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Social science education as a component of medical training
Sm. Sci. Med. Vol. 39, No. 9, pp. 1367-1373, 1994 Elsevier Science Ltd. Printed in Great Britain
Pergamon
0277-9536(94)00215-O
SECTION
SOCIAL SCIENCE*
P
EDUCATION AS A COMPONENT MEDICAL TRAINING
S. M. MACLEOD~ and H. N. MCCULLOUGHS Father Sean O’Sullivan Research Centre, 50 Charlton Avenue East, Hamilton, Ontario,
Canada
OF
L8N 4A6
Abstract-The broad view of health espoused by the World Health Organization is now generally accepted by medical educators. Implicit in the new paradigm is a recognition of multiple determinants of health and of shifting divisions of professional responsibilities among providers. As a consequence, the importance of social and behavioural science education as a foundation to medical training is increasingly
appreciated. At the same time medical programmes are under pressure to contend with the explosion of knowledge in basic biomedical and life sciences and with technological innovation. Curricula are being submerged in facts, causing medical schools to look for innovative teaching models that feature more flexible approaches to the diverse body of knowledge supporting professional practice. Independent learning methods are being explored and revised teaching programs are being organized around coordinating themes, such as aging, human development and environmental health. Future programmes must be designed to encourage multiprofessional approaches while fostering awareness of the important interplay between health care (both curative and preventive) and social/behavioural science. Within the curriculum students should be offered options that include sociology, child growth and development, gerontology, medical anthropology, psychology, medical geography, health economics, political science and related subthemes. More important than the inclusion of any specific discipline is the creation of an environment in which future physicians may be exposed to critical thinking across a wide range of themes that characterize the social and cultural context for medical practice. Such enquiry is also likely to drive a closer relationship between medical schools and their parent universities within which the social science expertize resides. Success will see a welcome development from a symbiotic relationship to one which is more clearly synergistic with the potential to stimulate broad improvements in health services. The goal of improved training in social and behavioural sciences is important to the future of medical education as well as to the public’s health and it is essential that leadership emerge at this time. Key words-social
Medicine
is a social
sciences,
science
and
medical
politics
education,
nothing
gerontology,
but
medicine on a large scale. Rudolph Virchow, 1821-1902 Medical education is undergoing a period of intense scrutiny in all parts of the world, driven by evolution in our thinking about health and about roles and responsibilities for health professionals. Flexner, in
*The definition of social sciences remains moot, at least in the mind of a medical educator trained in basic biomedical science and clinical medicine. It is clear that many health-related enquiries have both a biological and a social component. For the purposes of this discussion, social sciences are taken as those that generate research data applicable to social policy. Lit& benefit will be derived from a rigid definition of social science and indeed, in an independent learning curriculum as advocated in this essay, semantic purity is likely to become irrelevant. tFormer dean of the Faculty of Health Sciences, McMaster University, Hamilton, Canada, is presently a Professor in the departments of Clinical EGdemiolbgy and Biostatistics, Pediatrics, Biomedical Sciences and Medicine at McMaster. $Pharmacologist working in the pharmaceutical industry.
anthropology,
social policy,
environment
his landmark report of 1910 on medical education in the United States and Canada, predicted an imminent shift in provision of physician services from the predominantly individual and curative approach to one providing at least parallel emphasis to social and preventive measures [ 11. The physician’s function is fast becoming social and preventive rather than individual and curative. Upon him (sic) society relies to ascertain and, through measures essentially educational, to enforce the conditions that prevent disease and make positively for physical and moral well-being.
While many would view Flexner’s analysis as prescient, relatively little movement has been evident in the intervening 83 years. In the United States in particular, such a rebalancing has been impeded by the longstanding separation of schools of public health from schools of medicine [2]. Nonetheless, there is presently general acceptance of a broad definition of health which recognizes various societal forces as influential determinants of wellness and which places a high premium on the ‘caring’ 1367
1368
S. M. MACLEOD and H. N. MCCULLOUGH
approach to health services as an important complement to curative interventions [3-51. There has also been a dramatic change in recent years in international patterns of disease morbidity and mortality, the so-called ‘health transition’. As death from communicable diseases has been increasingly controlled, the average life expectancy worldwide has increased and is now well in excess of 60 years [6. 71. The major difference in average longevity between developed and developing countries is now accounted for by unacceptably high rates of underhvc mortality in many parts of the developing world [8]. While this is still attributable to potentially controllable communicable diseases, compounded by malnutrition. poverty and poor sanitation, it is clear that. in the absence of economic obstacles. these differences can bc overcome in the near future and will result in comparable life expectancies in developed and dcvcloping countries [9]. Increasingly then, the attention of health service providers and profcssionals will turn to quality of lift issues and to more subtle, less well characterized dctcrminants of health. A corresponding increase in the emphasis placed on social sciences in the medical curriculum may be anticipated. As part of a closer examination of sociocultural and preventive aspects of health. there will also bc an cnhanccd reliance on population health sciences. The most tangible reflection of this shift will be the demand for evidence based on population studies as a support for health practice and policy. This approach. usually referred to as ‘cvidencc based medicine’, implicitly downplays the intuitive ‘art’ of medicine in prcfcrcncc for maximal use of rigorously evaluated (thcrapcutic and diagnostic) interventions [IO I?]. Such evidence will more and more frequently be drawn from rcscarch in the social sciences. particularly as it applies to decision making concerning quality of lift. Inputs from both quantitative and qualitative research will furthermore be sought as the foundation to inform health policy at all levels. Institutions responsible for medical education and training sit at R critical juncture They must be alert to change in individual views of health and yet remain responsive to influences from both professional and community groups. A dynamic tension exists between the relatively narrowly focused interests of professionals and the more diffuse interests of communitics. Resolution of this tension usually falls to the planners or administrators and all those whose interests are served by increasing etficiency, effectiveness or equity in the health care system. This latter group clearly includes educators and medical school leaders who somctimcs face a difficult task simply surviving in the midst of such unbalanced forces. Traditionally the narrow interests of health professionals have easily dominated the broader demands of users, including individuals and communities; however, because of the shift in the health paradigm, societal expectations in the health arena are becoming
