- Email: [email protected]
Medical education and the behavioral sciences
302
Book Revie\vs
mothering. Their offspring are often neglected and on occasion attacked. Thus, one obvious line ofresearchamong primatologists interested in models of infant abuse has been to investigate different upbringing conditions and assess their abuse-related consequences among adults. A chapter by Stephen J. Suomi and Chris Ripp reviews much of the relevant data in this area. This approach would seem to fit well with human data which suggest that children who are abused have a higher than average probability of abusing their own children. If Suomi and Ripp’s chapter focuses on experimental situations which can be relatively well controlled, many of the authors of other chapters attempt to identify possible critical abuse-‘causing’ variables by evaluating data from naturalistic situations. This undertaking is probably no easier for the investigator of nonhuman primates than it is for those studying humans. Many variables may be implicated. Thus, for example, Terry L. Maple and Amye Warren-Leubecker focus on variability in parental conduct and factors which influence it, while Ronald D. Nadler reviews findings which suggest that there are close relationships between ambiguous and uufamiliar environments and infant abuse (primarily among gorillas). Edward Plimpton and Leonard Rosenblum explore the idea that tierent environments influence behavior by developing a three dimensional construct of ecological context; alteration in any of the dimensions may tip the balance towards abuse. Steven J. Schapiro and G. Mitchell provide specific examples of the effect of different environments on behavior-‘precipitatory factors’-and the relationship of these factors to abuse in captive groups. J. Erwin emphasizes yet another approach, communication and its relationship to conflict. Tiiany Field compares abuse in monkeys and humans and argues for a multi-factor etiology, thus echoing similar arguments made by each of the authors. The editors, Caine and Reite, argue for the value of assessing parallels across species, using common hypotheses, and the importance of modeling human behavior using nonhuman primates. Together these chapters provide a thorough review of the major issues and leave the reader with a clear understanding of the complexity of the problems this book addresses. The book is not easy to fault except in one area: namely, serious consideration of the potential adaptive value of child abuse. Certainly in our views of abuse among humans, and preponderantly among the contributors to this book, infant abuse. is considered a “symptom”. This may be the appropriate characterization because all behaviors are not adaptive. Yet to dismiss the adaptive possibility it must be shown that abusers and the abused, when studied in natural or semi-natural settings, suffer consequenazs in terms of evolutionary variables, such as reproductive success. This the contributors have not done. On balance, the book is well worth the effort. The chapters are clear and appropriately cautious with respect to potential cross-species generalization problems. A large number of species are discussed lending weight to comparative arguments. Models are clearly developed and complexity is not avoided. Critical references are included and alternative views are acknowledged. In short, a fair and balanced treatment of available data, organized in terms of a number of possibly fruitful hypotheses and methodological analyses. The book is recommended for those concerned with child abuse as well as others who might be interested in why some persons who are primarily interested in humans study other species. Neuropsychiatric Institute University 0s Calijbrnia-Los Los Angeles, CA, U.S.A.
MICHAEL T.
