Executive Summary

ABSTRACT

In response to growing recognition of the role played by behavioral and social factors in health and disease, the National Institutes of Health and The Robert Wood Johnson Foundation asked the Institute of Medicine to conduct a study of medical school education in the behavioral and social sciences. The study included a review of the approaches used by medical schools to incorporate the behavioral and social sciences into their curricula, development of a prioritized list of behavioral and social science topics for future inclusion in those curricula, and an examination of ways in which barriers to the incorporation of behavioral and social science topics can be overcome.

The committee finds that existing databases provide inadequate information on behavioral and social science curriculum content, teaching techniques, and assessment methodologies in U.S. medical schools and recommends development of a new national behavioral and social science database. It also recommends that medical students be provided with an integrated behavioral and social science curriculum that extends throughout the 4 years of medical school. The committee identifies 26 topics in six behavioral and social science domains that it believes should be included in medical school curricula. The six domains are mind–body interactions in health and disease, patient behavior, physician role and behavior, physician–patient interactions, social and cultural issues in health care, and health policy and economics.



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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Executive Summary ABSTRACT In response to growing recognition of the role played by behavioral and social factors in health and disease, the National Institutes of Health and The Robert Wood Johnson Foundation asked the Institute of Medicine to conduct a study of medical school education in the behavioral and social sciences. The study included a review of the approaches used by medical schools to incorporate the behavioral and social sciences into their curricula, development of a prioritized list of behavioral and social science topics for future inclusion in those curricula, and an examination of ways in which barriers to the incorporation of behavioral and social science topics can be overcome. The committee finds that existing databases provide inadequate information on behavioral and social science curriculum content, teaching techniques, and assessment methodologies in U.S. medical schools and recommends development of a new national behavioral and social science database. It also recommends that medical students be provided with an integrated behavioral and social science curriculum that extends throughout the 4 years of medical school. The committee identifies 26 topics in six behavioral and social science domains that it believes should be included in medical school curricula. The six domains are mind–body interactions in health and disease, patient behavior, physician role and behavior, physician–patient interactions, social and cultural issues in health care, and health policy and economics.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula To help overcome multiple barriers to the incorporation of the behavioral and social sciences into medical school curricula, the committee recommends that the National Institutes of Health or private foundations establish behavioral and social sciences career development and curriculum development awards. Moreover, concerned that the U.S. Medical Licensing Examination currently places insufficient emphasis on test items related to the behavioral and social sciences, the committee recommends that the National Board of Medical Examiners ensure that the exam adequately covers the behavioral and social science subject matter recommended in this report. ROLE OF BEHAVIORAL AND SOCIAL FACTORS IN HEALTH AND DISEASE For more than a decade it has been well established that approximately half of all causes of morbidity and mortality in the United States are linked to behavioral and social factors (McGinnis and Foege, 1993; NCHS, 2003a). In fact, the leading cause of preventable death and disease in the United States—smoking—significantly increases the risk of lung cancer and chronic lung disease, as well as the risk of heart disease and stroke (CDC, 1999; Mokdad et al., 2004; NCHS, 2003a). A sedentary lifestyle, along with poor dietary habits, has also been associated with increased risk of heart disease, as well as a myriad of other adverse health conditions, and may soon overtake tobacco as the leading cause of preventable death (Graves and Miller, 2003; Mokdad et al., 2004; Morsiani et al., 1985; U.S. DHHS, 2001). Alcohol consumption is the third leading cause of preventable death in the United States (Mokdad et al., 2004). And although moderate alcohol intake may have some protective effects against heart disease, excessive consumption has been linked to a variety of potentially preventable conditions (Maekawa et al., 2003; Nanchahal et al., 2000; Pessione et al., 2003). Illnesses related to behavioral factors include, among others, cancer, heart disease, poor pregnancy outcome, chronic obstructive pulmonary disease, type II diabetes, and unintentional injury (Hoyert, 1996; NCHS, 2003a; NHLBI, 2003a,b; U.S. DHHS, 1996). In addition to these adverse health effects of harmful behaviors, psychological and social factors have been shown to influence chronic disease risk and recovery. Psychological factors, such as personality, developmental history, spiritual beliefs, expectations, fears, hopes, and past experiences, shape people’s emotional reactions and behaviors regarding health and illness. Social factors, including support of family and friends, institutions, communities, culture, politics, and economics, can have profound effects as well. Indeed, scientific evidence is increasing on the effects of psychological and social factors on biology, and recent studies have demonstrated that psychosocial stress may be a significant risk factor for a variety of diseases (Barefoot et al., 2000; Carroll et al.,