increasingly influential at the expense of professional prerogative. Such empowerment has obvious implications for medical training and the role of social and behavioural sciences therein 13-51. Since most medical schools remain the responsibility of a university, a further challenge is introduced. Medical educators must balance their increasing inclination to respond positively to society’s needs and expectations with the resultant of similar forces in the broader university community. In many countries, universities are struggling to maintain their autonomy in a time of greater public accountability, and some threat may be perceived from within as the medical school, sensitive to its public service mandate, rushes to adapt. What some see as essential change in medical school curricula will bc seen by others as expedience, sacrificing academic freedom [I3, 141. Universities have at times been slow to respond to the shifting public agenda and often stand accused of indifference, introversion or, at worst. irrelevance. As some would have it, the half-life of change in universities is measured in millennia. Where does the impcrative to protect the spirit of free enquiry leave off and the balanced sentient pursuit of social progress begin? The interface between social science disciplines rooted in the university and medical disciplines devoted to public service may provide interesting ground for exploration of these tensions [l3]. The opportunities for interaction of medical school and university are brought to the fore as social science foundations to sound medical practice arc emphasized, while multiprofessionalism and multidisciplinary approaches to health arc endorsed. Nonetheless. recognition of a community of interests wjith other university faculties and departments may sometimes still be impeded by an ivory tower mcntality that places academic freedom in its purest sense above social responsiveness and recognition of the benefits of an integrated approach to health [14]. Quite apart from their educational responsibilities. medical teachers and academic leaders also require a window on the social and cultural context for health professional practice. A coordinated approach to health policy and medical ethics cannot bc separated from societal values. and it is important that the medical school develop closer links with influential community groupings as well as with departments of humanities and social science. Health professionals 01 the future will need a greater understanding of the dynamics shaping societal values if they arc to perform their service. educational and research functions appropriately. Never has the time been more opportune for reexamination of the social science curriculum in medical education. By exercising its overall moral responsibility for the higher education environment. the university has the chance to serve as &LIS (1.~ machinu, diverting medical education from the cvident excesses of reductionist biomedical science and
Social science education as a component of medical training helping it toward a more open recognition of the role played in health by social and behavioural factors ]2,
151. CURRICULUM
1369
recognition of the important interplay between social and behavioral sciences and curative and preventive medicine. The options in any menu of social sciences offerings should include the following:
ISSUES
Much harm has been done to the fabric of health professional education by the isolation of disciplines, often fuelled by a misguided sense of the importance of departmental hegemony. The resulting partitioning of thought may impede innovative solutions to health concerns. In recent years considerable attention has been paid to the need for greater integration in the medical curriculum, particularly between preclinical and clinical programme components. This concern is normally focused on the division between basic and clinical sciences; however, increasingly it is appreciated that there is a need for active encouragement of bridging disciplines that may link the process of scientific questioning with clinical practice. Much of the bridging emphasis to date has been placed on evaluative and probabilistic sciences (clinical epidemiology and biostatistics [ 161 with some tangential acknowledgment of hybrid clinical life science disciplines, such as clinical immunology, nutrition, clinical pharmacology and clinical infectious disease that bring basic science laboratory methods and principles to bear upon bedside clinical problems. As more recognition is given to the physical and sociocultural environments as important determinants of health, there is greater willingness to include behavioural science in the medical curriculum as a key integrating theme. Indeed, the interface between biology and behaviour is emerging as one of the major areas of interest in health, with particular attention directed to, among others, relationships between prosperity and health, early childhood development and subsequent ‘wellness’, and psychological state and immune system function. Inroads in molecular genetics lead to the hope that the biological basis will soon be better understood for conditions previously seen as solely or mainly in the behavioral domain, including alcoholism, substance abuse and depression. Our understanding of the interplay between genetic factors and diseases associated with human behaviour is increasing exponentially and this growing understanding will inevitably alter the approach to social and behavioural sciences as a foundation for medical practice. In almost all areas of social science one can anticipate products of continuing enquiry relevant to medical practice and health policy. The abundance of potential applications underscores the importance of an approach to health professional education designed to permit maximum choice for students, Indeed, it is inconceivable that we will be able to define a ‘core’ medical education curriculum and still leave enough latitude for offering choices adequate to satisfy all individuals interested in a medical career, We must aspire to a curriculum which will encourage
Sociology
There is longstanding appreciation of the importance of health’s social determinants, legitimized particularly through studies of the relationships among wealth, social status and disease and through study of adolescent development and health related behaviours. Increasingly the impact of work attitudes to employment and the supporting framework for adjustments within the labour market is perceived as important both in determining health and as a background to occupational medicine. Child growth
and development
There are suggestions from many sources that early childhood development, social environment, and progression to literacy may substantially influence subsequent health outcomes. Evidence from the Headstart Programme and similar initiatives reinforces the impression that this is an area of potential health improvement and indeed may be the most critical target for any initiative aimed at improved health equity. The study of female literacy and its impact on child health is a fertile field of enquiry in international health. Understanding of these relationships cannot be separated from our ongoing attempts to define brain/behaviour/ biological linkages. Gerontology
Because of the health transition, there is increasing interest in the health concerns of aging adults. Until recently this has been a priority issue for developed countries, but the implications of an aging population in the developing world now attract parallel attention. Of course, aging is a good prism through which to focus the disparate interests of several social sciences. For example, health providers of various kinds will require a broad understanding of death and dying. Medical
anthropology
The understanding of cultural determinants of health is particularly important in the context of international and tropical medicine. Increasingly, these issues are also seen as important in the multicultural societies of developed countries. Greater awareness of the links between the socially and culturally influenced central nervous system and other biological functions (e.g. immune surveillance) may further heighten the importance assigned to our understanding of anthropological determinants of health.
1370 Psychology
S. M.
MACLEOD and H. N. MCCULLOUGH
and behavioral sciences
As noted elsewhere, improved understanding of the relationship between the central nervous system and other biological systems will inevitably prove important to our comprehensive understanding of health. As the mapping of the human genome proceeds. it is likely that we will gain further insights into normal and abnormal behaviour. The importance of these sciences as foundation to health professional practice is likely to be correspondingly augmented. Human sexuality, a complicated domain within behavioural sciences has obvious implications for health and quality of life. and stands as a leading candidate for early inclusion in a foundation curriculum for general preparation of health (i.e. multiprofessional) providers. Medical and social ethics Medical and social ethics cannot be separated from an awareness of social and cultural values which in turn are increasingly driven in the health domain by economic concerns. We arc consistently confronted by dilemmas created through our own technological virtuosity. For example. through molecular engineering we now have the ability to treat a rare genetic disease (Gauchcr‘s) with a replacement enzyme (alglucerase) at a cost that may run as high as several hundred thousand dollars annually. but we lack guidelines to support the making of such a major resource allocation decision [ 171. Education cannot be dissociated from a wide range of social scicncc disciplines that have bearing on our understanding of the value system that serves as a foundation for ethical decision making.
