Journal of Clinical Psychology in Medical Settblgs, Vol. t, No. 2, 1994
Psychology, Behavioral Sciences, and tKe Challenge to Medical Education I J o h n E. Carr 2
It is generally agreed that the health care system is hz crisis despite reform efforts over the past two decades. Evidence is presented which suggests that medical education has failed successfully to integrate medically relevant behavioral science research findings into medical school curricula or train physicians & the application of behaviorally based treatment technologies. Psychologists in nzedical education setth~gs have the opportunity to hnpact medical education and foster psychology's role in health care. If psychology fails to respond to this opportunity, we cannot then complain of the inevitable consequences. KEY WORDS: medical education; health psychology.
INTRODUCTION In the 1970s the Canadian Lalonde Commission (1974) and the U.S. Surgeon General (1979) presented unassailable evidence that Americans and Canadians were at greater risk of dying fl:om behavioral factors, unhealthy lifestyles, environmental hazards, and inadequacies in the health care system than from biological pathology. Simultaneously Engle (1977) called for the teaching of a more comprehensive "biopsychosocial model" of medicine. These calls for reform underscored the importance of preventative care and gave birth to the emerging fields of behavioral medicine and health psychology. Burgeoning research in these areas was complemented by in1An earlier version of this paper was presented at tile annual meeting of the American Assocation of Medical Colleges, Washington, DC, November 1993. 2Division of Behavioral Medicine, Department of Psychiatry &Bchavioral Sciences, University of Washington, D-45, Seattle, Washington 98195. 109
1068-9583/9410600-0109S07.0010© 1994 Plenum PublishingCorporation
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creasing collaboration between physicians and psychologists in neuropsychology, pain management, eating disorders, sexual dysfunction, headaches, stress disorders, treatment compliance, and management problems in a wide range of chronic diseases such as cancer, diabetes, and AIDS. Yet two decades later, we find a U.S. health care system in crisis, including an overemphasis on expensive hospital care, surgery, and other high-tech treatments; limited payment; for selected treatments; and an emphasis on predominantly physical vs. psychological complaints. We find a system that reinforces somatization, biases epidemiological and treatment outcome data, and invites financial abuse and administrative mismanagement. We find health promotion, prevention, and behavior change programs as well as services for the elderly, children, youth, families, and the underinsured underemphasized or ignored. H o w do we explain this seeming contradiction? Given the evidence, why do we find change only in limited areas of clinical practice and no sign that this has impacted upon the health care system as a whole? Why is it that it will take literally an act of Congress to get the U.S. health care system to respond to the mandates of the 1979 Surgeon General's report?
BEHAVIORAL SCIENCES IN MEDICAL EDUCATION I submit that the answer lies in a massive failure of medical education. Despite lip service to the contrary, medical education has failed to teach our physicians in training the large body of behavioral science research findings that apply to health care. Further, medical education has failed to train or even acquaint physicians in the treatment technologies that have been developed in behavioral medicine and health psychology over the past 15 years. Medical education as we know it had its origins in the Flexner Commission report of 1910, which established the dominance of allopathic medicine over homeopathic medicine, defined modern biomedicine, and outlined curricula for training physicians in the basic biological sciences. Psychology, as a basic science in medical education, certainly never was considered by the Flexner Commission but was considered at a conference on "The Relations of Psychology and Medical Education" just 1 year later, in 1911. At that conference, psychologists, including S. I. Franz and J. B. Watson, joined with physicians Adolf Meyer, E. E. Southard, and Morton Prince in proposing that the new science of psychology had much to offer medical education, if it could be made clinically relevant to the physician's practice (Thompson, 1991).
