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Current Approaches to Incorporating the Behavioral and Social Sciences into Medical School Curricula

TASK 1: Review the approaches used by medical schools that have incorporated behavioral and social sciences into their curricula.

SUMMARY: Given the shifts in the structure of medical education that have occurred over time, increasing emphasis is now being placed on trying to educate students in the behavioral and social sciences throughout the 4 years of medical school using an integrated curriculum. Although only a small number of schools have accomplished this, content in the behavioral and social sciences does appear to be increasing in the curricula of many medical schools. This increase may be due in part to the requirement of the Liaison Committee on Medical Education (LCME) that, to be accredited, schools must include behavioral and socioeconomic subjects in their curricula.

Because LCME does not specify how schools should incorporate any subjects, each school covers behavioral and social science content in a distinct manner appropriate to that institution. Each has its own course titles, materials, and content as well as teaching methods, often using a variety of faculty who may or may not be trained in the behavioral and social sciences. As a result, it is difficult if not impossible to specify the topics within the behavioral and social sciences that are being covered by all 126 U.S. medical schools without having a comprehensive, updated database. Such a database would allow individual medical schools to compare their curricula and student evaluation methods with those of other institutions that have successfully incorporated



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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula 2 Current Approaches to Incorporating the Behavioral and Social Sciences into Medical School Curricula TASK 1: Review the approaches used by medical schools that have incorporated behavioral and social sciences into their curricula. SUMMARY: Given the shifts in the structure of medical education that have occurred over time, increasing emphasis is now being placed on trying to educate students in the behavioral and social sciences throughout the 4 years of medical school using an integrated curriculum. Although only a small number of schools have accomplished this, content in the behavioral and social sciences does appear to be increasing in the curricula of many medical schools. This increase may be due in part to the requirement of the Liaison Committee on Medical Education (LCME) that, to be accredited, schools must include behavioral and socioeconomic subjects in their curricula. Because LCME does not specify how schools should incorporate any subjects, each school covers behavioral and social science content in a distinct manner appropriate to that institution. Each has its own course titles, materials, and content as well as teaching methods, often using a variety of faculty who may or may not be trained in the behavioral and social sciences. As a result, it is difficult if not impossible to specify the topics within the behavioral and social sciences that are being covered by all 126 U.S. medical schools without having a comprehensive, updated database. Such a database would allow individual medical schools to compare their curricula and student evaluation methods with those of other institutions that have successfully incorporated

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula the behavioral and social sciences into their curricula. Other agencies and organizations concerned about ensuring that appropriate behavioral and social science information is being adequately taught to all U.S. medical students would also find this database useful. Based on the finding that existing national databases provide inadequate information on behavioral and social science content, teaching techniques, and assessment methodologies, the committee recommends the development of a comprehensive database that is updated on a regular basis. The current structure of American medical education was adopted in the early 1900s and has not varied greatly since that time (Ludmerer, 1985). The basic sciences—anatomy, physiology, biochemistry, and microbiology—were introduced as a scientific foundation on which clinical practice knowledge and skills were built. In addition, the introduction of clinical science in the context of a university constituted a significant shift from a community practice–based, apprenticeship model of preparation for careers in medicine to one in which clinical medicine was taught by full-time faculty in a university-owned or university-affiliated teaching hospital. The Carnegie Foundation was instrumental in this reform of medical education, sponsoring a study by Abraham Flexner that became a blueprint for the transformation of medical schools nationally (Flexner, 1910). Over the years, however, shifts have occurred within the basic structure of medical education, including those related to learning techniques. An example is the movement from a focus on passive learning through lectures to active learning through the use of small-group exercises focused on cases and exercises that help integrate biological, psychological, and sociological perspectives, as well as clinical and basic science knowledge (Irby and Hekelman, 1997). These new directions have coincided with significant changes in the practice of medicine and important developments in medicine itself. For example, medical schools have become only one element of academic health centers, which combine schools of various health professions, medical centers and hospitals, major clinical practice facilities, and research facilities. The practice of medicine itself has become highly organized and has generally moved from solo, private practices to practices in large groups and institutions. In addition, dramatic improvements have occurred in medical therapeutics, especially compared with the therapeutic modalities available a century ago, when it has been asserted that no more than six useful drugs were available (Osler and Harvey, 1976). Another change is one that complicates attempts to identify and assess specific content taught in medical school courses. In the early 1900s, it was relatively easy to identify the science content (at least by subject area) of medical school courses because the courses were often given titles derived from the science being taught. Today, however, although the science content is still present, it is diffused across courses and is difficult to identify from outside the classroom and from a course title alone. For example, gross anatomy, which was classically

