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The Behavioral and Social Sciences in Medical School Curricula

TASK 2: 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, low) may be assigned to topic areas.

SUMMARY: Adverse health effects can be created or exacerbated by harmful behaviors (smoking, poor diet, sedentary lifestyle, excessive alcohol consumption, and risky sexual behaviors). Similarly, psychological, social, biological, and behavioral factors have been shown to influence disease risk and illness recurrence. Such mind–body interactions and behavioral influences on health and disease are important concepts to which medical students should be exposed. Students should also graduate with an understanding of how their background and beliefs can affect patient care and their own well-being; how they can best interact with patients and their families; how cultural issues influence health care; and how social factors, such as health policy and economics, affect physicians’ ability to provide optimal care for their patients.

Practicing physicians need to be skilled in all 26 of the priority topics identified in this chapter. Because medical education is a continuum, it is neither necessary nor desirable for medical students to become experts in every priority topic. By graduation, however, students should be able to demonstrate competency in the six domains described in this report and at a minimum have an understanding of the 20 high-priority topics within those domains. These topics should be reinforced



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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula 3 The Behavioral and Social Sciences in Medical School Curricula TASK 2: 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, low) may be assigned to topic areas. SUMMARY: Adverse health effects can be created or exacerbated by harmful behaviors (smoking, poor diet, sedentary lifestyle, excessive alcohol consumption, and risky sexual behaviors). Similarly, psychological, social, biological, and behavioral factors have been shown to influence disease risk and illness recurrence. Such mind–body interactions and behavioral influences on health and disease are important concepts to which medical students should be exposed. Students should also graduate with an understanding of how their background and beliefs can affect patient care and their own well-being; how they can best interact with patients and their families; how cultural issues influence health care; and how social factors, such as health policy and economics, affect physicians’ ability to provide optimal care for their patients. Practicing physicians need to be skilled in all 26 of the priority topics identified in this chapter. Because medical education is a continuum, it is neither necessary nor desirable for medical students to become experts in every priority topic. By graduation, however, students should be able to demonstrate competency in the six domains described in this report and at a minimum have an understanding of the 20 high-priority topics within those domains. These topics should be reinforced

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula throughout the 4 years of medical school. To what depth the 26 priority topics are taught and evaluated will vary according to the focus and needs of the particular medical school. 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 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 chapter responds to the second part of the committee’s 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. Before presenting the prioritized topics, however, the committee offers 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).

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula 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. Before attempting to identify the specific topics in the behavioral and social sciences to which medical students should be exposed, the committee considered ways in which material from these disciplines might be included in the curriculum. Experiences at the medical schools of the University of California, San Francisco, at the University of Pennsylvania, and at the University of Rochester, among others (UCSF, 2003; University of Rochester, 2002), have shown that an effective way to present the behavioral and social sciences to medical students is in an integrated manner throughout the 4 years of medical school, rather than confining this material to the preclinical years. Providing this content over the 4 years of medical school will introduce it at a time when students perceive it to be most relevant and facilitate reinforcement of important concepts throughout the preclinical and clinical years. Moreover, integrating 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. In formulating recommendations for core content in the behavioral and social sciences, the committee was aware that the current medical school curriculum is extremely full. The committee therefore attempted to limit its recommendations to those items it believes are most important and should be covered at a relatively early stage in a physician’s education. The presentation of additional material, as well as reinforcement of the material covered in medical school, could be reserved for later stages of the medical education continuum. The committee also recognized that it had neither the license nor the time to delineate a detailed curriculum (specific methods of instruction, detailed content, and the appropriate time to introduce various items) in the behavioral and social sciences. Formulation of a curriculum is the responsibility of medical school faculties, and the recommendations made in this report might be incorporated into a curriculum in a number of different ways. Innovation and the diversity it produces have been strengths of the American medical education system, and should apply to the behavioral and social sciences as well as to other components of the medical school curriculum. To formulate the priorities recommended in this report, the committee developed an extensive list of possible behavioral and social science topics on the basis of a number of sources and considerations:

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Relevant evidence-based articles and reports in the literature Presentations to the committee by content experts and medical school representatives Literature and other materials from the Association of American Medical Colleges (AAMC) and the Liaison Committee on Medical Education Considerations related to the health of the public, driven mainly by root causes of morbidity and mortality The gap between what is known and what is actually done in practice Following extensive deliberations, the committee used a modified Delphi process to prioritize this initial list. (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 3-1, is organized so as to have meaning for medical school curriculum committees. The 26 recommended topics fall into the following 6 general domains of knowledge:1 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. 1   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 3-1 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 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 3-1. 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

