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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula (2004)

Chapter: 3 The Behavioral and Social Sciences in Medical School Curricula

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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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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

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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).

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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:

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
  • 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.

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
  • 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

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

(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

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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).

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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-

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

ties in which patients live give meaning to illnesses and how this meaning affects their patients’ health and treatment decisions. They should also understand the importance of eliciting familial and cultural information that can positively or negatively influence their patients’ medical care.

PATIENT BEHAVIOR

High Priority

  • Health risk behaviors

  • Principles of behavior change

  • Impact of psychosocial stressors and psychiatric disorders on manifestations of other illnesses and on health behavior

High-Priority Topics

Health Risk Behaviors

Numerous behaviors influence health. The six behaviors discussed below are included here because they are currently the major causes of morbidity and mortality in the United States, especially among youth (Kann et al., 1996). At a minimum, medical students should be knowledgeable about the psychosocial factors associated with the development and maintenance of these six behaviors that place their patients at risk, and should become skilled in assessing their patients for these behaviors. They should also understand key strategies for the prevention and cessation of behaviors that pose a health risk, and in particular should be aware of the role of the health care provider in instigating and maintaining changes in such behaviors.

Tobacco use. Cigarette smoking is the major cause of preventable morbidity and mortality in the United States. Overall, smoking causes more than 430,000 deaths per year in this country alone (U.S. DHHS, 2000b). It causes coronary heart disease (NHLBI, 2003b; Wilson et al., 1998); chronic obstructive pulmonary disease (NHLBI, 2003a); and cancers of the lung, larynx, esophagus, pharynx, mouth, and bladder (U.S. DHHS, 2000b). It is also the most important modifiable cause of poor pregnancy outcomes in the United States (Hoyert, 1996).

The prevalence of smoking among the U.S. population is currently about 23 percent, although in some population subgroups, such as those with low educational attainment, the prevalence is between 26 and 38 percent (NCHS, 2003a). Effective treatment programs are available for smoking cessation, including both behavioral and pharmacological components. It is recommended that at every health care encounter, health care providers deliver brief counseling on smoking

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

cessation and offer pharmacotherapy and follow-up to all users of tobacco products (Fiore et al., 2000).

Physical inactivity, poor diet, and obesity. The combination of physical inactivity and detrimental dietary patterns, including excess caloric intake, is the second most important factor contributing to mortality and morbidity in the United States (McGinnis and Foege, 1993; Mokdad et al., 2004). Sedentary lifestyles have been linked to 23 percent of deaths from major chronic diseases, while dietary factors are associated with 4 of the 10 leading causes of death—coronary heart disease, stroke, type II diabetes, and some forms of cancer (Hahn et al., 1990). Obesity, which is often linked to physical inactivity and poor diet, is a major factor in type II diabetes (Morsiani et al., 1985). Physical inactivity and obesity are widespread in the United States, where more than 60 percent of adults do not meet current physical activity guidelines, and 61 percent of adults are overweight or obese (U.S. DHHS, 2001).

Excessive alcohol consumption. Long-term excessive use of alcohol increases the risk of hypertension, arrhythmias, cardiomyopathy, and stroke, as well as some cancers (NIAAA, 2002) and poor pregnancy outcomes (Hoyert, 1996). Heavy use of alcohol is a major risk factor for chronic liver disease and cirrhosis (NIAAA, 1998) and is a major contributor to fatalities resulting from motor vehicle accidents. There were 19,358 alcohol-induced deaths in the United States in 2000, not including fatalities from motor vehicle accidents, and 26,552 deaths from chronic liver disease and cirrhosis to which alcohol consumption was a major contributor (Minino et al., 2002; NIAAA, 2002). Yet alcohol use is a complex issue because low levels of alcohol consumption (one drink per day for women, two drinks per day for men) have been shown to have protective health effects for certain diseases (Sacco et al., 1999; Valmadrid et al., 1999). Fully 62 percent of U.S. adults are considered current drinkers at any level of consumption, and 32 percent of current drinkers had five or more drinks on a single occasion at least once in the past year (NCHS, 2002; U.S. DHHS, 2000a).

