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Strategies for Incorporating the Behavioral and Social Sciences into Medical School Curricula

TASK 3: Provide options for how changes in curricula can be achieved, such as encouraging the leadership of medical schools to incorporate behavioral and social sciences, funding opportunities that would advance this goal, or other novel approaches that would achieve this aim. In developing these options, the barriers to implementing curricula change and approaches to overcome these barriers should be considered.

SUMMARY: There are a number of barriers to the incorporation of behavioral and social science content into medical school curricula. Some of these barriers are common to medical school curriculum change in general, whereas others pertain more specifically to the behavioral and social sciences. These barriers include resistance from poorly informed faculty and administrators, inadequate resources to support faculty and curriculum development in the behavioral and social sciences, a lack of leadership, and dispersion of behavioral and social science faculty among multiple departments and other units.

None of the barriers described in this chapter are insurmountable, however, and several strategies can be used to overcome them. For example, many medical schools lack faculty members who can serve as champions for the behavioral and social sciences in the curriculum. The committee believes this problem could be overcome by the creation of a career development award program. Such a program has been effective in other health-related disciplines. In the behavioral and social sciences,



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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula 4 Strategies for Incorporating the Behavioral and Social Sciences into Medical School Curricula TASK 3: Provide options for how changes in curricula can be achieved, such as encouraging the leadership of medical schools to incorporate behavioral and social sciences, funding opportunities that would advance this goal, or other novel approaches that would achieve this aim. In developing these options, the barriers to implementing curricula change and approaches to overcome these barriers should be considered. SUMMARY: There are a number of barriers to the incorporation of behavioral and social science content into medical school curricula. Some of these barriers are common to medical school curriculum change in general, whereas others pertain more specifically to the behavioral and social sciences. These barriers include resistance from poorly informed faculty and administrators, inadequate resources to support faculty and curriculum development in the behavioral and social sciences, a lack of leadership, and dispersion of behavioral and social science faculty among multiple departments and other units. None of the barriers described in this chapter are insurmountable, however, and several strategies can be used to overcome them. For example, many medical schools lack faculty members who can serve as champions for the behavioral and social sciences in the curriculum. The committee believes this problem could be overcome by the creation of a career development award program. Such a program has been effective in other health-related disciplines. In the behavioral and social sciences,

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula it could free recipients from other faculty responsibilities, permitting them to develop leadership skills, work toward improving the behavioral and social science content of the curriculum, and develop a research program in an area related to the behavioral and social sciences. Individuals receiving career development awards could be used as information resources by other schools trying to enhance the behavioral and social science content of their own curricula. The committee also recommends the creation of a program that provides curriculum development awards. One major purpose of these awards would be to develop model behavioral and social science curricula that could be emulated at other schools. Another major purpose, of course, would be to improve the behavioral and social science curriculum at the school receiving the award. More specifically, such awards would provide medical schools with funds to improve the behavioral and social science content of their curricula and teaching techniques, as well as their assessment methodologies, which could include new assessment techniques in addition to multiple-choice questions. Curriculum development funds could also be used to improve the teaching and assessment skills of a broad range of faculty members involved in courses with content related to the behavioral and social sciences. In addition to constituting an essential tool for measurement of an individual’s ability to practice medicine, the U.S. Medical Licensing Examination (USMLE) exerts a major influence on medical school curricula because it indicates what subject matter licensing authorities believe is important. There is a lack of hard data regarding the proportion of the USMLE devoted to the behavioral and social sciences, but a number of knowledgeable individuals believe the percentage is inadequate and has decreased in recent years. The committee recommends that the National Board of Medical Examiners review the test items included on the USMLE to ensure that they adequately reflect the behavioral and social science subject matter recommended in Chapter 3 of this report. Incorporation of the behavioral and social sciences into medical school curricula poses unique challenges to curriculum committees, especially when there is resistance from faculty and department chairs. Some faculty may be opposed because of a perception that the behavioral and social sciences are not “hard” sciences and are therefore somewhat less important than other topics in the curriculum. Other barriers include inadequate resources to support training of faculty leaders and curriculum development in the behavioral and social sciences. This chapter focuses on these barriers and strategies that can be used to overcome them. It should be noted that, because there are limited published data on specific strategies for incorporating the behavioral and social sciences into medical school

