Satterfield, Jason M. PhD; Mitteness, Linda S. PhD; Tervalon, Melanie MD; Adler, Nancy PhD
Dramatic global-migration patterns over recent decades have forever changed the racial, ethnic, social, and cultural makeup of the people of the United States. Simultaneously, the patterns of disease and risk factor distribution within the U.S. population are changing in ways that accentuate the role of lifestyle, behavior, and social and economic differences in the onset and outcomes of disease. In response to these and other realities, medical education is in the midst of a sea change. Over 50% of U.S. medical schools are currently revising their undergraduate curricula to meet the changing needs of society and medicine.1–3 Some reforms focus on pedagogical methods (e.g., problem-based learning versus lectures) whereas others incorporate new developments in the basic and clinical sciences. These changes are concurrent with a growing awareness of the importance of social and behavioral factors on health and health disparities. As discussed in this article, the patients treated by tomorrow’s doctors will be older, more culturally and ethnically diverse, and suffering from chronic diseases that have social, behavioral, and environmental roots. At the same time, the scientific knowledge and “technology” of behavior and health have also greatly advanced in recent years. These advances make possible new curricular content to teach physicians-in-training to deliver more effective, efficient, and socially just clinical care.4–9 In short, the social and behavioral sciences—whether as useful adjuncts, process tools, or as scientific content in their own right—offer substantial promise for educational reform.10–13
In this article, we focus on the social and behavioral sciences (SBS) taught in the first portion of the new undergraduate medical curriculum at the University of California, San Francisco (UCSF), including medical anthropology, sociology, health psychology, behavioral medicine, public health, and other related disciplines. First, we provide a brief description of the entire new curriculum and the general principles that have helped guide curricular development for all disciplines. Second, we describe the development of core longitudinal themes and content for the social and behavioral sciences in the first two years of undergraduate medical education. Third, we provide content examples from the Prologue block to illustrate the pedagogical methods that have been used to teach SBS content in its initial cycle, including how this material is integrated with the basic and clinical sciences. Finally, we discuss evaluations of the new curriculum and future directions for further curricular reform. We plan to offer a more detailed description of SBS in years 3 and 4 in future publications.
The UCSF Undergraduate Medical Curriculum
A dramatically new undergraduate medical curriculum was launched at UCSF in September 2001.1,14 “The interaction of biology and the environment in determining health” was established as the foundational theme for the new curriculum, which was designed to model full interdisciplinary integration and to emphasize clinical and case-based material, evidence-based teaching, and small-group learning to encourage active thinkers. These core guiding principles helped make SBS integration possible. Though in many ways unique, the new curriculum greatly benefited from the work of other innovative reforms, including the New Pathways curriculum at Harvard, the Double Helix curriculum at Rochester, and more focal reform projects such as UME-21.15–17
The new UCSF curriculum replaced the traditional undergraduate medical structure of two years of basic sciences plus two years of clinical rotations with a model divided into three stages spanning four years: the Essential Core, the Clinical Core, and Advanced Studies. The first two years of basic science classes were replaced by courses taught in 16 months of integrated blocks, each centered on clinical cases. Cases taken from primary, secondary, and tertiary care illustrate not only clinical manifestations of disease, but also provide an integrative vehicle for basic, social, and behavioral sciences. The second phase of the curriculum, the Clinical Core, encompasses 44 weeks of clinical clerkships interspersed with four weeks of intersessions, an important innovation that provides critical time for reflection, integration, and consolidation.18 The third phase, Advanced Studies (34 weeks), gives students a wide selection of elective choices. These include the option to return to basic science, more time for independent scholarly and creative pursuits, and opportunities to gain teaching skills and to experience subspecialty rotations.
An overarching goal of the new curriculum is to practice “evidence-based teaching” using educational literature that describes how medical knowledge and skills can best be learned, retained, and applied.19–21 Essential Core lectures normally do not exceed two hours per day usually followed by two hours of small group or lab work. Students are encouraged to be active learners through the use of problem-based learning, “integrated learning modules” (electronic self-guided study materials), and the use of a fully interactive, Web-based curriculum. The order and length of each block were collaboratively determined by a core faculty steering committee based on a number of factors including logical progression of learning objectives, maximal stimulation of student interest, faculty schedules, and facility availability.