Risky sexual behavior. Sexually transmitted diseases are especially problematic among adolescents, a group with a high frequency of short-term relationships, and only about 60 percent of adolescents who are currently sexually active regularly use condoms (CDC, 2002b). HIV, the virus that causes AIDS, is transmitted primarily through sexual contact or the sharing of needles among drug users (IOM, 2003b). Efforts to decrease HIV transmission therefore focus on behavioral interventions that minimize high-risk behaviors and decrease exposure to HIV. Other, more common sexually transmitted infections (e.g., human papilloma virus infection, gonorrhea, and chlamydia infection) have also been associated with poor health outcomes, including cancer, infertility, and long-term disability (IOM, 2003b). The Centers for Disease Control and Prevention esti-

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

mates that in the United States, 700,000 people are infected with chlamydia, and 350,000–400,000 are infected with HIV (CDC, 2003).

Homicides and physical abuse. Homicide is a major cause of death in the United States and is the leading cause of death among Hispanic and non-Hispanic blacks aged 15–24 (CDC, 2002a). Major behavioral and psychosocial factors associated with homicide and domestic violence include poverty, firearm availability, alcohol abuse, drug abuse, and cultural acceptance of violent behavior (Brook et al., 2003). Physical intimidation and violent behavior may occur in the workplace, schools, and the home. Emergency department personnel or patients’ personal physicians (e.g., pediatrician or gynecologist) are often the first responsible persons not belonging to the family to become aware that physical abuse is occurring.

Domestic violence is frequently underrecognized in medical practice (Reid and Glasser, 1997). Physicians should regularly inquire about domestic physical abuse because of its high prevalence and high rate of morbidity (Alpert, 1995; Gin et al., 1991; Hamberger et al., 1992; Warshaw, 1997; Warshaw and Alpert, 1999). A history of sexual and physical abuse is common among female patients with functional gastrointestinal disorders and leads to increased rates of health care utilization and medically unexplained symptoms. However, these women rarely disclose this history unless they are asked directly (Leserman and Drossman, 1995; Leserman et al., 1998; Walker et al., 1995). Thus, it is important that physicians be able to ask about such a history comfortably and sensitively when appropriate. Physician education and the simple inclusion of a single question about domestic abuse during the patient interview can significantly improve the rates of recognition of this behavior (Freund et al., 1996; Kripke et al., 1998; Thompson et al., 2000).

Unintentional injuries. Another leading cause of death in the United States is accidents, which peak at ages 15–24 and then rise again after age 60 (NCHS, 2003a). Nearly half of all deaths among young people are related to motor vehicles, whereas falls are the leading cause of unintentional injuries among older people. Young men in particular are prone to unintentional injury, which is often related to high-risk behaviors and alcohol use (Holtzman et al., 2000).

Principles of Behavior Change

Mounting evidence indicates that primary care physicians can be effective in changing patient behavior by using a variety of techniques (Beresford et al., 1997; IOM, 2001b; Nawaz et al., 2000; Wadden et al., 1997; Walker et al., 1981). Often, however, physicians have not received training in such techniques and therefore cannot appreciate how theoretical concepts of behavior change can be operationalized through effective patient counseling. A number of conceptual

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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models (classical conditioning, cognitive social learning theory, health belief model, theory of reasoned action, stages-of-change or transtheoretical model, and social action theory) are available to guide behavior change interventions that address various behavioral attributes (Bandura, 1986; IOM, 2001b; Prochaska and DiClemente, 1986; Williams et al., 1998). Although each of these models has its limitations, they are useful constructs for thinking about behavior change and can be applied to a variety of desirable changes, including adhering to weight loss regimens, actively seeking breast cancer screening, reducing risk-taking sexual activities, and maintaining smoking cessation (Ashing-Giwa, 1999; Farkas et al., 1996; Keller and Allan, 2001).