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula curricula, the committee found it necessary in developing such strategies to rely in part on more-generic studies related to medical school curriculum change, and in part on the collective experience of committee members and those interviewed during the course of this study. It should also be noted that, while the committee makes suggestions and recommendations regarding both content and other ways to improve behavioral and social science instruction in medical school, the committee believes each school should design its own educational program, and has therefore not attempted to specify details of a behavioral and social science curriculum per se. BARRIERS TO INCORPORATING THE BEHAVIORAL AND SOCIAL SCIENCES INTO MEDICAL SCHOOL CURRICULA The development and administration of the medical school curriculum are the centralized responsibility of each school of medicine, but the curriculum is difficult to change, in part because so many individuals, departments, and committees are involved. Curriculum reform occurs when there is consensus or the need for change among faculty leaders (AAMC, 2000). At present, however, no consensus exists regarding the importance of the behavioral and social sciences in medical education, making curriculum committees uncertain about how to proceed. A general lack of leadership in medical schools is often cited as the most fundamental barrier to curriculum change (Bland et al., 2000b). Faculty and administrative leaders often oppose such change because they do not understand or agree with the vision and rationale for the change, are uncertain that the change will improve learning, are unwilling to undertake the extra work required during the planning process, or do not want to relinquish instructional time for something new. Resistance to change can also arise from faculty members’ failure to understand the importance of content outside their own domains of knowledge, a lack of innovative teaching skills, and inadequate funding (Robins et al., 2000). The behavioral and social sciences remain undiscovered by many medical school faculty members because they are not familiar with the literature and do not perceive these disciplines as relevant to the practice of medicine. Traditionally, “real medicine” has been defined exclusively as biological medicine—the domain of science—whereas the behavioral and social sciences are often referred to as “soft” sciences and are even considered by some to provide only marginal knowledge (Taylor, 2003a,b). Additional problems arise from a lack of available faculty with expertise in these areas. Not only do faculty members frequently lack the requisite knowledge, but they may also lack the pedagogical skills needed to capture student interest in these subjects (Beckman and Frankel, 1984; Benbassat et al., 2003; Freidin et al., 1990; Sachdeva, 2000). Moreover, it can be difficult for faculty to move from a traditional lecture format to small-group and problem-

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula based learning formats, which are often more effective in teaching behavioral and social science content (see Chapter 2). Resources for instruction in the behavioral and social sciences are often lacking, and it is rare that adequate funding is available to maintain a single departmental home for behavioral and social science faculty, who are often appointed to a variety of departments (e.g., medicine) or a research center. Two notable exceptions—the Department of Behavioral Science at the University of Kentucky College of Medicine, founded in 1959 (Strauss, 1996), and the Social Medicine Department at the University of North Carolina School of Medicine, established in 1978—have interdisciplinary faculty in their departments with joint appointments in their fields of expertise. The lack of a single home for behavioral and social science faculty is detrimental for two reasons: (1) diminished access to resources that typically flow through departments, and (2) the lack of a common ground for interaction among behavioral and social science faculty members. Resources to support curriculum development and time for instruction in the behavioral and social sciences are often scarce. This is especially troublesome given that a successful behavioral and social science program requires additional resources to cover the cost of the many faculty needed to provide small-group instruction. The successful incorporation of the behavioral and social sciences into a medical school curriculum also requires central resources for faculty development (from the dean’s office or the school of medicine) so that the new content and the process by which it is incorporated will be of high quality, and faculty will feel confident in educating students in these disciplines using new teaching methods. In summary, curriculum development in the behavioral and social sciences often faces all of the barriers associated with institutional change in general in addition to the specific challenges associated with teaching these disciplines. Despite these and other barriers, however, the committee was able to identify successful efforts in major structural curriculum change in medical education that include the incorporation of behavioral and social science content into the curriculum. STRATEGIES FOR CURRICULUM CHANGE Medical school curricula undergo continual evaluation and updating as new scientific information becomes available, health care priorities change, and innovative instructional techniques are introduced. Although, as noted, there is relatively little information in the literature addressing the specific topic of curriculum development and change in relation to the behavioral and social sciences, there is considerable information regarding the characteristics of successful medical school curriculum change more generally. These characteristics include strong leadership, the presence of faculty development programs, a formal curriculum