Whether as a component of medical and cultural anthropology or of behavioural science. the study of language and communications is likely to bc seminal to our improved understanding of health. As a subset of this undertaking educational research and the study of the means by which we may achieve greater user involvement in health decision making promises to occupy scholarly interest. Health economics trod politiccd .scicnce (including closelj~ relutcd eraluutirc sc~icnws) Much of the discussion of future directions in medical training is driven by economic and political imperatives. Increasingly, governments are conscious of the cost of meeting their responsibilities in the health domain. Even in the poorest economies, health is recognized as a prime element in infrastructure and an essential social good. This attitude has been reinforced recently by the World Development Report “Investing in Health” [9]. Many of the other social sciences are likely to be focused on health through being caught up in economic and political analysis. Health professional awareness of these
issues will to apply unlimited quality of
be unavoidable in a world which attempts limited fiscal resources to a potentially demand for good health and optima1 life.
Studies of‘ the serrices deliwr:,, As we examine patterns of use of health services we increasingly recognize cultural influences that govern interactions with the health system. Lynn Payer has drawn interesting comparisons among the approaches to medical care taken in the United States, England, Germany and France [18]. There are insights in her transnational observations that may help us to understand the differences that can occur within a single country. as highlighted by Brook [19], Wennberg [20], Billings [21] and Caper [22]. Although our appetite for understanding in this field derives from economic imperatives it is nonetheless likely that such studies will reinforce essential links between social and behavioural sciences and medical practice or health policy. Medicul geogruphr: (including
urban planning)
There is a tradition of interest in geographical determinants of health. communicable diseases in particular. In recent years there has been, in parallel. a developing focus on the influence of urban living on health, and recognition of the potential for urban planning to influence patterns of disease. health outcomes and quality of life.
It is difficult to discern the exact boundary between social sciences and all-embracing concerns of environmental health. While some social sciences. such as geography. have taken a major interest in environmental issues. there is nothing to be gained in a narrow departmental or disciplinary view. No medical school in 1994 can afford to ignore the importance of the relationships between physical environment and health. nor can educators avoid their responsibility to examine the complex interplay among economic factors related to sustainable development and other more obvious determinants of health, including the exposure to environmental toxins. Concerns about the workplace environment. particularly the potential for exposure to physicochemical hazards. also form a continuum with other environmental health concerns. Medical school interests must be blended with those of a wide range of relevant social sciences in this critical domain. In all disciplines where social science investigation and teaching may be blended and harmonized with medical training it will be important to keep in mind the importance of evidence as a guide to health professional practice and health policy [lOpl2]. In every case this will require refinement of our ability to apply evaluative science methodologies. Perhaps the greatest skill to impart to health professional students will be the ability to critically appraise the
Social science education as a component of medical training scientific literature in both basic biomedical and social sciences, and to apply the information that stands up to careful critical analysis to subsequent health professional practices [16]. In this domain there will be substantial overlap with the increasing expertize being developed in information sciences (health informatics) [23]. We will need to improve our understanding of the appropriate packaging of research data and the merging of credible data from various sources through meta analysis in order to derive compelling guidelines for health practice. Further development of the focus on evidence based practice will inevitably demand a greater rigour in social science investigations. In some disciplines presently heavily reliant on qualitative research this may prove difficult; however, the obstacles should not prove insurmountable and success will lead to a more strongly synergistic relationship between social sciences and health professional practice. MEDICAL
EDUCATION
APPROACHES
A detailed review of current approaches to medical education is beyond the scope of this essay; however, the interested reader will find many provocative reviews [24-271. For example, the state of medical education in Britain has recently been carefully analyzed by Stella Lowry in a thoughtful series of articles in the British Medical Journal, later published in book form [28]. Most of her observations related to medical education in Britain are relevant to the current programmes in other developed countries. Certainly a counterpart is found in several reports detailing the state of undergraduate medical education in the United States [15,29, 301. There is now widespread recognition of a shifting health paradigm [4]. This has resulted in demand for a more comprehensive and better integrated approach to medical education, with corresponding avoidance of a curriculum driven by factual content and dominated by departmental rivalries over core knowledge. Instead, the emphasis is likely to be placed increasingly on the encouragement of a spirit of enquiry, guided by recognition of the importance of evidence both from basic medical sciences and social sciences relevant to health practice [IO-121. The undergraduate educational process must provide a contextual framework for lifelong learning and for subsequent continuous adjustment of professional practice. It goes without saying that preparation so directed will demand emphasis on independent approaches to learning. The experience of several innovative medical schools suggests that such an ideal outcome is best achieved through reduced emphasis on teaching of facts and increasing use of task oriented and small group learning [31, 321. Two recent reviews have focused on problem based learning as a promising tool for achievement of new models of medical practice [33, 341. It will not suffice to institute independent learning
1371
for undergraduate health professional education only. Such programmes which, because of their selfdirected character, are bound to be broadly based must also be seen as meeting the responsibility to provide an appropriate foundation for graduate and continuing education that will place a high premium on the maintenance of competence. A curriculum that recognizes the entire breadth of health determinants will also demand the inclusion of social science as an integral part of professional upgrading after graduation. SOCIAL
SCIENCES
(a) Intellectual
AND
MEDICAL
CURRENT
ISSUES
EDUCATION:
environment
It has been suggested that medical schools are failing to provide an attractive environment for social and behavioral scientists [15], but perhaps this criticism is better levelled at the universities themselves. Any university which offers health professional training has a responsibility to maintain an environment that encourages multiprofessionalism, cross-fertilization and integration of multidisciplinary interests relevant to health. All too often, this is an ideal that has not been achieved. Although formal structures should not be required, there may be a case for nurturing shared horizontal research and education programmes under omnibus titles such as ‘Social Medicine’. The experience at McMaster University’s Faculty of Health Sciences in this regard is interesting. An early attempt at integration of basic and social sciences saw the creation of a ‘brain and behaviour programme’. However, this proved too narrow as an integrating topic. Ten years later, the creation of a programme in aging and health (The Educational Centre for Aging and Health) proved much more successful, perhaps because the programme theme was sufficiently broad to recognize multiple facets of interaction between social/ behavioral science and geriatric medical practice. Experience suggests that the study of aging has been more commonly impeded in the past by the erection of partitions between putatively complementary disciplines than has the continuum of neuropsychiatric-psychological interests. (b) The challenge
of chronic disease
The health transition in developing countries and the slowly increasing tendency to longer life in developed countries is likely to result in greater recognition of the importance of social and behavioral sciences in the context of optimal management of disability resulting from chronic diseases. As more emphasis is placed on the long term management of such patients in the community, there is likely to be a corresponding reduction in the use of the tertiary care hospital as a primary venue for medical education. Greater awareness of the special demands of community based care and the importance of user involvement in
S.M. MACLEOD
1372
and
influencing the nature of that care will unquestionably augment the importance accorded physician training in social and behavioral sciences. The university may yet find another opportunity to confirm its social relevance by encouraging development of a living laboratory for teaching of social sciences relcvant to the education of health service providers. (c) Internntionul
health
Many medical schools are actively increasing their involvement in international health and tropical medicine, partly in recognition of the research and service opportunity presented by the substantial burden of preventable disease in those countries still beset by high rates of communicable disease mortality and morbidity. International health activity inevitably leads Northern institutions to re-examination of public health teaching and population health sciences as well as to greater awareness of transcultural issues in health. Medical schools who become involved internationally at this time will be well positioned to observe the health transition at first hand and will be more conscious of the need to enrich the learning opportunities provided to their students in social sciences.