The Essential Core consists of eight integrated blocks: Prologue; Major Organ Systems (Cardiovascular, Pulmonary, Renal); Cancer; Brain, Mind, and Behavior; Infection, Immunity, and Inflammation; Metabolism/Nutrition; Life cycle; Integration-Consolidation; and one 16-month longitudinal block called Foundations of Patient Care (FPC).22 Physical examination skills, clinical reasoning and communication, professional development, and the physician–patient relationship are primarily taught in FPC. Other important longitudinal themes appear throughout the curriculum including genetics, medical ethics, and geriatrics. Each block is developed and administrated by a faculty team that includes a basic scientist, a clinician, and a behavioral and/or social scientist plus other relevant faculty. Each major department is given “ownership” of a block, with all blocks reporting to an Essential Core steering committee that oversees coordination, facilitates collaboration, and drives quality improvement.1,14 Coordination among faculty within and between blocks has been promoted with the use of Ilios, a new electronic database found at 〈http://medschool.ucsf.edu/ilios/〉. All teaching materials are first posted in the Ilios database and then made directly available to students through the electronic curriculum.
Social and Behavioral Sciences in the New Curriculum
The integration of SBS into the new curriculum was seen as essential for several reasons. First, changes in the leading causes of death point to the significant role of behavior in the treatment and prevention of disease, including heart disease, cancer, cerebrovascular disease, accidents, chronic obstructive pulmonary disease, pneumonia and influenza, diabetes, suicide, liver disease, and HIV.23 McGinnis and Foege23 analyzed the leading distal causes of death, finding that nearly half of preventable deaths are due to behavioral factors. The primary culprits are tobacco use, unhealthy diet and activity patterns, alcohol misuse, preventable exposure to microbial agents (e.g., failure to get an immunization, not washing one’s hands), exposure to toxic agents, misuse of firearms, risky sexual behavior, motor vehicle accidents, and illicit use of drugs.
The second rationale for inclusion of more behavioral and social material was the changing composition and needs of the public to be served. Twenty-eight percent of the current U.S. population is nonwhite. By 2050, nearly half the population will be nonwhite.24 In the San Francisco Bay Area, nearly 30% of residents are foreign born, and that number is likely to rise. This ethnic and cultural diversity has raised professional awareness of the risks of miscommunication and ineffective care.8 These challenges require greater skills in the practice of cultural humility and cultural competence, communication, negotiation, and motivational enhancement.
From 1990–2020, the proportion of people aged 65 to 74 years is projected to grow by 74% along with large increases in the 75-and-older age group.24 An aging population requires greater understanding of chronic disease management and geriatric medicine. This, in turn, requires training in prevention, behavior change, health policy, and skills in working with multidisciplinary health care teams. Geriatric medicine also requires understanding the special challenges and limitations faced by subgroups of elderly patients who are economically and socially disadvantaged and may have fewer supports for care.25
The third reason for SBS inclusion was the growing body of literature supporting “mind–body medicine.” Stress has been linked to a wide variety of diseases and health-compromising behaviors, including cardiovascular disease, chronic obstructive pulmonary disease, smoking, and possibly cancer.26–28 Exposure to potential stressors and the subjective experience of stress are strongly influenced by a patient’s social location and impinging social forces. Coping strategies are likewise influenced by sociocultural factors including social learning, cultural values, and available environmental resources. Interventions to reduce stress-related diseases must include a solid understanding of these important psychological and sociocultural variables.
Patients’ interest in mind–body medicine is rivaling traditional medical sciences. People from all walks of life rely on a variety of alternative and complementary therapeutic strategies to maintain health and treat illness. Medical science is challenged to interact with these other health care systems in ways that foster patients’ well-being. These include eliciting a patient’s disclosure of his or her complementary and alternative health practices, appropriating alternative strategies that are beneficial (e.g., meditation), and advising patients about therapies that may have untoward negative effects (e.g., use of ephedra in “natural” remedies29).