Learning and conditioning models are among the oldest and most widely researched models. Conditioning models are of particular importance for various aspects of health-related interventions, such as reinforcement, stimulus–response relationships, modeling, cues to action, and expectancies. Medical students should be made aware of the stimulus-control concept, which posits that patients vary their responses according to the situation in which they find themselves. For example, a person may be in the habit of smoking after a meal and may crave cigarettes only after eating lunch or dinner. Likewise, someone who has a drink every day after work grows to expect a drink at that time. By identifying such almost obligatory responses, the physician can target interventions to have a direct impact on the patient’s risky behavior.

Positive reinforcement (being rewarded) and negative reinforcement (getting rid of something unpleasant) are also important concepts for medical students to understand. Encompassed by these concepts are avoidance and escape behaviors—actions that make it possible to escape or prevent pain or discomfort. In such cases, a desirable action is reinforced by the relief it provides. Because different patients respond well to different stimuli, it is prudent for physicians to know which reinforcement will most likely produce the desired effect in their patients.

Medical students should have a grasp of the theoretical and empirical foundations of our understanding of how behaviors are acquired, maintained, and eliminated in the context of health risk. They should also possess a basic understanding of how patients’ social and economic situations, physical status, and psychological states affect their motivation to change their behavior and how this information can be linked to the appropriate behavior reinforcement method.

Impact of Psychosocial Stressors and Psychiatric Disorders on Manifestations of Other Illnesses and on Health Behavior

In a recent survey, six of seven physicians indicated their belief that people with chronic conditions have unmet mental health needs, and about half said they

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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believe unaddressed emotional problems lead to poorer medical outcomes (Partnership for Solutions, 2003). Psychosocial stressors, such as chronic medical conditions, divorce, and poverty, can lead to psychological disorders, such as anxiety and depression. However, nonpsychiatrists often fail to recognize the co-occurrence of mental distress and physical disorders, even though anxiety and depression usually present with physical symptoms in the general medical setting. About half to two-thirds of patients with multiple (six or more) medically unexplained physical symptoms, such as chest pain, abdominal pain, headache, and back pain, have either an underlying anxiety or depressive disorder (Kroenke, 2003; Kroenke et al., 1994). Such patients are frequently misdiagnosed. One study, for example, found that patients with panic disorder see 10 physicians on average before receiving a correct diagnosis (Sheehan et al., 1980).

To improve their ability to recognize and treat mental disorders and chronic medical illness, medical students must receive education and training in the co-occurrence of the two and the impact of depression and anxiety on the course of comorbid medical conditions. Students need to learn not only the range of effective treatments, but also how to undertake a conversation with their patients about these treatments. They must also know when to initiate treatment as a medical generalist or specialist and when to refer the patient to a psychiatrist.

For example, medical students should learn to screen for depression in patients with chronic disease. The evidence indicates that patients with chronic medical conditions have a high prevalence of major and minor depression (Cassano and Fava, 2002); conversely, older patients with multiple chronic conditions or disabilities experience high rates of depression (Lee et al., 2001). Indeed, evidence suggests that comorbid depression plays a role in the onset and course of several conditions, especially coronary artery disease and congestive heart failure (Januzzi et al., 2000). Likewise, it has been estimated that 10 to 15 percent of patients with diabetes have major depression (Lustman et al., 1998), and it has been found that the severity of depression is associated with the prognosis of the disease (Ciechanowski et al., 2000).

Depression affects a person’s ability to function in social and work environments and negatively impacts quality of life and overall well-being. Whooley and Simon (2000) suggest that providers should aggressively treat depressed patients who have other medical problems because depression makes people more vulnerable to somatic distress, results in poorer self-care, and worsens the prognosis for diseases such as cardiovascular disorders. Therefore, it is in the nation’s interest to train medical students to understand the pathogenetic relationships between depression and comorbid medical conditions.

