Creating an ideal social and behavioural sciences curriculum for medical students
Jason M Satterfield,1 Shelley R Adler,2 H Carrie Chen,3 Karen E Hauer,4 George W Saba2 & Rene Salazar1
OBJECTIVES
Undergraduate medical education programmes universally struggle with overfull curricula that make curricular changes quite challenging. Final content decisions are often influenced by available faculty staff, vocal champions or institutional culture. We present a multi-modal process for identifying ‘need to-know’ content while leveraging curricular change, using the social and behavioural sciences (SBS) as an exemplar.
METHODS
Several multi-modal approaches were used to identify and triangulate core SBS curricula, including:
a national survey of 204 faculty members who ranked the content importance of each of the SBS content areas;
a comprehensive review of leading medical SBS textbooks;
development of an algorithm to assess the strength of evidence for and potential clinical impact of each SBS construct;
solicitation of student input, and
review of guidelines from national advocacy organisations.
To leverage curricular change, curriculum mapping was used to compare the school’s ‘actual’ SBS curriculum with an ‘ideal’ SBS curriculum to highlight educational needs and areas for revision. Clinical clerkship directors assisted in translating core SBS content into relevant clinical competencies.
RESULTS
Essential SBS content areas were identified along with more effective and efficient ways of teaching SBS within a medical setting. The triangulation of several methods to identify content raised confidence in the resulting content list. Mapping actual versus ideal SBS curricula highlighted both current strengths and weaknesses and identified opportunities for change.
CONCLUSIONS
This multi-modal, several-stage process of generating need-to-know curricular content and comparing it with current practices helped promote curricular changes in SBS, a content area that has been traditionally difficult to teach and is often under-represented. It is likely that this process can be generalised to other emerging or underrepresented topic areas.
INTRODUCTION
급격한 의학 지식의 축적으로 인해 좋은 점도 많지만, 많은 의과대학들은 제한된 시간에 늘어난 지식을 가르치느라 고전하고 있다.
Although the rapidly expanding fund of medical knowledge offers new possibilities for the promotion of health and the treatment of disease, it creates a vexing problem for overburdened medical schools balancing dozens of growing disciplines and content areas with a static number of teaching hours and resources.
새로운 교육과정을 안정적으로 정착시키기 위해서는 새롭게 "알아야 하는" 내용을 확정하는 타당하고 신뢰도 있는 절차와 현재의 교육과정을 평가하는 과정이 필요하다. 다음의 모델들이 좋은 출발점이 될 것이다. 여기서는 curriculum mapping을 활용하여 사회/행동과학(SBS)교육과정의 개정한 사례를 제시하고자 한다.
A valid and reliable process of identifying ‘need-to-know’ content while evaluating current curricular efforts is required to integrate new knowledge and to change set curricula.
- Important models of curricular mapping,1,2
- curricular change management, 3 and
- educational evolution since the time of the Flexner Report4,5 have been offered as starting points in the consideration of change.
We present curricular change in the social and behavioural sciences (SBS) as an exemplar for identifying core content and using curriculum mapping as leverage for inclusion.
미국 내의 morbidity와 mortality의 원인은 행동적/사회적 요인과 관련되어 있으며, 의사들에게 SBS를 가르침으로서 outcome을 향상시킬 수 있으며, 반대로 사회문화적 차이를 모르면 outcome이 악화된다.
Approximately half of all causes of morbidity and mortality in the USA are linked to behavioural and social factors,6,7 and training doctors in the SBS is associated with improved outcomes.
- Superior interviewing skills are linked to more accurate diagnoses, increased adherence, improved outcomes and greater patient satisfaction.8,9
- Cultural competency training appears to reduce racial and ethnic health disparities and improve clinical outcomes.10
- Conversely, lack of appreciation, exploration or understanding of socio-cultural differences between doctors and patients can lead to decreased adherence and, subsequently, poorer health outcomes.11,12
미국 인구 건강 향상을 위하여 IOM은 의사들에게 SBS에 관한 지식과 스킬을 익힐 것을 권고하고 있다.