It is apparent that there is no room in the medical education curriculum for inclusion of all disciplines or active dissemination of all knowledge relevant to health. Realistically, emphasis must bc placed on concepts and illustrative principles, with a restriction of factual content to items required to understand key concepts. The acquisition of skills must be emphasized as appropriate to any health profession, but there must be sufficient latitude to permit eclecticism in the choice of professional practice profiles among graduates. It is critically important that Rexibility be maintained in the health professional curriculum and this is likely best achieved in a student-centred, problem based learning system which places a high premium on independent learning. Parallel reliance on flexible learning resources (particularly strong libraries and well equipped computing centres) provided in such a way as to encourage student autonomy in their use is also desirable. (~7)Whot is cow ond K,hut is not.? A potential threat to expanded social sciences education in medical training may be found in recent enthusiasm from some quarters for the definition of a core curriculum [35, 361. While supporters of this concept are quick to point out the parallel benefits of protected time for ‘options’, the prospect is nonetheless raised of an interminable conflict over definition of core factual content. Given the progressively more overwhelming deluge of biomedical knowledge, it will be difficult to hear the voices of those who support increasing exposure of health professional trainees to
H.N. MKULLOUGH social and behavioural sciences once the pack has set off in full cry pursuing the elusive core. There is nothing novel about the deceptive allure of a core curriculum; however. those tempted should be aware of generic arguments against this particular solution [37] and of voices which counsel moderation in the definition of foundation medical knowledge. The core-and-options model has been under active discussion in Britain since 1990 without resolution of concerns about the ‘restrictively fat core’ [38] or the elusiveness of defined objectives in core medical education [39]. Implicit in this approach is acceptance of a degree of homogeneity in professional practice profiles that flies in the face of reality. (‘ON(‘I.LlSION
The world’s medical schools arc caught in a maelstrom of change. The status quo is not defensible, although the optimal way forward is far from clear. Some difficult philosophical questions remain to be resolved, including in particular the confrontation between a normal human desire for optimal individualized care and the prevailing government-driven demand for maximal cost-effectiveness based on population outcomes [40.41]. Most medical educators will admit to sonic virtue in both points of view. Medical schools will need to diversify and to find a variety of adaptive strategies in order to meet these conflicting demands [41]. One of the key adaptive strategies will be found in the efficient blending of a menu of behavioural and social sciences with the array of life and clinical sciences that has been brought to such a high level of development in the postwar period. It should not be necessary to create from whole cloth new minidepartments within the medical school. Far greater advantage will bc gamed if present pressures lead to meaningful links between the medical school and potential partners within the university community. This is most likely to happen in an environment which stresses adaptability in its approach to curriculum. Learning opportunities responsive to the needs of future health care providers should be effectively grouped around themes such as human bchaviour and development, aging or environmental health. without any gerrymandering of current departmental or disciplinary mandates. If appropriate cross disciplinary links arc achieved. the outcome will prove beneficial to component departments, faculties, universities and the broader communities they serve. There is an outstanding opportunity in the current situation for the emergence of leadership. In a northern analogy drawn from the world of dog teams and snow; “It is always better to be the lead dog, because in other positions the view doesn’t change very much”. For those who cherish the excitement of a changing view as we plunge on across the tundra following the polestar of broadly based medical education, there can be no greater challenge than
Social science education as a component of medical training
defining the
realm
the place of social science education of essential
medical
within
19. Brook
training. 20.
Acknowledgements-This review was prepared during a residency at the Rockefeller Study and Conference Center, Villa Serbelloni, Bellagio, Italy, November 1993. The support of the Rockefeller Foundation (New York) is gratefully acknowledged.
21.
22. 23. REFERENCES
24. 1. Flexner A. Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching New York, 1910. 2. White K. L. Healing the Schism: Epidemiology, Medicine and the Public’s Health. Springer-Verlag, New York, 1991. S. A., Zones J. S. and Showstack J. A. 3. Schroeder Academic medicine as a public trust. JAMA 262, 803, 1989. 4. White K. L. and Connelly J. E. (Eds). The Medical School’s Mission and the Population’s Health. SpringerVerlag, New York, 1992. 5. Colloton J. W. Academic medicine’s changing covenant with society. Acad. Med. 64, 55, 1989. 6. Feachem R. G. A., Kjellstrom T., Murray C. J. L., Over M. and Phillips M. A. (Eds). The Health of Adults in the Developing World. Oxford University Press; New York, 1992. 7. Human Development Report 1993. Oxford University Press; Oxford, 1993. 8. State of the World’s Children 1993. Oxford University Press; Oxford, 1993. Report 1993: Investing in 9. The World Development Health; World Deoelopment Indicators. Oxford University Press; Oxford, 1993. Medicine Working Group. Evidence10. Evidence-Based based medicine: a new approach to teaching the practice of medicine. JAMA 268, 2420, 1992. 11. Eddy D. M. The challenge. JAMA 263, 287, 1990. 12. Brook R. H. Quality of care: do we care? Ann. Int. Med. 115, 486, 1991. 13. Bok D. Beyond the Ivory Tower: Social Responsibilities of the Modern L’niversity. Harvard University Press; Cambridge, MA, 1982. 14. Bok D. Higher Learning. Harvard University Press, Cambridge, MA 1986. 15. Marston R. Q. and Jones R. M. (Eds). Medical Education in Transition. Report of the Commission on Medical Education: The Sciences of Medical Practice. Robert Wood Johnson Foundation, Princeton, 1992. 16. Sackett D. L., Haynes R. B., Guyatt G..H. and Tugwell P. Clinical Epidemiology: A Basic Science for C&al Medicine, 2nd edn. Little, Brown&Co Inc. Boston. MA 1991. 17. Garber A. M. No price too high? NEJM 327, 1676, 1992. 18. Payer L. Medicine & Culture: Varieties of Treatment in the United States, England, West Germany and France. Henry Holt and Co, New York, 1988.
25.
26. 27. 28. 29.
30.
31.
32. 33.
34. 35.
36. 37. 38. 39. 40. 41. 42.