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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PHYSICIAN ROLE AND BEHAVIOR

High Priority

  • 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

High-Priority Topics

Ethical Guidelines for Professional Behavior

Violations of professionalism and ethical behavior are the major reasons for physicians losing their licenses (Papadakis et al., 1999). Codes of professional conduct help guide physicians’ actions and promote their personal commitment to the welfare of patients, while also informing collective efforts to improve the health care system.

The intent of education in medical ethics is to make explicit and understandable the many ethical and professional dilemmas faced by students and physicians and to offer guidelines on which to base ethical decision making. Many efforts, such as the Medical Professionalism Project sponsored by the American Board of Internal Medicine, have been aimed at identifying fundamental principles of professionalism—including the primacy of patient welfare, patient autonomy, and social justice—and sets of professional responsibilities (ABIM, 2001). A series of commitments to professional competence, honesty, confidentiality, and the establishment of appropriate relations with patients is derived from these principles. Ethical principles are needed in particular to guide practice in the many demanding and often emotionally charged situations and contexts of modern medicine, such as end-of-life treatment and care, withdrawal of life support, and reproductive decision making.

Student experiences in medical school can be used as learning opportunities to teach ethical values. Those experiences might include the need to address such questions as the following:

  • When is it acceptable for students to perform procedures on patients to gain experience and skills, although the risk to patients may be greater than it would be if more experienced trainees or graduate physicians were to carry out the same procedures?

  • How can students draw the line between acceptable and unacceptable behaviors when senior members of a medical team ask them to engage in actions that misrepresent who accomplished the work (e.g., students completing informed

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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consents instead of residents or writing progress notes and charts for others), especially in situations in which the students’ performance ratings and credentials are at stake?

  • How should students challenge inappropriate or even offensive treatment of patients observed in clinical work situations when they are on the lowest rung of the medical decision-making ladder?

  • Should students introduce themselves to patients and families as medical students, recognizing that patients may assume that anyone in a white coat is a fully credentialed medical doctor?

These are examples of clinical ethical quandaries that students must resolve, sometimes on their own. All of these value-laden situations demand clear reasoning, an understanding of underlying personal and professional values and basic first principles, well-developed communication skills, and even group leadership skills.

Medical schools have used numerous pedagogical approaches to address such issues. Many of these teaching and learning approaches—such as the use of problem-based cases, small-group exercises, interaction with standardized patients, reading and discussion of materials drawn from the humanities, discussions during clinical rounds, and opportunities to talk with and obtain feedback from senior personnel—are discussed in Chapter 2.

The education for a virtuous life in medicine does not, of course, begin or end in medical school, as many of the scholastic issues faced by medical students (e.g., cheating and plagiarizing) arise earlier. However, medical students first experience the distinct challenges of clinical responsibility in preceptorships and clerkships when they begin to care for patients.

Personal Values, Attitudes, and Biases as They Influence Patient Care

Physicians’ attitudes guide their behaviors, and these attitudes are in turn shaped by a variety of factors, including personal histories, family and cultural backgrounds, values, biases, and emotions. Both unrecognized and recognized feelings and attitudes can adversely affect physician–patient communication (Stein, 1985) and may emerge inappropriately during the medical encounter, endangering the physician–patient relationship (Bennett, 1987).

Assuming that physicians develop adequate levels of knowledge and skill through their training, it will be their attitudes that ultimately determine the quality of the care they provide. This includes attitudes about the importance of psychosocial factors in medical care and about the importance of self-sufficiency, personal responsibility, family values, aging, racial and ethnic differences, and death, all of which shape the physician–patient interaction (Carmel, 1997; Cheng et al., 1999; Ely et al., 1998; Epstein et al., 1993; Nightingale et al., 1991; Novack et al., 1997; O’Loughlin et al., 2001).