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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 High Priority Medium Priority Biological mediators between psychological and social factors and health Psychosocial, biological, and management issues in somatization Psychological, social, and behavioral factors in chronic disease Interaction among illness, family dynamics, and culture Psychological and social aspects of human development that influence disease and illness Psychosocial aspects of pain High-Priority Topics Biological Mediators Between Psychological and Social Factors and Health Research in psychosomatic medicine has documented how disease and illness are related to many potentially interacting causes. These can include biological insults (e.g., carcinogens and microbes), genetic susceptibility, early childhood experiences, personality, acute and chronic stressors, behaviors, socioeconomic status, and lifestyle. Comprehensive reviews of this science have recently been published by committees of the National Research Council and the Institute of Medicine (IOM, 2001b; NRC, 2001). A large body of research has established the presence of biological mediators between such factors and health. These include genetic mediators, as well as those of the central nervous system, the autonomic nervous system, and the endocrine and immune systems (IOM, 2001b; McEwen, 2002; NRC, 2001). To achieve a more comprehensive understanding of the maintenance of health and the genesis of disease, therefore, students need to learn the basics of psychophysiology, that is, how stressors and a variety of psychological, behavioral, and social factors alter physiology to make disease more likely, and how the systems that maintain homeostasis are interconnected and can react to various stressors in concert. For example, psychoneuroimmunology is the study of the interconnections among the central nervous system, the neuroendocrine system, and the immune system and the implications of those connections for the ways in which stress, emotions, and psychology affect immune function. Acute stress tends to enhance that function by promoting immune cell translocation to sites of immune challenge, whereas chronic stress (through the mediation of hormonal factors) tends to have a deleterious effect on immune function and disease processes

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula (Dhabhar and McEwen, 1999). The relationship between stress and the immune system has been demonstrated in animal models, which have shown that stress makes animals more vulnerable to experimental tumors (Ben-Eliyahu et al., 1991) and infections (Ben-Nathan and Feuerstein, 1990; Ben-Nathan et al., 1991; Bonneau et al., 1991; Friedman et al., 1965; Rasmussen et al., 1957). Research with humans also has shown that immune function may be altered by affective states and by major and minor acute and chronic stressful life experiences (Biondi, 2001). Chronic stress and a lack of social support, for example, increase the likelihood that a person will develop a cold after being challenged with a standard dose of a rhinovirus (Cohen, 1995). In addition, stress-induced modulation of the immune system has been linked to the expression of inflammatory, infectious, and autoimmune diseases. Psychological, Social, and Behavioral Factors in Chronic Disease In the year 2000, roughly 125 million Americans—nearly half of the U.S. population—were living with some type of chronic condition (Partnership for Solutions, 2003). Sedentary lifestyles, poor dietary habits, and the large population of aging baby boomers have all contributed to the rising rates of age- and lifestyle-related chronic medical conditions, such as diabetes, heart disease, and arthritis. The number of cancer patients has grown steadily over the past two decades, and these patients are surviving longer than ever before as a result of improvements in early detection and treatment of the disease. Likewise, the widespread use of potent combination antiretroviral therapy has led to a growing population of people living with HIV infection, who retain a potentially lifelong risk of spreading this infection to others (IOM, 2003b). These trends have led to recognition that medical students must be educated in the psychological, social, and behavioral factors that can potentially lead to chronic medical conditions and in the interplay between these factors and particular chronic illnesses. For example, it is strongly believed that hostility, chronic stress, depression, social isolation, and increased use of alcohol and tobacco are related to an elevated risk of coronary heart disease (Barefoot et al., 2000; Carroll et al., 1976; Frasure-Smith et al., 1993; Kawachi et al., 1996; Orth-Gomer et al., 1993). Conversely, changing behaviors that may place a person at risk of myocardial infarction, such as hostility and impatience, can reduce the risk of reinfarction in post-myocardial infarction patients (Friedman et al., 1986; Mendes de Leon et al., 1991). Studies have also shown that psychological and social factors influence the development and course of cancer (Everson et al., 1996; Watson et al., 1999). Other behaviors, such as engaging in risky sexual practices or sharing needles with an HIV-infected partner, significantly affect whether an uninfected patient will contract HIV. Medical students should know which individuals are at greatest risk of becoming infected with HIV and which are most likely to continue to