Angeles
MCGUIRE
Teaching Behavioral Science in Schools of Medicine, by DONALD A. KENNEDY,EVAN J. P-\TTISHALLJR and C. RICHARDFLETCHER.Association of Behavioral Sciences and Medical Education, Baltimore, MD, 1983. 109 pp. $4.50 Medical Education and the Behavioral Sciences, by DONALD
A. KENNEDY, EVAN J. P.ATTISHALL JR and DEWITT C. BALDWINJR. Association of Behavioral Sciences and Medical Education, Baltimore, MD. 1983. 398 pp. $9.50 The Association of Behavioral Sciences and Medical education (ABSAME) has recently published two companion reports. The first, and shorter of the two, is entitled Teaching Behacioral Science in Schools of Medicine and is authored by Kennedy, Pattishall and Fletcher. It represents an attempt to obtain wider readership of the summary report of the study of medical school behavioral science teaching originally supported by the National Center for Health Services Research and Development, which was originally published in 1972 but which subseauentlv- languished on the back _ shelves of medical libraries: Despite the 12-year hiatus, the book is remarkably contemporary. Cynics might suggest that this is due to the fact that little has happened in the interim. However, the more likely explanation is that the authors wrote with foresight and skillfully anticipated the crucial issues regarding the interrelationship between the behavioral sciences and medical education. In any case, most of the 33 recommendations for action still strike this reviewer as wiser than when I first read them 12 years ago. As with all such reports, some of the recommendations do IittIe more than repeat the obvious (e.g. Recommendation No. 6, which states that “the amount of behavioral science knowledge in the (medical school) curriculum be commensurate to the needs of the professional practice of medicine”). By my count, only about one-third of the 33 recommendations have actually been implemented, but these include such substantial steps as the-establishment of a National Board of Medical Examiners Behavioral Science Test Committee. In general, its calls for action by the Association of American Medical Colleges and the American Medical Association fell on deaf ears and only a few medical schools have followed the model originally established at Hershey in Pennsylvania to establish a separate basic science department of behavioral science (Recommendation No. 16) with a minimum staffing of 7 full-time faculty members (Recommendation No. 19) chaired by a Ph.D. behavioral scientist (Recommendation No. 20). Alsq, the recommendations largely ignore the investment that Departments of Psychiatry have made in the behavioral sciences-a fact confirmed by a recent study of faculty trends which found that in 1978-1979 of the 3098 behavioral science faculty in 117 U.S. Medical Schools, 1770 were members of departments of psychiatry and only 88 were in separate basic behavioral sciences departments (Stokes J. III, Strand J. P. and Jtie C. Distribution of behavioral science faculty in United States medical schools: 1968-1969 and 1978-1979. Sot. Sci. Med. lfI, 753-756, 1984). In the second book entitled Medical Education and the Behavioral Sciences, Dr Dewitt C. Baldwin Jr joins Doctors
Kennedy and Pattishall in reviewing the secular trends that have taken place in medical school &ricula over the l@year mriod between 1972-1973 and 1982-1983 including an intensive analysis of 14 key content areas. Althou& the authors depend primarily upon the AAMC curriculum directories for their data, they have also validated the data by means of reports from 23 medical schools, 14 of which are summarized in Chapter 5 of the book. In general, the authors conclude that there has been a fair amount of flux in the 9
Book
curriculum content categories. Courses on health care as a social system have shown the most consistent growth while there seems to have been less emphasis on physician-patient relations, sociocultural aspects of illness, and health and society. The authors also point to emergence of behavioral medicine as a new discipline. They also, quite rightly, give credit to Dr George Engel’s development of the biopsychosocial model as a useful application of genera1 systems theory. The book includes many text and appendix tables, not all of which are easy to interpret and many are burdened with unexplained abbreviations. Indeed, one is never told whether TH stands for Total Hours or Table of Horrors. Both books should be particularly helpful to those medical schools which are seeking to strengthen their behavioral science teaching. The books also encourage reform of medical school curricula, such as those suggested by the recent AAMC report on Genera1 Professional Education of Physicians (GPEP) and Derek Bok’s recent announcement of the New Pathway at Harvard Medical School.
Reviews
303
The publisher of these books also deserves credit. Since its inception in 1971, this vigorous band of indefatigable behavioral scientists and physicians have effectively promoted the behavioral sciences in medical education and ABSAME has represented the major means of enculturating new behavioral science faculty into that complex and confusing social environment known as the academic medical center, which probably ranks as society’s most intricate institution. The second volume also includes 534 references. Even though not all are referred to in the text, it probably represents the most comprehensive list of pertinent references in this area that has yet been assembled. Section of Preventive Medicine and Epidemiology Evans Department of Clinical Research Boston University School of Medicine Boston, MA, U.S.A.