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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An individual’s family of origin can have a major influence on his or her attitudes (Novack et al., 1997). This is the context in which one first learns about the nature, benefits, and pitfalls of caring; the roles of the caregiver; the balance of giving and receiving; the communication aspects of illness; and how to respond to distress—dynamics that are fundamentally important to the physician– patient relationship. Patients may remind physicians of family members with similar problems or behavioral patterns, eliciting such feelings as fear of harming the patient, being inadequate, or losing control, or discomfort in addressing certain difficult topics (Marshall and Smith, 1995).

Because personal factors can play such an important role in the development of physicians’ attitudes, some have stressed the need to emphasize in medical education activities that promote personal awareness (Anonymous, 1969; Epstein, 1999; Lipkin et al., 1995b; Longhurst, 1988; Novack et al., 1997, 1999). It is noted that improved personal awareness facilitates positive relationships with patients (Gorlin and Zucker, 1983; Marshall and Smith, 1995) and the ability to cope with stress (Quill and Williamson, 1990). Physicians who become more aware of the influence of personal factors on their behaviors can better examine how and why they make behavior choices (Stein, 1985). This personal awareness can be a first step in stimulating adaptive changes in attitude and behavior and can also lead to a deeper and more sophisticated understanding of patients’ behaviors.

For these reasons, it is essential that medical schools provide opportunities within their curricula for students to reflect upon and discuss how their family of origin, cultural background, gender, life experiences, and other personal factors have influenced their attitudes toward emotional reactions to patients. Students should be offered such structured activities as the Balint method2 (The Balint Society, 2003; Luban, 1995) and support groups (Brashear, 1987; Williamson, 1992) to help them process the difficult emotional encounters that regularly occur in medical care and to learn from the experiences of peers and teachers.

Physician Well-Being

The stresses of medical training have been well documented. Students are faced with acquiring an overwhelming amount of knowledge in a relatively short period, working long hours, and dealing with occasional abuse on rounds, as well as the suffering and death of patients (Bourgeois et al., 1993; Lubitz and Nguyen,

2  

The Balint method consists of regular case discussion in small groups under the guidance of a qualified group leader. The work of the group involves both training and research to help general practitioners gain a better understanding of the emotional content of the doctor–patient relationship. This method has been adapted for use in medical schools.

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

1996; Silver and Glicken, 1990). Medical education has even been characterized as a “neglectful and abusive family system,” promoting cynicism, callousness, and self-doubt (McKegney, 1989:452). A number of the stresses of medical training have been associated with long-term adverse effects on physical health, mental well-being, and work performance measures (Baldwin et al., 1997b; Shanafelt et al., 2002). In addition, many physicians have developed maladaptive responses to stressors and have not appropriately managed their own health care needs (Baldwin et al., 1997a; Martin, 1986).

Studies have documented increased anxiety and depression in large numbers of students upon entering medical school that persists throughout the 4 years (Clark and Zeldow, 1988; Rosal et al., 1997; Vitaliano et al., 1988) and into postgraduate training and physician practice (Clark et al., 1984; Hendrie et al., 1990; Ramirez et al., 1995; Reuben, 1983; Shanafelt et al., 2002; Smith et al., 1986; Vitaliano et al., 1988, 1989). Such high levels of stress often lead to burnout, which has been associated with residents’ reports of providing suboptimal patient care and a decreased sense of professional satisfaction (Fields et al., 1995; Shanafelt et al., 2002). Moreover, many trainees and physicians in practice carry work stress home with them, resulting in strained family relationships (Warde et al., 1999); decreased intimacy and greater marital discord (Gabbard and Menninger, 1989); and stress-related somatic complaints, such as headache, backache, fatigue, and atypical chest pain (Geurts et al., 1999).