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula engage in risky behaviors after becoming infected, especially if they do not show outward signs of disease. Students should also be educated in how to recognize distress in chronically ill patients. For example, HIV-infected individuals who exhibit signs of persistent depression have been shown to have increased rates of mortality (Ickovics et al., 2001; Mayne et al., 1996), and stressful life events have been shown to cause a faster progression from HIV-positive status to AIDS (Leserman et al., 2000). Psychological and Social Aspects of Human Development That Influence Disease and Illness Human development is the product of the elaborate interplay of biological, psychological, and social influences (U.S. DHHS, 1999), and disease and illness can be understood more fully when the combined effects of these factors are considered at different life stages (Hertzman and Power, 2003; Power and Hertzman, 1997). Exposure of the developing brain to severe or prolonged stress, for example, may result in anatomical and biological changes that can have profound effects lasting throughout the individual’s life (Charmandari et al., 2003; Weinstock, 1997). Abnormalities may appear in childhood, adolescence, and adulthood as excessive fear and addictive behaviors, dysthymia and/or depression, and symptoms of metabolic X syndrome (Charmandari et al., 2003; Tsigos and Chrousos, 2002). Life-cycle theories of Sigmund Freud, Jean Piaget, Erik Erikson, John Bowlby, and others on human development through infancy, toddlerhood, middle childhood, adolescence, adulthood, and old age help physicians understand the process of maturation from a variety of perspectives. Medical students should be exposed to these theories, as well as to their basic underlying principle—the Epigenetic Principle of the Lifecycle Theory—which states that the foundation for each step along the path to maturity is laid by the conditions and events that precede it (Kaplan et al., 1994). This is one of the compelling theories and approaches to adult development, and may fit well into the behavioral and social science portion of a medical school curriculum. Psychosocial Aspects of Pain Pain is the most common reason that people consult a physician (HBCC, 1993). There has been growing recognition that pain is a complex perceptual experience influenced by a wide range of psychosocial factors that can include emotions; social and environmental conditions; sociocultural background; personal experiences, beliefs, attitudes, and expectations; and biological factors (Turk and Okifuji, 2002). There is evidence that many physicians undertreat pain (Cleeland, 1998; Portenoy and Lesage, 1999). Furthermore, physician biases may

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula play a role in the undertreatment of pain in patients from certain minority ethnic groups (Cleeland et al., 1997; Todd et al., 1993). Medical students need to develop a solid understanding of the concept that pain is a multidimensional experience with sensory, affective, and behavioral components. Melzack and Wall’s (1965) gate-control theory of pain focuses on the basic anatomy and physiology of pain and provides a conceptual basis for understanding how psychological and behavioral processes exert their effects on the pain experience. Recent findings from functional and anatomical studies provide support for a new perspective that views pain as a homeostatic emotion that integrates both specific neural elements and convergent somatic activity (Craig, 2003). When there is an obvious physical cause for pain, such as in cancer or surgical patients, treatment through pharmacotherapy may be indicated. Anxiety, however, may exacerbate pain, and apparent symptoms of pain can develop in the context of emotionally stressful situations, such as job loss, low levels of social support, or marital difficulties (Krantz and Ostergren, 2000). Consequently, behavioral or cognitive techniques can be useful in combination with medication in treating pain in such patients. In the case of patients with chronic pain without a clear somatic abnormality, a functional analysis is useful for determining the factors eliciting the pain (Drossman, 1978; Kroenke and Swindle, 2000). Medical students should learn that culture is among the factors that can affect patients’ expression of pain. For example, certain ethnic groups have a tendency to express and describe physical complaints in a more dramatic manner than other ethnic groups who may be more apt to accept and conceal pain (Galianti, 1997). In either case, there is a risk that a patient’s pain may go untreated, depending on how it is expressed and interpreted by the physician. The International Association for the Study of Pain has published a useful outline of a curriculum on pain for medical school education (Pilowsky, 1988). Medium-Priority Topics Psychosocial, Biological, and Management Issues in Somatization Somatization is the tendency to experience, conceptualize, and communicate mental states and distress as physical symptoms or altered bodily function (Singh, 1998) and is commonly observed in medical practice (Bridges and Goldberg, 1985; Kroenke, 1992). The symptoms produced by somatization are among the leading reasons for medical outpatient clinic visits, with the most common symptoms, such as headache and fatigue, having a prevalence of 10 percent or more. Such common symptoms are frequently related to emotional stress. Affective illnesses such as anxiety and depression, which are frequently undiagnosed by primary care physicians, often present with somatic manifestations (Katon, 1984; Katon and Russo, 1989).