Finally, the inclusion of the social and behavioral sciences in the new curriculum promotes more humane medical education and practice. Today’s medical students are expected to learn and apply an unprecedented amount of medical science and technology to an increasingly diverse and medically complex patient population. With limited time and support from faculty, they must simultaneously learn to cope with intensely emotional and sometimes frightening clinical scenarios (e.g., death and dying). Not surprisingly, students have routinely shown decreases in empathy and humanism over the course of their training.30–33 For similar reasons, burnout among trainees has become a common and substantial problem.34 Social and behavioral sciences teach important coping skills, provide a framework for integrating and applying information, and affirm humanistic principles that may help offset the damaging “hidden” curriculum in the clinical years and beyond.35–39
We were fortunate in obtaining two generous grants from the California Endowment to support the development of the curriculum. The grants provided legitimacy for our efforts and an outside mandate for inclusion of the material. The grants allowed us to support the time needed for faculty to participate in the design of each block in the Essential Core, including the development of longitudinal themes and key learning objectives for the overall Essential Core, for each block, and for each relevant lecture or small group. One or two SBS faculty served on each block design committee and sometimes served as block codirectors to insure inclusion of SBS content and to assist with overall course administration. The personal relationships between basic scientists, clinicians, and social and behavioral scientists that developed over the course of each block have been important for developing faculty buy-in and facilitating integration. We also formed an SBS committee composed primarily (but not exclusively) of medical anthropologists, health psychologists, and clinicians interested in social and behavioral factors in health. The committee is overseeing the full curriculum and continues to refine our longitudinal plan.
Before developing specific SBS course content, we compared the cultures of medical education and SBS education and adapted our teaching approaches to better suit a medical culture.40 For example, medical education tends to emphasize practical facts followed by experiential learning whereas SBS education tends to emphasize theory and ways of thinking. Areas of focus, implicit values, and preferred teaching methods in these two traditions also vary. SBS takes a more holistic perspective and places more emphasis on care processes and prevention. And, finally, the language and terminology used by each tradition differ. “Culturally competent” teaching required careful attention to these differences and sensitivity to the values and traditions of biomedical education. SBS representatives often served as “cultural interpreters” between SBS teaching faculty and the basic or clinical scientists leading each block to minimize misunderstandings about teaching methods and philosophies.
Given the time and space pressures of an ambitious curriculum, only essential SBS content was included in the Essential Core. For each block, the SBS committee asked, “What are the essential attitudes, knowledge, and skills from the social and behavioral sciences that each medical student must know at this point in his or her professional development?” We used outside resources including expert consultations, national standards for culturally and linguistically appropriate services (CLAS) in health care,41 the Promoting, Reinforcing, and Improving Medical Education (PRIME) culture and diversity curriculum,42 seminal Institute of Medicine reports,5,8 and commercially available teaching materials.43–46
We identified five broad sociocultural themes and three behavioral themes to span all nine Essential Core blocks. These themes are (1) patterns of health and disease across populations, (2) ethnicity, gender, age, socioeconomic status, and health, (3) the cultures of medicine and health care institutions, (4) physician–patient relationships, and (5) the experience of illness and/or health. The three behavioral themes are (1) stress, distress, and coping, (2) understanding and facilitating behavior change, and (3) personality and social context. Where the sociocultural and behavioral themes overlap, collaborative approaches were used to design teaching content and format.
Because sociocultural and behavioral themes were found to be relevant for every block, longitudinal coordination was important to prevent redundancies and to build SBS content in a logical order. Several guiding principles helped to order content for each theme. Each theme starts with basic attitudes and knowledge as informed by block objectives and active clinical cases but quickly moves to complex, clinical applications. Sharing epidemiologic data, case studies, and master clinician testimonials demonstrated clinical significance and relevance to medical practice (see the Prologue example in the next section). Content was also ordered to foster the interplay of knowledge, skill building, experiential learning, and attitude shifts. Whenever possible, evidence-based medicine was emphasized. Thus, content was placed in a particular block based on the strength of the SBS literature on the topic. At the same time, personal and patient narratives were used throughout the curriculum to demonstrate the human face of the concepts being taught.