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula taught through the dissection of a cadaver, may have given way to prosected demonstrations, “dissections” of a virtual human body in software programs, and a course on biological structure. Likewise, a course such as systemic function can include content ranging from cell biology to doctor–patient relationships (NCME, 2003). Exploring the content of medical school curricula on the basis of course titles today is thus truly seeing through a glass darkly. This common disconnect between content and title can make the identification and assessment of the behavioral and social science content of medical coursework especially challenging, particularly when course titles are the only available source of data. This chapter first outlines issues related to behavioral and social science content in medical school curricula, how these disciplines are integrated into the curriculum,1 and the teaching methods that are generally used. It then identifies the barriers that hinder efforts to inventory behavioral and social science content in current medical school curricula. The third section presents the results of the committee’s inventory efforts. The final section offers the committee’s argument for the need to develop an improved database on the status of behavioral and social science instruction in U.S. medical schools and a recommendation to that end. THE BEHAVIORAL AND SOCIAL SCIENCES IN CURRENT MEDICAL SCHOOL CURRICULA The multidisciplinary perspective that emerges from studying the behavioral and social sciences provides students with an understanding of the patient as part of a broader social and environmental context that influences—and is influenced by—biological processes to produce health and illness behaviors, resilience, and functional capacity. Because the expression of human behavior occurs at the interface between the internal (physiological) and external (sociocultural) environments, and because some change in behavior is usually involved in biological and social dysfunction, the teaching of behavioral and social science is an effective way to integrate the various disciplinary perspectives in medicine (IOM, 1983). Given the breadth and diversity of the content of the behavioral and social sciences, however, it has been difficult for medical schools and medical school educators to agree on what constitutes the crucial core of behavioral and social science knowledge to which medical students should be exposed during their undergraduate education. Additionally, as the content encompassed by the behavioral and social sciences has grown, so, too, has the range of subject matter that could be taught to medical students. 1   An integrated curriculum for the purposes of this report means that behavioral and social science subject matter is taught as part of other courses in the basic and clinical sciences, not as a separate course.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Some of the areas emphasized in instruction in the behavioral and social sciences in medical education have been driven by population health needs and risks. Given the strong interactions between behavioral factors and the etiology and pathogenesis of illness and disease (see Chapter 1), many schools opt to focus on specific biopsychosocial aspects of health and disease that affect populations. For example, substance abuse became the focus of a curriculum with behavioral and social science content for four medical schools in North Carolina because of the large and growing problems of substance abuse nationwide (Fang et al., 1998). Some behavioral and social science content has already been considered part of classical medical education, serving to enlarge the content of courses in such areas as medical interviewing and the introduction to clinical medicine. Because effective communication skills are important to all physicians, the vast majority of schools teach such skills at some point within their curricula (AAMC, 1999b; Dube et al., 2000). Nevertheless, certain communication skills—such as communicating with diverse populations (in terms of culture, age, gender, and race), building trust in the presence of perceived or actual conflicts of interest, telecommunication, and physician–patient communication—are now receiving increased emphasis. As one example, the Macy Initiative in Health Communication at the University of Massachusetts Medical School was a curriculum designed to develop students’ skills in delivering bad news to parents regarding their fetus or child, with a particular focus on communicating in the areas of genetic counseling, risk assessment, and birth defects (Pettus, 2002). Communication among physicians and other members of the health care team has also received attention in the curriculum, especially given the movement toward more-integrated health care systems. The curricula in even traditional medical disciplines, such as psychiatry, have seen an expansion of behavioral and social science content. Although all schools of medicine have curricula in psychiatry, some focus on the overlap between mental and somatic health, or psychosomatic medicine, as many patients have significant emotional or behavioral problems expressed as somatic symptoms or personal distress. From a survey of 118 U.S. medical schools between 1997 and 1999 to which 54 schools responded, topics in biopsychosocial medicine were estimated to constitute approximately 10 percent of medical school curricula (Waldstein et al., 2001). Additionally, some schools are teaching future physicians about their own mental health needs to prepare them to deal with their feelings about sickness, dying, and death, and several have built self-awareness, personal growth, and well-being activities into their curricula and elective offerings (Novack et al., 1999). At the University of Rochester, for example, the Introduction to Clinical Medicine course, which incorporates parts of the previously taught Biopsychosocial Medicine course, helps students explore how their families and cultures influence their attitudes and motivations by sharing genograms and writing per-