Medical Education
111
By 1950, Robert Felix, Director of the Institute of Mental Health of the Public Health Service, had described psychology as a basic science for public health, and Carlyle Jacobsen, Executive Dean for Medical Education at SUNY, Brooklyn, defined psychology as a basic science in medicine, comparable to basic biological and natural sciences such as physiology and anatomy (Thompson, 1991). By the early 1970s, psychology and other behavioral sciences became part of medical-school curricula. In 1972, a behavioral sciences section was added to the National Board of Medical Examiners, Part I, exam. However, a recent survey by the Association of Behavioral Sciences and Medical Education (ABSAME) of test items on the United States Medical Licensing Exam revealed a paucity of questions relevant to medically relevant basic research in the behavioral sciences. Since the National Boards purport to be reflective of what is taught in medical schools across the country, it is not surprising to find that behavioral science teaching in medical-school curricula is woefully inadequate, simplistic, and superficial. A survey of medical-school curricula (AAMC, 1991) and a survey of selected texts carried out by the Association of Medical School Professors of Psychology (AMSPP) reveal the following: (1) Less than 5% of medical-school curricula is devoted to basic behavioral sciences, i.e., reflective of basic science research developments. (2) Much of the material called "behavioral science" is actually introduction to clinical medicine, i.e., diagnosis, interviewing, clinical psychiatry, etc. (3) In major psychiatric textbooks the basic behavioral science content is a b o u t 10%, while in textbooks devoted only to behavioral sciences, the content is about 20%. (4) The scientific quality of what is taught about the behavioral sciences is simplistic, superficial, and not reflective of current research developments in the field, e.g., the typical chapter on "learning" is at the introductory undergraduate psychology level. (5) The prevalent medical conceptualization continues to be Cartesian dualism, e.g., note the numerous references to functional vs. organic. (6) Curricula are presented in a fragmented, discipline-specific, and departmentalized manner. (7) There is no comprehensive model which integrates biomedical and behavioral science subject matter. While the biopsychosocial model sensitized physicians to a diversity of variables, it did not
112
Carr
provide an integrating framework other than a linear link from cell to social system. It has been almost a half-century since faculty members at the University of Chicago first used the term "behavioral sciences" to describe a series of interdisciplinary conferences integrating biologic and social sciences (West, 1959). About the same time, educators at a conference in Ithaca, New York (Lidz, 1951) concluded that a more comprehensive and scientific understanding of human ecology was needed, advocating a position most succinctly stated several years later by psychiatrist Louis Jolyon West (1959, pp. 1075-1076): • . .We must not lose what is most valuable in our present professional training of physicians: the hard core of basic science and the intellcctual discipline of the scientific a p p r o a c h . Entirely consistent with this orientation is the thesis that behavioral sciences must be considered basic to the education of the physician of tomorrow if he is properly to meet his responsibilities to his profession, to his patients, and to himself.
SOLUTIONS Basic medical research continues to reveal a remarkably complex interaction of cognitive, biologic, environmental, and behavioral variables in response to psychological and physical stress• The health promotion literature shows that by integrating lifestyle modification, injury control, and environmental enhancement strategies, the health care professional can maximize treatment impact on the patient's health care (Stokols, 1992). Medical educators agree that physicians need to appreciate these complexities and the ubiquitous nature of their influence upon the patient. Thus, the practice of medicine requires expertise in both the behavioral and the biomedical sciences, and the goal of medical education becomes the understanding of biobehavioral relationships and the clinical application of that knowledge. It is imperative that the present and future medical-school curricula reflect the momentous changes taking place in current conceptualizations of health care. Curricula must be significantly improved beginning with the updating of behavioral science research findings relevant to medical practice and their integration with biomedical knowledge in a comprehensive biobehavioral model. Toward this end, the ABSAME, the AMSPP, and the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) have initiated a collaborative curriculum review process in an attempt to formulate a guide to behavioral sciences curricula for medical-school programs. In-
113
Medical Education
dependently, the Pew Health Professions Commission (O'Neil, 1993) has also undertaken a behavioral sciences curriculum reform project addressing the same concerns raised here. These two independent efforts, one involving an interdisciplinary group of behavioral science teachers "in the trenches" and the other an interdisciplinary group of senior-level university, government, and congressional leaders, attest to both the seriousness of the problem and the universality of concern over the need for reform. If these efforts are to become more than just tedious exercises in redefining the "5000 facts" required of every medical student, the curriculum equivalent of rearranging the deck chairs on the Titanic, we must clearly address the central issue of a comprehensive model by which behavioral and biomedical knowledge are integrated. Until the behavioral sciences become a truly integral component of medical education as well as health care, we will continue to produce physicians who may affirm the importance of the behavioral sciences but lack both the knowledge and the tools for applying them or making appropriate referrals to psychologists in the medical setting. On the practical side, psychologists in medical settings can work at the grassroots level to educate their physician colleagues about the behavioral sciences and psychology. At formal teaching hospitals, psychologists oi psychology departments should become part of curriculum committees in any or all medical or surgical teaching services. Whatever the medical setting, teaching hospital, community hospital, outpatient service, or "medical" office building, the psychologist can offer to present grand rounds on a particular psychosocial issue, offer literature on medical cost offset of psychological services, or seek to educate the practicing physician or new intern, over lunch, about the robustness of the scientific or clinical literature concerning psychology in health care.