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula 1976; Everson et al., 1996; Frasure-Smith et al., 1993; Kawachi et al., 1996; Leserman et al., 2000; Mayne et al., 1996; Orth-Gomer et al., 1993). In the case of heart disease, for example, psychosocial stress appears to contribute directly to atherosclerotic processes by narrowing blood vessels, thus restricting circulation (Bairey Merz et al., 2002; Williams et al., 1991). Theories underlying behavioral interventions aimed at modifying disease course are based on the assumptions that behavioral and psychosocial influences on disease course are modifiable and that curtailing unhealthy practices will slow disease progression or minimize the recurrence of disease following treatment (IOM, 2000). Understanding that behavior can be changed and that proven methods are available to facilitate such change allows physicians to provide optimal interventions—behavioral and nonbehavioral—to improve the health of patients. Identifying personal, familial, social, and environmental factors that may affect a patient’s health enables physicians to provide better, more patient-centered care (IOM, 2001a, 2003a). In addition, physicians must be able to recognize their own personal and social biases and perceptions to best serve the needs of their patients. Although the scientific evidence linking biological, behavioral, psychological, and social variables to health, illness, and disease is impressive, the translation and incorporation of this knowledge into standard medical practice appear to have been less than successful. To make measurable improvements in the health of Americans, physicians must be equipped with the knowledge and skills from the behavioral and social sciences needed to recognize, understand, and effectively respond to patients as individuals, not just to their symptoms. Sobel (2000:393), an expert in mind–body health care, notes that “more and more studies point to simple, safe and relatively inexpensive interventions that can improve health outcomes and reduce the need for more expensive medical treatments. Far from a new miracle drug or medical technology, the treatment is simply the targeted use of mind–body and behavioral medicine interventions in a medical setting.” Thus, physicians with an understanding of disease causation that extends beyond biomedical approaches are more likely to see better intervention outcomes than have been achieved to date (IOM, 2000). A number of demographic factors in the United States also underscore the need for more attention to the behavioral and social components of health. First, the proportion of the population aged 65 and over is expected to grow by 57 percent by 2030 (U.S. Bureau of the Census, 1996), and with Americans now having an average life expectancy of 77 years (NCHS, 2003b), physicians need the knowledge and skills to care for this aging population. To this end, they must understand the interplay of social and behavioral factors (e.g., diet, exercise, and familial and social support) and the role these factors play in delaying or preventing the onset of disease and slowing its progression. Physicians also need to have been trained in pain management and means of improving quality-of-life mea-

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula sures that are essential to providing patient-centered care. Knowledge and skills in both of these areas are especially critical for the treatment of chronic conditions, common in this population, that require palliative care. A second demographic change is the rising percentage of minorities in the overall U.S. population. According to U.S. census data, 26 percent of the current population is nonwhite, a proportion that is expected to increase to almost 47 percent by 2050 (U.S. Bureau of the Census, 1996). The country’s growing cultural and ethnic diversity presents new challenges and opportunities for physicians and other health professionals, who must become culturally competent and better skilled in communicating and negotiating health management with diverse populations (Crawley et al., 2002; IOM, 2003c; Satterfield et al., 2004). WHY PHYSICIANS NEED EDUCATION AND TRAINING IN THE BEHAVIORAL AND SOCIAL SCIENCES It is clear that medical students with education in the behavioral and social sciences will be better equipped to recognize patients’ risky behaviors and foster changes in those behaviors through appropriate interventions. Skills in the behavioral and social sciences are essential for the prevention of many chronic diseases and for the effective management of patients with these diseases. Communication skills, which are emphasized in the behavioral and social sciences, will assist physicians in building therapeutic relationships with their patients and increase the likelihood that patients will follow their advice. In addition, good communication skills and the cross-disciplinary education discussed in this report will improve their ability to relate to their colleagues in medicine, as well as other professionals. Physicians truly wanting to influence patient behavior must also be aware of their patients’ social contexts. Given the demographic trends noted above, this will inevitably translate into physicians encountering more elderly patients and those from a greater variety of cultures, who will need guidance in how best to utilize available therapeutic services within the changing health care system. These matters, too, are covered by a comprehensive behavioral and social science curriculum. Additionally, teaching medical students how to care for themselves, function in a team environment, use ethical judgment, and understand the usefulness of community resources can improve their job satisfaction and prevent burnout when they enter practice. STATEMENT OF TASK In this context, the Institute of Medicine convened the Committee on Behavioral and Social Sciences in Medical School Curricula to examine the content and effectiveness of behavioral and social science teaching in medical school education. The committee was asked to address the following charge:

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Review the approaches used by medical schools that have tried to incorporate the behavioral and social sciences into their curricula. Develop a list of prioritized topics from the behavioral and social sciences for possible inclusion in medical school curricula. As an alternative to a numerical list, clustered priorities (e.g., top, high, medium, and low) may be assigned to topic areas. Provide options for how changes in curricula can be achieved, such as encouraging the leadership of medical schools to incorporate behavioral and social sciences, funding opportunities that would achieve this goal, or other novel approaches that would achieve this aim. In developing these options, the barriers to implementing curricula change and approaches to overcome these barriers should be considered. The committee met five times between December 2002 and October 2003 and cast a broad net to capture the relevant information. It held public meetings with medical schools and other organizations to explore and discuss relevant information regarding the status of the teaching of the behavioral and social sciences in medical schools. The committee also reviewed and considered information from the published literature, medical school websites, and a variety of other sources. (See Appendix A for details regarding the methods used by the committee in conducting this study.) CURRENT STATE OF THE BEHAVIORAL AND SOCIAL SCIENCES IN CURRICULA OF U.S. MEDICAL SCHOOLS U.S. medical schools appear to be moving toward incorporating the behavioral and social sciences into their curricula in some way, and international efforts are under way to systematically include the behavioral and social sciences as part of the foundations of medical education (IIME, 2003). It is difficult to document with certainty, however, how much behavioral and social science is currently being taught in U.S. medical schools. This is the case because definitions of what constitutes the behavioral and social sciences vary, and difficulties abound in identifying medical school courses that include such components. For the purposes of this report, the behavioral and social sciences as applied to medicine are ideally defined as those research-based disciplines that provide physicians with empirically verifiable knowledge that serves as a foundation for understanding and influencing individual, group, and societal actions relevant to improving and maintaining health. In reviewing the curricular content across U.S. medical schools, it became evident to the committee that there is significant variability in the teaching of the behavioral and social sciences: course titles differ; the number of hours of instruction varies; course content is inconsistent; the timing of instruction during the undergraduate experience differs (AAMC, 2003a; Milan et al., 1998; Muller,