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula sonal illness narratives (Novack et al., 1997). These essential skills and attitudes are further reinforced during the Comprehensive Assessment, a formative evaluation of clinical and basic science knowledge, skills, and attitudes held at the end of the second and third years (Epstein et al., in press). Many such courses are designed to provide students with the skills to monitor their own stress levels and formulate adaptive responses to stress that can help prevent burnout as a student and later as a physician. In reviewing curricular content across medical schools, it becomes evident that there are great differences in the amount of time spent covering the behavioral and social sciences, that a variety of courses are available, that behavioral and social science content is offered at various times during a student’s medical education, and that a wide range of topics is included under the rubric of behavioral and social science (AAMC, 2003a; Milan et al., 1998; Muller, 1984; Waldstein et al., 2001). Additionally, whether or not the behavioral and social sciences are fully integrated into the 4-year program depends on the institution. In 2000, 8 percent of the 62 U.S. medical schools that responded to a survey about their curricula reported having 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 University of California, San Francisco, is one school that uses an integrated curriculum incorporating the behavioral and social sciences and culture with basic biological and clinical training (Carpenter, 2001; Satterfield et al., 2004). Similarly, the Doctoring course at the University of California, Los Angeles, integrates behavioral and social science material by addressing topics at the intersection of medicine, the patient, and society (Wilkes et al., 1998). Just as medical schools offer a wide range of content in the behavioral and social sciences, they also use a variety of teaching methods to impart that content. Currently, no national survey or database compiles this information. However, data on teaching methods are available for some specific topic areas, such as communication, and these data indicate that small-group discussions and seminars are the methods most commonly used to teach basic communication skills (see Table 2-1). For psychosomatic medicine, among the vast majority of the 54 medical schools that responded to the above-mentioned curriculum survey, most courses appear to follow a lecture or seminar format (Waldstein et al., 2001). BARRIERS TO SYSTEMATIC ANALYSIS OF THE BEHAVIORAL AND SOCIAL SCIENCES IN MEDICAL SCHOOL CURRICULA A broad range of courses in the behavioral and social sciences have been incorporated into medical school curricula as a result of increasing concern that a focus on the biomedical aspects of disease may erode physicians’ humanistic attitudes; awareness of social, cultural, and environmental determinants of health; and ability to discriminate between technically possible and morally permissible

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula TABLE 2-1 Methods for Teaching Basic Communication Skills Teaching Methods in Use Percentage of 89 Schools Reporting* Small-group discussions/seminars 91 Lectures/presentations 82 Student interviews with simulated patients 79 Student observations of faculty with real patients 74 Student interviews with real patients 72 Role-playing with peers 60 Rounds 45 Video trigger tapes for discussion 43 Videotapes of student interactions 40 Instructional videotapes 30 Required attendance at community activities 24 Journals (i.e., written reflections) 19 Patient advocacy 14 Storytelling by students 14 Storytelling by patients (i.e., patient narrative) 10 *Of the 110 North American medical schools that reported teaching basic communication skills at some point within their curricula, 89 completed the second-stage survey section on teaching methods. The percentages in this table are based on responses from those 89 institutions. Teaching methods are listed if at least 5 percent of the respondents in this sample reported using them. SOURCE: Adapted from AAMC (1999b). interventions (Benbassat et al., 2003). Given this diversity, it is difficult to ascertain the precise behavioral and social science content offered and the approaches used to incorporate that content into the curriculum. One reason the data are difficult to analyze is that the behavioral and social sciences comprise a variety of disciplines, each with its own technology, language, and concepts (Bolman, 1995). How the behavioral and social sciences are defined and which of their aspects have been described in published reports will determine which courses are included in the analysis. 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. Another challenge that arises in reporting what medical schools are teaching students is that some behavioral and social science learning is incidental to the primary information being taught, cannot easily be identified and entered into a database, and is difficult to document and categorize. This is the case even though such incidental learning can profoundly influence a medical student’s knowledge, skills, and attitudes. For example, medical students’ views of depression

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula may be influenced more by their observation of how a supervising physician handles patients with depressive symptoms than by anything they hear in a lecture or read in a textbook. The teaching that occurs in this format is sometimes referred to as the “hidden curriculum,” which can be described as the implicit message continually being conveyed to students through a supervisor’s or a role model’s example, rather than the person’s spoken words. It also involves the imprinting of attitudes and values onto impressionable students by their more-experienced educators (Ludmerer, 1999). The lack of standardized course content and teaching methods in the behavioral and social sciences leads to the variability among medical schools noted above, which is a further impediment to data collection and analysis. The Liaison Committee on Medical Education (LCME), the accrediting body for U.S. and Canadian medical schools, tracks a number of special topics of relevance to the behavioral and social science content of medical school curricula. However, as is true for other special topic areas, it does not specify how the behavioral and social sciences should be taught, the number of hours a school should devote to these disciplines, or what topics should be covered. It merely states that the curriculum must include behavioral and socioeconomic subjects in addition to basic science and clinical disciplines (LCME, 2003). As a result, each medical school has great flexibility in designing an appropriate program for itself. The lack of a standard program design, however, hampers the systematic analysis of curricular content across medical schools, and makes it impossible to ensure that the most essential and empirically supported behavioral and social science content is included in medical school curricula. Use of the national database for medical school curricula of the Association of American Medical Colleges (AAMC) does not resolve these difficulties. AAMC’s Curriculum Management and Information Tool (CurrMIT) database is the most comprehensive tool available for collecting and analyzing the content of medical school curricula. It is a voluntary system designed to allow medical schools to examine the full spectrum of their course offerings, track key trends, support new innovations, and compare local curricula with those of other medical schools (AAMC, 2003b). Schools have flexibility in the way they enter their data, depending on program needs. As a result, data entry formats vary from school to school, as do the degree to which the information is updated and the level of detail entered (e.g., only 67 schools have provided course titles). The CurrMIT database lists 142 accredited medical schools (126 in the United States and 16 in Canada). Of these 142 schools, 55 have entered data reporting that the school offers a course in behavioral or social science (AAMC, personal communication, June 2003). Because LCME requires medical school curricula to include behavioral and socioeconomic subjects (LCME, 2003), it can be assumed that all accredited medical schools in the United States teach behavioral and social science topics in some form. The CurrMIT database may not identify all schools with behavioral