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula change process, curriculum development awards, and high-quality processes for assessment of student learning. These characteristics are discussed in turn below. Strong Leadership The presence of strong leadership is commonly cited as a primary factor in achieving successful curriculum change (AAMC, 2000; Bland et al., 2000b; Dannefer et al., 1998; Skochelak et al., 2001). Throughout the twentieth century, the most important experiments in curriculum change at U.S. medical schools were led by deans committed to educational reform (AAMC, 2000). Such strong leaders with a clear vision and effective communication skills are essential for all curriculum reform efforts. Leaders can be found throughout medical schools. They include faculty members and administrators who provide direction to educational programs and mentor junior colleagues interested in teaching (Wilkerson and Irby, 1998). To achieve change, the dean and other key leaders need to articulate clearly their support for educational change and take concrete steps to address faculty concerns. One way to recognize and encourage faculty able to take on leadership roles in curriculum reform is to establish a career development awards program. Investing in the careers of potential leaders in a discipline is a powerful and proven strategy for advancing that discipline (Gruppen et al., 2003). Such awards provide funds for a faculty member’s time away from other commitments, allowing him or her to focus on developing leadership skills and ability, obtaining and refining relevant knowledge, designing educational methods, conducting relevant research, and designing curriculum. Award recipients may concentrate on one or two of these areas to develop expertise in the discipline at their institution and become the leader or champion of curriculum reform. Faculty development and teaching scholar programs lasting a year or more have been successful in creating a cadre of educational leaders within a medical school (Gruppen et al., 2003; Steinert et al., 2003); however, there has been no such program for faculty in the behavioral and social sciences. The career development award strategy can make it possible to reward scholarship in the teaching of the behavioral and social sciences and other activities that support learning in these disciplines. Career development awards provide salary and other support for faculty members, allowing them to pursue the acquisition of new leadership skills, develop curriculum changes, or complete research projects. These awards have been used successfully to promote curriculum change and to enhance the careers of faculty in the pulmonary and cardiovascular sciences (ACS, 2003; NCI, 2000; NIH Guide, 2000; University of Wisconsin, 2003). Medical schools need to have a similar award system in the behavioral and social sciences to increase faculty knowledge in these disciplines and provide selected faculty the time and resources

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula needed to develop behavioral and social science content, teaching methods, and evaluation strategies (Steinert et al., 2003). A well-supported career development program in the behavioral and social sciences would free promising faculty members from competing responsibilities so they could pursue such efforts. Individuals receiving the awards could also serve as resources for other medical schools trying to enhance their behavioral and social science curricula (Cooke et al., 2003; Morzinski and Simpson, 2003). Conclusion 3. Instruction in the behavioral and social sciences suffers from a lack of qualified faculty, inadequate support and incentives for existing faculty, and the absence of career development programs in the behavioral and social sciences. Recommendation 3. Establish a career development award strategy. Because the provision of career development awards has been an effective strategy for improving instruction and research in other health-related areas, the Office of Behavioral and Social Sciences Research of the National Institutes of Health or private foundations, or both, should establish a career development awards program to produce leaders in the behavioral and social sciences in medical schools. Faculty Development Programs In addition to developing a cadre of leaders in the behavioral and social sciences, there is a need to improve the behavioral and social science–related teaching skills of a broader group of medical school faculty. Faculty development leads to improved skills for all faculty members as educators and scholars, and should be part of institutional policies for the promotion of academic excellence (Wilkerson and Irby, 1998). The improved skills that can be achieved through faculty development include the ability to write educational objectives, design and select teaching methods, develop and apply principles of learning, have enhanced presentation skills, lead small-group discussions, use effective questioning strategies, refine evaluation and feedback skills, and use educational technologies effectively (Hemmer and Pangaro, 2000; Hewson, 2000; Lang et al., 2000; Neely et al., 2000; Sachdeva, 2000). A curricular innovation is more likely to be adopted when the faculty members involved understand its theoretical underpinnings and are trained in the skills required for its implementation (Bland et al., 2000a). One initial training session for faculty at the beginning of a project is not enough. Follow-up coaching, coupled with opportunities to engage in problem solving with colleagues as new skills are being practiced, can significantly enhance the implementation process. Workshops lasting at least 2 days, followed up with practice, feedback, and re-