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R. H. and Lohr K. N. Efficacy, effectiveness, variations and quality: boundary crossing research. Med. Cure 23, 710, 1985. Wennberg J. E. Dealing with medical practice variations: a proposal for action. Hlth A,&irs Summer, 6, 1984. Billings J., Zeitell L. and Lukomnik J. et al. Impact of socioeconomic status on hospital use in New York City. Hlth Affairs Spring 162, 1993. Caper P. The microanatomy of health care. HI/h Affairs Spring, 174, 1993. Wyatt J. Uses and sources of medical knowledge. Lance/ 338, 1368, 1991. Towle A. Critical Thinking. The Future of Undergraduate Medical Education. The King’s Fund Centre, London, 199 1. Neufeld V. R., Maudsley R. F., Pickering R. J. and Walters B. C. et al. Demand-side medical education: educating future physicians for Ontario. CMAJ 148, 1471, 1993. Abrahamson S. Myths and shibboleths in medical education. Teaching Learning Med. 1, 4, 1989. Buckley E. G. Basic medical education in transition. Med. Educ. 21, 113, 1993. Lowry S. Medical Education. BMJ Publishing Group, London, 1993. Physicians for the 21st Century. Report of the Panel on the General Professional Education of the Physician and College Preparation for Medicine. J. Med. Educ. 59, suppl. 1, 1984. Educating Medical Students. Assessing Change in Medical Education: The Road to Implementation. ACME-TRI Report. AAMC, Washington, 1992. Neufeld V. R., Woodward C. A. and MacLeod S. M. The McMaster M. D. program: a case study of renewal in medical education. Acad. Med. 64, 423.. 1989. Tosteson D. C. New nathwavs in general medical education. NEJM 322, 234, 1990. Albanese M. A. and Mitchell S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad. Med. 68, 52, 1993. Norman G. R. and Schmidt H. G. The osvcholoaical basis of problem-based learning: a review -of theevidence. Acad. Med. 67, 557, 1992. General Medical Council. Undergraduate Medical Education. GMC, London 1991 (Discussion document by the working party of GMC Education Committee). Lowry S. A model for British medical education. BMJ 307, 1021, 1993. Hall J. W. and Kevles B. L. (Eds). In Opposition to Core Curriculum. Greenwood Press, London, 1982. Editori+ Pulling British medical education into the twentieth century. Lancet 337, 1448, 1991. Editorial. The core curriculum: can it be defined? Luncet 338, 1048, 1991. Eddy D. M. The individual vs society: resolving the conflict. JAMA 265, 2399, 1991. Eddy D. M. Cost effectiveness analysis: is it up to the _ task? JAMA 267, 3342, 1992. Showstack J., Fein 0.. Ford F.. Kaufman A. et al. Health of the public: the academic response. JAMA 267, 2497, 1992.
Pergamon
0277-9536(94)00215-O
SECTION
SOCIAL SCIENCE*
P
EDUCATION AS A COMPONENT MEDICAL TRAINING
S. M. MACLEOD~ and H. N. MCCULLOUGHS Father Sean O’Sullivan Research Centre, 50 Charlton Avenue East, Hamilton, Ontario,
Canada
OF
L8N 4A6
Abstract-The broad view of health espoused by the World Health Organization is now generally accepted by medical educators. Implicit in the new paradigm is a recognition of multiple determinants of health and of shifting divisions of professional responsibilities among providers. As a consequence, the importance of social and behavioural science education as a foundation to medical training is increasingly
appreciated. At the same time medical programmes are under pressure to contend with the explosion of knowledge in basic biomedical and life sciences and with technological innovation. Curricula are being submerged in facts, causing medical schools to look for innovative teaching models that feature more flexible approaches to the diverse body of knowledge supporting professional practice. Independent learning methods are being explored and revised teaching programs are being organized around coordinating themes, such as aging, human development and environmental health. Future programmes must be designed to encourage multiprofessional approaches while fostering awareness of the important interplay between health care (both curative and preventive) and social/behavioural science. Within the curriculum students should be offered options that include sociology, child growth and development, gerontology, medical anthropology, psychology, medical geography, health economics, political science and related subthemes. More important than the inclusion of any specific discipline is the creation of an environment in which future physicians may be exposed to critical thinking across a wide range of themes that characterize the social and cultural context for medical practice. Such enquiry is also likely to drive a closer relationship between medical schools and their parent universities within which the social science expertize resides. Success will see a welcome development from a symbiotic relationship to one which is more clearly synergistic with the potential to stimulate broad improvements in health services. The goal of improved training in social and behavioural sciences is important to the future of medical education as well as to the public’s health and it is essential that leadership emerge at this time. Key words-social
Medicine
is a social
sciences,
science
and
medical
politics
education,
nothing
gerontology,
but
medicine on a large scale. Rudolph Virchow, 1821-1902 Medical education is undergoing a period of intense scrutiny in all parts of the world, driven by evolution in our thinking about health and about roles and responsibilities for health professionals. Flexner, in
*The definition of social sciences remains moot, at least in the mind of a medical educator trained in basic biomedical science and clinical medicine. It is clear that many health-related enquiries have both a biological and a social component. For the purposes of this discussion, social sciences are taken as those that generate research data applicable to social policy. Lit& benefit will be derived from a rigid definition of social science and indeed, in an independent learning curriculum as advocated in this essay, semantic purity is likely to become irrelevant. tFormer dean of the Faculty of Health Sciences, McMaster University, Hamilton, Canada, is presently a Professor in the departments of Clinical EGdemiolbgy and Biostatistics, Pediatrics, Biomedical Sciences and Medicine at McMaster. $Pharmacologist working in the pharmaceutical industry.
anthropology,
social policy,
environment
his landmark report of 1910 on medical education in the United States and Canada, predicted an imminent shift in provision of physician services from the predominantly individual and curative approach to one providing at least parallel emphasis to social and preventive measures [ 11. The physician’s function is fast becoming social and preventive rather than individual and curative. Upon him (sic) society relies to ascertain and, through measures essentially educational, to enforce the conditions that prevent disease and make positively for physical and moral well-being.