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula and social science courses because not all schools provided the information (AAMC, 2003a) or because the course content and teaching methods could not be identified from the course title. Dartmouth Medical School, for example, offers a course during the second year called On Doctoring that aims to improve students’ communication skills through participating in small-group role-playing, visiting patients, and using standardized patients2 (Cochran and Schiffman, 2003; Dube et al., 2000). However, a search of course titles for the word “communication” would yield a list on which Dartmouth would not appear, whereas the University of Pittsburgh School of Medicine would be included because it offers a course entitled Cell Communication and Signaling (AAMC, 2003a). This example demonstrates the impossibility of using currently available data to conduct a systematic review of behavioral and social science content in the curricula of the 126 U.S. medical schools. To compound these difficulties, unless medical school data are regularly updated in the only current national database (CurrMIT), they cannot be considered accurate or useful for analyzing the state of behavioral and social science education in medical schools. A change in funding, for example, can drastically alter course content, faculty, and teaching methods, even though the curriculum and course titles may remain the same. In fact, a study at the University of Kansas found a 30–37 percent discrepancy between what course directors say is being taught about prevention in the curriculum and what trained student observers have witnessed in the class (Dismuke and McClary, 2000). INVENTORY OF CURRENT BEHAVIORAL AND SOCIAL SCIENCE CONTENT IN MEDICAL SCHOOL CURRICULA Within the limitations of the available data, as described above, the committee pursued its charge of taking an inventory of current behavioral and social science content in medical school curricula by compiling the available data and using indicators to signify the presence, intensity, location, and adequacy of such content. Tables 2-2a, b, and c summarize the results of these efforts. Although it would be desirable to compare the data in these three tables, such analysis is not recommended given that the data come from different sources that utilize varying collection methods and data analyses. The “Selected LCME Hot Topics” column in each table lists some of the topics on which the LCME focuses in the medical school self-study that is conducted the year before a formal accreditation visit and at the accreditation visit itself. The committee chose these topics as the framework for examining the state of the behavioral and social sciences in medical school curricula because they are 2   Individuals who portray patients with specific medical conditions so students can be trained and evaluated in their ability to interact with patients.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula TABLE 2-2a Number of Hours Selected LCME Hot Topics Are Taught Throughout the 4 Years of Medical School Selected LCME Hot Topics Mean No. of Hours Taught ± Standard Deviation (no. of schools providing data) Communication Skills 46±45 (105) Community Health 28±40 (94) Cultural Diversity* 15±24 (100) End-of-Life Care 20±22 (102) Palliative Care* 12±15 (96) Epidemiology* 16±11 (110) Health Care Quality Improvement 4±4 (74) Health Care Systems* 10±9 (99) Human Development/ Life Cycle 23±21 (106) Medical Ethics* 25±19 (109) Medical Socioeconomics 6±9 (85) Nutrition 20±15 (106) Pain Management 10±16 (103) Palliative Care* 12±15 (96) Patient Health Education 10±16 (95) Population-Based Medicine 1±19 (98) Prevention and Health Maintenance* 22±26 (103) Substance Abuse 14±15 (106) *These data are published in Barzansky and Etzel (2003). SOURCE: LCME 2002-2003 Annual Medical School Questionnaire. the only subject matter–related content domains with which one can query the LCME national data, the CurrMIT database, and the data from an AAMC-administered survey of graduating students’ satisfaction with their educational experiences by subject matter (the Graduation Questionnaire, administered annually to all graduating medical students). The committee identified the topics that have a prima facie relationship to behavioral and social science content; these appear in bold in the tables. Although many of these topics do not necessarily denote behavioral and social science subject matter, the committee assumed that if they were taught in a contemporary medical school, they would likely involve teaching or at least making reference to information from the behavioral and social sciences. Nutrition is one such example, as the major challenges of obesity and eating disorders involve managing behavioral change and cannot be taught effectively without including content in the behavioral and social sciences. Likewise, because clinical epidemiology is focused on medical decision making and the structuring of information to enable evidence-based clinical inferences and choices, that subject cannot be taught ap-