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula minders, have been found effective in changing teachers’ knowledge, attitudes, and skills (Wilkerson and Irby, 1998). Medical schools that have incorporated the behavioral and social sciences into their curricula have also provided instructional improvement grants designed to motivate faculty to work on targeted areas of curriculum management. Academies of medical educators at the University of California, San Francisco (UCSF) Medical School and Harvard Medical School are just two examples of this trend toward providing incentives for change. At Harvard, the academy provides direct support to a select group of faculty members for their talent in and dedication to education. This mechanism rewards teaching faculty, fosters educational innovation, and provides a forum for the exchange of ideas related to medical education that crosses departmental and institutional lines (Thibault et al., 2003). Similarly, the academy at UCSF fosters excellence in teaching by supporting and rewarding talented teachers (Cooke et al., 2003). Although neither program focuses solely on the behavioral and social sciences, the academy at UCSF has funded curriculum development in the behavioral and social sciences as part of its mini-grant program. In addition, UCSF initiated a mentoring program for junior faculty members built around peer observation of the junior faculty’s teaching abilities, although this program is not directed at the behavioral and social sciences. When such a program is well organized, a positive association is found between participation in the program and career satisfaction in medical schools (Chew et al., 2003; Palepu et al., 1996; Pololi et al., 2002). One high-priority area for faculty development that is especially important for the behavioral and social sciences is assessment (discussed more fully below). Medical educators should strongly consider increasing their faculty development efforts to improve the skills of their faculty in writing test questions in the behavioral and social sciences. Additionally, medical school faculty should be provided the resources and support needed to eliminate flawed multiple-choice questions from their tests (Downing, 2002a,b). To this end, faculty development should include not only training in how to write high-quality test questions in the behavioral and social sciences, but also feedback to the authors of those questions. Faculty development staff should include individuals who have been trained in test writing and measurement of student performance. Data derived from student feedback on the fairness of test questions can be used in the continuing dialogue between faculty development staff and the authors of the questions. Student assessment can also be improved through workshops that provide training in writing test questions. The National Board of Medical Examiners (NBME), for example, offers such workshops to help faculty construct better-quality multiple-choice questions in the basic and clinical sciences (NBME, 2003) and could serve as a similar resource for the writing of test questions in the behavioral and social sciences. Yet funds for faculty development to improve test-writing skills, and thus student assessment, continue to be scarce (Downing, 2002b).

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Faculty development can also be designed to increase faculty members’ basic understanding of the behavioral and social sciences, educate them on teaching techniques appropriate to those disciplines, and provide curriculum evaluation. Formal Curriculum Change Process Successful curriculum change processes have followed a standard model that includes needs assessment, specification of learning objectives, selection of content and teaching methods, and evaluation of the change. Needs assessment involves determining the appropriateness of current curriculum content, teaching methods, and timing of instruction. Many medical schools have completed needs assessments of their curricula and have found gaps and redundancies. Some of the gaps consist of issues related to the behavioral and social sciences (AAMC, 2000). As a result, as noted earlier, medical training programs across the United States have begun to incorporate the behavioral and social sciences into their curricula (AAMC, 2000; Benbassat et al., 2003; Brook et al., 2000; Tang et al., 2002). Additionally, numerous schools have moved to adopt a more integrated curriculum after careful assessment, evaluation, and discussion of their current content and teaching methods (AAMC, 2000; Maizes et al., 2002; Robins et al., 2000; Stalburg and Stein, 2002; Stine et al., 2000; University of Rochester, 2002). The reason for this shift is that scientific investigation and health care practice increasingly require the integration of multiple disciplines to adequately represent new ways of thinking about human health and disease as a result of the emergence of molecular and cellular medicine (Irby and Hekelman, 1997; Tosteson, 1994)—reflecting the fact, noted earlier, that the structure of the medical school curriculum is adjusted in accordance with national changes in medical research and health care. Once an initial needs assessment has been completed, the focus shifts to reaching agreement on learning objectives, identifying content, selecting teaching methods, and creating appropriate forms of assessment. In the case of the behavioral and social sciences, this process requires faculty members who can serve as theme coordinators or champions for the incorporation of these disciplines across the curriculum. Because the process involves curriculum committee reviews and negotiation with existing course directors so they will allow time for behavioral and social science content in their courses, interpersonal negotiation skills are helpful. In an effort to improve an unpopular Medical Humanities course at Ohio State University, for example, just such a person was asked to take the lead. This champion initiated multiple changes that included converting the course into a case-based lecture with a small-group format and modifying the schedule from an all-day class to a 90-minute session every week over 2 years. He also identified the knowledge domains to be taught and the best ways to integrate the material into the curriculum, found module directors to take responsibility for each do-

