discovered that there is very little literature on either barriers to the inclusion of the behavioral and social sciences in medical school curricula or strategies that might be employed to overcome such barriers. This portion of the report is therefore based largely on literature related to medical school curriculum change in general and on the experience of committee members, several of whom have been intimately involved with curriculum revisions at their own institutions. Two other important points should be emphasized. First, the committee recognizes that medical education is a continuum that begins in the prebaccalaureate years and continues through medical school, graduate medical education, and practice. It believes that material from the behavioral and social sciences should be incorporated into each of these phases but has restricted its recommendations to the 4 years of medical school in the belief that including other parts of the continuum would be going beyond its charge. Second, the importance of an institutional commitment to behavioral and social science instruction cannot be overemphasized. Without a firm belief on the part of medical school faculty and administration that knowledge and skill in the behavioral and social sciences are an important part of a physician’s education and training, the recommendations contained in this report will be ineffective in producing change. It is difficult to capture in words the enthusiasm with which this report is submitted. All who participated in the study are convinced that knowledge and

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula skill in the behavioral and social sciences are essential to good medical practice. The committee sincerely hopes that the conclusions and recommendations contained in this report will serve as a catalyst for the improvement of behavioral and social science education in U.S. medical schools. Neal A. Vanselow, M.D., Chair Committee on Behavioral and Social Sciences in Medical School Curricula

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Acknowledgments The committee recognizes the tremendous efforts of several individuals whose contributions invigorated meeting discussions and enhanced the quality of this report. For their expert advice, opinions, and willingness to assist, the committee thanks its consultants Michael G. Goldstein and Michael E. Whitcomb. The committee also acknowledges with appreciation the testimony of M. Brownell Anderson, DeWitt C. Baldwin, Jr., Barbara Barzansky, Gerry Dillon, Richard Holloway, Cathy Lazarus, and Lesly T. Mega. Additional thanks go to Robby Reynolds, Nielufar Varjavand, Brenda Butler, Jason Satterfield, Doug Post, and Alan Cross for their assistance to the committee in gathering data on specific topics. Special appreciation is extended to Janet Fleetwood, Gordon Harper, and Steven Locke for their extra efforts and repeated attention to the ongoing information and support needs of the study, and to Julian Bird, who spent many hours working on the domain material that served as the basis for the committee’s Delphi process. Lawrence J. Fine, M.D., Dr.P.H., and Raynard Kington, M.D., Ph.D., of the National Institutes of Health, Office of Behavioral and Social Sciences Research, and The Robert Wood Johnson Foundation deserve particular recognition for generously supporting the vision that medical education can be improved through the enhancement of behavioral and social science training of medical students in the United States. The committee would be remiss if it did not also acknowledge the hard work and dedication of the study staff in the Board on Neuroscience and Behavioral Health. Andy Pope was a valuable resource with his extensive know-how as the board director, and Gooloo Wunderlich, with her strict attention to the evidence base, ensured that the most recent factual data would be considered. For initiating

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula the study, the committee thanks former staff members Terry Pelmar, board director; Lauren Honess-Morreale, study director; Olufunmilola Odegbile, research assistant; and Allison Berger, project assistant. Special appreciation goes to Patricia Cuff, study director; Benjamin Hamlin, research assistant; and Judy Estep, senior project assistant for stepping in and bringing the study to its conclusion. Patricia did an excellent job of keeping the committee informed about the report’s status during and after the period of transition; Ben stalwartly pursued the daunting task of verifying references; and Judy, with her word processing ability and experience, was instrumental in getting the report into production. Final thanks go to writing and editorial consultants Rona Briere, Kathi Hanna, and Michael Hayes.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Contents     EXECUTIVE SUMMARY   1      Abstract,   1      Role of Behavioral and Social Factors in Health and Disease,   2      Why Physicians Need Education and Training in the Behavioral and Social Sciences,   4      Statement of Task,   4      Current State of the Behavioral and Social Sciences in Curricula of U.S. Medical Schools,   5      Conclusions and Recommendations,   6 1   INTRODUCTION   15      Role of Behavioral and Social Factors in Health and Disease,   15      Purpose of the Study,   18      Study Origin and Tasks and Organization of the Report,   18 2   CURRENT APPROACHES TO INCORPORATING THE BEHAVIORAL AND SOCIAL SCIENCES INTO MEDICAL SCHOOL CURRICULA   20      Summary,   20      The Behavioral and Social Sciences in Current Medical School Curricula,   22      Barriers to Systematic Analysis of the Behavioral and Social Sciences in Medical School Curricula,   24      Inventory of Current Behavioral and Social Science Content in Medical School Curricula,   27

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula      Approaches of Selected Medical Schools to Integrating Behavioral and Social Science Content into Their Curricula,   32      Need for an Improved Database on the Status of Behavioral and Social Science Instruction in U.S. Medical Schools,   50 3   THE BEHAVIORAL AND SOCIAL SCIENCES IN MEDICAL SCHOOL CURRICULA   52      Summary,   52      Mind–Body Interactions in Health and Disease,   58      Patient Behavior,   63      Physician Role and Behavior,   68      Physician–Patient Interactions,   74      Social and Cultural Issues in Health Care,   79      Health Policy and Economics,   83 4   STRATEGIES FOR INCORPORATING THE BEHAVIORAL AND SOCIAL SCIENCES INTO MEDICAL SCHOOL CURRICULA   87      Summary,   87      Barriers to Incorporating the Behavioral and Social Sciences into Medical School Curricula,   89      Strategies for Curriculum Change,   90     REFERENCES   99     APPENDIXES     A   Methods   119 B   Committee and Staff Biographies   135     INDEX   141

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Tables, Figures, and Boxes TABLES ES-1   Behavioral and Social Science Topics of High and Medium Priority for Inclusion in Medical School Curricula,   10 2-1   Methods for Teaching Basic Communication Skills,   25 2-2a   Number of Hours Selected LCME Hot Topics Are Taught Throughout the 4 Years of Medical School,   28 2-2b   Percentage of Medical Schools Teaching Specific Topics During Each Year of Medical School,   29 2-2c   Medical Student Satisfaction with Selected Topics at Time of Graduation,   30 3-1   Behavioral and Social Science Topics of High and Medium Priority for Inclusion in Medical School Curricula,   56 FIGURES 1-1   Model of the determinants of health,   17 A-1   MEDLINE search results,   120 A-2   Results of electronic multiple-database search,   121

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula BOXES 2-1   Schools with Educational Programs in the Behavioral and Social Sciences, Based on the Literature and Website Information,   33 2-2   Behavioral and Social Science Education in the Medical School Curriculum of Ohio State University,   34 2-3   Behavioral and Social Science Education in the Medical School Curriculum of the University of California, San Francisco (UCSF),   36 2-4   Behavioral and Social Science Education in the Medical School Curriculum of the University of Rochester,   41 2-5   Behavioral and Social Science Education in the Medical School Curriculum of the University of North Carolina,   45 3-1   Complex Communication Skills,   77 A-1   List of Interested Associations, Organizations, and Medical Schools Represented by Invited Speakers,   122 A-2   Suggested Curriculum Content Organized by Five Domains,   124

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula IMPROVING MEDICAL EDUCATION

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