Sot. Sci. & Med., Vol
9. pp. 221 to 225. Pcrgamon Press 1975. Prmtd
in Great Bntain.
TEACHING BEHAVIORAL SCIENCES IN SCHOOLS MEDICINE: OBSERVATIONS ON SOME LATIN-AMERICAN SCHOOLS
OF
RODNEYM. COE Department
of Community Medicine, St. Louis University School of Medicine, 1320 South Grand Avenue. St. Louis, MO 63104, U.S.A.
Abstract-This paper discusses the conceptualization and implementation of teaching behavioral sciences in schools of medicine. Data were collected through interviews with key personnel and documents obtained from ten schools of medicine in Latin-America. Observations lead to a conceptual clarification of the terms social medicine and community medicine. Consideration of variations in scope and sequence of curricula programming leads to tentative identification of three “types” ‘of curricula: traditional, expanded and integrated. Recommendations are made for changes in curricula to enhance the teaching of behavioral sciences in other schools of medicine.
This report discusses some observations made during a study of programs for teaching behavioral sciences in selected Latin-American schools of medicine. The study also reviewed the uses of community resources in teaching medical students and identified some factors influencing the course of medical education. The information developed in this study forms the basis for some recommendations for the teaching of behavioral sciences in schools of medicine in other countries. The present interest in including behavioral sciences in medical school curricula in the United States is an outcome of the convergence of behavioral. sciences and the general field of medicine. This convergence (actually a reconvergence) has come about in part because of: (a) changing patterns of morbidity and mortality; (b) increasing inequities in the delivery of health services; and (c) the maturation of behavioral sciences in terms of capability for scientific theory-building and methodology [l]. The increasing discrepancy between what is taught in medical schools and what is required in medical practice [2,3] has led to increasing demands for change in the curricula of medical schools, especially for including the behavioral sciences [4-6]. However, among the various schools of medicine, the form and amount of development and speed of integration of behavioral sciences into the curriculum have varied greatly [7,8]. Thus, one objective of this investigation has been to determine what lessons programs in South American schools might hold for medical schools in the United States and other countries as well. Data were collected by means of personal interviews, documents describing various program components and tours of facilities [9]. Interviews were held most often with behavioral scientists in each setting and with physicians who teach or provide supervision for medical students or who render direct care services in clinics. In addition, chairmen of Departments of Preventive and Social Medicine (and Dentistry) were seen. In a few instances. administrative officers such as Deans and a Director of medical education were interviewed. Many documents were obtained which related to organization and operation of medical school curri-
cula in Departments of Preventive and Social Medicine especially with reference to the integration of various disciplines comprising the behavioral sciences. Other papers reflect the particular research and/or teaching interests of informants such as syllabi for courses in behavioral sciences and reprints of articles in professional journals. Although these materials cover a wide range of topics and activities, it should be kept in mind that the following statements refer to the sites visited (which vary considerably among themselves) and may not necessarily reflect the situation in other schools. CONCEPTUALIZATION
AND
IMPLEMENTATION
The comments made here address the issues of conceptualization -and implementation of behavioral sciences and use of the community as a teaching tool. One observation that was reinforced over and over is the sharp distinction made between the concepts of social medicine and community medicine. Although there are a few important exceptions, the emphasis in Latin-American programs is on the teaching of behavioral sciences as they relate to the practice of social medicine [lo], not community medicine which is more than just the application of social medicine in a community setting. In the United States, more emphasis is placed on learning about a community’s structure, resources and health problems and participating with others through community organization efforts in identifying those problems and developing solutions to them. It would be fair to say that most theoretical statements about social medicine involve systemic relationships between measures of need resources and institutional (government and educational) policy and employ behavioral sciences in a scientific approach to the measuring of and planning for meeting society’s health needs [l 11. For example, the model shown in Fig. 1 links health need, health resources and institutional philosophy. Need reflects actual health status which is measured epidemiologically in terms of amounts and types of diseases in a population, according to position in the social structure and subject to cultural influences. Resources or state of health
RODNEY M. COE
222
Need Epidemiology, SOCIOeconomic structure, cultural influences
Philosophy Priorities research medical
on teaching, and service in education
Resources Organization and financing of health services
Fig. 1.