A partial timeline and sample classes for each theme can be found in Tables 1 and 2. Full block calendars, session outlines, learning objectives, and samples of teaching materials can be found at 〈http://medschool.ucsf.edu/ilios/〉.
Illustration of Process and Content: The Prologue Block
As an illustrative example, we provide below some of the specific behavioral content for the Prologue, the introductory Essential Core block. The Prologue was intended both as an engaging overview of medicine and also an opportunity to bring students from diverse academic backgrounds “up to speed” in the basic conceptual arenas central to later blocks. It begins with a dramatic reenactment: A young man (Mr. Danovic) is brought into the emergency department after a serious motorcycle accident that is alcohol related. Mr. Danovic’s medical care is followed over the eight weeks of the Prologue, ending with the creation of his hospital discharge plan. All lectures and small groups are built from the latest reenacted chapter of the Danovic case. Social and behavioral scientists helped to author the case and included psychosocial issues of family dynamics, social support, unemployment, socioeconomic status, possible psychiatric illness and substance abuse, behavior change and preventive health issues, and difficult social work needs. Overall, SBS content for the Prologue constitutes about 10% to 15% of lecture and small-group time.
The SBS Prologue classes were developed to highlight the psychosocial issues relevant to the Danovic case while introducing our core longitudinal themes. A chronological list of all SBS Prologue classes can be found in List 1, including the “chapters” in the Danovic case developed and enacted by SBS faculty. Sample objectives for the Health Risk Behavior lecture and the Culture in Medicine lecture are listed in List 2.
The behavioral science materials in the Prologue provide a broad overview of the role of behavior in health and introduce the three behavior longitudinal themes. Students are introduced to the biopsychosocial model, including the science of understanding behavior and its interdependence with the basic and clinical sciences.47–48 Students learn basic epidemiology of the proximal and distal causes of death and are introduced to the Stages of Change and Health Beliefs Model as a means of understanding and eventually changing health-related behaviors. Basic stress physiology and psychoneuroimmunology are introduced in the context of the Mr. Danovic case. And, finally, in small groups and lectures, students explore the role of the physician in behavioral interventions and design a treatment protocol and discharge plan for the case.
The priorities for sociocultural material for the Prologue were threefold. First, we introduced students to the culture of medicine and encouraged them to approach medical school as an education in the varying ways health care systems work as well as an education in the scientific underpinnings of medical practice. This was done by analyzing the social organization of emergency medicine and the complexities of posthospital care. Second, we introduced students to the five major sociocultural themes (listed earlier) that would be elaborated in the succeeding blocks. In particular, we challenged preconceptions about concepts of “culture” and “ethnicity”—namely that culture includes more than ethnicity and understanding culture goes far beyond placing patients into stereotypical categories. A small group exercise where the students observed a videotaped physician–patient interaction that gradually revealed three distinct constellations of “cultural” material demonstrated the importance of moving beyond stereotypes to understanding an individual patient’s social context and background. Third, we introduced the practice of focusing on the human side of medicine and the experience of patients, a practice carried through all the blocks. In the Prologue, this is done via an in-class interview with a patient who is recovering from major trauma.
We have used a variety of methods to integrate SBS content. Throughout the Prologue, we intersperse lectures by SBS faculty and small groups led by SBS faculty between classes taught by faculty in other disciplines, and have inserted SBS “teachable moments” into other non-SBS classes with instructions for delivery. For example, when students are learning about the basic physiology of Mr. Danovic’s chronic and acute pain (given by physiologists), they also learn how depression and substance abuse can be linked to pain. After the pain physiology lecture, students see a reenactment showing how Mr. Danovic’s pain and ways of coping affected his interactions with his doctors and family. A mock discharge conference that included representation from social work, behavioral medicine, nursing, rehabilitation medicine, and primary care demonstrates how various disciplines would approach the challenge of providing for Mr. Danovic’s ongoing care. And, finally, integrated block examinations are often built around clinical case stems, allowing each discipline to assess mastery of learning objectives around a common case.