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula TABLE 2-2b Percentage of Medical Schools Teaching Specific Topics During Each Year of Medical School   Percentageb Selected LCME Hot Topicsa Year 1 Year 2 Year 3 Year 4 Communication Skills 51 27 15 3 Patient interviewing skills 39 27 6 2 Doctor–patient communication skills 2 3 3 0 Community Health 15 12 8 5 Cultural Diversity 13 0 0 0 Cultural competency 15 5 2 2 End-of-Life Care 60 52 13 16 Palliative Care – – – – Epidemiology 40 49 8 12 Clinical epidemiology 9 9 0 0 Health Care Quality Improvement 5 2 2 2 Health Care Systems 15 8 2 3 Human Development/ Life Cycle 31 16 2 2 Medical Ethics 70 51 22 13 Biomedical ethics 3 0 2 0 Medical Socioeconomics – – – – Medical economics 12 13 3 3 Nutrition 75 75 28 8 Pain Management – – – – Combined Pain and Palliative Care 72 78 36 19 Patient Health Education 8 6 2 2 Population-Based Medicine 11 15 5 2 Prevention and Health Maintenance 39 45 13 5 Substance Abuse – – – – Drug and alcohol abuse 49 81 24 12 NOTE: Data based on 67 medical schools that entered over 200 session titles in the CurrMIT database. “–” indicates data not available. aLCME Hot Topics are shown in bold. Subheadings under those topics represent the closest match to the Hot Topic and Medical School Graduation Questionnaire variables (see Table that can be found in the AAMC CurrMit database). bPercentages calculated from the total number of schools teaching the topic/total number of schools. SOURCE: AAMC CurrMIT database. propriately without addressing the psychology and cognitive structure of clinical decision making (Fletcher et al., 1998). Table 2-2a shows the mean number of hours devoted to teaching each topic and the number of schools on which this mean is based. This mean value is an indicator of the “intensity” of teaching in each behavioral and social science area for which data are available. It should be noted that hours taught may be reported for each topic without the available hours attributable to each having been parsed. For example, if a portion of the clinical communication course were dedicated to

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula TABLE 2-2c Medical Student Satisfaction with Selected Topics at Time of Graduation Selected LCME Hot Topics Percentage N = 14,200 Percentage of students who believe the time devoted to instruction in this area was appropriate   Communication Skills Patient interviewing skills/doctor–patient communication skills 89/88 End-of-Life Care 68 Palliative Care 67 Health Care Quality Improvement Quality assurance in medicine 55 Nutrition 36 Pain Management 45 Percentage of students who believe the time devoted to instruction in the area was appropriate   Population-Based Medicine Population-based role of community health and social service agencies 61 Substance Abuse Drug and alcohol abuse 86 Percentage of students who believe the subject was adequately covered in all 4 years of medical school   Community Health 56 Cultural Diversity Cultural competency 59 Epidemiology Clinical epidemiology 58 Health Care Systems 30 Medical Ethics Biomedical ethics 70 Medical Socioeconomics Medical economics 17 Prevention and Health Maintenance Health promotion and disease prevention 68 NOTE: LCME Hot Topics are shown in bold. Subheadings under those topics represent the closest match to the LCME Hot Topic as it appears on the Medical School Graduation Questionnaire. SOURCE: 2002–2003 AAMC Graduation Questionnaire (AAMC, 2003c).