REFERENCES AAMC (1992). A A M C directory of American medical ed,cation 1991-92. Washington, DC: Association of American Medical Colleges. Engle, G. (1977). The need for a new medical model: A challenge for biomedicine. Science 196, 129-136. Lalonde, M. (1974).A new perspective on the health of Canadians. Ottawa: Ministry of National Health and Welfare. Lidz, T. (1955). The 1951 Ithaca Conference on Psychiatry in Medical Education. Journal of Medical Education, 30:689-697. O'Neil, E. H. (1993). Health professions education for the fiaure: Schools b1 service to the nations. San Francisco: Pew Health Professions Commission. Stokols, D. (1992). Establishing and maintaining healthy environments: Toward a social ecology of health promotion. American Psychologist, 47, 6-22.
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Thompson, R. J. (1991). Psychology and the health care system: Characteristics and transitions. In J. J. Sweet, R. H. Rozensky, & S. M. Tovian (Eds.), Handbook of clinical psychology in medical settings (pp. 11-25) New York: Plenum Press. U.S. Department of Health, Education, and Welfare (1979). Healthy people: The Surgeon General's report on health promotion and disease prevention. Washington, DC: DHEW (PHS) Publication No. 79-55071. West, L. J. (1959). Behavioral sciences in the medical school curriculum. Journal of Medical Education, 34, 1070-1076.
Psychology, Behavioral Sciences, and tKe Challenge to Medical Education I J o h n E. Carr 2
It is generally agreed that the health care system is hz crisis despite reform efforts over the past two decades. Evidence is presented which suggests that medical education has failed successfully to integrate medically relevant behavioral science research findings into medical school curricula or train physicians & the application of behaviorally based treatment technologies. Psychologists in nzedical education setth~gs have the opportunity to hnpact medical education and foster psychology's role in health care. If psychology fails to respond to this opportunity, we cannot then complain of the inevitable consequences. KEY WORDS: medical education; health psychology.
INTRODUCTION In the 1970s the Canadian Lalonde Commission (1974) and the U.S. Surgeon General (1979) presented unassailable evidence that Americans and Canadians were at greater risk of dying fl:om behavioral factors, unhealthy lifestyles, environmental hazards, and inadequacies in the health care system than from biological pathology. Simultaneously Engle (1977) called for the teaching of a more comprehensive "biopsychosocial model" of medicine. These calls for reform underscored the importance of preventative care and gave birth to the emerging fields of behavioral medicine and health psychology. Burgeoning research in these areas was complemented by in1An earlier version of this paper was presented at tile annual meeting of the American Assocation of Medical Colleges, Washington, DC, November 1993. 2Division of Behavioral Medicine, Department of Psychiatry &Bchavioral Sciences, University of Washington, D-45, Seattle, Washington 98195. 109
1068-9583/9410600-0109S07.0010© 1994 Plenum PublishingCorporation
110
Carr
creasing collaboration between physicians and psychologists in neuropsychology, pain management, eating disorders, sexual dysfunction, headaches, stress disorders, treatment compliance, and management problems in a wide range of chronic diseases such as cancer, diabetes, and AIDS. Yet two decades later, we find a U.S. health care system in crisis, including an overemphasis on expensive hospital care, surgery, and other high-tech treatments; limited payment; for selected treatments; and an emphasis on predominantly physical vs. psychological complaints. We find a system that reinforces somatization, biases epidemiological and treatment outcome data, and invites financial abuse and administrative mismanagement. We find health promotion, prevention, and behavior change programs as well as services for the elderly, children, youth, families, and the underinsured underemphasized or ignored. H o w do we explain this seeming contradiction? Given the evidence, why do we find change only in limited areas of clinical practice and no sign that this has impacted upon the health care system as a whole? Why is it that it will take literally an act of Congress to get the U.S. health care system to respond to the mandates of the 1979 Surgeon General's report?