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula main, formed a course committee, and recruited tutors for the small groups. As a result, many more students now attend the class than was the case when it was the Medical Humanities course (Doug Post, Ohio State University, personal communication, September 2003). A critical component of any curriculum development project is its evaluation. A well-conducted evaluation serves to legitimize the innovation process, provides feedback to stakeholders, refines the program, and maintains faculty enthusiasm for the change (Bland et al., 2000b; Henry, 1996; Robins et al., 2000). The University of Rochester, for example, formally evaluates its fully integrated curriculum by examining data from the Association of American Medical Colleges’ Graduation Questionnaire. The university also developed a questionnaire given to students at the end of years 1, 2, and 4 that addresses issues relevant to the behavioral and social sciences. This questionnaire includes student perceptions of how well the six curricular themes (many of which relate to the behavioral and social sciences) are taught. As another example, the Social Medicine Department at the University of North Carolina, Chapel Hill (UNC) evaluates its Medicine and Society course in two ways: (1) a centrally distributed course evaluation given to all students at the medical school, and (2) a customized evaluation designed by the Social Medicine Department to address its specific concerns. More empirically, a prospective pretest–posttest controlled trial—the strongest study design for determining the effect of a curriculum intervention (Campbell and Stanley, 1966; Fitz-Gibbon and Morris, 1987; Green, 2001)—has been used to evaluate the impact of education in the behavioral and social sciences on students’ attitudes toward sociocultural issues in medicine (Tang et al., 2002). Accurate evaluation of curriculum innovation requires time to assess important outcomes, which in some cases may necessitate separate funding dedicated to the completion of the evaluation (Wartman et al., 2001). In fact, any curriculum change effort comes at a cost. Acquiring the funds needed to launch the change may require the establishment of partnerships with external organizations, such as foundations, or the identification of internal sources of funding (Bland et al., 2000b). As the curriculum innovation progresses, care must be taken to ensure that sufficient funds are available to support the change effort so it can continue once the initial grant support has expired. Evaluating the effectiveness and impact of the innovation can prove useful in leveraging funds for continuing the effort. In addition, funders should consider whether their support for curriculum innovations would have the most impact if directed toward specific departments or a more centralized source. For example, the Interdisciplinary Generalist Curriculum project of the federal Health Resources and Services Administration found that providing money to the dean’s office was probably the best means of effecting a multidisciplinary curriculum change because the curriculum as a whole was affected, and centralized leadership was required. Because curriculum change is a labor-intensive process, faculty members

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula need protected time to plan activities associated with implementing and evaluating the reform. However, resources for this purpose are generally lacking (Griner and Danoff, 2000; IOM, 2001a; Meyer et al., 1997). This lack of resources is especially problematic for medical school faculty who want to work on incorporating the behavioral and social sciences into the curriculum, although exceptions do exist. For example, the Social Medicine Department at the UNC School of Medicine receives significant funding from the state legislature for medical education in the behavioral and social sciences, as well as dedicated federal resources through the Area Health Education Center Program. These direct-funding sources ensure the department’s stability, setting it apart from departments at other medical schools that have cited major difficulties regarding the sustainability of their curricular changes in the behavioral and social sciences (Alan Cross, University of North Carolina; Jason Satterfield, UCSF; and Doug Post, Ohio State University, personal communication, September 2003). External funding does not, however, diminish the responsibility of medical schools to provide adequate internal support for the behavioral and social science program. Such support should include adequate core funding, an appropriate organizational “home” for the behavioral and social science faculty, and promotion and tenure criteria that reward accomplishments in the behavioral and social sciences as well as those in the traditional basic sciences and clinical disciplines. Conclusion 4. Financial support for efforts by U.S. medical schools to improve their curricular content, teaching methodologies, and assessment of student performance in the behavioral and social sciences is inadequate. Curriculum Development Awards Whereas career development awards fund specific individuals, curriculum development awards fund schools to initiate or reform a curriculum. These resources go toward salary support for faculty members working on curriculum development, as well as administrative staff. The funds are often used to offer faculty development workshops that provide training in effective methods of teaching and assessing student competency. The Health Resources and Services Administration has helped fund several curriculum development initiatives, including the Interdisciplinary Generalist Program, Undergraduate Medical Education for the 21st Century, and Women’s Health in the Medical School Curriculum (HRSA, 2003; Rabinowitz et al., 2001). Similarly, the Nutrition Academic Award Program developed by the National Heart, Lung, and Blood Institute in 1997 awards 5-year grants to applicant U.S. medical schools to encourage the development or enhancement of medical school curricula (NHLBI, 2003c). Although these initiatives are excellent resources for curriculum reform that include components of the behavioral and social sciences, they are not specific to those disciplines.