services are indicated by factors associated with the delivery of health care. Likewise, institutional policies are expressed in terms of relative emphasis or priority on teaching, research and service. The basic assumption is that each of the elements of the “system” influences and is influenced by the others. This would be applicable also to community medicine in the United States except that the “community” dimension of organization and participation of clients in the decision-making and action programming is omitted. Thus, the model shown above can be restated in terms of community medicine with only slight, but conceptually important modifications (see Fig. 2). The concept of need, which is a professional estimate of what the community requires to meet health standards, is expanded to include demand which is an expression of what the community (through its individuals and organizations) perceives to be its needs and what it wants. Similarly, the organization and utilization of health resources are influenced by the need-demand dimension and are not based solely on what health professionals view as their capacity to meet needs or what priorities professionals believe ought to be assigned when resources are scarce, but they include also the interests of the community (and the community itself becomes a resource). In the same way, community representatives participate in establishing a “social contract” between educational, governmental and community organizations so that the interests and priorities of each group can be maximized. This represents a somewhat different role for the behavioral sciences.
This becomes a little more apparent in observing the application of these principles in health care settings. Thus, Latin-American medical students learn about the principles of social medicine in the classroom and apply them in the clinics in the community as an extension of the medical center rather than as a core of a community-based and communityoriented health and education center. The emphasis. however, stems from the professional model of the “expert” doing something to the patient not with the patient. In other words, there is little effort to involve the patient or his family as a partner in the treatment process nor is there much effort at using a behavioral sciences approach to organizing the community to prevent, diagnose, treat or rehabilitate its own health problems or to evaluate the results. In contrast, community medicine programs in the United States more often direct their efforts at involving the community in health care processes. In part, the community may be seen as the “patient” and medical students and others in allied health fields are encouraged to examine and treat the “whole patient” while at the same time treating specific diseases of individuals in that community. This emphasis in the United States, however, is usually associated with weakly developed and poorly integrated didactic programs of social medicine. Thus, programs in the United States differ from Latin-American programs in degree of emphasis on principles of social medicine as well as focusof their application in community settings. The foregoing generalization is very broad and based on observation of only a few programs; another
Need/demand Eprdemiology, socialeconomic structure, cultural differences, perceptions of community
Philosophy
needs
Priorities on teaching, research and service‘community’as client
by
residents
(indrviduals izations)
and
orgon-
Resources Organization and financing of health servicescomprehensive program through integration of existing community facilities
Fig. 2.
Teaching behavioral sciences
way of saying there are always exceptions to the rule. In this regard, there are some notable exceptions *among the programs visited during this tour. One of the outstanding examples of community medicine is the Pasantia Rural managed by the University of Zulia in the health center of San Rafael de Mara, Venezuela [12]. Over a period of the last 10 yr, medical students assigned to the health center for short periods of training not only learned about preventive and curative medicine. but participated in programs of political organization of a community, assisted in the creation of a community industry and ,established a food cooperative. At the same time, students participated in education programs regarding nutrition, sanitation and infant care. By performing as interviewers in a household health survey, students learned much about the community residents’ views of disease while contributing to the fund of knowledge about the degree of health problems in the community. It may be added that a few other programs involve this approach to community medicine (one is in preventive and social dentistry in Venezuela and another in medicine is getting underway in Brazil). IMPLEMENTATION The differences in the models, however subtle, are reflected in some observations of differences in the teaching of behavioral sciences. First, almost by definition, there is little in the curricula of LatinAmerican schools on the principles of community medicine, rather, the focus is on social medicine. In part, this is related to the stress placed on epidemiology of diseases as a method and to the priorities given to local major health problems of communicable diseases and malnutrition. Another influence on the curriculum may be the strong role played by governments in setting those priorities and in determining the ways in which medical care services will be delivered. Secondly, Latin-American programs in behavioral sciences show a “‘balance” between the theoretical concerns of one or another of the disciplines involved and their application in a medical context. That balance is not as often found in the U.S. programs,. For example. behavioral sciences courses integrate study of the political, economic and psychological aspects of issues such as .class structure of a society along with application to health related issues of epidemiology and utilization. An important factor in acceptance of this approach by students, however, is reference to the medical context [13]. Third, behavioral sciences in Latin-American programs tend also to have more continuity throughout the entire medical education program. That is to say, some dimension of behavioral sciences--theoretical, applied or both-is found in almost every year of the curriculum. In U.S. programs, they tend more to be concentrated in either the basic science years or in the clinical years, but not throughout the whole professional educational process. The actual programming of behavioral science materials in the curricula of the schools that were visited varied vvidely. of course, just as it does in medical schools in other countries. .In an effort to organize these data. a preliminary identification of “types” of curriculum models has been made along dimensions of scope of the curriculum and its order.