BEHAVIORAL SCIENCES IN MEDICAL EDUCATION I submit that the answer lies in a massive failure of medical education. Despite lip service to the contrary, medical education has failed to teach our physicians in training the large body of behavioral science research findings that apply to health care. Further, medical education has failed to train or even acquaint physicians in the treatment technologies that have been developed in behavioral medicine and health psychology over the past 15 years. Medical education as we know it had its origins in the Flexner Commission report of 1910, which established the dominance of allopathic medicine over homeopathic medicine, defined modern biomedicine, and outlined curricula for training physicians in the basic biological sciences. Psychology, as a basic science in medical education, certainly never was considered by the Flexner Commission but was considered at a conference on "The Relations of Psychology and Medical Education" just 1 year later, in 1911. At that conference, psychologists, including S. I. Franz and J. B. Watson, joined with physicians Adolf Meyer, E. E. Southard, and Morton Prince in proposing that the new science of psychology had much to offer medical education, if it could be made clinically relevant to the physician's practice (Thompson, 1991).
Medical Education
111
By 1950, Robert Felix, Director of the Institute of Mental Health of the Public Health Service, had described psychology as a basic science for public health, and Carlyle Jacobsen, Executive Dean for Medical Education at SUNY, Brooklyn, defined psychology as a basic science in medicine, comparable to basic biological and natural sciences such as physiology and anatomy (Thompson, 1991). By the early 1970s, psychology and other behavioral sciences became part of medical-school curricula. In 1972, a behavioral sciences section was added to the National Board of Medical Examiners, Part I, exam. However, a recent survey by the Association of Behavioral Sciences and Medical Education (ABSAME) of test items on the United States Medical Licensing Exam revealed a paucity of questions relevant to medically relevant basic research in the behavioral sciences. Since the National Boards purport to be reflective of what is taught in medical schools across the country, it is not surprising to find that behavioral science teaching in medical-school curricula is woefully inadequate, simplistic, and superficial. A survey of medical-school curricula (AAMC, 1991) and a survey of selected texts carried out by the Association of Medical School Professors of Psychology (AMSPP) reveal the following: (1) Less than 5% of medical-school curricula is devoted to basic behavioral sciences, i.e., reflective of basic science research developments. (2) Much of the material called "behavioral science" is actually introduction to clinical medicine, i.e., diagnosis, interviewing, clinical psychiatry, etc. (3) In major psychiatric textbooks the basic behavioral science content is a b o u t 10%, while in textbooks devoted only to behavioral sciences, the content is about 20%. (4) The scientific quality of what is taught about the behavioral sciences is simplistic, superficial, and not reflective of current research developments in the field, e.g., the typical chapter on "learning" is at the introductory undergraduate psychology level. (5) The prevalent medical conceptualization continues to be Cartesian dualism, e.g., note the numerous references to functional vs. organic. (6) Curricula are presented in a fragmented, discipline-specific, and departmentalized manner. (7) There is no comprehensive model which integrates biomedical and behavioral science subject matter. While the biopsychosocial model sensitized physicians to a diversity of variables, it did not
112
Carr
provide an integrating framework other than a linear link from cell to social system. It has been almost a half-century since faculty members at the University of Chicago first used the term "behavioral sciences" to describe a series of interdisciplinary conferences integrating biologic and social sciences (West, 1959). About the same time, educators at a conference in Ithaca, New York (Lidz, 1951) concluded that a more comprehensive and scientific understanding of human ecology was needed, advocating a position most succinctly stated several years later by psychiatrist Louis Jolyon West (1959, pp. 1075-1076): • . .We must not lose what is most valuable in our present professional training of physicians: the hard core of basic science and the intellcctual discipline of the scientific a p p r o a c h . Entirely consistent with this orientation is the thesis that behavioral sciences must be considered basic to the education of the physician of tomorrow if he is properly to meet his responsibilities to his profession, to his patients, and to himself.