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula BOX 2-4 Behavioral and Social Science Education in the Medical School Curriculum of the University of Rochester The Double Helix Curriculum (DHC) at the University of Rochester School of Medicine and Dentistry was built on the strong tradition of biopsychosocial medicine that has been a hallmark of a Rochester education since the 1940s (see table that follows). The goal is to produce patient-centered physicians who maintain a passion for lifelong learning and are able to keep pace with the biomedical advances that influence the study and clinical practice of medicine. With this goal in mind, the DHC weaves basic science and clinical strands across all 4 years of undergraduate medical education. Pharmacology, pathology, and genetics, for example, do not exist as separate courses but are incorporated in every course in the curriculum. In recognition of the essential role of the behavioral and social sciences in the practice of medicine, six themes are integrated throughout the curriculum. These themes (aging, diversity, ethics and law, health economics, nutrition, and prevention) are often “orphan topics” at many schools. At Rochester, however, each of these themes has specific learning objectives for each course and year. Many of the core behavioral and social science topics are addressed within the learning objectives for these themes. Faculty theme directors work with course and clerkship directors in the development of problem-based learning cases, as well as in the creation of innovative learning opportunities for behavioral and social science topics. Additional core behavioral and social science topics are covered in other courses and clerkships throughout the DHC. The initial medical school course at Rochester is entitled Mastering Medical Information. In this course, students not only learn about medical informatics, epidemiology, and biostatistics, but also begin to study aspects of nutrition and diversity through problem-based learning cases. The first component of the Ambulatory Clerkship emphasizes prevention and health maintenance. In addition to building on their interviewing and physical examination skills, students learn and practice behavioral medicine skills, such as smoking cessation counseling, alcohol and drug screening and counseling, diet and exercise counseling, and adolescent health maintenance topics, in primary care offices. Behavioral and social science topics in year 2 are emphasized in the context of the integrated neuroscience course, entitled Mind, Brain and Behavior, and in the integrated pathophysiology course, entitled Disease Processes and Therapeutics. Near the end of year 2, students participate in a formative comprehensive assessment, which emphasizes basic

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula science topics in a clinical setting utilizing a variety of assessment methods, including standardized patients, computer-based exams, and a team-based evaluation with an anesthesia simulator. The comprehensive assessment pays significant attention to students’ communication and counseling skills, which have been honed over the course of the Ambulatory Clerkship. Additionally, it examines the student’s ability to integrate essential behavioral and social science topics encompassed by courses, clerkships, and themes. Behavioral and social science coursework is also incorporated in years 3 and 4 of the DHC through clerkship directors’ attention to the theme learning objectives. Moreover, another formative comprehensive assessment is completed at the end of year 3, in which students are able to assess their growth and development over the year. The DHC also includes a required year 4 Community Health Improvement Clerkship that is tied to the community health mission of the University of Rochester Medical Center. This clerkship provides students with an opportunity not only to engage in structured service learning, but also to learn more about related health economics, health disparities, and diversity, essential topics in today’s health care environment. Rochester’s long-standing tradition in biopsychosocial medicine and patient-centered care has a renewed emphasis in the DHC. The outcomes of the relatively new curriculum are being followed through regular internal evaluation of themes, courses, and clerkships, as well as review of external assessments, including the AAMC Graduation Questionnaire results and student performance on the U.S. Medical Licensing Examination. University of Rochester, School of Medicine Topic Course(s) Responsible Department(s) Year(s) Taught Teaching Method* Communication skills Introduction to Clinical Medicine Ambulatory clerkship Internal Medicine Family Medicine Psychiatry 1, 2 SG, L Community health Mastering Medical Information Ambulatory clerkship—community health Improvement clerkship Community and Preventive Medicine Internal Medicine Family Medicine Psychiatry 1, 2, 4 PBL, SG, L

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula University of Rochester, School of Medicine Topic Course(s) Responsible Department(s) Year(s) Taught Teaching Method* Cultural diversity Diversity theme Addressed in problem-based learning cases within courses in years 1 and 2 Multiple departments 1, 2, 3, 4 PBL, SG, L End-of-life care Ambulatory clerkship Ethics and law theme Aging theme Internal Medicine Family Medicine Pediatrics Medical Humanities 2, 3 SG, L Epidemiology Mastering Medical Information Community and Preventive Medicine 1 PBL, L Family/domestic violence Ambulatory clerkship Emergency medicine clerkship Internal Medicine Family Medicine Emergency Medicine Pediatrics 2, 4 L, O Health care quality improvement Health economics theme Year 2 case seminars Successful Interning Neurology Community and Preventive Internal Medicine 2 PBL, L Health care systems Health economics theme Year 2 case seminars Neurology Community and Preventive Medicine Internal Medicine 2 PBL, L Health literacy — — — — Human development/ life cycle Introduction to Clinical Medicine Mind, Brain and Behavior Ambulatory clerkship Internal Medicine Family Medicine Pediatrics Psychiatry 1, 2, 3 PBL, L Medical social economics — — — —

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula University of Rochester, School of Medicine Topic Course(s) Responsible Department(s) Year(s) Taught Teaching Method* Pain management Ambulatory clerkship Inpatient clerkships Internal Medicine Family Medicine Pediatrics Pharmacology/ Physiology 2, 3 PBL, SG, L Palliative care Ambulatory clerkship Ethics and law theme Inpatient clerkships Electives Internal Medicine Family Medicine Pediatrics Medical Humanities Nursing 2, 3 SG, L Patient health education — — — — Population-based medicine Mastering Medical Information Community and improvement clerkship Community health Preventive Medicine 1, 4 PBL, L, O Prevention and health maintenance Ambulatory clerkship Mastering Medical Information Nutrition theme Internal Medicine Family Medicine Pediatrics Community and Preventive Medicine 1 SG, L Substance abuse Ambulatory clerkship Mind, Brain and Behavior Psychiatry clerkship Internal Medicine Family Medicine Pediatrics Neurology Psychiatry 1, 2, 3 PBL, SG, L *L = lecture, PBL = problem-based learning, SG = small group, U = unknown, O = other (describe).