Medical schools can do much to address the issues of balance and self-care, as well as the prevention of stress, burnout, and impairment in their students. Rigorously designed interventional studies on stress management in medical students have shown that teaching stress reduction techniques can reduce psychological distress and anxiety (Palan and Chandwani, 1989; Shapiro et al., 1998; Whitehouse et al., 1996). These techniques can be used throughout students’ medical training and into their medical practice. Students can also be taught to recognize risk factors and warning signs of depression, burnout, substance abuse, and other mental health problems in themselves (Chang et al., 1997; Clark et al., 1984; Firth-Cozens, 2001; Linzer et al., 2001; McCranie and Brandsma, 1988; Shanafelt et al., 2003); to adopt wellness strategies that promote physician well-being (Firth-Cozens, 2001; Quill and Williamson, 1990; Shanafelt et al., 2003; Weiner et al., 2001); to apply principles for creating healthy, intimate relationships (Christie-Seely, 1986; Myers, 2001); to clarify personal values (Clever, 2001); and to openly discuss realistic strategies for creating balance in their lives (Coombs and Virshup, 1994). This can be done both as part of the curriculum and as part of extracurricular activities.

Students learn best when they are physically and emotionally healthy. If they can learn during medical training about attending to balance in their lives and to the prevention, early detection, and treatment of burnout and emotional problems, they can acquire habits that will enhance their lives and their medical practices over the long term.

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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Social Accountability and Responsibility

A socially responsible individual has been defined as “a person who takes part in activities that contribute to the happiness, health, and prosperity of a community and its members” (Faulkner and McCurdy, 2000:347). Some educators have expressed concern that medical training is not adequately preparing physicians to be socially responsible members of society and that medical schools are not fulfilling their social responsibility to improve the health of the public (Coulehan et al., 2003; Schroeder et al., 1989). AAMC also recognizes that medical schools have a special duty to teach their medical students how to become socially responsible physicians (McCurdy et al., 1997). It is vitally important for educators to understand and nurture the social contract that exists between medical schools and the public.

Defining the elements of a socially accountable and responsible curriculum is difficult and not within the scope of this report, but the committee notes that two fundamental principles should be paramount in medical school curricula. First, medical students should be engaged in activities that foster their development as socially responsible leaders. These activities must extend beyond the doctor–patient relationship to encompass the complex web of multidisciplinary relationships within society. The World Federation for Medical Education has recommended that schools enlarge the range of settings in which educational programs are conducted to include all health resources of the community, not hospitals alone (Anonymous, 1988; Byrne and Wasylenki, 1996). Progress is being made toward accomplishing this goal. Although much of medical education is still conducted in tertiary-care hospitals, medical students are increasingly being exposed to community-based health settings and to organizations that serve the community.

In addition, students must be taught to recognize the priority health concerns of the community, region, and/or nation they serve (Boelen, 1995). Graduates should understand that health care needs change over time and that they must be prepared to respond to the changing needs of the community in which they practice. By continually profiling the health status and health care needs of the community, medical schools can create an awareness in students of the current and emerging needs of their individual communities within the larger context of national and international trends (Parboosingh, 2003). This understanding of community needs can then be reinforced by experiential learning that acquaints students with real-world problems as they engage in socially responsible public service.

Work in Health Care Teams and Organizations

Increasingly, health care is delivered by multidisciplinary teams of professionals that can include physicians, social workers, nurses, nutritionists, and

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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physical and mental health therapists. Each discipline brings a unique perspective to the care of the patient, and physicians must recognize what each has to offer. They must also accept the fact that most health care organizations and institutions no longer embrace the top-down model of medical treatment whereby the physician is the sole decision maker in the patient’s care. A doctor who does not interact well with those in other disciplines will likely experience greater difficulty in expediting his or her wishes. It is therefore crucial that physicians know how to work effectively in the context of integrated teams. They must understand their role as part of a team and why it is important to foster positive relationships with other team members.