223
Scope refers to the degree to which non-biological sciences and disciplines such as behavioral sciences and humanities are included while order refers to the degree to which the curriculum involves a rigid sequence of courses. At this early stage of analysis we can identify at least three curriculum “types”. (1) Traditional mod&--includes only basic biological sciences and clinical courses taught in a rigid sequence. (2) Expanded mode&courses on principles of the behavioral sciences are taught as a “basic” science and then applied to clinical situations, but the sequential nature of the curriculum is maintained. (3) Integrated modeCbehaviora1 sciences principles and practices are introduced in the context of a multi-disciplinary perspective on health issues. The sequential nature of the curriculum is much relaxed. It should be noted that while the traditional model is still a common pattern, it probably does not exist anywhere in pure form. That is, almost every medical school curriculum includes some instruction on behavioral science implications of ill health and medical care even if limited to only a few casual lectures. The exception to this general observation is the special preparatory program in basic biological sciences. At the Federal University of Minas Gerais, for example, medical students spend the first 2 years in medical school at a separate Institute for Biological Sciences. The balance of the o-year program however, includes much behavioral sciences training. Similarly, the first 2 years of the program at the Federal University of Rio de Janeiro (CLATES) include only basic biological sciences not only for medical students, but for students in all the health sciences, i.e. dentistry, nursing, biological research etc. Increasing numbers of schools have greatly broadened the scope of the curriculum although the sequential pattern has been maintained typical of the “expanded model”. The program of the Universidad Central de Venezuela (Jose Vargas) is illustrative of this model. During the first 3 (basic science) years, students take courses in biostatistics, medical sociology and epidemiology along with basic biological science courses. Fourth-year students have a course in behavioral aspects of Preventive Medicine along with instruction in standard clinical disciplines. In the 5th year they experience practice in barrio clinics along with didactic work in health care administration. Clearly, the amount of behavioral science materials is considerable, but the sequential pattern is traditional. A model of an integrated curriculum is rarely found in pure form although the Program in Community Medicine at Vniversidad Peruana Cayetano Heredia comes close. The program is university-wide and draws upon skills of faculty and staff in other departments such as preventive medicine (which itself is an expanded model), pediatrics, obstetrics-gynecology, etc. Principles of community medicine are introduced in the context of other, more traditional courses by means of multidisciplinary perspectives on significant health issues. For example, the problem of malnutrition would be presented to students from a biochemical and physiological perspective as those systems interact with the social epidemiological and economic perspectives. These didactic materials are augmented
RODNEY
224
by training experiences in health posts and clinics in local barrios and in more remote jungle areas.