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Physicians who fail to make organic diagnoses may label their patients as “somatizing,” “problem patients,” or even “hateful,” which results in patients feeling rejected. No single theory adequately explains somatization (Kellner, 1990). A biopsychosocial approach to the phenomenon could help students understand how a variety of factors can lead to the presentation of somatic distress (Epstein et al., 1999). Students should understand the diagnostic criteria for somatoform disorders, the many somatic manifestations of affective disorders, and how analysis of their own reactions to patients can help them recognize possible somatoform disorders in their patients. They should also understand how to use the physician– patient relationship as a therapeutic tool for these patients (Hahn et al., 1994; Novack, 1987). Early recognition and appropriate management of somatization may prevent needless medical workups, doctor shopping, and a further decline in health (Singh, 1998). A number of effective therapeutic strategies for somatoform disorders have been outlined (Barsky and Borus, 1999; Drossman, 1978; Goldberg et al., 1992), and students should be familiar with these and other approaches (Epstein et al., 1999). Interactions Among Illness, Family Dynamics, and Culture Family dynamics and culture have a significant influence on a person’s perception and expression of illness. In many cultures, for example, an HIV or AIDS diagnosis is perceived as shameful (Paxton, 2000). These feelings of shame and guilt can prevent infected patients from disclosing their HIV status to their families, with the result that they experience isolation and depression at a time when family support is most needed (Black and Miles, 2002; Kadushin, 2000; Kalichman et al., 2003). Physicians must be taught that such cultural biases can influence many aspects of medical treatment. In the case of mental illness, cultural factors influence whether a distressed person seeks help, what type of care is sought, what coping styles are employed, and how much stigma the patient attaches to his or her condition (U.S. DHHS, 1999). Culture also influences the meanings people attribute to their illness. Among some African Americans, Alzheimer’s disease is believed to reflect a life of worry and strain that affects the mind in old age (Dilworth-Anderson and Gibson, 2002). In Asian families, dementia is often viewed as an internal imbalance or lack of harmony. These interpretations of illness affect the type of medical care sought. Moreover, patient, sibling, and parental ages and the developmental stages of each family member affect when, where, and how care is sought, as well as how patients’ symptoms are manifested (Christ, 2000; Henderson and Gutierrez-Mayka, 1992; King and Dixon, 1996; Montgomery et al., 2002; Ritchie, 2001; Rothchild, 1994; Schiffrin, 2001; Sholevar and Perkel, 1990). Medical students should learn to recognize how families and the communi-

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Agree, Assist, Arrange follow-up), which has been recommended by the U.S. Preventive Services Task Force’s Counseling and Behavioral Interventions Work Group as a unifying conceptual framework for delivering and evaluating health behavioral counseling interventions in primary and general health care settings (Goldstein et al., 1994; Whitlock et al., 2002). Complex Communication Skills Although the basic communication skills needed by physicians for taking an accurate medical history are necessary for every physician–patient encounter, a number of situations require expertise in more-specific areas. A panel of senior faculty of the American Academy on Physician and Patient created a list of clinical encounters that require such specialized knowledge and skills (see Box 3-1) (Novack, 1998). Relevant conceptual and practical issues can be identified for all of these encounters, as can specific strategies and behaviors that will promote effective communication. Because the first two groups (I and II) of items listed in Box 3-1 represent core clinical encounters in medical care, all students upon graduation should be able to demonstrate proficiency in dealing with these encounters. Medical students can learn the basic issues involved in the items listed in groups III and IV, but they would not be expected to attain proficiency in these encounters until residency. Medium-Priority Topics Context of a Patient’s Social and Economic Situation, Capacity for Self-Care, and Ability to Participate in Shared Decision Making The personal, social, and economic resources available to patients can affect their ability to participate in shared decision making about their health care. Medical students need to be taught to be aware of their patients’ ability to participate in decision making, and, when possible, determine whether the necessary resources are available to ensure access to care and avoid obstacles that could impede diagnosis and treatment of a disease. Personal resources are considered attributes of the individual, and can include age, health status, level of motivation, and education. Social resources encompass primary and secondary relationships that provide sources of social support to patients. Patients who are embedded within strong social support networks (e.g., families and places of religion) often report less depressive symptoms than those who are not (Goldberg et al., 1985). Economic resources, such as employment or income, are those that enable individuals to meet their economic needs, such as employment or income. When these economic needs are met, patients are

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula BOX 3-1 Complex Communication Skills Contextual/Developmental Factors Cultural issues in the interview Working with a translator Family interviewing The pediatric interview The adolescent interview The geriatric interview Assessment and Counseling Smoking cessation Diet/exercise Cognitive dysfunction Risky sexual behaviors Anxiety/panic disorder Depressive disorders Domestic violence Alcoholism Drug addiction Challenging Situations The angry patient/family Patients demanding inappropriate treatment Assessing and managing somatization and “problem patients” Discussing advanced directives Giving bad news Talking with patients about hospice care Talking with terminal patients about pain Being with a dying patient Talking with grieving patients/family members Talking to a patient/family about medical mistakes Terminating the doctor–patient relationship Communicating with Colleagues Communication with others on the health care team Talking to an impaired colleague Principles of teaching junior colleagues