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula Recommendation 4. Establish curriculum development demonstration project awards. The National Institutes of Health or private foundations, or both, should establish a program that funds demonstration projects in behavioral and social science curriculum development at U.S. medical schools. Assessment of Student Learning Assessment of individual students is an essential element of the instructional process, making it possible to determine the extent to which learning objectives have been met through a particular curriculum or instructional methodology (Blue et al., 2000). Assessment also focuses learners and program participants on the most important aspects of a program and often drives learning. Thus, it is important to consider all aspects of student assessment, from internal examinations within courses to external licensing examinations, to fully assess both students and the adequacy of the curriculum. Most medical schools test their students throughout the curriculum using multiple-choice examinations with questions written by faculty members (Downing, 2002a; Jozefowicz et al., 2002). Although few studies evaluate the quality of these in-house examinations, a recent study from the NBME revealed that violations of the most basic item-writing principles are common in the achievement tests used in medical schools (Downing, 2002a; Jozefowicz et al., 2002). Poorly crafted test questions add an artificial layer of difficulty to examinations that can result in inflation or deflation of test scores (Downing, 2002a,b). Many faculty members simply do not have the psychometric expertise to write high-quality tests, a point that applies especially to faculty in the behavioral and social sciences, in which the content is often heavily contextual. Multiple-choice questions are the most widely used format for knowledge assessment because, unlike open-ended questions, they allow for consistency in grading, a sampling of student knowledge in an area with vast amounts of information, and a cost-effective means of assessment. In addition, large numbers of examinations can be scored more easily, and the test is less time-consuming to administer (Anbar, 1991; Edelstein et al., 2000; Veloski et al., 1999). Nontraditional testing methods, however, such as short essay questions, structured oral examinations, and objective structured clinical examinations, may be better suited for use in the behavioral and social sciences because they reveal, more so than other modes of testing, how the student frames problems, appraises and replies to alternative views, evaluates evidence, and defends conclusions. As discussed above, regardless of the testing method used, it is critical that faculty development and assistance resources be provided to ensure that faculty produce high-quality evaluations of behavioral and social science content. The material covered on the U.S. Medical Licensing Examination (USMLE)

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Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula signals to teachers and students alike what is considered important in the field of medicine and thus what should be emphasized in medical school curricula (Elstein, 1993; Swanson et al., 1992). Despite considerable effort, the committee was unable to determine what proportion of the content of the exam is currently devoted to the behavioral and social sciences. In part this is due to the exam’s integrative format and the emphasis NBME has placed on the presentation of material in a clinical context, since Step 1 of the USMLE replaced Part I of the NBME examination.1 NBME also cites differences in defining what constitutes a behavioral and social science question as a factor in its inability to quantify behavioral and social science content on the exam (Gerry Dillon, NBME, personal communication, September 2003). It is the impression of a number of informed individuals, however, that the proportion of material on the USMLE devoted to the behavioral and social sciences has declined. Some believe this is due to changes in the overall design of the exam, while others cite difficulty in writing high-quality test questions on the part of experienced faculty who lack formal training in the behavioral and social sciences. The committee does not believe it is necessary to specify a particular number of behavioral and social science questions that should be on the exam. Rather, the designed questions, however many it may take, should sufficiently cover the topics delineated in this report. Likewise, the committee believes the behavioral and social sciences should be part of the new clinical skills exam that will soon be included as part of the USMLE series. Conclusion 5. The subject matter covered by questions on the U.S. Medical Licensing Examination has a significant impact on the curricular decisions made by U.S. medical schools. The committee believes that the U.S. Medical Licensing Examination currently places insufficient emphasis on test items related to the behavioral and social sciences. Recommendation 5. Increase behavioral and social science content on the U.S. Medical Licensing Examination. The National Board of Medical Examiners should review the test items included on the U.S. Medical Licensing Examination to ensure that it adequately reflects the topics in the behavioral and social sciences recommended in this report. 1   Before the USMLE, NBME Part I was essentially a collection of seven independently developed tests in basic science areas. The behavioral sciences received equal coverage at that time.