SOLUTIONS Basic medical research continues to reveal a remarkably complex interaction of cognitive, biologic, environmental, and behavioral variables in response to psychological and physical stress• The health promotion literature shows that by integrating lifestyle modification, injury control, and environmental enhancement strategies, the health care professional can maximize treatment impact on the patient's health care (Stokols, 1992). Medical educators agree that physicians need to appreciate these complexities and the ubiquitous nature of their influence upon the patient. Thus, the practice of medicine requires expertise in both the behavioral and the biomedical sciences, and the goal of medical education becomes the understanding of biobehavioral relationships and the clinical application of that knowledge. It is imperative that the present and future medical-school curricula reflect the momentous changes taking place in current conceptualizations of health care. Curricula must be significantly improved beginning with the updating of behavioral science research findings relevant to medical practice and their integration with biomedical knowledge in a comprehensive biobehavioral model. Toward this end, the ABSAME, the AMSPP, and the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) have initiated a collaborative curriculum review process in an attempt to formulate a guide to behavioral sciences curricula for medical-school programs. In-
113
Medical Education
dependently, the Pew Health Professions Commission (O'Neil, 1993) has also undertaken a behavioral sciences curriculum reform project addressing the same concerns raised here. These two independent efforts, one involving an interdisciplinary group of behavioral science teachers "in the trenches" and the other an interdisciplinary group of senior-level university, government, and congressional leaders, attest to both the seriousness of the problem and the universality of concern over the need for reform. If these efforts are to become more than just tedious exercises in redefining the "5000 facts" required of every medical student, the curriculum equivalent of rearranging the deck chairs on the Titanic, we must clearly address the central issue of a comprehensive model by which behavioral and biomedical knowledge are integrated. Until the behavioral sciences become a truly integral component of medical education as well as health care, we will continue to produce physicians who may affirm the importance of the behavioral sciences but lack both the knowledge and the tools for applying them or making appropriate referrals to psychologists in the medical setting. On the practical side, psychologists in medical settings can work at the grassroots level to educate their physician colleagues about the behavioral sciences and psychology. At formal teaching hospitals, psychologists oi psychology departments should become part of curriculum committees in any or all medical or surgical teaching services. Whatever the medical setting, teaching hospital, community hospital, outpatient service, or "medical" office building, the psychologist can offer to present grand rounds on a particular psychosocial issue, offer literature on medical cost offset of psychological services, or seek to educate the practicing physician or new intern, over lunch, about the robustness of the scientific or clinical literature concerning psychology in health care.
REFERENCES AAMC (1992). A A M C directory of American medical ed,cation 1991-92. Washington, DC: Association of American Medical Colleges. Engle, G. (1977). The need for a new medical model: A challenge for biomedicine. Science 196, 129-136. Lalonde, M. (1974).A new perspective on the health of Canadians. Ottawa: Ministry of National Health and Welfare. Lidz, T. (1955). The 1951 Ithaca Conference on Psychiatry in Medical Education. Journal of Medical Education, 30:689-697. O'Neil, E. H. (1993). Health professions education for the fiaure: Schools b1 service to the nations. San Francisco: Pew Health Professions Commission. Stokols, D. (1992). Establishing and maintaining healthy environments: Toward a social ecology of health promotion. American Psychologist, 47, 6-22.
114
Carr
Thompson, R. J. (1991). Psychology and the health care system: Characteristics and transitions. In J. J. Sweet, R. H. Rozensky, & S. M. Tovian (Eds.), Handbook of clinical psychology in medical settings (pp. 11-25) New York: Plenum Press. U.S. Department of Health, Education, and Welfare (1979). Healthy people: The Surgeon General's report on health promotion and disease prevention. Washington, DC: DHEW (PHS) Publication No. 79-55071. West, L. J. (1959). Behavioral sciences in the medical school curriculum. Journal of Medical Education, 34, 1070-1076.