Another example of an integrated model might be the experimental program at the University of Sa6 Paulo (there is also a traditional curriculum at this school). The first five semesters focus on human biology generally (including behavioral science aspects) and the last three of those use a “systems” approach. For example, materials on the cardiovascular system will be presented from the perspectives of anatomy. physiology and other biological sciences along with some epidemiological and behavioral ‘science aspects. The sixth semester emphasizes preventive medicine including microbiology and parasitology, but also the demographic and epidemiologic dimensions. Practical experience in clinical training occupies the balance of the curriculum. There is a significant amount of curriculum time given to instruction in the behavioral science, but great flexibility in the pattern of implementation. There are no doubt other ways to classify these curricula. In addition, such data must be linked with studies of other important factors affecting the behavior of practitioners such as changes in patterns of morbidity. emergence of new forms of medical organization, modes of financing care, etc. However, much of this will remain academic until these various programs are able to produce sufficient practitioners so that long-term outcomes of different training programs can be evaluated. Since many of these programs are very new, some just beginning there may be a lo-year delay in developing data to assess outcomes. SOME
RECOMMENDATIONS
Based on the observations made during this study tour, it is possible to make some recommendations for teaching behavioral sciences in other medical schools. These suggestions are made cautiously since they are based on review of only a few Latin-American programs. Furthermore, it should be noted also that these comments rest on pedagogical assumptions since there is as yet no evidence available that any of these recommendations will yield significant changes in the quality and type of practitioner. With these constraints in mind, the following recommendations seem reasonable. (1) There should be a stronger emphasis on integrating the academic dimensions of behavioral sciences with fieldwork in the community. This is particularly the case for employing basic behavioral science concepts such as social class, ethnicity, personality, family life cycle, etc. in identifying and solving community health problems. However. it is important also to apply the behavioral science interests of social medicine to community problems, especially models for organizing and financing community health services. (2) The curriculum of medical schools should offer a community medicine experience as part of the program each year to provide continuity in the exposure to community medicine and provide opportunities to apply principles of behavioral sciences in clinical settings and other community organizations along the lines of the present model for medicine, pediatrics. surgery and the other clinical departments.
M.
COE
(3) Increased continuity throughout the whole of the educational program would provide opportunity for increased “vertical integration” of community and social medicine concepts. That is. what students learn in the 1st year should be more closely linked with the content in the 2nd year and those. in turn. should have bearing on the following years. This, of course. would be primarily the responsibility of one department although it would involve collaboration with other parts of the medical school faculty. At the same time. increased efforts should be made to provide more “horizontal integration” or interrelationships among courses taught during the same year. Here the responsibility must be shared by several departments. Some examples observed during the study tour included presenting biostatistics. epidemiology, microbiology and parasitology as a combined course. In another school. preventive medicine was combined with biochemistry, physiology and pediatrics around the issue of malnutrition. These and many other possible combinations are readily apparent. (4) Finally, but not exhaustively, medical schools should look toward the establishment of a graduate training program in community medicine as an extension of undergraduate medical education and along with strengthening continuing education programs for physicians and other health professionals along similar lines. The model of the combined M.D.Ph.D. degree programs often found in basic biological science departments could be used to develop a joint M.D.-master’s degree program in community health sciences. In summary, there seems to be a general recognition of the need for behavioral sciences in medicine. What is less clear. in the United States at least, is how the principles of those sciences can best be taught and learned. The rather obvious recommendations identified above are intended to bring about a more clear perspective. Acknowledgrmmrs-The information for this paper was taken from a project entitled “Medical Education For Comprehensive Health Care” sponsored and financed by the Department of Health Manpower, Pan American Health Organization. Washington. D.C.. in collaboration with Saint Louis University School of Medicine. I am also indebted to my friend and colleague Dr. Max Pepper and to the anonymous on this paper.
reviewers for their helpful comments
REFERENCES
Coe R. M. Socioloyy of Medicine. McGraw-Hill, New York. 1970. 2. Caughey 3. M. Obligation of medical schools to stude&. j. Ant. Med. Ass. 185. 107, 1963. 3. Freidin R. B. rt al. Medical education and nhvsician behavior: preparing physicians for new roles: i Med. 1.
Educ. 41. 163, 1972. 4. Pattishall E. G. Concepts and teaching of behavioral sciences. SW. Sci. and Med. 4. 157, 1970.
5. Slater C. Student participation in curriculum planning and evaluation. J. Med. Educ. 44. 675, 1969. 6. Tyler R. Curriculum improvement in the medical school. J. Med. Educ. 45. 42. 1970. 7. Kennedy D. S., Pattishall E. G. and Fletcher C. R. Teaching
Behuvioral Sciences
in Schools of Medicine
Vol. I (mimeo). National Center for Health Services Research and Development. Rockville. Maryland. July, 1972.