With the goal of substantially improving the health of the US population, the Institute of Medicine (IOM) has called for doctors to acquire
‘the knowledge and skills from the behavioural and social sciences needed to recognise, understand, and effectively respond to patients as individuals’.13
또한 이 보고서에서는 의과대학에서는 4년간의 통합된 SBS교육을 다음의 여섯 개 영역에 대해서 할 것을 권고했다.
This report recommends that medical schools offer a 4-year, integrated SBS curriculum addressing six domains:
- mind–body interactions;
- patient behaviour;
- the doctor’s role and behaviour;
- doctor–patient interactions;
- social and cultural issues in health care, and
- health policy and economics.
보고서에서 26개의 SBS토픽을 구분했지만, 의과대학은 총체적인 접근법을 고민해야 할 것이다.
Although the report identifies 26 different SBS topics, medical schools need a systematic approach to determining the specific knowledge and skills essential for every medical student. To address this challenge, we employed a multi-modal process for identifying need-to-know SBS content for medical students while promoting curricular revisions.
다음의 과정을 밟았다.
This process included the use of:
- a locally generated topic list ranked by national SBS experts to validate and focus the IOM content suggestions;
- a curriculum-mapping project to compare a local actual curriculum with the ‘ideal’ SBS curriculum, and
- collaboration with clinicians to translate ideal SBS content into clinical competencies to support clinical clerkship revisions.
We first review current challenges for SBS in undergraduate medical education, describe the ‘need-to-know’ principle, and then outline our content development and mapping processes. Although we focus on the SBS, this process may be applicable to content in other domains.
의과대학 교육과정에서 SBS교육과정 디자인과 도입시 도전과제들
Challenges in designing and implementing SBS curricula in medical schools
대부분 미국 의과대학이 약간의 SBS교육과정들을 가지고 있지만 정규 교육과정에서 다루고 있는 정도와 성공 수준에서 차이가 크다. 그 원인은 아래와 같은 것들이 있다.
Although most US medical schools include some SBS education, the degree and success of formal curricular implementation has been inconsistent. The variation in programmes results from challenges that include...
- competing curricula,
- the legacy of the culture of biomedicine, and
- inadequate SBS faculty development and support.13
Because current medical curricula are already crowded, the addition of SBS instruction may be viewed as threatening to other curricular content.14 This struggle for curricular space is unfortunately exacerbated by social and behavioural scientists and clinicians who fail to work well together. In some settings, an ‘us-and-them’ stance develops, negatively influencing the educational environment.15 Although this dynamic can exist in any content area, it tends to be more pronounced in the SBS, which is often not accepted by a medical culture that may see the field as less relevant to clinical care. Even among those faculty staff who support medical students’ education in the SBS, the need to reduce teaching time, share resources, and collaborate effectively can prove challenging.14,15
더 넓게는 생의학적 문화가 상당한 장애물이 되고 있다.
More broadly, the legacy of the biomedical culture remains a significant impediment to the development of integrated and valued SBS curricula.
Although beliefs are shifting, mainstream clinical reasoning still attributes human disease to anatomic and biochemical abnormalities and tends to dismiss psychosocial determinants as less relevant.15 Without trained SBS educators advocating for SBS curricular content, the SBS may be overlooked or integrated poorly into the overall curriculum.16 If SBS content remains separate while other content is increasingly delivered in integrated formats, its peripheral status is highlighted and its value questioned. Teaching of the SBS can also be impeded by the ‘hidden curriculum’, the implicit messages communicated through role modelling and the imprinting of attitudes and values onto students by experienced educators.17
명확하게 규정된 SBS교육내용 세트와 SBS역량이 필요하다. 또한 통합이 필수적이다.
To create an appropriately integrated, interdependent curriculum, a clearly defined (ideal) set of SBS content and competencies is required. Integration is critical to ensure that various components of the SBS curriculum reinforce one another and the larger curriculum, and that there is sequential development of SBS learning in an iterative or spiral configuration.