While many would view Flexner’s analysis as prescient, relatively little movement has been evident in the intervening 83 years. In the United States in particular, such a rebalancing has been impeded by the longstanding separation of schools of public health from schools of medicine [2]. Nonetheless, there is presently general acceptance of a broad definition of health which recognizes various societal forces as influential determinants of wellness and which places a high premium on the ‘caring’ 1367
1368
S. M. MACLEOD and H. N. MCCULLOUGH
approach to health services as an important complement to curative interventions [3-51. There has also been a dramatic change in recent years in international patterns of disease morbidity and mortality, the so-called ‘health transition’. As death from communicable diseases has been increasingly controlled, the average life expectancy worldwide has increased and is now well in excess of 60 years [6. 71. The major difference in average longevity between developed and developing countries is now accounted for by unacceptably high rates of underhvc mortality in many parts of the developing world [8]. While this is still attributable to potentially controllable communicable diseases, compounded by malnutrition. poverty and poor sanitation, it is clear that. in the absence of economic obstacles. these differences can bc overcome in the near future and will result in comparable life expectancies in developed and dcvcloping countries [9]. Increasingly then, the attention of health service providers and profcssionals will turn to quality of lift issues and to more subtle, less well characterized dctcrminants of health. A corresponding increase in the emphasis placed on social sciences in the medical curriculum may be anticipated. As part of a closer examination of sociocultural and preventive aspects of health. there will also bc an cnhanccd reliance on population health sciences. The most tangible reflection of this shift will be the demand for evidence based on population studies as a support for health practice and policy. This approach. usually referred to as ‘cvidencc based medicine’, implicitly downplays the intuitive ‘art’ of medicine in prcfcrcncc for maximal use of rigorously evaluated (thcrapcutic and diagnostic) interventions [IO I?]. Such evidence will more and more frequently be drawn from rcscarch in the social sciences. particularly as it applies to decision making concerning quality of lift. Inputs from both quantitative and qualitative research will furthermore be sought as the foundation to inform health policy at all levels. Institutions responsible for medical education and training sit at R critical juncture They must be alert to change in individual views of health and yet remain responsive to influences from both professional and community groups. A dynamic tension exists between the relatively narrowly focused interests of professionals and the more diffuse interests of communitics. Resolution of this tension usually falls to the planners or administrators and all those whose interests are served by increasing etficiency, effectiveness or equity in the health care system. This latter group clearly includes educators and medical school leaders who somctimcs face a difficult task simply surviving in the midst of such unbalanced forces. Traditionally the narrow interests of health professionals have easily dominated the broader demands of users, including individuals and communities; however, because of the shift in the health paradigm, societal expectations in the health arena are becoming
increasingly influential at the expense of professional prerogative. Such empowerment has obvious implications for medical training and the role of social and behavioural sciences therein 13-51. Since most medical schools remain the responsibility of a university, a further challenge is introduced. Medical educators must balance their increasing inclination to respond positively to society’s needs and expectations with the resultant of similar forces in the broader university community. In many countries, universities are struggling to maintain their autonomy in a time of greater public accountability, and some threat may be perceived from within as the medical school, sensitive to its public service mandate, rushes to adapt. What some see as essential change in medical school curricula will bc seen by others as expedience, sacrificing academic freedom [I3, 141. Universities have at times been slow to respond to the shifting public agenda and often stand accused of indifference, introversion or, at worst. irrelevance. As some would have it, the half-life of change in universities is measured in millennia. Where does the impcrative to protect the spirit of free enquiry leave off and the balanced sentient pursuit of social progress begin? The interface between social science disciplines rooted in the university and medical disciplines devoted to public service may provide interesting ground for exploration of these tensions [l3]. The opportunities for interaction of medical school and university are brought to the fore as social science foundations to sound medical practice arc emphasized, while multiprofessionalism and multidisciplinary approaches to health arc endorsed. Nonetheless. recognition of a community of interests wjith other university faculties and departments may sometimes still be impeded by an ivory tower mcntality that places academic freedom in its purest sense above social responsiveness and recognition of the benefits of an integrated approach to health [14]. Quite apart from their educational responsibilities. medical teachers and academic leaders also require a window on the social and cultural context for health professional practice. A coordinated approach to health policy and medical ethics cannot bc separated from societal values. and it is important that the medical school develop closer links with influential community groupings as well as with departments of humanities and social science. Health professionals 01 the future will need a greater understanding of the dynamics shaping societal values if they arc to perform their service. educational and research functions appropriately. Never has the time been more opportune for reexamination of the social science curriculum in medical education. By exercising its overall moral responsibility for the higher education environment. the university has the chance to serve as &LIS (1.~ machinu, diverting medical education from the cvident excesses of reductionist biomedical science and
Social science education as a component of medical training helping it toward a more open recognition of the role played in health by social and behavioural factors ]2,
151. CURRICULUM
1369
recognition of the important interplay between social and behavioral sciences and curative and preventive medicine. The options in any menu of social sciences offerings should include the following:
ISSUES
Much harm has been done to the fabric of health professional education by the isolation of disciplines, often fuelled by a misguided sense of the importance of departmental hegemony. The resulting partitioning of thought may impede innovative solutions to health concerns. In recent years considerable attention has been paid to the need for greater integration in the medical curriculum, particularly between preclinical and clinical programme components. This concern is normally focused on the division between basic and clinical sciences; however, increasingly it is appreciated that there is a need for active encouragement of bridging disciplines that may link the process of scientific questioning with clinical practice. Much of the bridging emphasis to date has been placed on evaluative and probabilistic sciences (clinical epidemiology and biostatistics [ 161 with some tangential acknowledgment of hybrid clinical life science disciplines, such as clinical immunology, nutrition, clinical pharmacology and clinical infectious disease that bring basic science laboratory methods and principles to bear upon bedside clinical problems. As more recognition is given to the physical and sociocultural environments as important determinants of health, there is greater willingness to include behavioural science in the medical curriculum as a key integrating theme. Indeed, the interface between biology and behaviour is emerging as one of the major areas of interest in health, with particular attention directed to, among others, relationships between prosperity and health, early childhood development and subsequent ‘wellness’, and psychological state and immune system function. Inroads in molecular genetics lead to the hope that the biological basis will soon be better understood for conditions previously seen as solely or mainly in the behavioral domain, including alcoholism, substance abuse and depression. Our understanding of the interplay between genetic factors and diseases associated with human behaviour is increasing exponentially and this growing understanding will inevitably alter the approach to social and behavioural sciences as a foundation for medical practice. In almost all areas of social science one can anticipate products of continuing enquiry relevant to medical practice and health policy. The abundance of potential applications underscores the importance of an approach to health professional education designed to permit maximum choice for students, Indeed, it is inconceivable that we will be able to define a ‘core’ medical education curriculum and still leave enough latitude for offering choices adequate to satisfy all individuals interested in a medical career, We must aspire to a curriculum which will encourage
Sociology
There is longstanding appreciation of the importance of health’s social determinants, legitimized particularly through studies of the relationships among wealth, social status and disease and through study of adolescent development and health related behaviours. Increasingly the impact of work attitudes to employment and the supporting framework for adjustments within the labour market is perceived as important both in determining health and as a background to occupational medicine. Child growth
and development
There are suggestions from many sources that early childhood development, social environment, and progression to literacy may substantially influence subsequent health outcomes. Evidence from the Headstart Programme and similar initiatives reinforces the impression that this is an area of potential health improvement and indeed may be the most critical target for any initiative aimed at improved health equity. The study of female literacy and its impact on child health is a fertile field of enquiry in international health. Understanding of these relationships cannot be separated from our ongoing attempts to define brain/behaviour/ biological linkages. Gerontology
Because of the health transition, there is increasing interest in the health concerns of aging adults. Until recently this has been a priority issue for developed countries, but the implications of an aging population in the developing world now attract parallel attention. Of course, aging is a good prism through which to focus the disparate interests of several social sciences. For example, health providers of various kinds will require a broad understanding of death and dying. Medical
anthropology
The understanding of cultural determinants of health is particularly important in the context of international and tropical medicine. Increasingly, these issues are also seen as important in the multicultural societies of developed countries. Greater awareness of the links between the socially and culturally influenced central nervous system and other biological functions (e.g. immune surveillance) may further heighten the importance assigned to our understanding of anthropological determinants of health.