Teaching behavioral ‘sciences 8. New P. K. and May J. T. Teaching activities of social scientists in medical and public health schools. Sot. Sci. and Med. 2. 447. 1968. 9. The sites visited were Central University of Venezuela
(Jose Vargas School of Medicine). Caracas; University of Zulia, Maracaibo ; Cayetano Heredia, Lima ; Federal University of Rio de Janeiro and State University of Guanabara. Rio de Janeiro; Federal University of Minas Gerais, Belo Horizonte; State University of Sa6 Paula; and State University of Campinas tn Campinas. In addition, health centers, ambulatory care clinics in each city and two rural health centers were visited.
225
10. Garcia J. C. La Educacibn MPdica en la Amhrica Latina PAHO, Washington, DC., 1972. Il. McKeown T. and Lowe C. R. Introduction to Social Medicine. Blackwell. Oxford, 1966. 12. Navarro A. A. et al. Docencia medica integral de la universidad de1 Zulia en el medio rural. Cuadernos de la Escuela de Salud Puhlica 19. Caracas, 1970. 13. Machado de Paiacios Y. La enseiianza de las ciencias sociales en 10s estudios medicos. Educ. Med. y Salud 5. 297. 1971.
9. pp. 221 to 225. Pcrgamon Press 1975. Prmtd
in Great Bntain.
TEACHING BEHAVIORAL SCIENCES IN SCHOOLS MEDICINE: OBSERVATIONS ON SOME LATIN-AMERICAN SCHOOLS
OF
RODNEYM. COE Department
of Community Medicine, St. Louis University School of Medicine, 1320 South Grand Avenue. St. Louis, MO 63104, U.S.A.
Abstract-This paper discusses the conceptualization and implementation of teaching behavioral sciences in schools of medicine. Data were collected through interviews with key personnel and documents obtained from ten schools of medicine in Latin-America. Observations lead to a conceptual clarification of the terms social medicine and community medicine. Consideration of variations in scope and sequence of curricula programming leads to tentative identification of three “types” ‘of curricula: traditional, expanded and integrated. Recommendations are made for changes in curricula to enhance the teaching of behavioral sciences in other schools of medicine.
This report discusses some observations made during a study of programs for teaching behavioral sciences in selected Latin-American schools of medicine. The study also reviewed the uses of community resources in teaching medical students and identified some factors influencing the course of medical education. The information developed in this study forms the basis for some recommendations for the teaching of behavioral sciences in schools of medicine in other countries. The present interest in including behavioral sciences in medical school curricula in the United States is an outcome of the convergence of behavioral. sciences and the general field of medicine. This convergence (actually a reconvergence) has come about in part because of: (a) changing patterns of morbidity and mortality; (b) increasing inequities in the delivery of health services; and (c) the maturation of behavioral sciences in terms of capability for scientific theory-building and methodology [l]. The increasing discrepancy between what is taught in medical schools and what is required in medical practice [2,3] has led to increasing demands for change in the curricula of medical schools, especially for including the behavioral sciences [4-6]. However, among the various schools of medicine, the form and amount of development and speed of integration of behavioral sciences into the curriculum have varied greatly [7,8]. Thus, one objective of this investigation has been to determine what lessons programs in South American schools might hold for medical schools in the United States and other countries as well. Data were collected by means of personal interviews, documents describing various program components and tours of facilities [9]. Interviews were held most often with behavioral scientists in each setting and with physicians who teach or provide supervision for medical students or who render direct care services in clinics. In addition, chairmen of Departments of Preventive and Social Medicine (and Dentistry) were seen. In a few instances. administrative officers such as Deans and a Director of medical education were interviewed. Many documents were obtained which related to organization and operation of medical school curri-
cula in Departments of Preventive and Social Medicine especially with reference to the integration of various disciplines comprising the behavioral sciences. Other papers reflect the particular research and/or teaching interests of informants such as syllabi for courses in behavioral sciences and reprints of articles in professional journals. Although these materials cover a wide range of topics and activities, it should be kept in mind that the following statements refer to the sites visited (which vary considerably among themselves) and may not necessarily reflect the situation in other schools. CONCEPTUALIZATION
AND
IMPLEMENTATION
The comments made here address the issues of conceptualization -and implementation of behavioral sciences and use of the community as a teaching tool. One observation that was reinforced over and over is the sharp distinction made between the concepts of social medicine and community medicine. Although there are a few important exceptions, the emphasis in Latin-American programs is on the teaching of behavioral sciences as they relate to the practice of social medicine [lo], not community medicine which is more than just the application of social medicine in a community setting. In the United States, more emphasis is placed on learning about a community’s structure, resources and health problems and participating with others through community organization efforts in identifying those problems and developing solutions to them. It would be fair to say that most theoretical statements about social medicine involve systemic relationships between measures of need resources and institutional (government and educational) policy and employ behavioral sciences in a scientific approach to the measuring of and planning for meeting society’s health needs [l 11. For example, the model shown in Fig. 1 links health need, health resources and institutional philosophy. Need reflects actual health status which is measured epidemiologically in terms of amounts and types of diseases in a population, according to position in the social structure and subject to cultural influences. Resources or state of health
RODNEY M. COE
222
Need Epidemiology, SOCIOeconomic structure, cultural influences
Philosophy Priorities research medical
on teaching, and service in education
Resources Organization and financing of health services
Fig. 1.
