Educational Resources
 
Our professional education committee is in the process of creating new curricular materials and initiatives in psychosomatic medicine for medical education. As part of these efforts, we produced a "white paper" that we thought would be of interest to our members. We hope that many of you who are members of your medical school curriculum committees will be able to use this outline as a foundation for expanding psychosomatic education at your institution. If you are not members of a curriculum committee, please consider joining and begin advocating for change! If you are interested in joining the professional education committee, please email Peter Halperin at phalperin@notes.cc.sunysb.edu

Designing and Implementing a Comprehensive, Integrated, Longitudinal Medical School Curriculum in Biopsychosocial Medicine

Dennis H. Novack, M.D.

Shari R.Waldstein, Ph.D.,

Douglas A Drossman, M. D.,

Barbara Schindler, M.D.

Herbert Ochitill, M. D.

For the Professional Education Committee, American Psychosomatic Society,

In 1977, George Engel challenged the medical profession to turn from a strict biomedical model of education and practice toward a more comprehensive biopsychosocial model. The biopsychosocial model allows clinicians to understand and use their knowledge of how psychological and social factors contribute to and interact with biological factors in the prevention, onset, maintenance and resolution of patients' illnesses. (1) However, though progress has been made in medical education, surveys of medical curricula reveal that much remains to be done before Engel's challenge is met. (2, 3)

There is a great need for physicians to practice medicine from a biopsychosocial perspective. Modifiable behaviors such as smoking, alcoholism, drug addiction and unhealthy diet and activity patterns are etiologic in the leading causes of death in this nation. (4) Many other psychosocial factors are related to morbidity and mortality of a wide variety of chronic illnesses.(5-8) For example, hostility, anxiety, depression and low levels of social support may be risk factors for the development of cardiovascular disease. (9, 10) Depression after an MI is associated with increased health care costs, decreased quality of life, worse adherence to medical therapy and increased mortality. (11-14)

It has been well known for years that psychosocial and behavioral factors play a major role in the onset of the most common presenting symptoms in primary care. (15) Furthermore, primary-care physicians care for the bulk of mental health problems in the American population, leading Regier to call primary care "the de facto mental health services system. " (16) Depression and anxiety are highly prevalent, cause much patient suffering, increased morbidity and mortality, and prompt many of the somatic concerns that patients bring to physicians. Both depression and anxiety are underrecognized and undertreated by physicians. (17-19)

Because many patients feel that they are not getting all of their health care needs met by physicians, a great number of individuals seek consultation in alternative health care settings instead of or in addition to seeking medical care from physicians. For example, a recent study showed that visits to alternative health practitioners exceeded total visits to all US primary care physicians. Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $27.0 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services. (20)

In order to provide optimal care to patients, medical schools need to ensure that their students have the requisite knowledge, attitudes and skills to practice medicine from a biopsychosocial perspective. A biopsychosocial perspective allows practitioners to better understand patients' illnesses as well as their diseases. Practitioners well-trained in this model will seek to understand the psychological and social factors that contribute to the onset and maintenance of illnesses, and know how to intervene to modify these factors for their patients' benefit. In other words, physicians practicing medicine from a biopsychosocial perspective should be as effective in healing patients' illnesses as they are in curing their diseases.

Healing has always been a part of the physician's art, especially through the ages when most theories of disease were wrong and most remedies worthless or harmful. However, in the modern era the many advances in scientific knowledge and technology have captured the greatest portion of medical school curricula and focused physicians' attention on the processes of diagnosing and curing disease. Yet, patients come to physicians with illnesses that may or may not involve disease processes, and seek healing - to be made "whole" again, to be restored to health.

It has long been considered part of the physician's "art" to be able to promote healing of patients' illnesses, to help patients better cope with and manage chronic conditions, or to come to terms with terminal illnesses. It was part of Engel's insight in noting that there is a science to the physician's art that is found within a biopsychosocial perspective.

Since Engel's initial articles on this subject, essential scientific components of the biopsychosocial model have evolved in separate and sometimes overlapping fields. The field of psychosomatic medicine has made remarkable advances over the last half century, and provides many insights into mind-body relationships in health and disease. Behavioral medicine has provided powerful new theories of human behavior and proven new therapies. Psychiatry has advanced new nosologies, biologic understandings, and therapeutic agents. The insights of psychodynamic psychiatry are still important in medical care(21), but are probably not emphasized in medical curricula. (22) The field of doctor-patient communication has burgeoned, with important new models for teaching and research. (23, 24) This field has also emphasized attention to physician personal-awareness, growth, and well-being in medical curricula, so that physicians may effectively use their personal reactions to patients for their patients' benefit. (25-28)