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula less likely to have medical problems, are more likely to seek medical help, and are more likely to comply with medical interventions (IOM, 2003c). Management of Difficult or Problematic Physician–Patient Interactions Physicians consider about one in six patients in the outpatient care setting to be “difficult” (Hahn et al., 1996; Jackson and Kroenke, 1999). Such patients are not necessarily those with complex medical problems; rather, they are patients whom physicians perceive as being demanding and aggressive, seeking secondary gains, and/or having a variety of nonspecific complaints that persist despite the physician’s best treatment efforts (Drossman, 1978; Novack and Landau, 1985; Steinmetz and Tabenkin, 2001). Difficult patients often have mental, mood, or personality disorders with or without comorbid alcohol abuse or dependence (Hahn et al., 1996; Jackson and Kroenke, 1999; Novack and Landau, 1985); display greater somatization (Jackson and Kroenke, 1999; Lin et al., 1991; Walker et al., 1997); and exhibit higher rates of health care utilization (Jackson and Kroenke, 1999; John et al., 1987; Lin et al., 1991). Problematic physician–patient interactions can result when patients with unmet expectations become dissatisfied with their care, and physicians become frustrated by patients who continue to complain despite the physician’s therapeutic attempts (Jackson and Kroenke, 1999). A number of investigators have recommended general treatment approaches for difficult patients that include treating the underlying issue, such as depression or somatization, and improving specific communication skills (Block and Coulehan, 1987; Drossman, 1978, 1997; Epstein et al., 1999; Katon et al., 1990; Kroenke and Swindle, 2000; Lidbeck, 2003; McLeod et al., 1997; Novack, 1993; Okugawa et al., 2002; Platt and Gordon, 1999; Quill, 1985, 1989; Schwenk and Romano, 1992; Smith, 1992). Students should be aware of these approaches. Additionally, educating students in how to work with difficult patients enhances their understanding of why the behavioral and social sciences are critical to their training. For example, physicians with positive attitudes toward psychosocial aspects of care may better recognize and empathize with the suffering of such patients (Cassell, 1999). Physicians with optimal communication skills that incorporate a biopsychosocial perspective may be less likely to label certain patients as difficult (Jackson and Kroenke, 1999; Levinson and Roter, 1995; Williamson et al., 1981), more likely to learn about and help alleviate such patients’ emotional distress, and thereby engender greater patient satisfaction (Roter et al., 1995). Additionally, physicians with greater knowledge of the diagnosis of mental disorders are more likely to recognize and appropriately treat the mental health problems associated with difficult patients (Roter et al., 1997). Medical students’ success in working with difficult patients is related to the effectiveness of their instruction in the social and behavioral sciences. Students must have positive attitudes toward working with psychosocial aspects of care. They must also acquire effective interviewing skills that enable them to elicit and

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula understand the multiple factors in patients’ lives that may cause them to be difficult, including developmental issues such as deprivation and abuse, personality and affective disorders, substance abuse, and current life stressors. Students should know and be skillful in the therapeutic approaches that can be helpful to these patients. SOCIAL AND CULTURAL ISSUES IN HEALTH CARE High Priority Medium Priority Impact of social inequalities in health care and the social factors that are determinants of health outcomes Role of complementary and alternative medicine Cultural competency High-Priority Topics Impact of Social Inequalities in Health Care and the Social Factors That Are Determinants of Health Outcomes As emphasized throughout this report, the role of social factors in health outcomes is increasingly being recognized. It is now known more widely among researchers that morbidity, mortality, and disability rates have been linked to such social factors as race or ethnicity, education, income, and occupation. For example, African Americans and Native Americans consistently have among the worst disease outcomes, while Caucasian Americans typically survive disease with the best health outcomes. Both subtle and more blatant forms of discrimination have been documented in the U.S. health care system (Farley et al., 2001; Geiger and Borchelt, 2003; IOM, 2003c; Mayberry et al., 2000; Wojcik et al., 1998)—among different racial and ethnic groups, as well as between genders (Babey et al., 2003; Elster et al., 2003; Jha et al., 2003; Potosky et al., 2002). Substantial evidence suggests that education and income are also linked to health outcomes. Those with higher socioeconomic status3 fare the best, whereas those who are disadvantaged fare the worst (Kaplan and Keil, 1993; Kawachi and Kennedy, 1997; Marmot et al., 1991). The association between socioeconomic 3   The committee recognizes that the terms socioeconomic position and socioeconomic status are both commonly used to describe a person’s position in relation to social strata. For the sake of consistency, the committee uses the latter term in this report.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula status and mortality is particularly striking because it appears to be graded and continuous. The finding that differences in health and mortality by socioeconomic status are not confined to those living in poverty or with poor access to health care indicates that other factors are also involved. Although there is clearly an inverse relationship between socioeconomic status and the prevalence of behaviors that pose a risk to health, statistical adjustment for behavioral and biological risk factors attenuates, but fails to eliminate, the excess mortality associated with low socioeconomic status (Davey Smith et al., 1998). Evidence suggests that contextual factors, such as poor social cohesion (Kawachi and Kennedy, 1997) and lack of community investment in human capital (Kaplan et al., 1996), are involved as well. The workplace is another important social factor that can have adverse effects on health. Work conditions, including job demands, control, and latitude in decision making, have been found to be related to health outcomes (Karasek et al., 1988). Work-related stress, for example, has been associated with an increased incidence of coronary heart disease and a poorer prognosis in men with that condition (Schnall et al., 1994). Likewise, epidemiological studies have shown a relationship between downsizing or unemployment and cardiovascular disease risk (Mattiasson et al., 1990). Medical students should be aware of the profound influence social factors can have on patients’ health, including their health behaviors and outcomes. Students should be aware that they need to consider these factors if they are to provide optimal health care to all patients. Students should also understand the impact their social views can have on their ability to deliver effective health care. Cultural Competency Social factors such as those discussed above have also been found to influence how patients are treated by physicians (van Jaarsveld et al., 2001; van Ryn and Burke, 2000). The ability to understand and effectively treat diverse populations requires a recognition that the cultural context of illness can be an essential aspect of a successful therapeutic relationship (Braveman and Gruskin, 2003; Goodenough, 1981; IOM, 2003c). Culture, often in the form of ethnicity, provides a context for understanding normative beliefs and practices regarding health and illness (Dinan et al., 1991). For example, dementia is defined and perceived differently among various cultural groups (Bernstein et al., 2002; Dilworth-Anderson and Gibson, 2002; Henderson and Gutierrez-Mayka, 1992). Likewise, a survey of women of various races, cultures, geographic locations, and sexual orientations found that both decision-making patterns regarding certain female health issues and experiences with health care providers differed among the ethnic groups (Galavotti and Richter, 2000). African Americans expressed mistrust of physicians’ motives for recommending a hysterectomy, as did several of the Caucasian, non-Hispanic women, whereas most of the Hispanic participants re-

