Feature

When first-year medical students at the University of California, San Francisco (UCSF), started classes this September, they stepped into a radically different curriculum--the first in the nation to integrate behavioral and social science and culture into every aspect of instruction, from students' first day of class to the last clinical rotation.

Behavioral medicine specialists hope UCSF's program, the culmination of five years of painstaking self-examination and planning, will kindle a new way of thinking about medical training and pave the way for far greater integration of behavioral and social science in medicine.

"The overall goal is to ensure that medical students recognize that there's a basic science to understanding behavior, so that when they go out into practice, they can think about it and keep up with the behavioral medicine literature, just as they do with the biological sciences," explains Nancy E. Adler, PhD, a professor of psychology in UCSF's departments of psychiatry and pediatrics and chair of the medical school's curriculum committee.

Integrating behavioral and social science and culture with basic biological and clinical training is part of a broader effort, within the new curriculum, to train physicians to be "lifelong learners," adds UCSF clinical psychologist Jason M. Satterfield, PhD, a member of the "culture and behavior" committee that helped shape the curriculum. "We want to shift the focus of medical education from rote learning followed by hands-on practice to a more learner-centered model."

The changes at UCSF are the latest and perhaps the most ambitious development in a nationwide trend to include more behavioral and social science in medical training, says psychologist Judith K. Ockene, PhD, of the University of Massachusetts Medical School and a member of the boards of directors of the Society of Behavioral Medicine (SBM) and the Association of Teachers of Preventive Medicine (ATPM).

Increasing demand for more training in behavioral medicine among medical school faculty and preventive medicine specialists has led organizations such as SBM, ATPM and the Association of American Medical Colleges to develop behavioral medicine curricula for medical education and professional development. In addition, the National Institutes of Health (NIH) Office of Behavioral and Social Science Research is planning an initiative to encourage more medical schools to further integrate behavioral and social sciences into their curricula.

"We know that at least half of all deaths in the United States have behavioral and social factors as significant causes, from smoking to adherence to physicians' recommendations for treatment to social and cultural factors that influence the interaction between a patient and the health-care system," says Raynard S. Kington, MD, PhD, associate director of behavioral and social sciences research at NIH. "If we expect physicians to do their best in providing medical care, they have to understand the roles that these factors play in disease and health."

Fostering a holistic approach

Although many medical schools have included more behavioral and social science in their curricula in recent years, such instruction is typically isolated from students' education in the basic biological and clinical sciences, says Elissa S. Epel, PhD, a postdoctoral scholar in health psychology in UCSF's department of psychiatry and a member of the culture and behavior committee.

The disadvantage of that strategy, she argues, is that "when students learn about behavioral science in a separate class, they may seal it off into a separate compartment in their memory and think, 'Well, this is psychiatry, and I'm not going into psychiatry.' They may not realize that normal psychological processes, not just psychopathology, are important in medical care."

The goal of the new UCSF curriculum, in contrast, is to teach medical students to think more holistically about patients' medical problems, including the social and behavioral factors that may contribute to them.

The curriculum provides students with a series of medical cases, throughout their first two years, that integrate basic biological, behavioral and clinical concepts. For example, in a unit on organ systems during the first year of medical school, students will learn about biological principles of cardiac, pulmonary and renal health, as well as about behavioral and social factors--such as diet, exercise, depression, social support and relaxation--that affect these organ systems.

Likewise, education about cancer will include not only instruction in basic cell biology, tumor growth and other physiological aspects of cancer, but also lectures and discussion of smoking and obesity, cancer prevention efforts and other behavioral factors in cancer.

"We don't expect the students to become behavioral scientists, but we do expect them to learn about assessing behavior and implementing short-term behavioral interventions when they're needed," says Epel. "We want to foster a focus on preventing disease, not just curing disease."

In fact, she says, UCSF's long-term goal is to develop "a new generation of physicians who can incorporate an understanding of psychosocial issues, regardless of their area of practice."