A report released in March by the Institute of Medicine (IOM)--part of the National Academies of Science--calls for the integration of behavioral and social science findings into U.S. medical schools' curricula, including such areas as behavior's role in health, physician-patient communication and social influences on the larger health-care system.
A multidisciplinary committee that included psychologists Neil Schneiderman, PhD, director of the University of Miami's Behavioral Research Center, and Eugene Emory, PhD, director of clinical psychology training at Emory University, wrote the report, which was commissioned by the Office of Behavioral and Social Science Research at the National Institutes of Health and the Robert Wood Johnson Foundation.
The report represents a landmark recognition of behavior's role in the health-care system, says psychologist Suzanne Bennett Johnson, PhD, chair of the medical humanities and social sciences department at the Florida State University College of Medicine and chair of APA's Board of Scientific Affairs.
"It's been very, very difficult to get the message out that behavior is critically important," explains Johnson. "But this report does a wonderful job explaining that over 50 percent of morbidity and mortality in the U.S. can be traced to behavior."
Though that 50 percent figure--recently publicized in a March 10 Journal of the American Medical Association article--is nothing new to health researchers, many physicians lack the training to translate such findings into their daily practice, according to the report.
For example, physicians are uniquely positioned to communicate with patients about changing exercise, eating, smoking and other health behaviors--and to refer patients to specialists, such as psychologists, when they need such interventions. However, medical schools don't always supply them with the necessary training in behavior change, communication skills and social and cultural issues to be able to do so, the report says.
Medical education today
Still, overall, the committee found that U.S. medical schools are making strides in incorporating the behavioral and social sciences, but the ways in which they include them varies widely.
While a few institutions integrate these sciences throughout all four years of medical education, the report notes, most programs confine such training to the first two years of medical school, which students spend in the classroom. Moreover, the content and hours of instruction that faculty provide in the behavioral and social sciences fluctuates.
"Even though there might be a lot of good will for integration," says Johnson, "there's often not adequate expertise or support or even incentives for faculty to do these sorts of things."
The challenge, says IOM committee member Dennis Novack, MD, is partly structural: Medical schools historically have been divided into separate disciplines--basic sciences such as anatomy, biochemistry and physiology and clinical specialties such as surgery and pediatrics--that students rotate through during their education.
"But the science of psychosomatic medicine, which is the scientific basis of the biopsychosocial model, really resides in the interaction of all those fields," explains Novack, associate dean of medical education at Drexel University College of Medicine. "And the need to understand and address patients' motivations and behaviors is present in all clinical work. We need people who can span the disciplines."
Psychologists have been actively involved in bridging the gaps, says Cynthia Belar, PhD, APA's executive director for education. For example, APA's Div. 12 (Society of Clinical Psychology) includes a section called the Association of Medical School Psychologists, and members of Div. 38 (Health) are active in medical education. Independently of APA, psychologists have been involved in the Association of Behavioral Science Medical Educators.
However, they and other medical faculty face an unbending roadblock--limited time. The four-year curriculum is already jam-packed, says psychologist John Linton, PhD, director of the psychiatry clerkship at the West Virginia University School of Medicine at Charleston. The Association of American Medical Colleges (AAMC)--the accrediting body for medical schools--lays out strict guidelines on what students must learn. And students must pass board exams on that material after the second, third and fourth years of medical school.
"While we try not to teach to the test," says Johnson, "medical school is very intense--there is a lot of information--and you are going to put your priorities where the test items are."
An action plan
The report outlines three strategies to help medical schools overcome such roadblocks:
Integrating behavioral and social science topics into the mainstream curriculum. The committee compiled a list of priority behavioral and social science topics, divided into six domains, such as mind-body interactions and physician-patient interactions. They recommend that at minimum faculty cover the high-priority topics (see sidebar) and require students to demonstrate competency in each of the domains.
Johnson says she was particularly pleased to see that the recommendations reached beyond mental illness.
Indeed, the report notes that topics such as physician-patient communication, cultural and social biases and behavior change are key areas for physicians. Students could use training in how to break bad news to family members, discourage smoking, counsel patients on drug and alcohol use or understand why some people delay seeking medical care, she says, adding that psychologists and other social scientists have the expertise to conduct that training.
However, Novack notes that physician and behavioral scientist faculty alike not only need curriculum models to teach such skills, they also need assessments that accurately gather whether students have really mastered the skills.
Moreover, Linton of West Virginia University notes that integrating the social sciences into the time-crunched medical school environment will only be possible if behavior's role in medicine is deemed important by those in key positions-- from medical school deans down to the residents who work with students daily. To encourage medical school buy-in, the report calls for the U.S. Medical Licensing Exam--the test students take after years two through four--to add behavioral and social science questions that test students' knowledge of the domains.
Developing a new national behavioral and social science curriculum database. The report found that medical school faculty's best tool for tracking curriculum innovations--AAMC's Curriculum Management and Information Tool (CurrMIT), a database into which schools voluntarily enter their curricula--includes little information on behavioral and social sciences courses, leaving faculty interested in adding behavioral elements at a loss.
So the report calls for AAMC or another organization to either upgrade CurrMIT or create a new resource that will remedy the lack of information on behavioral and social science curriculum content, teaching techniques and assessment methods.
Creating career development and curriculum development awards. While the National Institutes of Health and other organizations offer development awards in individual medical disciplines, there's little support for psychologists, psychiatrists and other physicians who want to bridge those disciplines with the behavioral and social sciences, says Schneiderman. As a remedy, the committee calls for the federal government and nonprofit funding agencies to offer awards designated for faculty who teach the behavioral and social sciences or develop related curricula--awards that, if created, could go to psychologists as well as physicians, he says.
The hope, he explains, is that supporting faculty who value social sciences will lead to a zeitgeist change in the profession's understanding of behavior.
"[Physicians] are the ones who are monitoring your weight, talking to you about smoking, advising you about exercise every time they see you," Johnson explains. "If they understand how important behavior is, you can have a very pervasive change in the health-care landscape."
Indeed, physicians who back behavioral interventions might also persuade more insurers to pay for proven behavioral interventions, such as diabetes prevention, say committee members.
"The report's information, if used properly, can only enhance the quality of training," says Emory, "and by extension, the quality of care offered to American citizens."