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula spected and trusted their providers. Interestingly, all the groups surveyed said they would seek additional medical opinions if they could afford to do so. Careful attention to patients’ language and language nuances offers a window into their cultural world view and explanatory models (Kleinman et al., 1978). Language nuances refer to how different cultural groups who speak the same language may use different phrases to refer to the same situation. Cultural nuances may be contextual, in that certain words are indigenous only to particular people within a certain region or locale. To avoid cultural stereotyping, it is vital for physicians to remember that there is wide intragroup diversity and that culture comes one patient at a time. This expression of culture at the individual level is referred to as “cultural frame,” which is developed through the consolidation of the totality of one’s experiences, interactions, and thoughts with the norms and expectations one perceives to be held by other members of a cultural group (Goodenough, 1981). Moreover, culture is expressed in many forms: ethnicity or national origin, religious traditions, regional norms and customs, occupational values and traditions, organizational norms, and geographic setting. Medical students need to understand that cultural competency encompasses language, customs, values, belief systems, and rituals that patients bring to the medical encounter. Medical students, therefore, need to develop a level of cultural competency that moves them far beyond familiarity with a group to engender a firm understanding of how patients’ language, customs, values, belief systems, and rituals can and do affect health care delivery, patient compliance, and effective and relevant doctor–patient communication. Medium-Priority Topic Role of Complementary and Alternative Medicine People often seek health-related care from individuals other than biomedical practitioners (Foster and Anderson, 1978; NCCAM, 2003). A popular form of this practice is complementary and alternative medicine (CAM). Earlier as well as contemporary forms of CAM have been termed “folk medicine” and “medicine rooted in popular culture.” Physicians often refer to themselves as “clinicians,” whereas those practicing CAM therapy are considered “practitioners” (Sugarman and Burk, 1998), a distinction that invariably leads to stigmatization of CAM therapy as an ineffective method of treatment. It is important to recognize that many patients may be reticent to reveal their CAM-related beliefs and behaviors to their physicians, fearing disapproval or ridicule. It has been estimated that 629 million visits were made to providers of CAM therapy in the United States in 1997 (Eisenberg et al., 1998), and in that same year, about 15 million U.S. adults were thought to have taken CAM therapy along with their prescription medications (Eisenberg et al., 1998). Medical students must be aware of and have knowledge of CAM practices, as recent studies have