"꼭 알아야 하는 것(need-to-know)"의 원칙
The ‘need-to-know’ principle
급격히 증가하는 의과대학 교육과정 내용에 대응하기 위해서, 교육자들은 모든 의과대학생이 알아야 하는 지식과 술기의 내용을 제한할 필요가 있다. 이러한 rationale 하에 미국에서는 ACGME가 전공의 수련의 18개 역량을 개발하였다. 이 broad competencies는 모든 수련중인 의사가 "꼭 알아야 하는(need to know)" 것에 대한 전공과목간에 합의된 내용이다.
To address the dramatic increase in medical school curricular content, educators must restrict material to the fundamental knowledge and skills that every medical student needs to know, regardless of ultimate specialty. In the USA, the Accreditation Council for Graduate Medical Education (ACGME) developed competencies18 for residency training based on this rationale. These broad competencies represent a consensus among medical disciplines regarding the need-to-know content and skills for all resident doctors-in-training. These baseline competencies in knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice are applicable and have been adapted to all disciplines.
ACGME 전공의 역량은 포괄적인 가이드를 주기 위한 것이며, 교육과정 설계를 위한 세세한 내용은 담고있지 않다.
The ACGME resident competencies are designed to offer broad guidance for general programme development and may provide insufficient detail for the construction of specific curricula.18
For example, although the competencies of communication and professionalism may be considered SBS in nature, they are not described in sufficient detail and are too limited in scope to guide the development of a comprehensive SBS curriculum in graduate medical education.
Specific knowledge and skills, such as those in mind–body interactions and patient behaviour content emphasised in the 2004 IOM report,13 are not addressed.
Accreditation standards for US medical schools19 include SBS content, but are similarly too broad to guide content development for medical students.
더 구체적인 가이드가 있어야 할 것이다.
Without more specific guidelines, individual medical schools and residencies must develop internal benchmarks and competency definitions in determining required SBS content.
METHODS
이상적인 교육과정, 실제 교육과정, 그리고 역량의 'translation"
The ideal curriculum, the actual curriculum and translating competencies
교육과정 설문과 mapping 프로젝트를 하였다. 이상적인 SBS교육과정과 비교하는 것.
We developed and implemented a curriculum survey and mapping project1,2 to validate and focus the IOM content suggestions,13 estimate local curricular needs and translate essential content into clinical competencies. This project included a comparison of our school’s existing SBS curriculum with an ideal one.
Firstly, we identified core SBS content by reviewing expert resources and reports from professional societies to create a comprehensive content list, which was subsequently winnowed to establish core SBS content based on the need-to-know principle.
Secondly, we conducted a national survey of medical school faculty to validate and refine the truncated core content list (Fig. 1).
실제 교육과정을 이상적인 교육과정과 비교함으로써 부족한 것이 무엇인지를 알 수 있었고, 이것이 교육과정 개혁의 지렛대 역할을 할 수 있었다.
Our school’s ‘actual’ SBS curriculum was determined using electronic keyword searches and faculty interviews. The comparison of actual with ideal helped to identify core SBS teaching priorities, effectively direct limited resources and leverage curricular change. In collaboration with the clinical clerkships, SBS content was translated into clinical competencies complementary to existing third-year materials.
이상적인 교육과정 만들기
Creating the ideal curriculum
우리는 이상적인 학부 SBS교육과정을 정의하는 것에 있어서 몇 가지 핵심 요소를 포함시키고자 했다.
We define the ideal undergraduate medical education SBS curriculum as including several key features, including:
- comprehensive coverage of core content;
- a strong evidence base;
- potential for integration with other scientific disciplines;
- clinical relevance, and
- sensitivity to curricular structure limitations (e.g. available curricular hours, competing accreditation requirements,19 course organisation).
포괄적이고 걸러지지 않은(unfiltered) 목록을 만들었다. (1)교과서 중심 (2)미 전문직 조직들로부터 목록 수합
We created a comprehensive, unfiltered list of SBS topics using a variety of resources.
- We began by reviewing six leading SBS textbooks for medical students and residents.20–25 The first author (JMS) developed matrices of content areas that included all topics covered in the six textbooks, ratings on a scale of 1–5 for the depth of coverage of each topic in each textbook (i.e. no, minimal, fair, good or comprehensive coverage), and notations on special strategies for presenting and reinforcing the materials. Topics receiving at least fair coverage in one textbook were added to an initial SBS topic list.