1370 Psychology
S. M.
MACLEOD and H. N. MCCULLOUGH
and behavioral sciences
As noted elsewhere, improved understanding of the relationship between the central nervous system and other biological systems will inevitably prove important to our comprehensive understanding of health. As the mapping of the human genome proceeds. it is likely that we will gain further insights into normal and abnormal behaviour. The importance of these sciences as foundation to health professional practice is likely to be correspondingly augmented. Human sexuality, a complicated domain within behavioural sciences has obvious implications for health and quality of life. and stands as a leading candidate for early inclusion in a foundation curriculum for general preparation of health (i.e. multiprofessional) providers. Medical and social ethics Medical and social ethics cannot be separated from an awareness of social and cultural values which in turn are increasingly driven in the health domain by economic concerns. We arc consistently confronted by dilemmas created through our own technological virtuosity. For example. through molecular engineering we now have the ability to treat a rare genetic disease (Gauchcr‘s) with a replacement enzyme (alglucerase) at a cost that may run as high as several hundred thousand dollars annually. but we lack guidelines to support the making of such a major resource allocation decision [ 171. Education cannot be dissociated from a wide range of social scicncc disciplines that have bearing on our understanding of the value system that serves as a foundation for ethical decision making.
Whether as a component of medical and cultural anthropology or of behavioural science. the study of language and communications is likely to bc seminal to our improved understanding of health. As a subset of this undertaking educational research and the study of the means by which we may achieve greater user involvement in health decision making promises to occupy scholarly interest. Health economics trod politiccd .scicnce (including closelj~ relutcd eraluutirc sc~icnws) Much of the discussion of future directions in medical training is driven by economic and political imperatives. Increasingly, governments are conscious of the cost of meeting their responsibilities in the health domain. Even in the poorest economies, health is recognized as a prime element in infrastructure and an essential social good. This attitude has been reinforced recently by the World Development Report “Investing in Health” [9]. Many of the other social sciences are likely to be focused on health through being caught up in economic and political analysis. Health professional awareness of these
issues will to apply unlimited quality of
be unavoidable in a world which attempts limited fiscal resources to a potentially demand for good health and optima1 life.
Studies of‘ the serrices deliwr:,, As we examine patterns of use of health services we increasingly recognize cultural influences that govern interactions with the health system. Lynn Payer has drawn interesting comparisons among the approaches to medical care taken in the United States, England, Germany and France [18]. There are insights in her transnational observations that may help us to understand the differences that can occur within a single country. as highlighted by Brook [19], Wennberg [20], Billings [21] and Caper [22]. Although our appetite for understanding in this field derives from economic imperatives it is nonetheless likely that such studies will reinforce essential links between social and behavioural sciences and medical practice or health policy. Medicul geogruphr: (including
urban planning)
There is a tradition of interest in geographical determinants of health. communicable diseases in particular. In recent years there has been, in parallel. a developing focus on the influence of urban living on health, and recognition of the potential for urban planning to influence patterns of disease. health outcomes and quality of life.
It is difficult to discern the exact boundary between social sciences and all-embracing concerns of environmental health. While some social sciences. such as geography. have taken a major interest in environmental issues. there is nothing to be gained in a narrow departmental or disciplinary view. No medical school in 1994 can afford to ignore the importance of the relationships between physical environment and health. nor can educators avoid their responsibility to examine the complex interplay among economic factors related to sustainable development and other more obvious determinants of health, including the exposure to environmental toxins. Concerns about the workplace environment. particularly the potential for exposure to physicochemical hazards. also form a continuum with other environmental health concerns. Medical school interests must be blended with those of a wide range of relevant social sciences in this critical domain. In all disciplines where social science investigation and teaching may be blended and harmonized with medical training it will be important to keep in mind the importance of evidence as a guide to health professional practice and health policy [lOpl2]. In every case this will require refinement of our ability to apply evaluative science methodologies. Perhaps the greatest skill to impart to health professional students will be the ability to critically appraise the
Social science education as a component of medical training scientific literature in both basic biomedical and social sciences, and to apply the information that stands up to careful critical analysis to subsequent health professional practices [16]. In this domain there will be substantial overlap with the increasing expertize being developed in information sciences (health informatics) [23]. We will need to improve our understanding of the appropriate packaging of research data and the merging of credible data from various sources through meta analysis in order to derive compelling guidelines for health practice. Further development of the focus on evidence based practice will inevitably demand a greater rigour in social science investigations. In some disciplines presently heavily reliant on qualitative research this may prove difficult; however, the obstacles should not prove insurmountable and success will lead to a more strongly synergistic relationship between social sciences and health professional practice. MEDICAL
EDUCATION
APPROACHES
A detailed review of current approaches to medical education is beyond the scope of this essay; however, the interested reader will find many provocative reviews [24-271. For example, the state of medical education in Britain has recently been carefully analyzed by Stella Lowry in a thoughtful series of articles in the British Medical Journal, later published in book form [28]. Most of her observations related to medical education in Britain are relevant to the current programmes in other developed countries. Certainly a counterpart is found in several reports detailing the state of undergraduate medical education in the United States [15,29, 301. There is now widespread recognition of a shifting health paradigm [4]. This has resulted in demand for a more comprehensive and better integrated approach to medical education, with corresponding avoidance of a curriculum driven by factual content and dominated by departmental rivalries over core knowledge. Instead, the emphasis is likely to be placed increasingly on the encouragement of a spirit of enquiry, guided by recognition of the importance of evidence both from basic medical sciences and social sciences relevant to health practice [IO-121. The undergraduate educational process must provide a contextual framework for lifelong learning and for subsequent continuous adjustment of professional practice. It goes without saying that preparation so directed will demand emphasis on independent approaches to learning. The experience of several innovative medical schools suggests that such an ideal outcome is best achieved through reduced emphasis on teaching of facts and increasing use of task oriented and small group learning [31, 321. Two recent reviews have focused on problem based learning as a promising tool for achievement of new models of medical practice [33, 341. It will not suffice to institute independent learning
1371
for undergraduate health professional education only. Such programmes which, because of their selfdirected character, are bound to be broadly based must also be seen as meeting the responsibility to provide an appropriate foundation for graduate and continuing education that will place a high premium on the maintenance of competence. A curriculum that recognizes the entire breadth of health determinants will also demand the inclusion of social science as an integral part of professional upgrading after graduation. SOCIAL
