Today it is widely recognized that high-quality patient care is built on a foundation of knowledge and abilities in the basic, clinical, and behavioral and social sciences. Social and behavioral factors are estimated to contribute to more than half of all causes of disease and death in the United States, including cancer, heart disease, chronic obstructive pulmonary disease, and type II diabetes. Growing knowledge of the complex behavioral, social, and psychological contributors to disease has important implications for clinical practice and physician education, both formal and informal. Physicians must understand these factors and their interrelationships, and be able to apply this knowledge in the care of patients to optimize health outcomes as well as to equip them with the skills that promote their own sense of well-being, foster lifelong personal and professional growth, and decrease feelings of cynicism and burnout.

Whereas many health training programs have incorporated behavioral and social science content into their formal education, many curricula remain fragmented, incomplete, and marginalized. Emphasis on formal curricular development may also overlook the importance of the informal curriculum (or learning environment)—the physician and resident modeling of behaviors and attitudes that medical students experience every day. Therefore, educators must be attentive to both influences on student education. Using current theories of learning, this chapter illustrates innovative educational methods that integrate the formal and informal curricula to effectively teach social and behavioral science (SBS).

The IOM report, Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula, identifies 26 topics in six SBS domains that are important to the education of future physicians (see Table 42-1). The demographic and social contexts contributing to the need for such training in the behavioral and social sciences have been well documented. Nevertheless, several decades of efforts to teach this content have resulted in mixed success. Medical education literature clearly identifies several types of difficulties specific to the teaching of SBS in the formal curriculum, including the marginalization of SBS content, lack of appropriately trained faculty, timing of teaching the SBS content, mismatch between teaching methods and context of use, and failure of social scientists and clinicians to work together to create effective learning experiences. It is not difficult to find examples. SBS content may be treated as an “add on” to the traditional basic science and clinical curricula. Medical training programs may lack support and incentives for faculty to include SBS content, and for career development programs in SBS. SBS topics may fit into available time slots rather than taught at the appropriate times in the trainees’ development and in the appropriate depth. For example, topics such as death and dying are often covered in small-group discussions in the first or second year and not revisited in any formal way in the clerkship years, yet research on knowledge use and acquisition concludes that there is little immediate transfer of learning from one context of use to another. Thus, students who discuss death and dying only in the early year or two of training (academic context) will be challenged to exhibit professional and humanistic behavior in the presence of real patients (practice context) without further formal training in the clinical context.

There are also additional, well-documented structural impediments from a systems perspective to fully realizing the successful integration of SBS into the larger medical education curriculum. Medical education is by and large examination driven, quantitative in nature, and competition among and between students is based on these numerical rankings. This system continues to perpetuate the marginalization of SBS to a supporting or secondary role in the minds of faculty and students in favor of more influential “objective” measures. For example, on the national level, the Association of American Medical Colleges’ Medical College Admission Test (MCAT) as well as other high-stakes examinations (e.g., USMLE Step 1) are not Pass/Fail despite sufficient evidence that once a learner achieves a particular threshold of success on the examination there is no difference in clinical performance based on achieving a greater numerical score. Yet, despite this evidence, many institutions continue to use the specific scores to screen applicants for entrance to US medical schools and residencies, and school administrators are under pressure, and in some cases even rewarded, for only recruiting and admitting those with the highest test scores instead of developing criteria that would focus on such areas as the 26 topics in the six SBS domains as the discriminating factors.

In response to similar concerns, Canada’s McMaster University developed the Multiple Mini-Interview (MMI) for use in the admissions process. Resembling an objective structured clinical examination (OSCE) the MMI consists of short-interview stations that focus exclusively on noncognitive domains. The open-ended interviewer–applicant interactions instead revolve around areas such as the ability to collaborate, communication skills, and moral reasoning. By focusing on these noncognitive professional abilities the MMI has consistently demonstrated greater reliability (i.e., around 0.75) than standard interview methods to accurately assess for these qualities, which are grounded in SBS and valued in clinical practice. It has also been established that the MMI has a significant and moderately large positive correlation in predicting clinical clerkship performance as well as a statistically significant positive correlation for those subsections of national licensing examinations assessing professional quality domains.

On the local level, many courses in the basic sciences lend themselves to “multiple choice” measures making the evaluation of SBS content difficult to objectively evaluate given the time and resources SBS curriculum often requires in both teaching and evaluating. Therefore, even if SBS content is woven into the curriculum, it is often not as heavily weighted or given equal focus in course examinations. This not only perpetuates the idea that SBS content is not as important, but for the learner whose measure of success rests on quantitative success (i.e., to get into medical school, a residency, or pass an examination), it creates a systems-induced survival strategy of “if it’s not going to help me on the test then it’s not important.” This mentality or two-tiered system of valuing the objectively quantifiable over the more often subjectively qualitative SBS is as much a systems issue as it is those difficulties specific to the teaching of SBS in the curriculum noted above.

Finally, emphasis on discipline-based knowledge creates another barrier to integration of SBS content. True integration of SBS content requires disciplinary communities to work closely together to establish joint responsibility for knowledge creation, development and dissemination. With the exception of family medicine residency training programs, which have emphasized training in SBS, the same limitations and critiques directed toward undergraduate medical education hold true for graduate medical education as well.

Informal education in the SBS also has presented a challenge. Research indicates that it is the social environment of the medical school, the so-called “informal curriculum,” that guides most aspects of a future physician’s behavior. The role modeling that physicians and residents actually do, much more than what they say, powerfully influences the beliefs, values, and role expectations of physicians-in-training. Patient care and clerkship experiences—where physical, emotional, behavioral, social, and cultural issues become embodied for learners in their patients—have the potential to be particularly important behavioral and social science learning opportunities. Here attending and resident teaching could seamlessly integrate SBS education into daily clinical activities. Unfortunately, studies show that attributes such as social-mindedness and interest in the psychosocial issues embedded in all illness decline rather than improve during this time, and many students experience a diminishment, not enhancement, of their moral values base.

Work must be done to raise faculty and resident consciousness of the power that their words and actions have in shaping students’ perceptions of patients, their specialty and medicine in general. Students and faculty benefit alike from the opportunity to process and learn from their own experiences, making each more conscious of the relationship between their values, actions, and behavior, and better prepared to model and teach the SBS aspects of patient care and the practice of medicine.

Educational Learning Theories Foundational to Creating Social and Behavioral Science Curriculum

As medical training programs seek to integrate their formal and informal curricula to improve SBS education, current learning theories provide a useful underlying framework. Understanding the various theoretical orientations will allow educators to address concerns raised in the IOM report about incorporating the most appropriate teaching methodologies when teaching SBS. The five learning theories described in the adult learning literature include behaviorist, humanist, social learning, cognitivist, and constructivist orientations. An overview of these orientations, associated educational methods, and theoretical principles are briefly summarized in Table 42-2.