List 1 Social and Behavioral Sciences Lectures and Small Groups in the Introductory Block of the Essential Core of the UCSF Undergraduate Medical Curriculum, 2003
The Biopsychosocial Model
Culture and the Emergency Department*
Socioeconomic Status and Health
Health Risk Behaviors*
Stress and Wound Healing
Mr. Danovic’s Discharge Conference (panel presentation)
Live interview of trauma patient
Social Location and Social Forces
Biopsychosocial Issues in Action
Mr. Danovic’s Discharge Plan
*See List 2 for details about this lecture.
The quality of the SBS curriculum has been evaluated by examining student performance and using student “town hall” meetings, focus groups, and electronic student evaluations (“e-value”). In 2001–2002, an SBS student advisory board gathered feedback on SBS classes and provided suggestions for future improvements. Student performance on SBS content was evaluated through standard multiple-choice questions, short-answer questions, essay examinations, and special applied projects such as dietary self-monitoring, writing a biopsychosocial discharge plan, role plays for smoking cessation, and dietary counseling for a diabetic patient from a culture different from the student’s own. In the near future, a competency-based, comprehensive assessment for SBS and other objectives will be implemented at the end of students’ second year of medical school using standardized patients and adapted objective structured clinical examinations.49 Faculty satisfaction and opinions about the new curriculum and its effects will also be assessed in the near future.
To date, students have had widely divergent attitudes toward the value of SBS. Negative comments mostly regarded the quantity, relevance, or teaching methods used for SBS content. Some overwhelmed students were more anxious about learning the basic and clinical sciences and resented having to invest time in the social and behavioral sciences, which they perceived as mere “common sense.” Others thought a much greater emphasis on anatomy and less on SBS would serve them better in clinical practice. Still others thought the qualitatively different SBS content in some lectures was better suited for small-group discussions.
List 2 Sample Learning Objectives in the Introductory Block of the Essential Core of the UCSF Undergraduate Medical Curriculum, 2003
Lecture: Health Risk Behaviors
Students should be able to:
1. Describe the role of behavior in contributing to many of the leading causes of disability and death.
2. Describe social/environmental and psychological obstacles to individuals engaging in health-promoting behavior and why individuals may engage in known health-compromising behaviors.
3. Describe social and psychological factors that promote behavior change. Understand why health education is necessary but not sufficient to promote behavior change.
4. Compare and contrast the Health Beliefs Model and the Stages of Change Model, noting the relative strengths and weaknesses of each.
Lecture: Culture and the Emergency Department
Students should be able to:
1. Describe the differences between cultural knowledge, cultural awareness, and skills useful for addressing cultural issues in patient care.
2. Draw the model that links social and cultural processes with individual behaviors.
3. Define each of the core concepts in the culture model.
4. Specify three to five elements of social location and describe at least one way in which each is relevant to work in an emergency department.
5. Specify at least two social forces that affect medical practice in emergency departments. Be prepared to defend your position on their relative importance.
6. List three examples of the utility of the cultural model in understanding the functioning of an emergency department.
At the same time, many students were enthusiastic about SBS content. Some indicated that the SBS emphasis reflected their reasons for entering medicine and most closely touched the meaning of medical practice. Other students expressed their appreciation for the “explicit and nonapologetic” inclusion of the “heart and soul” of medicine in the curriculum.
Two basic issues are evident in the students’ responses. First, students vary widely in their backgrounds. Approximately one third of the students have undergraduate majors in the social or behavioral sciences. Some have prior professional experience as social workers, psychologists, community outreach workers, etc. But a large percentage of students come from traditional premed tracks and have almost no background in these disciplines. Providing introductory level instruction for these students while serving the needs of the more advanced students is a complex dance. To our knowledge, the background composition of our classes has not changed since the introduction of the new curriculum, and we anticipate continued professional and personal diversity in our students.
The second issue in students’ responses to SBS material relates to their preconceptions about medicine. Many starting medical students have limited clinical experience, and many of their assumptions have been molded by popular media, whether the “discovery of the week” in the news media or the “drama of the week” on television. Combined with an optimistic confidence in the power of science, these assumptions foster a common belief that if they simply learn all the hard science well, they will be good physicians. The struggles of physicians to assist patients with complex behavior change or to work with patients whose cultural backgrounds are vastly different from their own are more subtle, less dramatic, and more challenging than the popular images of medicine. Until they have real clinical experience, some medical students don’t know what to do with parts of the SBS material. In the current curriculum, students do get earlier clinical exposure than was true previously, but it may still take some time for them to see enough patients to appreciate the value of SBS concepts and skills.