- Next, we collected content lists and reports from US professional organisations (e.g. the Association of Behavioral Science and Medical Education,26 the American Psychosomatic Society,27 the American Medical Student Association,28 the American Board of Internal Medicine,29 the Institute of Medicine,13 the Association of American Medical Colleges30 and the Society of Teachers of Family Medicine31). Substantial redundancies in the list were removed and similar items combined.
설문 결과
Survey results
Frequency counts and mean ratings were calculated across all participants for each content area and for each item. Items were rated on a 5-point scale, on which
- 1 = ‘We do not need to ensure that students are offered exposure to this topic during medical school’,
- 3 = ‘Worth some effort to see that students are offered exposure to this topic, but not a top priority’ and
- 5 = ‘It is essential that every effort is made to cover this topic’.
Overall content area means were as follows:
- mind–body interactions, 3.92 (standard deviation [SD] = 0.37);
- patient behaviour, 4.13 (SD = 0.50);
- the doctor’s role and behaviour, 4.10 (SD = 0.36);
- doctor–patient interactions, 4.36 (SD = 0.21);
- socio-cultural issues, 4.22 (SD = 0.35), and
- health policy, 3.98 (SD = 0.32). Item means ranged from 3.07 to 4.77.
Tables 1 and 2 list the highest- and lowest-rated items based on mean item ratings.
실제 SBS교육과정에 적용시키기
Application of the ideal to the actual SBS curriculum
"이상적인" SBS교육과정을 만들었더라도, 지금 진행중인 실제 SBS교육과정을 분석하기 전까지는 교육과정을 바꿀 수 없었다. 또한 교육과정 구조, 교수법, 문화 등에 대한 면밀한 조사가 필요했다.
Although the robust, convergent validity of our newly created ‘ideal’ SBS curriculum was persuasive in its own right, curricular revisions could not be recommended until we had examined our school’s actual SBS curriculum. Moreover, many complex issues such as curricular structure, pedagogy and the local teaching culture required careful attention before any dissemination or implementation efforts could be made.
우리 학교의 SBS 교육과정을 리뷰하였다.
We reviewed our school’s medical student curriculum SBS content to...
- maximise the coordination and
- use of pre-existing materials and to
- identify unmet curricular needs by comparing the actual with the ideal SBS curriculum.
방법
- 키워드 검색
Using an electronic keyword search (n = 370 keywords across six IOM domains13 derived from our core content list and synonymous MeSH terms), we identified, downloaded and reviewed all teaching materials in our school’s electronic curriculum database (‘Ilios’), including teaching cases, special projects and assignments, and learning objectives. (Ilios is a UCSF-developed database program used to store, coordinate and revise content for all undergraduate medical education teaching sessions. ‘Published’ (i.e. completed) teaching materials are fully searchable and openly accessible via the Internet.) We found a total of 1444 hits and handreviewed all associated teaching materials. - 반구조화 면접
Our team also conducted semi-structured interviews with all clerkship directors to elicit and catalogue formal and informal SBS teaching in core clerkships. - Medical education curricular maps
We subsequently created six undergraduate medical education curricular maps with visual timelines corresponding to the six IOM domains. Comprehensive appendices for each map detailed case content, learning objectives and other curricular elements. This detailed, actual SBS curriculum was then compared with the ideal SBS curriculum to set development goals and priorities for medical school Years 1–3.
예상했던 바와 같이 가장 요구가 크고, 기회가 많은 학년은 3학년의 임상실습이었다.
As anticipated, the area of greatest need and opportunity was the third-year clinical clerkships.
Although students acquired a solid SBS knowledge base in Years 1 and 2, the concepts were often difficult to translate to clinical practice, inconsistently reinforced, and sometimes actively devalued by supervising residents and faculty members.
"이상적인 SBS교육과정"의 내용이 각 IOM 영역에 translate 되었고, 이상적인 역량을 실제 임상실습 역량과 비교하고, 요구도가 높은 SBS역량으로 목록을 좁혀 나갔음.