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula BOX 2-5 Behavioral and Social Science Education in the Medical School Curriculum of the University of North Carolina The Department of Social Medicine is the primary source of behavioral and social science education for medical students at the University of North Carolina School of Medicine. Behavioral and social science material is integrated as a content theme across several courses in the curriculum and is taught as a content theme in six required courses: two in year 1 and four in year 2 (see table that follows). In the Medicine and Society course, offered through the Department of Social Medicine in year 1, there are no examinations, but students are required to participate in creative writing assignments and engage in group discussions that teach a habit of critical reflection using the tools of the social sciences and humanities. Cultural diversity, end-of-life care, and medical social economics are some examples of the behavioral and social science topics discussed in the course. Selection of small-group leaders for the Medicine and Society course is fairly competitive and requires a strong commitment from faculty as both active learners and teachers. Despite the requirements, many members of the faculty are willing to make the necessary commitments to teach this course. An interdepartmental course that complements Medicine and Society—Introduction to Clinical Medicine—is directed by the dean’s office. The faculties that teach both courses are careful to distinguish between the courses: Medicine and Society is not trying to teach specific skills, and Introduction to Clinical Medicine is not attempting to teach social science theory or concepts; rather, the two courses run in parallel and draw from each other. This sort of coordination is facilitated by the dean’s office, which brings course directors together on a monthly basis.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula University of North Carolina, School of Medicine, Social Medicine Department Topic Course(s) Responsible Department(s) Year(s) Taught Teaching Method* Communication skills Introduction to Clinical Medicine (ICM) 1 (ICM-1) ICM-2 Clinical Epidemiology Various clerkships Dean’s Office Social Medicine Medicine, Pediatrics, Family Medicine, Obstetrics/ Gynecology clerkships 1, 2, 3 PBL, SG, O—one-on-one on medical wards Community health ICM-1and ICM-2 Medicine and Society (M&S) M&S (1st year) Family Medicine Pediatrics, and Obstetrics/ Gynecology clerkships Ambulatory care selective (4th year) Dean’s Office (ICM) Social Medicine Family Medicine, Pediatrics Obstetrics/ Gynecology 1, 2, 3, 4 PBL, SG, O—experience in communities Cultural diversity ICM-1 and ICM-2 M&S Various clerkships (Dean’s Office) ICM Social Medicine Various clinical departments 1, 2, 3 SG End-of-life care M&S Special Topics day (1st year) Humanities and Social Science (HSS) Seminar selective Medicine, Family Medicine, and Obstetrics/ Gynecology clerkships Social Medicine Dean’s Office Social Medicine Internal Medicine Family Medicine Obstetrics/ Gynecology 1, 2, 3 SG, L Epidemiology Clinical Epidemiology Medicine clerkship Social Medicine Internal Medicine 2, 3 PBL, SG

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula University of North Carolina, School of Medicine, Social Medicine Department Topic Course(s) Responsible Department(s) Year(s) Taught Teaching Method* Family/domestic violence Special Topics day (1st year) Clinical Epidemiology Family Medicine Pediatrics, and Obstetrics/ Gynecology clerkships Dean’s Office Social Medicine Family Medicine, Pediatrics Obstetrics/ Gynecology 1, 2, 3 PBL, SG, L Health care quality improvement M&S (1st year) HSS selective Social Medicine 1 PBL, SG Health care systems M&S (1st year) HSS selective Social Medicine 1 PBL, SG Health literacy ICM-1 and ICM-2 Clinical Epidemiology Medicine Clerkship Dean’s Office Social Medicine Internal Medicine 1, 2, 3 SG Human development/ life cycle Family Medicine, Pediatrics, and Obstetrics/ Gynecology, and Internal Medicine clerkships Family Medicine Pediatrics Obstetrics/ Gynecology Internal Medicine 3 Medical social economics M&S (1st year) HSS selective Social Medicine 1 PBL, SG, L Pain management Surgery, Obstetrics/ Gynecology, and Internal Medicine Surgery Obstetrics/ Gynecology Internal Medicine 3 — Palliative care Internal Medicine Family Medicine, Obstetrics/ Gynecology, and Surgery clerkships Internal Medicine Family Medicine Obstetrics/ Gynecology Surgery 3 Patient health education ICM-1 and ICM-2 Pediatrics, Obstetrics/ Gynecology, and Family Medicine Dean’s Office Pediatrics Obstetrics/ Gynecology Family Medicine 1, 2, 3 PBL, SG

