Improving Medical Education Enhancing the Behavioral and Social Science Content of Medical School Curricula (2004) / Chapter Skim
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3 The Behavioral and Social Sciences in Medical School Curricula
3 The Behavioral and Social Sciences in Medical School Curricula
Pages 52-86
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From page 52... ...
Such mindbody 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.
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From page 53... ...
The results of this research indicate that physicians need basic communication skills in order to take accurate patient histories, build therapeutic relationships, and engage patients in an educative process of shared decision making (IOM, 2001a, 2003a; Peterson et al., 1992; Safran et al., 1998)
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From page 54... ...
Innovation and the diversity it produces have been strengths of the American medical education system, and should apply to the behavioral and social sciences as well as to other components of the medical school curriculum. To formulate the priorities recommended in this report, the committee developed an extensive list of possible behavioral and social science topics on the basis of a number of sources and considerations:
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From page 55... ...
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.
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From page 56... ...
56 IMPROVING MEDICAL EDUCATION TABLE 3-1 Behavioral and Social Science Topics of High and Medium Priority for Inclusion in Medical School Curricula Domain High Priority Medium Priority MindBody · Biological mediators between · Psychosocial, biological, and Interactions in psychological and social management issues in Health and Disease factors and health somatization · Psychological, social, and · Interaction among illness, behavioral factors in chronic family dynamics, and culture disease · Psychological and social aspects of human development that influence disease and illness · Psychosocial aspects of pain 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 · Ethical guidelines for and Behavior 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 PhysicianPatient · Basic communication skills · Context of patient's social and Interactions · Complex communication skills economic situation, capacity for self-care, and ability to participate in shared decision making · Management of difficult or problematic physicianpatient interactions Social and Cultural · Impact of social inequalities in · Role of complementary and Issues in Health Care health care and the social factors alternative medicine that are determinants of health outcomes · Cultural competency Health Policy and · Overview of U.S. health care system · Variations in care Economics · Economic incentives affecting patients' health-related behaviors · Costs, cost-effectiveness, and physician responses to financial incentives
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From page 57... ...
· 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.
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From page 58... ...
. 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.
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From page 59... ...
. 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.
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From page 60... ...
. 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)
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From page 61... ...
and is commonly observed in medical practice (Bridges and Goldberg, 1985; Kroenke, 1992)
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. 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.
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From page 63... ...
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)
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From page 64... ...
. 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)
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From page 65... ...
. 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)
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From page 66... ...
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
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From page 67... ...
. To improve their ability to recognize and treat mental disorders and chronic medical illness, medical students must receive education and training in the cooccurrence of the two and the impact of depression and anxiety on the course of comorbid medical conditions.
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From page 68... ...
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)
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From page 69... ...
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 physicianpatient 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)
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From page 70... ...
. 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)
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From page 71... ...
. Medical education has even been characterized as a "neglectful and abusive family system," promoting cynicism, callousness, and self-doubt (McKegney, 1989:452)
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From page 72... ...
. 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)
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From page 73... ...
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.
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From page 74... ...
Remaining current with available community resources is an important element of continuing education. PHYSICIANPATIENT INTERACTIONS High Priority Medium Priority · Basic communication skills · Context of patient's social and · Complex communication skills economic situation, capacity for self-care, and ability to participate in shared decision making · Management of difficult or problematic physicianpatient 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.
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From page 75... ...
. 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)
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From page 76... ...
. Complex Communication Skills Although the basic communication skills needed by physicians for taking an accurate medical history are necessary for every physicianpatient encounter, a number of situations require expertise in more-specific areas.
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From page 77... ...
Assessment and Counseling Smoking cessation Diet/exercise Cognitive dysfunction Risky sexual behaviors Anxiety/panic disorder Depressive disorders Domestic violence Alcoholism Drug addiction III. 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 doctorpatient relationship IV.
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From page 78... ...
. 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)
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From page 79... ...
SOCIAL AND CULTURAL ISSUES IN HEALTH CARE High Priority Medium Priority · Impact of social inequalities in · Role of complementary and health care and the social alternative medicine factors that are determinants of health outcomes · 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.
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From page 80... ...
. Medical students should be aware of the profound influence social factors can have on patients' health, including their health behaviors and outcomes.
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From page 81... ...
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 doctorpatient communication.
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From page 82... ...
. 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)
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From page 83... ...
. The undergraduate medical school curriculum provides the ideal opportunity for developing these foundations through basic instruction in health economics and health policy.
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From page 84... ...
The patient will therefore want additional care, and a "conscientious" physician will provide it even though its cost to society exceeds the benefit to the patient. Regardless of the specific topics selected, medical students need to graduate with a basic understanding of the health care system that can be reinforced and further explored during postgraduate training.
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From page 85... ...
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.
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From page 86... ...
(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)
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