services are indicated by factors associated with the delivery of health care. Likewise, institutional policies are expressed in terms of relative emphasis or priority on teaching, research and service. The basic assumption is that each of the elements of the “system” influences and is influenced by the others. This would be applicable also to community medicine in the United States except that the “community” dimension of organization and participation of clients in the decision-making and action programming is omitted. Thus, the model shown above can be restated in terms of community medicine with only slight, but conceptually important modifications (see Fig. 2). The concept of need, which is a professional estimate of what the community requires to meet health standards, is expanded to include demand which is an expression of what the community (through its individuals and organizations) perceives to be its needs and what it wants. Similarly, the organization and utilization of health resources are influenced by the need-demand dimension and are not based solely on what health professionals view as their capacity to meet needs or what priorities professionals believe ought to be assigned when resources are scarce, but they include also the interests of the community (and the community itself becomes a resource). In the same way, community representatives participate in establishing a “social contract” between educational, governmental and community organizations so that the interests and priorities of each group can be maximized. This represents a somewhat different role for the behavioral sciences.
This becomes a little more apparent in observing the application of these principles in health care settings. Thus, Latin-American medical students learn about the principles of social medicine in the classroom and apply them in the clinics in the community as an extension of the medical center rather than as a core of a community-based and communityoriented health and education center. The emphasis. however, stems from the professional model of the “expert” doing something to the patient not with the patient. In other words, there is little effort to involve the patient or his family as a partner in the treatment process nor is there much effort at using a behavioral sciences approach to organizing the community to prevent, diagnose, treat or rehabilitate its own health problems or to evaluate the results. In contrast, community medicine programs in the United States more often direct their efforts at involving the community in health care processes. In part, the community may be seen as the “patient” and medical students and others in allied health fields are encouraged to examine and treat the “whole patient” while at the same time treating specific diseases of individuals in that community. This emphasis in the United States, however, is usually associated with weakly developed and poorly integrated didactic programs of social medicine. Thus, programs in the United States differ from Latin-American programs in degree of emphasis on principles of social medicine as well as focusof their application in community settings. The foregoing generalization is very broad and based on observation of only a few programs; another
Need/demand Eprdemiology, socialeconomic structure, cultural differences, perceptions of community
Philosophy
needs
Priorities on teaching, research and service‘community’as client
by
residents
(indrviduals izations)
and
orgon-
Resources Organization and financing of health servicescomprehensive program through integration of existing community facilities
Fig. 2.