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula shown that a significant majority of people seeing a physician and using CAM therapies report preferring the use of both to the use of either alone (Astin, 1998; Eisenberg et al., 2001). Thus, medical students need to be skillful at eliciting information from their patients who are actively seeking or currently using other forms of treatment. Otherwise, patients may not disclose the other forms of care they use or their reasons for doing so. Students should be encouraged to take an interest during regular office visits in their patients’ rationale for using complementary, cultural, alternative, folk, or popular medicine. In addition, the content of medical school courses should include attention to those health-related practices that are unique to the region of the medical student’s training (e.g., predominant ethnic and religious groups) and techniques for eliciting other treatments a patient may be undergoing. Rather than simply objecting to a patient who uses CAM, the medical student should consider the meaning a given practice may hold and the need it may meet—that is, the patient’s view of its efficacy. At the same time, students need to be able to determine from a biomedical viewpoint whether a practice is helpful, harmful, or neutral. Given the possibility of severe drug interactions, all dietary supplements, medications, and nonprescription drugs being used by the patient should be ascertained when the history is taken (Piscitelli, 2000). Additionally, patients may be turning to their physicians for guidance on whether these therapies are effective and safe and can be used concurrently with their prescription medications. Of the 117 medical schools responding to a 1997 survey, only 75 reported offering elective courses in CAM or including relevant CAM topics in required courses (Wetzel et al., 1998). Resistance to the incorporation of these therapies into medical education is the result of a common attitude that CAM therapies are not grounded in scientific method and are therefore not a priority in medical education (Sugarman and Burk, 1998; Wetzel et al., 2003). The most persuasive arguments for incorporating CAM into the curricula are made by recent studies showing the adverse effects of the use of CAM therapies concurrently with pharmaceuticals (Nortier et al., 2000; Piscitelli et al., 2000; Ruschitzka et al., 2000).