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula 1984); and whether or not the behavioral and social sciences are fully integrated1 into students’ 4-year education depends on the institution (Waldstein et al., 2001). A few medical schools do offer curricula in which behavioral and social science material is included in all 4 years of medical education, rather than being confined to the preclinical years. It appears more common, however, that behavioral and social science courses are taught during the first 2 years. In 2000, only 8 percent of the 62 U.S. medical schools that responded to a survey about their curricula reported that they had integrated programs of behavioral medicine that stressed the effects of human behavior on health and illness using a biopsychosocial model (Brook et al., 2000). The Curriculum Management and Information Tool (CurrMIT) database of the Association of American Medical Colleges (AAMC) is the most comprehensive tool available for collecting and analyzing the content of medical school curricula. However, it is a voluntary system, and not all medical schools participate. It is designed to allow medical schools to examine the full spectrum of their curricula, track key trends, support innovations, and compare local curricula with those of other medical schools (AAMC, 1999a). Schools have flexibility regarding how they enter their data in the CurrMIT database, depending on program needs. As a result, data entry formats vary from school to school, as do the level of detail and the degree to which the information is updated. Currently, only 67 medical schools have entered course titles related to the behavioral and social sciences into the CurrMIT database (AAMC, personal communication, September 2003). CONCLUSIONS AND RECOMMENDATIONS In response to its charge, the committee developed several conclusions and recommendations aimed at enhancing the incorporation of the behavioral and social sciences into medical school curricula. These conclusions and recommendations, as well as strategies for accomplishing the specific tasks outlined in the committee’s charge, are presented below. Routine Survey of Behavioral and Social Science Curricula The lack of national standardization among medical school curricula, of standardization in the terminology used to describe curricular content, and of a comprehensive strategy for creating a national database of medical school curricula makes it difficult to describe systematically the subject matter medical schools 1   An integrated curriculum for the purposes of this report is one in which behavioral and social science subject matter is taught as part of other courses in the basic and clinical sciences, not as separate courses.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula have incorporated into their curricula. The committee believes the creation of an improved, periodically updated database on the state of behavioral and social science instruction in U.S. medical schools would be of significant benefit to individual medical schools, credentialing bodies, government agencies, and professional organizations. An alternative to creating a new database would be to modify CurrMIT to produce these data. Because both are major undertakings, the decision to develop a new database or modify CurrMIT should be based on which method best collects behavioral and social science teaching information within the available resources. The committee also believes AAMC is the logical organization to design and operate such a database, as it has access to and is respected by all U.S. allopathic medical schools, and its staff has considerable experience and expertise in data collection and analysis. AAMC should consider collaborating with other relevant professional organizations, such as the American Association of Colleges of Osteopathic Medicine and the Liaison Committee on Medical Education (LCME), in the design and operation of the database. It is beyond the scope of the committee’s charge to specify the data that should be collected, the collection methodology, or the types of analyses that should be performed—matters that would best be decided by those using the database. It may be noted that the ad hoc survey conducted by the committee for this study reflects some of its thinking about the minimum contents of a curriculum database. Conclusion 1. Existing national databases provide inadequate information on behavioral and social science content, teaching techniques, and assessment methodologies. This lack of data impedes the ability to reach conclusions about the current state and adequacy of behavioral and social science instruction in U.S. medical schools. Recommendation 1: Develop and maintain a database. The National Institutes of Health’s Office of Behavioral and Social Sciences Research should contract with the Association of American Medical Colleges to develop and maintain a database on behavioral and social science curricular content, teaching techniques, and assessment methodologies in U.S. medical schools. This database should be updated on a regular basis. Behavioral and Social Science Content in Medical School Curricula No physician’s education would be complete without an understanding of the role played by behavioral and social factors in human health and disease, knowledge of the ways in which these factors can be modified, and an appreciation of how personal life experiences influence physician–patient relationships. The committee believes that each medical school should expect entering students

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula to have completed course work in the behavioral and social sciences during their prebaccalaureate education and should inform prospective applicants of its behavioral and social science–related requirements and/or recommendations. Behavioral and social science instruction in medical school should build on this prebaccalaureate foundation. The committee also believes that material from the behavioral and social sciences should be included in the post–medical school phases of the medical education continuum. These phases include residency and fellowship training, as well as continuing (postgraduate) medical education. While the emphasis in this report is on the 4 years of medical school, the importance of continuing behavioral and social science education throughout a physician’s career cannot be overemphasized. This section presents the committee’s response to the second part of its charge, to develop a list of prioritized topics from the behavioral and social sciences for possible inclusion in medical school curricula. The committee considers this to be the most important part of its work. The committee’s recommended list of topics is supported by two conclusions reached during its deliberations. Conclusion 2a. Human health and illness are influenced by multiple interacting biological, psychological, social, cultural, behavioral, and economic factors. The behavioral and social sciences have contributed a great deal of research-based knowledge in each of these areas that can inform physicians’ approaches to prevention, diagnosis, and patient care. Some areas of the behavioral and social sciences have been more thoroughly researched and rigorously tested than others. This observation does not diminish the importance of those areas with less verifiable evidence, but rather points to the need for more research. One such example is the strong influence physicians’ actions can have on the attitudes and values of medical students, even though this nonverbal form of communication has not been thoroughly tested (Ludmerer, 1999). In contrast, the importance of effective physician communication has received a fair amount of attention by researchers. The results of this research indicate that physicians need basic communication skills in order to take accurate patient histories, build therapeutic relationships, and engage patients in an educative process of shared decision making (IOM, 2001a, 2003a; Peterson et al., 1992; Safran et al., 1998). Conclusion 2b. Within the clinical encounter, certain interactional competencies are critically related to the effectiveness and subsequent outcomes of health care. These competencies include the taking of the medical history, communication, counseling, and behavioral management. Providing the core content in the behavioral and social sciences identified in this report during the 4 years of medical school will introduce this material at a time when students perceive it to be most relevant and facilitate reinforcement of important concepts throughout the preclinical and clinical years. Moreover, inte-