The chronic care model developed by Wagner and colleagues is an example of how physicians can work effectively in the context of integrated systems and teams (Glasgow et al., 2000, 2001a; Von Korff et al., 1997; Wagner et al., 1996, 2001). Recently, this model has been applied to preventive care as well (Glasgow et al., 2001a,b). The overall goal of the chronic care model is to create an environment that supports productive interactions between informed, activated patients and a prepared, proactive team of clinicians (Von Korff et al., 1997; Wagner et al., 1996, 2001). Exposing medical students to such theoretical models is helpful but not sufficient; medical students should also participate in educational experiences with other health professionals. This type of learning environment fosters communication across health care disciplines and exposes medical students to perspectives other than medicine in the care of patients. Such interdisciplinary learning prepares students for the realities of working in integrated health care teams and organizations and should be reinforced throughout the 4 years of medical school.

Use of and Linkage with Community Resources to Enhance Patient Care

An emphasis on disease prevention and the economic constraints of medical practice and care delivery are often at odds, limiting the time available for providers to devote to preventive care issues. However, a number of community resources can assist health care providers in their efforts to offer preventive services to their patients. These resources may include social work, mental health counseling, and nutrition education services.

Learning about available community resources can help medical students identify valuable health and social services in the patient’s community. For example, exposing medical students to a local hospice organization during discussion of end-of-life care provides a natural link to a valuable resource for both patient care and physician information. Numerous community-based programs for behavior counseling and disease prevention and health promotion—such as drug abuse programs, protective services for domestic violence, HIV prevention programs, smoking cessation programs, and nutritional counseling—may be available as well. In addition, some local, state, and federal programs provide

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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access to screening and medical treatment for those with or at risk of developing specific illnesses. Examples include local initiatives for breast and prostate cancer screening for underserved populations (Boyd et al., 2001; Frelix et al., 1999; McCoy et al., 1994). These services provide an opportunity for health care providers to extend their own preventive care efforts and provide access to prevention services for low-income and/or underinsured patients.

Physicians should be aware of the availability of these services in their community and have a working knowledge of the types of interventions offered. While this information can be found through local chapters of voluntary health organizations, social service agencies, and websites of national associations and organizations, students should be made aware during their training of the utility of such allied services in fostering the health of their patients. Remaining current with available community resources is an important element of continuing education.

PHYSICIAN–PATIENT INTERACTIONS

High Priority

Medium Priority

  • Basic communication skills

  • Context of patient’s social and economic situation, capacity for self-care, and ability to participate in shared decision making

  • Complex communication skills

  • Management of difficult or problematic physician–patient interactions

High-Priority Topics

Basic Communication Skills

Good communication skills are necessary if physicians are to take accurate patient histories, build therapeutic relationships, engage patients in an educative process of shared decision making, and encourage patient adherence to treatment. In fact, 75 to 95 percent of the information needed for physicians to make a correct diagnosis comes from the patient-reported medical history (Gruppen et al., 1988; Peterson et al., 1992), and competent history taking is known to be essential to providing effective care (Matthews et al., 1993; Novack, 1987; Safran et al., 1998; Stewart et al., 1999). The quality and quantity of diagnostic information gathered in the medical interview depend on the physician’s approach to interviewing and his or her interviewing skills (Beckman and Frankel, 1984; Marvel et al., 1999).

Conceptual advances and research findings that have emerged in recent de-

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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cades have radically changed physicians’ understanding of the process and teaching of medical interviewing. For example, clinical reasoning can be taught and integrated into medical students’ interviewing skills to facilitate successful history taking (Kahn et al., 1979; Makoul, 1998; Novack et al., 1993; Schmidt et al., 1990; Stoeckle and Billings, 1987). These skills include establishing rapport and building trust, eliciting adequate information to permit a robust differential diagnosis, understanding and addressing patient concerns, and initiating patient education and counseling. Medical students who learn these skills have the ability to conduct thorough interviews in a time-efficient manner (Cole and Bird, 2000). A variety of models have been developed to guide students in learning these skills (Cole and Bird, 2000; Coulehan and Block, 2001; Haidet and Paterniti, 2003; Kurtz et al., 1998; Lazare et al., 1995; Lipkin et al., 1995a; Makoul, 1998; Platt and Platt, 2003; Platt et al., 2001; Smith, 1996; Stewart et al., 1995).