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula HEALTH POLICY AND ECONOMICS High Priority Medium Priority Overview of U.S. health care system Variations in care Economic incentives affecting patients’ health-related behaviors Costs, cost-effectiveness, and physician responses to financial incentives High-Priority Topics Overview of U.S. Health Care System Throughout their professional careers, physicians must make decisions about how to allocate scarce medical resources to improve health and satisfy wants. Health economics is the scientific study of these choices. In virtually all health care environments, physicians interact not only with patients, but also with insurers and myriad health care systems. Physicians trained in health economics—and health policy—will have a much better understanding of how resources should be allocated and what constraints are involved. The result will be better clinicians (Eisenberg, 1989a,b). The undergraduate medical school curriculum provides the ideal opportunity for developing these foundations through basic instruction in health economics and health policy. This basic instruction should include, among other important topics, an overview of the U.S. health care system. Because this is such a broad subject, it is up to the individual medical school to determine the specific aspects of the system on which to focus. One concept that might be addressed is that, unlike many other service sectors, the health care industry is dominated by the public sector. Public payments for health care services rose to $647 billion and paid almost half of all health care expenditures in 2001. Similarly, in just 30 years, the proportion of gross domestic product4 spent on health care in the United States had doubled to roughly 14 percent by 2001 (Levit et al., 2003). Medical students can be taught to understand the unique role the U.S. health care industry plays in the larger economy and the trends that have motivated efforts to contain costs. This can be done by providing an overview of the U.S. health care system from the clinician’s perspective. A 4   Gross domestic product is a measure of the total goods and services produced at the national level.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula good source is an article published by John Iglehart in the New England Journal of Medicine (Iglehart, 1998). It provides a basic understanding of the public and private insurance systems that is appropriate for medical students. Students might also be taught that a broad cross section of Americans are uninsured (AHRQ, 2002), and that roughly one-quarter of the uninsured come from families with a member who has access to employer-provided insurance but chooses not to purchase it (Gruber and Washington, 2003). Such individuals may have access to free or subsidized care, but otherwise pay the full price of medical care from their own pockets and fail to benefit from the discounted fees and medication prices that health plans typically negotiate. Although many uninsured adults come from low-income households, some 19 percent of the uninsured are from families with incomes above 300 percent of the poverty line (Kaiser Family Foundation, 2003). The effects of being uninsured on health are the subject of ongoing study, with conflicting results (Bhattacharya et al., 2003; Goldman et al., 2001; Levy and Meltzer, 2001). Medical students can be introduced to the different systems of care and their explicit (and implicit) attempts to control costs. Medicare and some Medicaid programs regulate the prices paid to providers directly. Capitated plans pay physicians a fixed amount regardless of how much care is delivered. Managed care plans sometimes intercede directly in the patient–provider relationship through practice guidelines, although physicians have chafed at the imposition of such controls (Studdert et al., 2002). In fact, most cost increases can be tied to the development of new medical technologies and the increased use of existing technologies. For example, increases in the supply of diagnostic imaging and cardiac, cancer, and neonatal technologies are associated with higher utilization and spending (Baker et al., 2003). More generally, medical students can learn how medical services are rationed and how central their actions are to this process. As noted by Fuchs (1984), the basic method of rationing goods and services in this country is through the marketplace. The willingness of patients to purchase physician services and of physicians to supply them determines how they are apportioned and distributed. For most nonmedical goods, consumers balance the benefits expected from a purchase against the cost, with the result being an efficient allocation of resources. Expenditures for medical services are different because most patients have insurance, and even the uninsured have a safety net. This means a third party is paying for care. The patient will therefore want additional care, and a “conscientious” physician will provide it even though its cost to society exceeds the benefit to the patient. Regardless of the specific topics selected, medical students need to graduate with a basic understanding of the health care system that can be reinforced and further explored during postgraduate training.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Economic Incentives Affecting Patients’ Health-Related Behaviors Throughout their lives, patients make numerous complex decisions relating to their health. They engage in healthy (or risky) behaviors associated with diet, exercise, car safety, and smoking; they choose occupations and places to live that can place them in harm’s way or expose them to deleterious environments. Medical students should have a conceptual understanding of how economic incentives shape healthy behaviors. Grossman (1972) provides an excellent model that can be used for this purpose. Grossman suggests that medical care can be viewed as one input into a “production function” that creates health. In this framework, health is a durable good in much the same way as education or a home. People make investments in their health, just as they invest in graduate-level education or new plumbing, for the purpose of realizing better outcomes in the future. The importance of this model lies in its predictive ability. The model explains why people (rationally) might have differing demands for health and, within a set of health care choices, might act on preferences that vary among individuals and/or among subpopulations. For example, a highly paid professional athlete may have more motivation to stay fit than an accountant. An understanding of this model would allow physicians to better predict patients’ behaviors and to appreciate the limits on what medical care can do. Grossman’s model is an example of a broader set of “rational choice” models. Other rational choice or behavioral models may be more appropriate; what is important is that students understand the scientific underpinnings of the particular model being presented and not simply its application. Costs, Cost-Effectiveness, and Physician Responses to Financial Incentives Given the resource limitations noted above, it is not unethical to consider cost when providing patient care. In fact, the real cost of engaging in an activity is the benefit lost by not using the same resources for the most highly valued alternative. In the health care arena, cost-effectiveness is the formal study of the costs and benefits of a medical intervention to determine whether it is worth undertaking. Benefits are measured in terms of some standard clinical outcome, such as mortality rate, years of added life, or quality-adjusted life years. This is closely related to cost–benefit analysis, although in that case benefits are measured in monetary equivalents. Unfortunately, concepts such as cost-effectiveness are used in health care without an understanding of these formal methods, and misallocation of resources often results (Drummond et al., 1987). Eisenberg (1989b) provides a useful guide to the economic analysis of clinical practices. The goal is not to teach medical students to be analysts, but rather informed readers who can understand the usefulness and limitations of studies that use such terms as “cost-effective” in describing treatment options.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Medical students also should understand the role they will play in delivering services and affecting total costs. For example, physicians often prescribe additional treatments of little social benefit for insurance reasons. Insurance basically gives patients and their physicians incentives to use services until the marginal benefit of additional treatment is small, even though these services may be expensive for the insurer. The result is a loss to society (which is consuming services of limited benefit). Cost-containment efforts such as managed care generally—and practice guidelines in particular—can be viewed as a way to prevent this overuse and thereby improve quality of care. These are only two examples of the many administrative mechanisms developed to control the overuse, and perhaps inappropriate use, of medical services by physicians and their patients. Such mechanisms also may include capitation versus fee-for-service differential payments for in-network versus out-of-network referrals, and withholding of payments subject to financial performance, quality, or patient satisfaction outcomes. Medium-Priority Topic Variations in Care In 1938, Sir Allison Glover first presented a study documenting that the incidence of tonsillectomy varied dramatically and systematically by locale within the United Kingdom (Glover, 1938). Since then, an enormous body of medical literature has documented similar variations in treatment for numerous procedures across many similar locales. In their pioneering study, Wennberg and Gittelsohn (1973) found that the chance of receiving a tonsillectomy varied from 7 to 70 percent across similar towns in Vermont. Wennberg et al. (1987) compared the use of medical procedures in Boston and New Haven (two very similar cities in terms of the presence of major academic medical centers, demographics, incomes, and health insurance coverage rates), and found that Boston residents spent almost 87 percent more per capita than New Haven residents on hospital care. Medical students need to understand the traditional explanations for variations in practice patterns across geographic areas, including sampling variation, income, physician and hospital density, and underlying health status. Other economic explanations also need to be considered. In part, the variations in care may reflect the fact that even patients with identical diagnosis or symptoms may prefer different treatments. However, this heterogeneity means that doctors must help patients place a value on the risks associated with treatments and potential health outcomes.