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula grating the curriculum so that behavioral and social science topics are included as part of other basic science and clinical courses, instead of being presented in separate courses, will enable the educational experience to simulate real-world experience, in which behavioral and social factors in health and disease must be considered in the context of complex clinical situations. The committee recognizes that there are many important topics to which students must be exposed during their 4 years of medical school. As with any suggested change to medical school curricula, calls to include the behavioral and social sciences must be balanced against similar requests from other disciplines that are vying for precious teaching time. As noted earlier, however, evidence is mounting that tremendous strides could be made in preventing disease and promoting health if more attention were given to the behavioral and social science priorities outlined in this report. Knowing this, the committee selected potential priority topics on the basis of (1) relevant evidence-based articles and reports in the literature; (2) presentations to the committee by content experts and medical school representatives; (3) literature and other material from the AAMC and LCME; (4) considerations related to the health of the public, driven mainly by root causes of morbidity and mortality; and (5) the gap between what is known and what is actually done in practice. Following extensive deliberations, a modified Delphi process was used to prioritize this initial list of topics. (A detailed description of this process is included in Appendix A.) Committee members rated each of the topics on the list using a scale system, and then assigned each high, medium, or low priority based on its mean score and standard deviation. This list was further refined and finalized using the collective and individual experience of the committee as experts in medical school curriculum development and reform in the behavioral and social sciences. The low priorities were then discarded, and the remaining 26 topics were categorized as top, high, or medium priority. The results of this process constitute the committee’s recommendation for those behavioral and social science topics that should be included in medical school curricula. In the committee’s view, the 20 topics ranked top and high must be included in medical school curricula and were therefore combined into one high-priority group. The 6 medium-priority topics are also important and would significantly enhance the education of medical students. Inclusion of the medium priorities, as well as the depth of teaching and evaluation, is dependent upon the needs of the individual medical school. The final listing of topics, presented in Table ES-1, is organized so as to have meaning for medical school curriculum committees. The 26 recommended topics fall into the following six general domains of knowledge:2 2   The order in which the various domains are listed is random and does not reflect the committee’s view of their relative importance.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula TABLE ES-1 Behavioral and Social Science Topics of High and Medium Priority for Inclusion in Medical School Curricula Domain High Priority Medium Priority Mind–Body Interactions in Health and Disease Biological mediators between psychological and social factors and health Psychological, social, and behavioral factors in chronic disease Psychological and social aspects of human development that influence disease and illness Psychosocial aspects of pain Psychosocial, biological, and management issues in somatization Interaction among illness, family dynamics, and culture Patient Behavior Health risk behaviors Principles of behavior change Impact of psychosocial stressors and psychiatric disorders on manifestations of other illnesses and on health behavior Physician Role and Behavior Ethical guidelines for professional behavior Personal values, attitudes, and biases as they influence patient care Physician well-being Social accountability and responsibility Work in health care teams and organizations Use of and linkage with community resources to enhance patient care Physician–Patient Interactions Basic communication skills Complex communication skills Context of patient’s social and economic situation, capacity for self-care, and ability to participate in shared decision making Management of difficult or problematic physician–patient interactions Social and Cultural Issues in Health Care Impact of social inequalities in health care and the social factors that are determinants of health outcomes Cultural competency Role of complementary and alternative medicine Health Policy and Economics Overview of U.S. health care system Economic incentives affecting patients’ health-related behaviors Costs, cost-effectiveness, and physician responses to financial incentives Variations in care

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Mind–body interactions in health and disease—focuses on the four primary pathways of disease (biological, behavioral, psychological, and social). Students need to recognize and understand the many complex interactions among these pathways that may be compromising a patient’s physical and/or mental health. Patient behavior—centers on behavioral pathways to promoting health and preventing disease. Educating medical students about behaviors that pose a risk to health will better equip them to provide appropriate interventions and influence patient behavior. Physician role and behavior—emphasizes the physician’s personal background and beliefs as they may affect patient care, as well as the physician’s own well-being. Physician–patient interactions—focuses on the ability to communicate effectively, which, as noted above, is a critical component of the practice of medicine. Social and cultural issues in health care—addresses what physicians need to know and do to provide appropriate care to patients with differing social, cultural, and economic backgrounds. Health policy and economics—includes those topics to which medical students should be exposed to help them understand the health care system in which they will eventually practice (although additional material regarding the U.S. health care system should be presented in the residency years). Recommendation 2. Provide an integrated 4-year curriculum in the behavioral and social sciences. Medical students should be provided with an integrated curriculum in the behavioral and social sciences throughout the 4 years of medical school. At a minimum, this curriculum should include the high-priority items delineated in this report and summarized in Table ES-1. Medical students should demonstrate competency in the following domains: Mind–body interactions in health and disease Patient behavior Physician role and behavior Physician–patient interactions Social and cultural issues in health care Health policy and economics Strategies for Incorporating Behavioral and Social Sciences into the Medical School Curriculum The committee found that many barriers exist to incorporating the behavioral and social sciences into medical school curricula. Incorporating this material is a