Regardless of the availability of this new body of knowledge, medical school education remains overwhelmingly biomedical in focus. Though many educators recognize the need for medical curricular reform towards a more humanistic, integrated, biopsychosocial model of education (29), curricular reform efforts fall short in most schools. Aside from the minority of problem-based curricula that offer opportunities for integrated teaching, even some of the best efforts in traditional curricula still segregate the behavioral sciences from other basic sciences, and course lecturers seldom reinforce one another's teaching or promote integration of learning. It appears that many of the basic principles and exciting findings of psychosomatic research in the last few decades have not made their way into medical school courses. For example, a perusal of major texts in physiology reveals that they offer only a cursory treatment of psychophysiology. (30-32). In a recent survey conducted by the American Psychosomatic Society, about 50% of medical schools endorsed less than 40 hours of total instruction in psychosomatic/behavioral medicine out of the 7000-8000 hours in the average medical school curriculum. This survey identified many areas for improvement. For example, only about 50% of respondents said that they teach autoimmune diseases, infectious diseases and diabetes from a biopsychosocial perspective; 63-67% teach GI disorders and cancer from this perspective. (33). In a previous survey of clinical skills teaching that included skills such as patient education, diet, exercise and smoking cessation counseling, most schools were lacking in providing written goals and objectives, adequate evaluation of skills, and faculty development to ensure quality and consistency of teaching. (3)

We believe that it is time that medical educators take up the challenge of creating a comprehensive, longitudinal, integrated biopsychosocial curriculum. This curriculum would have the central goal of creating physicians who practice medicine and/or conduct research from a biopsychosocial perspective, and who are competent in both healing illness and curing disease. Such a curriculum would have several requirements:
  1. Core Content:
    • A curriculum in psychosomatic medicine. Students should understand psychosomatic interactions from the molecular and physiologic to behavioral and social perspectives. It should include broad basic topics in psychophysiology such as psychoendocrinology and psychoneuroimmunology. Along with teaching various diseases and their underlying pathologies, teachers should introduce the many symptom complexes and illnesses-- fatigue, panic disorder, fibromyalgia, functional bowel disorders, headache, back pain, anxiety, depression, etc -- that constitute so much of medical practice, also speaking to their pathophysiologies. This curriculum would also cover the impact of emotions and social stress on disease pathogenesis, onset, maintenance, and recovery
    • Psychosocial epidemiology, e.g., the impacts of SES, social support, job stress, culture, etc. on health and illness.
    • Psychosocial aspects of acute and chronic diseases - AIDS and other infectious diseases, cardiovascular diseases, renal diseases, etc.
    • A comprehensive behavioral science curriculum that includes essential behavioral and psychodynamic principles in medical care, psychopathology, personality types and disorders, psychiatric diagnoses and behavioral theory and treatments. It should also include psychological and behavioral principles and techniques that can be applied by medical clinicians, as well as knowledge of therapeutic techniques used by behavioral medicine specialists.
    • A longitudinal curriculum in doctor-patient communication, that includes basic skills such as data gathering, patient education, and communicating empathy, as well as advanced skills, such as giving bad news, communicating with patients with terminal illnesses, recognizing and treating anxiety and depressive disorders, alcohol counseling, and others. This curriculum should provide opportunities for students to interview patients and families from the start of the first year on, focusing on the social, economic, family and personal factors that promote health and are associated with the onset, course and outcomes of ill health, disease, depression, etc., always enhancing students' appreciation of the importance of the doctor-patient relationship.
  2. Integration and reinforcement of teaching in both the preclinical and clinical years
    • Teachers in physiology, biochemistry, microbiology, pathology, community health, clinical skills and other preclinical courses should have segments of their curricula or topics in specific lectures that present basic psychosomatic concepts. These presentations should be complimentary and coordinated to enhance student understanding. Behavioral science clinicians should have a role in teaching activities on inpatient wards, ambulatory care settings, and in conferences in all clinical rotations, including surgery and ob/gyn.
  3. Programmatic attention to medical students' personal and professional growth and well-being throughout medical school.
  4. Attention to educational process
    • Written goals and objectives should be developed for each educational endeavor
    • Development of high quality teaching materials
    • Development of standardized procedures for oral presentation, clinical evaluations and documentation that explicitly require gathering, integrating and using psychosocial data. These procedures would be required in all clinical rotations and teaching activities.
    • Faculty development to ensure consistency and quality of teaching, and
    • A comprehensive assessment that includes
      • student evaluations of the teaching,
      • assessment of student knowledge and skills, using content examinations, structured faculty observations and/or standardized patient exams,
      • assessment of the impact of the curriculum on student attitudes toward psychosocial aspects of care, and on students personal growth and well-being
      • assessment of the outcomes of such teaching on patient care.
  5. Identification of potential barriers to implementing this curricular reform and creating strategies for overcoming these barriers.
There are many published curricula and educational materials that could serve as a starting point for individual medical school efforts, such as the Association for the Behavioral Sciences and Medical Education (ABSME) curriculum guide. (34) In addition, the American Psychosomatic Society is in the process of developing educational materials that would prove useful to schools. We have described the outlines for a longitudinal, comprehensive biopsychosocial curriculum for medical education. There are many barriers to instituting such a curriculum, including lack of trained faculty, lack of faculty and curricular time, and faculty resistance to changing established courses. However, a number of foundations are interested in promoting psychosocial and humanistic medical education, so it may be possible to secure funding to aid in curricular reform efforts. The reasons for moving forward to realize Engel's vision are compelling. The development and implementation of such a curriculum could go a long way toward educating physicians to be more balanced and comprehensive in their care, and to be as skilled in healing illness as they are in curing disease.


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