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula University of North Carolina, School of Medicine, Social Medicine Department Topic Course(s) Responsible Department(s) Year(s) Taught Teaching Method* Population-based medicine Some students (5–10/year) take a year off between the 3rd and 4th years of medical school and complete a master’s of public health in the School of Public Health. Many also do community service projects.       Prevention and health maintenance ICM-1 and ICM-2 Clinical Epidemiology Family Medicine Pediatrics, Medicine, and Obstetrics/ Gynecology Dean’s Office Social Medicine Family Medicine, Pediatrics Internal Medicine Obstetrics/ Gynecology 1, 2, 3 PBL, SG, L Substance abuse Special Topics day (1st year) Family Medicine Medicine, Obstetrics/ Gynecology, and Pediatrics clerkships Dean’s Office Family Medicine, Medicine Obstetrics/ Gynecology Pediatrics 1, 3 PBL, SG, L Determinants of health (extra-credit question) M&S   Social Medicine 1 SG, L Human sexuality (extra-credit day question) Special Topics (1st year) HSS selective* Reproductive Medicine   Dean’s Office Social Medicine Obstetrics/ Gynecology 1, 2 PBL, *L = lecture, PBL = problem-based learning, SG = small group, U = unknown, O = other (describe). SG, L

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula A recognizable challenge is also apparent in the area of faculty development. Because the facilitators of problem-based learning exercises are typically generalist faculty or specialists who are not themselves behavioral or social scientists, they require training in behavioral and social science content before they can effectively facilitate student learning in these small-group discussions. Individuals from three of the four schools surveyed—University of California, San Francisco; University of Rochester; and Ohio State University—acknowledged a need for more faculty development. The fourth school, University of North Carolina, has a 26-year history of well-supported curriculum innovation in the behavioral and social sciences and a faculty that possesses the needed expertise. That expertise is the product of many years of experience in providing faculty training, coteaching arrangements that pair generalists with behavioral and social science specialists, and regular updates in the behavioral and social sciences for faculty who participate in this curriculum. A particularly noteworthy finding from interviews of individuals from the three other schools was that formal faculty development in the behavioral and social sciences does not generally occur, often because of constraints on faculty time. At these exemplar schools, the overall faculty response to new behavioral and social science content in the curriculum has generally been favorable. The strongest advocates of this content are the faculty participants in the courses that serve as vehicles for the new content. The interviews also revealed a somewhat less-favorable attitude toward such content by basic science faculty whose preclinical courses are often being downsized not because of the new behavioral and social science content per se, but because the objectives of overall curriculum reform often include providing students with more time for self-directed learning. The attitude toward new behavioral and social science content among students has generally been favorable. There are some examples of new courses that have become extraordinarily popular with students, partly because of the introduction of new behavioral and social science content and partly because of the use of innovative teaching methods. Overall, the results of these surveys and interviews reveal both similarities and some distinctive differences in the behavioral and social science content in the four institutions’ curricula. The general dynamics and challenges of their curriculum and faculty development can be seen at all schools (and are dealt with more extensively in Chapter 4 of this report). The distinctive approaches taken to incorporate the behavioral and social sciences, on the other hand, are representative of the enduring missions and traditions of these schools, which establish the framework within which change is encouraged and accommodated.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula NEED FOR AN IMPROVED DATABASE ON THE STATUS OF BEHAVIORAL AND SOCIAL SCIENCE INSTRUCTION IN U.S. MEDICAL SCHOOLS The review of the current literature and the available data conducted for this report revealed that medical school courses incorporating the behavioral and social sciences vary greatly in their titles, the teaching methods used, and the hours devoted to these topics. This variation reflects the breadth of the behavioral and social sciences and their application to the practice of medicine, the differing needs of communities, and the preferences and expertise of faculty members. National empirical data based on voluntary reporting by schools of medicine (from the CurrMIT database) and accreditation data (from LCME) confirm the variability in subject matter from topic to topic and school to school. 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 have incorporated into their curricula. The committee believes the creation of an improved, periodically updated database for information on the state of behavioral and social science instruction in U.S. medical schools would be of significant benefit. 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. Individual medical schools could use this database to compare their coverage of the behavioral and social sciences with that of other institutions to determine whether their curricular content, teaching methods, or means of evaluating student performance need revision. Credentialing bodies could use the database to compare what is actually being taught with the subject matter that is assessed by their evaluation instruments. Government agencies and professional organizations concerned with improving the quality of behavioral and social science instruction and ensuring that new physicians have been exposed to important research findings would also find the database helpful. The committee 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 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

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula 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.