SCIENCES
(a) Intellectual
AND
MEDICAL
CURRENT
ISSUES
EDUCATION:
environment
It has been suggested that medical schools are failing to provide an attractive environment for social and behavioral scientists [15], but perhaps this criticism is better levelled at the universities themselves. Any university which offers health professional training has a responsibility to maintain an environment that encourages multiprofessionalism, cross-fertilization and integration of multidisciplinary interests relevant to health. All too often, this is an ideal that has not been achieved. Although formal structures should not be required, there may be a case for nurturing shared horizontal research and education programmes under omnibus titles such as ‘Social Medicine’. The experience at McMaster University’s Faculty of Health Sciences in this regard is interesting. An early attempt at integration of basic and social sciences saw the creation of a ‘brain and behaviour programme’. However, this proved too narrow as an integrating topic. Ten years later, the creation of a programme in aging and health (The Educational Centre for Aging and Health) proved much more successful, perhaps because the programme theme was sufficiently broad to recognize multiple facets of interaction between social/ behavioral science and geriatric medical practice. Experience suggests that the study of aging has been more commonly impeded in the past by the erection of partitions between putatively complementary disciplines than has the continuum of neuropsychiatric-psychological interests. (b) The challenge
of chronic disease
The health transition in developing countries and the slowly increasing tendency to longer life in developed countries is likely to result in greater recognition of the importance of social and behavioral sciences in the context of optimal management of disability resulting from chronic diseases. As more emphasis is placed on the long term management of such patients in the community, there is likely to be a corresponding reduction in the use of the tertiary care hospital as a primary venue for medical education. Greater awareness of the special demands of community based care and the importance of user involvement in
S.M. MACLEOD
1372
and
influencing the nature of that care will unquestionably augment the importance accorded physician training in social and behavioral sciences. The university may yet find another opportunity to confirm its social relevance by encouraging development of a living laboratory for teaching of social sciences relcvant to the education of health service providers. (c) Internntionul
health
Many medical schools are actively increasing their involvement in international health and tropical medicine, partly in recognition of the research and service opportunity presented by the substantial burden of preventable disease in those countries still beset by high rates of communicable disease mortality and morbidity. International health activity inevitably leads Northern institutions to re-examination of public health teaching and population health sciences as well as to greater awareness of transcultural issues in health. Medical schools who become involved internationally at this time will be well positioned to observe the health transition at first hand and will be more conscious of the need to enrich the learning opportunities provided to their students in social sciences.
It is apparent that there is no room in the medical education curriculum for inclusion of all disciplines or active dissemination of all knowledge relevant to health. Realistically, emphasis must bc placed on concepts and illustrative principles, with a restriction of factual content to items required to understand key concepts. The acquisition of skills must be emphasized as appropriate to any health profession, but there must be sufficient latitude to permit eclecticism in the choice of professional practice profiles among graduates. It is critically important that Rexibility be maintained in the health professional curriculum and this is likely best achieved in a student-centred, problem based learning system which places a high premium on independent learning. Parallel reliance on flexible learning resources (particularly strong libraries and well equipped computing centres) provided in such a way as to encourage student autonomy in their use is also desirable. (~7)Whot is cow ond K,hut is not.? A potential threat to expanded social sciences education in medical training may be found in recent enthusiasm from some quarters for the definition of a core curriculum [35, 361. While supporters of this concept are quick to point out the parallel benefits of protected time for ‘options’, the prospect is nonetheless raised of an interminable conflict over definition of core factual content. Given the progressively more overwhelming deluge of biomedical knowledge, it will be difficult to hear the voices of those who support increasing exposure of health professional trainees to
H.N. MKULLOUGH social and behavioural sciences once the pack has set off in full cry pursuing the elusive core. There is nothing novel about the deceptive allure of a core curriculum; however. those tempted should be aware of generic arguments against this particular solution [37] and of voices which counsel moderation in the definition of foundation medical knowledge. The core-and-options model has been under active discussion in Britain since 1990 without resolution of concerns about the ‘restrictively fat core’ [38] or the elusiveness of defined objectives in core medical education [39]. Implicit in this approach is acceptance of a degree of homogeneity in professional practice profiles that flies in the face of reality. (‘ON(‘I.LlSION
The world’s medical schools arc caught in a maelstrom of change. The status quo is not defensible, although the optimal way forward is far from clear. Some difficult philosophical questions remain to be resolved, including in particular the confrontation between a normal human desire for optimal individualized care and the prevailing government-driven demand for maximal cost-effectiveness based on population outcomes [40.41]. Most medical educators will admit to sonic virtue in both points of view. Medical schools will need to diversify and to find a variety of adaptive strategies in order to meet these conflicting demands [41]. One of the key adaptive strategies will be found in the efficient blending of a menu of behavioural and social sciences with the array of life and clinical sciences that has been brought to such a high level of development in the postwar period. It should not be necessary to create from whole cloth new minidepartments within the medical school. Far greater advantage will bc gamed if present pressures lead to meaningful links between the medical school and potential partners within the university community. This is most likely to happen in an environment which stresses adaptability in its approach to curriculum. Learning opportunities responsive to the needs of future health care providers should be effectively grouped around themes such as human bchaviour and development, aging or environmental health. without any gerrymandering of current departmental or disciplinary mandates. If appropriate cross disciplinary links arc achieved. the outcome will prove beneficial to component departments, faculties, universities and the broader communities they serve. There is an outstanding opportunity in the current situation for the emergence of leadership. In a northern analogy drawn from the world of dog teams and snow; “It is always better to be the lead dog, because in other positions the view doesn’t change very much”. For those who cherish the excitement of a changing view as we plunge on across the tundra following the polestar of broadly based medical education, there can be no greater challenge than
Social science education as a component of medical training
defining the
realm
the place of social science education of essential
medical
within
19. Brook
training. 20.
Acknowledgements-This review was prepared during a residency at the Rockefeller Study and Conference Center, Villa Serbelloni, Bellagio, Italy, November 1993. The support of the Rockefeller Foundation (New York) is gratefully acknowledged.
21.
22. 23. REFERENCES
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