JOSEPH STOKES
III
Book Revie\vs
mothering. Their offspring are often neglected and on occasion attacked. Thus, one obvious line ofresearchamong primatologists interested in models of infant abuse has been to investigate different upbringing conditions and assess their abuse-related consequences among adults. A chapter by Stephen J. Suomi and Chris Ripp reviews much of the relevant data in this area. This approach would seem to fit well with human data which suggest that children who are abused have a higher than average probability of abusing their own children. If Suomi and Ripp’s chapter focuses on experimental situations which can be relatively well controlled, many of the authors of other chapters attempt to identify possible critical abuse-‘causing’ variables by evaluating data from naturalistic situations. This undertaking is probably no easier for the investigator of nonhuman primates than it is for those studying humans. Many variables may be implicated. Thus, for example, Terry L. Maple and Amye Warren-Leubecker focus on variability in parental conduct and factors which influence it, while Ronald D. Nadler reviews findings which suggest that there are close relationships between ambiguous and uufamiliar environments and infant abuse (primarily among gorillas). Edward Plimpton and Leonard Rosenblum explore the idea that tierent environments influence behavior by developing a three dimensional construct of ecological context; alteration in any of the dimensions may tip the balance towards abuse. Steven J. Schapiro and G. Mitchell provide specific examples of the effect of different environments on behavior-‘precipitatory factors’-and the relationship of these factors to abuse in captive groups. J. Erwin emphasizes yet another approach, communication and its relationship to conflict. Tiiany Field compares abuse in monkeys and humans and argues for a multi-factor etiology, thus echoing similar arguments made by each of the authors. The editors, Caine and Reite, argue for the value of assessing parallels across species, using common hypotheses, and the importance of modeling human behavior using nonhuman primates. Together these chapters provide a thorough review of the major issues and leave the reader with a clear understanding of the complexity of the problems this book addresses. The book is not easy to fault except in one area: namely, serious consideration of the potential adaptive value of child abuse. Certainly in our views of abuse among humans, and preponderantly among the contributors to this book, infant abuse. is considered a “symptom”. This may be the appropriate characterization because all behaviors are not adaptive. Yet to dismiss the adaptive possibility it must be shown that abusers and the abused, when studied in natural or semi-natural settings, suffer consequenazs in terms of evolutionary variables, such as reproductive success. This the contributors have not done. On balance, the book is well worth the effort. The chapters are clear and appropriately cautious with respect to potential cross-species generalization problems. A large number of species are discussed lending weight to comparative arguments. Models are clearly developed and complexity is not avoided. Critical references are included and alternative views are acknowledged. In short, a fair and balanced treatment of available data, organized in terms of a number of possibly fruitful hypotheses and methodological analyses. The book is recommended for those concerned with child abuse as well as others who might be interested in why some persons who are primarily interested in humans study other species. Neuropsychiatric Institute University 0s Calijbrnia-Los Los Angeles, CA, U.S.A.
MICHAEL T.