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula special challenge because of the nature of the content, the lack of faculty members in these disciplines, the lower status accorded to these disciplines by some in the medical school community, the lack of departmental status for behavioral and social science faculty, and the limited leadership and financial resources available to support such efforts. Curriculum change rarely occurs without a champion or leader pushing the agenda forward. A well-supported career development program in the behavioral and social sciences would free promising faculty members from competing responsibilities so they could develop leadership skills and work toward incorporating the behavioral and social sciences into medical school curricula. Individuals receiving career development awards could also serve as resources to assist other medical schools attempting to enhance their behavioral and social science curricula. Conclusion 3. Instruction in the behavioral and social sciences suffers from a lack of qualified faculty, inadequate support and incentives for existing faculty, and the absence of career development programs in the behavioral and social sciences. Recommendation 3. Establish a career development award strategy. Because the provision of career development awards has been an effective strategy for improving instruction and research in other health-related areas, the Office of Behavioral and Social Sciences Research of the National Institutes of Health or private foundations, or both, should establish a career development awards program to produce leaders in the behavioral and social sciences in medical schools. In addition to career development awards designed to produce medical school leaders in the behavioral and social sciences, the committee believes there is a need for a program of curriculum development awards. One major purpose of these awards would be to fund the development of model behavioral and social science curricula that could be emulated at other schools. Another major purpose, of course, would be to improve the behavioral and social science curriculum at the school receiving the award. Specifically, the award would enable a medical school to develop more-effective teaching techniques and create better ways of assessing student performance in the behavioral and social sciences. Such awards could also provide funding for a broad-based program of faculty development in the behavioral and social sciences, including both basic science and clinical faculty members. Conclusion 4. Financial support for efforts by U.S. medical schools to improve their curricular content, teaching methodologies, and assessment of student performance in the behavioral and social sciences is inadequate.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Recommendation 4. Establish curriculum development demonstration project awards. The National Institutes of Health or private foundations, or both, should establish a program that funds demonstration projects in behavioral and social science curriculum development at U.S. medical schools. Evaluation, which can occur within a specific course or on a medical licensing examination, is a critical process for determining the extent to which medical students have mastered course objectives. Faculty should be provided with the knowledge and other resources required to develop effective methods for evaluating student competence in the behavioral and social sciences. Provision of these resources should include instruction in the development of quality behavioral and social science examination questions. Because medical faculty members create the test items for the U.S. Medical Licensing Examination (USMLE), improving their test-writing skills at the local level will also serve to improve the quality of the behavioral and social science questions on the licensing exam. The material covered on the USMLE signals to both teachers and students what is considered important in the field of medicine and thus what should be emphasized in medical school curricula (Elstein, 1993; Swanson et al., 1992). Despite considerable effort, the committee was unable to determine the percentage of USMLE test questions currently devoted to the behavioral and social sciences. It is the impression of a number of informed individuals interviewed by the committee, however, that the amount of test material devoted to the behavioral and social sciences has decreased. Furthermore, it is the belief of this committee that the behavioral and social sciences are underrepresented on the USMLE. The committee does not believe it is necessary to specify a particular number of behavioral and social science questions that should be on the exam. Rather, the designed questions, however many it may take, should sufficiently cover the topics delineated in this report. Likewise, the committee believes the behavioral and social sciences should be part of the new clinical skills exam that will soon be included as part of the USMLE series. Conclusion 5. The subject matter covered by questions on the U.S. Medical Licensing Examination has a significant impact on the curricular decisions made by U.S. medical schools. The committee believes that the U.S. Medical Licensing Examination currently places insufficient emphasis on test items related to the behavioral and social sciences. Recommendation 5. Increase behavioral and social science content on the U.S. Medical Licensing Examination. The National Board of Medical Examiners should review the test items included on the U.S. Medical Licensing Examination to ensure that it adequately reflects the topics in the behavioral and social sciences recommended in this report.

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