Teaching behavioral sciences
way of saying there are always exceptions to the rule. In this regard, there are some notable exceptions *among the programs visited during this tour. One of the outstanding examples of community medicine is the Pasantia Rural managed by the University of Zulia in the health center of San Rafael de Mara, Venezuela [12]. Over a period of the last 10 yr, medical students assigned to the health center for short periods of training not only learned about preventive and curative medicine. but participated in programs of political organization of a community, assisted in the creation of a community industry and ,established a food cooperative. At the same time, students participated in education programs regarding nutrition, sanitation and infant care. By performing as interviewers in a household health survey, students learned much about the community residents’ views of disease while contributing to the fund of knowledge about the degree of health problems in the community. It may be added that a few other programs involve this approach to community medicine (one is in preventive and social dentistry in Venezuela and another in medicine is getting underway in Brazil). IMPLEMENTATION The differences in the models, however subtle, are reflected in some observations of differences in the teaching of behavioral sciences. First, almost by definition, there is little in the curricula of LatinAmerican schools on the principles of community medicine, rather, the focus is on social medicine. In part, this is related to the stress placed on epidemiology of diseases as a method and to the priorities given to local major health problems of communicable diseases and malnutrition. Another influence on the curriculum may be the strong role played by governments in setting those priorities and in determining the ways in which medical care services will be delivered. Secondly, Latin-American programs in behavioral sciences show a “‘balance” between the theoretical concerns of one or another of the disciplines involved and their application in a medical context. That balance is not as often found in the U.S. programs,. For example. behavioral sciences courses integrate study of the political, economic and psychological aspects of issues such as .class structure of a society along with application to health related issues of epidemiology and utilization. An important factor in acceptance of this approach by students, however, is reference to the medical context [13]. Third, behavioral sciences in Latin-American programs tend also to have more continuity throughout the entire medical education program. That is to say, some dimension of behavioral sciences--theoretical, applied or both-is found in almost every year of the curriculum. In U.S. programs, they tend more to be concentrated in either the basic science years or in the clinical years, but not throughout the whole professional educational process. The actual programming of behavioral science materials in the curricula of the schools that were visited varied vvidely. of course, just as it does in medical schools in other countries. .In an effort to organize these data. a preliminary identification of “types” of curriculum models has been made along dimensions of scope of the curriculum and its order.
223
Scope refers to the degree to which non-biological sciences and disciplines such as behavioral sciences and humanities are included while order refers to the degree to which the curriculum involves a rigid sequence of courses. At this early stage of analysis we can identify at least three curriculum “types”. (1) Traditional mod&--includes only basic biological sciences and clinical courses taught in a rigid sequence. (2) Expanded mode&courses on principles of the behavioral sciences are taught as a “basic” science and then applied to clinical situations, but the sequential nature of the curriculum is maintained. (3) Integrated modeCbehaviora1 sciences principles and practices are introduced in the context of a multi-disciplinary perspective on health issues. The sequential nature of the curriculum is much relaxed. It should be noted that while the traditional model is still a common pattern, it probably does not exist anywhere in pure form. That is, almost every medical school curriculum includes some instruction on behavioral science implications of ill health and medical care even if limited to only a few casual lectures. The exception to this general observation is the special preparatory program in basic biological sciences. At the Federal University of Minas Gerais, for example, medical students spend the first 2 years in medical school at a separate Institute for Biological Sciences. The balance of the o-year program however, includes much behavioral sciences training. Similarly, the first 2 years of the program at the Federal University of Rio de Janeiro (CLATES) include only basic biological sciences not only for medical students, but for students in all the health sciences, i.e. dentistry, nursing, biological research etc. Increasing numbers of schools have greatly broadened the scope of the curriculum although the sequential pattern has been maintained typical of the “expanded model”. The program of the Universidad Central de Venezuela (Jose Vargas) is illustrative of this model. During the first 3 (basic science) years, students take courses in biostatistics, medical sociology and epidemiology along with basic biological science courses. Fourth-year students have a course in behavioral aspects of Preventive Medicine along with instruction in standard clinical disciplines. In the 5th year they experience practice in barrio clinics along with didactic work in health care administration. Clearly, the amount of behavioral science materials is considerable, but the sequential pattern is traditional. A model of an integrated curriculum is rarely found in pure form although the Program in Community Medicine at Vniversidad Peruana Cayetano Heredia comes close. The program is university-wide and draws upon skills of faculty and staff in other departments such as preventive medicine (which itself is an expanded model), pediatrics, obstetrics-gynecology, etc. Principles of community medicine are introduced in the context of other, more traditional courses by means of multidisciplinary perspectives on significant health issues. For example, the problem of malnutrition would be presented to students from a biochemical and physiological perspective as those systems interact with the social epidemiological and economic perspectives. These didactic materials are augmented
RODNEY
224
by training experiences in health posts and clinics in local barrios and in more remote jungle areas.