Angeles
MCGUIRE
Teaching Behavioral Science in Schools of Medicine, by DONALD A. KENNEDY,EVAN J. P-\TTISHALLJR and C. RICHARDFLETCHER.Association of Behavioral Sciences and Medical Education, Baltimore, MD, 1983. 109 pp. $4.50 Medical Education and the Behavioral Sciences, by DONALD
A. KENNEDY, EVAN J. P.ATTISHALL JR and DEWITT C. BALDWINJR. Association of Behavioral Sciences and Medical Education, Baltimore, MD. 1983. 398 pp. $9.50 The Association of Behavioral Sciences and Medical education (ABSAME) has recently published two companion reports. The first, and shorter of the two, is entitled Teaching Behacioral Science in Schools of Medicine and is authored by Kennedy, Pattishall and Fletcher. It represents an attempt to obtain wider readership of the summary report of the study of medical school behavioral science teaching originally supported by the National Center for Health Services Research and Development, which was originally published in 1972 but which subseauentlv- languished on the back _ shelves of medical libraries: Despite the 12-year hiatus, the book is remarkably contemporary. Cynics might suggest that this is due to the fact that little has happened in the interim. However, the more likely explanation is that the authors wrote with foresight and skillfully anticipated the crucial issues regarding the interrelationship between the behavioral sciences and medical education. In any case, most of the 33 recommendations for action still strike this reviewer as wiser than when I first read them 12 years ago. As with all such reports, some of the recommendations do IittIe more than repeat the obvious (e.g. Recommendation No. 6, which states that “the amount of behavioral science knowledge in the (medical school) curriculum be commensurate to the needs of the professional practice of medicine”). By my count, only about one-third of the 33 recommendations have actually been implemented, but these include such substantial steps as the-establishment of a National Board of Medical Examiners Behavioral Science Test Committee. In general, its calls for action by the Association of American Medical Colleges and the American Medical Association fell on deaf ears and only a few medical schools have followed the model originally established at Hershey in Pennsylvania to establish a separate basic science department of behavioral science (Recommendation No. 16) with a minimum staffing of 7 full-time faculty members (Recommendation No. 19) chaired by a Ph.D. behavioral scientist (Recommendation No. 20). Alsq, the recommendations largely ignore the investment that Departments of Psychiatry have made in the behavioral sciences-a fact confirmed by a recent study of faculty trends which found that in 1978-1979 of the 3098 behavioral science faculty in 117 U.S. Medical Schools, 1770 were members of departments of psychiatry and only 88 were in separate basic behavioral sciences departments (Stokes J. III, Strand J. P. and Jtie C. Distribution of behavioral science faculty in United States medical schools: 1968-1969 and 1978-1979. Sot. Sci. Med. lfI, 753-756, 1984). In the second book entitled Medical Education and the Behavioral Sciences, Dr Dewitt C. Baldwin Jr joins Doctors
Kennedy and Pattishall in reviewing the secular trends that have taken place in medical school &ricula over the l@year mriod between 1972-1973 and 1982-1983 including an intensive analysis of 14 key content areas. Althou& the authors depend primarily upon the AAMC curriculum directories for their data, they have also validated the data by means of reports from 23 medical schools, 14 of which are summarized in Chapter 5 of the book. In general, the authors conclude that there has been a fair amount of flux in the 9
Book
curriculum content categories. Courses on health care as a social system have shown the most consistent growth while there seems to have been less emphasis on physician-patient relations, sociocultural aspects of illness, and health and society. The authors also point to emergence of behavioral medicine as a new discipline. They also, quite rightly, give credit to Dr George Engel’s development of the biopsychosocial model as a useful application of genera1 systems theory. The book includes many text and appendix tables, not all of which are easy to interpret and many are burdened with unexplained abbreviations. Indeed, one is never told whether TH stands for Total Hours or Table of Horrors. Both books should be particularly helpful to those medical schools which are seeking to strengthen their behavioral science teaching. The books also encourage reform of medical school curricula, such as those suggested by the recent AAMC report on Genera1 Professional Education of Physicians (GPEP) and Derek Bok’s recent announcement of the New Pathway at Harvard Medical School.
Reviews
303
The publisher of these books also deserves credit. Since its inception in 1971, this vigorous band of indefatigable behavioral scientists and physicians have effectively promoted the behavioral sciences in medical education and ABSAME has represented the major means of enculturating new behavioral science faculty into that complex and confusing social environment known as the academic medical center, which probably ranks as society’s most intricate institution. The second volume also includes 534 references. Even though not all are referred to in the text, it probably represents the most comprehensive list of pertinent references in this area that has yet been assembled. Section of Preventive Medicine and Epidemiology Evans Department of Clinical Research Boston University School of Medicine Boston, MA, U.S.A.
JOSEPH STOKES
III