Medical students need to acquire skills that promote communication with patients beyond simply asking about their disease symptoms. As emphasized earlier, cultural sensitivity and physician self-awareness are key components of effective communication in this regard (Epstein, 1999; Kleinman et al., 1978; Novack et al., 1997). In addition to the many biomedical questions that must be asked in every standard medical interview, students need to be trained to inquire comfortably about patients’ concerns, emotions, social situations, and behaviors (Goldberg and Novack, 1992). Medical students who learn how to elicit information needed to understand how biological, personal, and social factors interact in the onset and maintenance of illness will diagnose and treat their future patients more effectively. In addition, medical students need to understand how to engender a therapeutic relationship and be trained to recognize potential barriers between physician and patient that could endanger this relationship and hinder patient compliance (Lazare et al., 1995; Quill, 1989). Skills needed to accomplish this include expressing empathy (Spiro, 1993); actively listening (Beckman et al., 1994); and eliciting information about patients’ lives, as well as their expectations and concerns about their medical care (Levinson et al., 2000; Rao et al., 2000).

Effective communication, together with skilled health behavior counseling, promotes patient adherence to treatment and facilitates changes in patients’ problematic or risky health behaviors, including smoking, substance use, and unsafe sexual practices (DiMatteo, 1994a,b; Glasgow et al., 2002; Goldstein et al., 1998; Grueninger et al., 1995; Roter and Kinmonth, 2002; Whitlock et al., 2002). Motivational interviewing (Miller and Rollnick, 2002) is an approach to patient health behavior counseling that integrates principles of patient-centered counseling with established models of health behavior change, including the transtheoretical model, self-determination theory, and social cognitive theory. The technique has been modified for use in clinical settings and is a promising approach to treating problem behaviors (Burke et al., 2003). Students should be exposed to this interviewing technique, as well as the 5As counseling approach (Assess, Advise,

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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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

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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BOX 3-1
Complex Communication Skills

  1. Contextual/Developmental Factors

    Cultural issues in the interview

    Working with a translator

    Family interviewing

    The pediatric interview

    The adolescent interview

    The geriatric interview

  2. Assessment and Counseling

    Smoking cessation

    Diet/exercise

    Cognitive dysfunction

    Risky sexual behaviors

    Anxiety/panic disorder

    Depressive disorders

    Domestic violence

    Alcoholism

    Drug addiction

  3. 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

  4. Communicating with Colleagues

    Communication with others on the health care team

    Talking to an impaired colleague

    Principles of teaching junior colleagues

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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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

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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.

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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-

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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).

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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.

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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.

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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.

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×

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.

Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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×
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×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
×
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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Suggested Citation:"3 The Behavioral and Social Sciences in Medical School Curricula." Institute of Medicine. 2004. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: The National Academies Press. doi: 10.17226/10956.
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Roughly half of all deaths in the United States are linked to behavioral and social factors. The leading causes of preventable death and disease in the United States are smoking, sedentary lifestyle, along with poor dietary habits, and alcohol consumption. To make measurable improvements in the health of Americans, physicians must be equipped with the knowledge and skills from the behavioral and social sciences needed to recognize, understand, and effectively respond to patients as individuals, not just to their symptoms. What are medical schools teaching students about the behavioral and social sciences?

In the report, the committee concluded that there is inadequate information available to sufficiently describe behavioral and social science curriculum content, teaching techniques, and assessment methodologies in U.S. medical schools and recommends development of a new national behavioral and social science database. The committee also recommended that the National Board of Medical Examiners ensure that the U.S. Medical Licensing Examination adequately cover the behavioral and social science subject matter recommended in this report.

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