As a first translational step, we applied the ACGME clinical competencies framework to our ideal SBS curriculum and translated the ideal SBS concepts into skill-based competencies for each IOM domain. 13 We then compared this list of ideal SBS competencies with actual clerkship competencies and data from the semi-structured clerkship director interviews. Lists of high-need SBS competencies were narrowed to a locally relevant list of nine competencies to guide future clerkship revisions.
토론
DISCUSSION
We developed a multi-modal process to find the closest, objective approximation to an ideal SBS curriculum for medical students. In an overfull curriculum with competing disciplinary champions, this transparent and carefully derived content list was more persuasive than personal opinions or student preference. This ideal SBS content was then adapted to carefully assessed local curricular needs, teaching priorities and available resources using an ‘ideal versus actual’ mapping approach to leverage change. Social and behavioural sciences content was translated into clinical competencies to make its clinical relevance more obvious to non-SBS faculty members and students. Although specific SBS curricular needs are likely to vary across schools, the derived ideal SBS curriculum can be used as a starting point for curricular comparisons and need assessments at other institutions. Given the breadth of SBS content and its potential inclusion in many different courses and clinical teaching cases, a careful mapping and oversight process is probably even more essential for SBS than for other more circumscribed content areas. The translation of core content into clinical competencies may hold important benefits for other content areas, including the basic sciences.
응답자들이 자신이 준 점수에 대한 설명을 하지 않았으므로 왜 덜 중요하다고 했는지 이유는 알 수 없다.
Because survey respondents did not explain or justify their ratings, we cannot determine why certain items were viewed as less important.
한 설문에서 1/3의 응답자들은 정신사회적 요인을 아는 것이 별로 도움이 안된다고 했다.
In two surveys of doctor, resident and student attitudes toward psychosocial factors in medicine, Astin et al.32,33 found about one-third of respondents believed that addressing psychosocial factors yielded minimal or no improvement in patient care. Most participants believed their past psychosocial training was ineffective and few desired additional training.
이상적인 SBS교육과정에서 그 중요성을 높게 평가받은 항목들이 있더라도 정신사회적 내용에 대한 훈련 필요성을 낮게 보는 분위기는 이런 높은 우선순위 항목에조차 영향을 줄 수 있다.
Reasons cited for the view that psychosocial factors are less important included low self-efficacy, limited knowledge base, insufficient time and low reimbursement. 32,33 Although the perceived value of highly rated items in an ideal SBS curriculum may improve learner acceptance and motivation, prevailing attitudes regarding the value of psychosocial training and the importance of psychosocial factors in clinical care could undermine even the highest priority content.
Creating an ideal social and behavioural sciences curriculum for medical students.
Abstract
OBJECTIVES:
Undergraduate medical education programmes universally struggle with overfull curricula that make curricular changes quite challenging. Final content decisions are often influenced by available faculty staff, vocal champions or institutional culture. We present a multi-modal process for identifying 'need-to-know' content while leveraging curricular change, using the social and behavioural sciences (SBS) as an exemplar.
METHODS:
Several multi-modal approaches were used to identify and triangulate core SBS curricula, including: a national survey of 204 faculty members who ranked the content importance of each of the SBS content areas; a comprehensive review of leading medical SBS textbooks; development of an algorithm to assess the strength of evidence for and potential clinical impact of each SBS construct; solicitation of student input, and review of guidelines from national advocacy organisations. To leverage curricular change, curriculum mapping was used to compare the school's 'actual' SBS curriculum with an 'ideal' SBS curriculum to highlight educational needs and areas for revision. Clinical clerkship directors assisted in translating core SBS content into relevant clinical competencies.
RESULTS:
Essential SBS content areas were identified along with more effective and efficient ways of teaching SBS within a medical setting. The triangulation of several methods to identify content raised confidence in the resulting content list. Mapping actual versus ideal SBS curricula highlighted both current strengths and weaknesses and identified opportunities for change.
CONCLUSIONS:
This multi-modal, several-stage process of generating need-to-know curricular content and comparing it with current practices helped promote curricular changes in SBS, a content area that has been traditionally difficult to teach and is often under-represented. It is likely that this process can be generalised to other emerging or under-represented topic areas.
© Blackwell Publishing Ltd 2010.
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