Another example of an integrated model might be the experimental program at the University of Sa6 Paulo (there is also a traditional curriculum at this school). The first five semesters focus on human biology generally (including behavioral science aspects) and the last three of those use a “systems” approach. For example, materials on the cardiovascular system will be presented from the perspectives of anatomy. physiology and other biological sciences along with some epidemiological and behavioral ‘science aspects. The sixth semester emphasizes preventive medicine including microbiology and parasitology, but also the demographic and epidemiologic dimensions. Practical experience in clinical training occupies the balance of the curriculum. There is a significant amount of curriculum time given to instruction in the behavioral science, but great flexibility in the pattern of implementation. There are no doubt other ways to classify these curricula. In addition, such data must be linked with studies of other important factors affecting the behavior of practitioners such as changes in patterns of morbidity. emergence of new forms of medical organization, modes of financing care, etc. However, much of this will remain academic until these various programs are able to produce sufficient practitioners so that long-term outcomes of different training programs can be evaluated. Since many of these programs are very new, some just beginning there may be a lo-year delay in developing data to assess outcomes. SOME
RECOMMENDATIONS
Based on the observations made during this study tour, it is possible to make some recommendations for teaching behavioral sciences in other medical schools. These suggestions are made cautiously since they are based on review of only a few Latin-American programs. Furthermore, it should be noted also that these comments rest on pedagogical assumptions since there is as yet no evidence available that any of these recommendations will yield significant changes in the quality and type of practitioner. With these constraints in mind, the following recommendations seem reasonable. (1) There should be a stronger emphasis on integrating the academic dimensions of behavioral sciences with fieldwork in the community. This is particularly the case for employing basic behavioral science concepts such as social class, ethnicity, personality, family life cycle, etc. in identifying and solving community health problems. However. it is important also to apply the behavioral science interests of social medicine to community problems, especially models for organizing and financing community health services. (2) The curriculum of medical schools should offer a community medicine experience as part of the program each year to provide continuity in the exposure to community medicine and provide opportunities to apply principles of behavioral sciences in clinical settings and other community organizations along the lines of the present model for medicine, pediatrics. surgery and the other clinical departments.
M.
COE
(3) Increased continuity throughout the whole of the educational program would provide opportunity for increased “vertical integration” of community and social medicine concepts. That is. what students learn in the 1st year should be more closely linked with the content in the 2nd year and those. in turn. should have bearing on the following years. This, of course. would be primarily the responsibility of one department although it would involve collaboration with other parts of the medical school faculty. At the same time. increased efforts should be made to provide more “horizontal integration” or interrelationships among courses taught during the same year. Here the responsibility must be shared by several departments. Some examples observed during the study tour included presenting biostatistics. epidemiology, microbiology and parasitology as a combined course. In another school. preventive medicine was combined with biochemistry, physiology and pediatrics around the issue of malnutrition. These and many other possible combinations are readily apparent. (4) Finally, but not exhaustively, medical schools should look toward the establishment of a graduate training program in community medicine as an extension of undergraduate medical education and along with strengthening continuing education programs for physicians and other health professionals along similar lines. The model of the combined M.D.Ph.D. degree programs often found in basic biological science departments could be used to develop a joint M.D.-master’s degree program in community health sciences. In summary, there seems to be a general recognition of the need for behavioral sciences in medicine. What is less clear. in the United States at least, is how the principles of those sciences can best be taught and learned. The rather obvious recommendations identified above are intended to bring about a more clear perspective. Acknowledgrmmrs-The information for this paper was taken from a project entitled “Medical Education For Comprehensive Health Care” sponsored and financed by the Department of Health Manpower, Pan American Health Organization. Washington. D.C.. in collaboration with Saint Louis University School of Medicine. I am also indebted to my friend and colleague Dr. Max Pepper and to the anonymous on this paper.
reviewers for their helpful comments
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