Limitations and Future Directions
Having been through one cycle of the new curriculum, we have identified significant areas for improvement. These areas, similar to those faced by other medical schools integrating SBS into their curricula, include the need for further work on the presentation and integration of complex materials, the need for improved methods of evaluating student learning, and the need for faculty recruitment and development.40
We currently have uneven coverage of SBS themes across blocks and are repairing gaps and redundancies as we do the second round of each block. The longitudinal integration of material across blocks also remains a work in progress. The SBS teaching methods will most likely continue to expand beyond the traditional lecture and small group formats to include special projects, guided patient contacts, and supplemented learning through more in-depth SBS electives. We are also addressing the integration of SBS content into the clinical clerkships and advanced study year.
The SBS faculty sometimes had difficulty relating to the traditional medical school syllabus, which has little to no outside readings and little emphasis on theory. The faculty members feared a “spoon-feeding” approach would engender superficial learning, and some students were, in fact, critical of the syllabus’s lack of depth and complexity. In the future, the acceptance of syllabus content and depth is likely to change as both the cultures of biomedicine and SBS evolve by challenging and responding to one another.
Difficulties in adapting SBS material for the traditional culture of medical education also emerged in assessment strategies. Overreliance on standard multiple-choice examinations encouraged rote memorization rather than active, integrative learning. There was insufficient time for important, individual reflection required to truly understand and internalize many of the sociocultural and behavioral constructs. We are considering new teaching and assessment methods including initial surveys of attitudes, time for guided self-reflection, and a focus on students’ applying social-cultural and behavioral constructs to themselves and their patients.
Experienced clinicians are often the most receptive colleagues for SBS material, because they recognize that the topics and issues are central to clinical practice. Basic biological science faculty often have little exposure to the complicated social worlds of medical practice, limiting their ability to evaluate SBS material. This can lead to misunderstandings based on differing traditions of scientific method rather than on more substantive issues. Joint faculty development and the coauthoring of clinical teaching cases may facilitate a common language and understanding. The cofacilitation of FPC small groups by SBS and clinical faculty and their spillover into preceptor training and debriefing may serve as an important model to extend to the third year of medical school and beyond.22
We need to build a larger core of trained SBS teaching faculty, particularly those who reflect the diversity of the students and patients we serve. Lack of adequate diversity among faculty may convey a subtle message that SBS principles have not truly been translated into institutional practice. Providing financial support for faculty is an additional challenge. Although UCSF is a medical sciences campus, most SBS faculty members are grant-supported graduate school faculty, which limits their ability to devote time to education. The California Endowment grant was critical in supporting the time-consuming process of developing a new curriculum. Fortunately, the demands of teaching it are substantially less, though not insignificant. Moreover, many faculty are researchers with limited experience as medical educators. They would benefit from formal coursework in pedagogical methods and exposure to clinical teaching settings. This would build stronger relationships with clinical teaching faculty, enhance the SBS faculty’s ability to do effective translational teaching, and increase their authority for teaching in the medical curriculum. In addition, we are encouraging our faculty to participate in faculty development courses and are initiating a peer review process for most teaching activities.
Despite the substantial challenges we have encountered, we remain excited about the potential of integrating the social and behavioral sciences in undergraduate medical education. By applying SBS knowledge and principles, students trained in new integrated curricula may ultimately practice medicine in a more equitable, efficient, and effective way. Although the curricula of UCSF and other medical schools may need further evolution, an open sharing of this ongoing educational process could be an important contribution to the nascent national dialogue about medical education in the 21st century.
The authors acknowledge the important support and contributions of Haile Debas, David Irby, Helen Loeser, Jessica Muller, Elissa Epel, Lauri Pasch, Shelly Adler, Judith Barker, and other members of the Culture and Behavior Committee. This project was supported by grants from the California Endowment, The California Wellness Foundation, and the UCSF Academy of Medical Educators.
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